Every finding on record at Lancaster Health Services

Based on observation, interview, and record review the facility did not ensure that 1 (R8) of 5 residents drug regimen was free from unnecessary drugs. R8 was prescribed Risperidone for verbal and physical aggression. The facility failed to adequately monitor R8's response to Risperidone and failed to recognize adverse consequences of Risperidone therapy including lethargy, decreased Activities of Daily Living (ADL) function and decreased oral intake. The facility failed to adjust R8's Risperidone when R8 presented with adverse consequences. R8 was administered Risperidone (Antipsychotic) daily starting on 6/22/25 following two days of intermittent verbal and physical aggression. Following initiation of Risperidone, R8 presented with lethargy, decreases in activity participation, ADL abilities and oral intake. The facility continued the Risperidone without evidence of monitoring for adverse consequences or side effects related to the initiation of the antipsychotic. The Risperidone was not reduced in attempts to see if the Risperidone was the causative factor for R8's acute decline. R8 was observed multiple times to be somnolent, lethargic, and non-interactive with staff during survey.The facility's failure to ensure R8 drug regime was free from unnecessary drugs created a finding of Immediate Jeopardy, beginning on 7/10/25. The NHA A (Nursing Home Administrator) and DON B (Director of Nursing) were informed of the Immediate Jeopardy on 8/7/25 at 3:49 PM. The immediate jeopardy was removed on 8/7/25; however, the deficient practice continues at a scope/severity level of D (Potential for harm/Isolated) as the facility continues to implement its action plan.Findings include:The facility's policy and procedure entitled, Restraint Free Environment, dated 9/22/22, states, in part: Policy: It is the policy of this facility that each resident shall attain and maintain his/her highest practicable well-being in an environment that prohibits the use of restraints for discipline or convenience and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of restraints. Chemical Restraint refers to any medication that is used for discipline or staff convenience, and not required to treat medical symptoms. Convenience refers to any action taken by the facility to control a resident's behavior or manage a resident's behavior with a lesser amount of effort by the facility and not in the resident's best interest. Medical Symptom refers to an indication or characteristic of a physical or psychological condition. 5. Before a resident is restrained, the facility will determine the presence of a specific medical symptom that would require the use of restraints, and determine: a. How the use of restraints would treat the medical symptom. b. The length of time the restraint is anticipated to be used to treat the medical symptom. c. The direct monitoring and supervision that will be provided during use of the restraint. d. How the resident will request staff assistance and how his/her needs will be met while the restraint is in place. e. How to assist the resident in attaining or maintaining his or her highest practicable level of physical and psychosocial well-being.The facility policy entitled, Use of Psychotropic Medication(s), dated 4/27/25, states in part: Policy: It is the intent of this policy to ensure that residents only receive psychotropic medications when other nonpharmacological interventions are clinically contraindicated. Additionally, these medications should only be used to treat the resident's medical symptoms and not used for discipline or staff convenience, which would deem it a chemical restraint. For psychotropic medications, without documentation in the record explaining that the practitioner has determined that other treatments have been deemed clinically contraindicated, the indication for use is inadequate. Also, adequate indication for use means that the medication administered is consistent with manufacturer's recommendations and/or clinical practice guidelines, clinical standards of practice, medication references, clinical studies or evidence-based review of articles that are published in medical and/or pharmacy journals. Adverse consequence is a broad term referring to unwanted, unintended, or dangerous effects that a drug may have, such as impairment or decline in an individual's mental or physical condition or functional or psychosocial status. 1. A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. Psychotropic drugs include but are not limited to the following categories: antipsychotics. 2. Psychotropic medications are to be used only when a practitioner determines that the medication(s) is appropriate to treat a resident's specific, diagnosed, and documented condition and the medication(s) is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s). 6. Non-pharmacological approaches should be attempted, unless clinically contraindicated, to minimize the need for psychotropic medications, use the lowest possible dose, or discontinue the medications. 7. The resident's medical record shall include documentation of this evaluation and the rationale for chosen treatment options. 14. The effects of the psychotropic medications on a resident's physical, mental, and psychosocial well-being will be evaluated on an ongoing basis such as: a. Upon physician evaluation (routine and as needed), b. During the pharmacist's monthly medication regimen review, c. During MDS (Minimum Data Set) review, and d. In accordance with nurse assessment and medication monitoring parameters consistent with clinical standards of practice, manufacturer's specifications and the resident's comprehensive plan of care. 15. The resident's response to the medication(s), including progress towards goals and presence/absence of adverse consequences, shall be documented in the resident's medical record.R8 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease without dyskinesia, without mention of fluctuations (movement disorder caused by neuron degeneration that affects the nervous system), weakness, type 2 diabetes, mild cognitive impairment of uncertain or unknown etiology, congestive heart failure (heart is unable to pump blood effectively leading to fluid buildup in the lungs and legs), and adult failure to thrive.R8's Minimum Data Set (MDS) with Assessment Reference Date (ARD) 5/9/25 indicates R8 had a Brief Interview for Mental Status (BIMS) score of 11 out of 15, indicating moderate cognitive impairment. Section GG indicates R8 was independent with eating, required supervision/touching assistance with oral hygiene, and required partial/moderate assistance with rolling left/right. Section GG also indicates R8 required substantial/maximal assistance with toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, moving from sitting to lying, lying to sitting, sit to stand, chair/bed to chair transfer, toilet transfer, tub/shower transfer, and walking 10 feet.(Of note: R8's previous MDS data, dated 3/27/25 indicates R8 had improved from not being able to ambulate previously to now being able to ambulate 10 feet.)R8's Comprehensive Care Plan states, in part:Focus: Enjoys activities such as (reading newspapers and magazines, music, pets/animals, outdoors). Date Initiated: 3/22/25.Goals: Will actively participate in independent activities of choice. Date Initiated: 3/22/25. Target Date: 10/9/25. Will participate in activities that promote socialization with peers consistent with likes and interests such as: eating in the dining room, music groups, Bingo, and other games as he allows. Date Initiated: 3/22/25. Target Date: 10/9/25. Will participate in independent activities of choice such as: watching TV in his room, visiting with family. Date Initiated: 3/22/25. Target Date: 10/9/25.Interventions:Assist in planning and/or encourage to plan own leisure time activities. Date Initiated: 3/22/25.Assist to transport to and from activities of choice. Date Initiated: 3/22/25.Encourage participation in group activities of interest. Date Initiated: 3/22/25.Offer activities consistent with resident's known interest, physical and intellectual capabilities such as: outdoor activities, Bingo, Music Groups. Date Initiated: 3/22/25.Offer/supply large print materials. Date Initiated: 3/22/25.Provide supplies/materials for leisure activities as needed/requested. Date Initiated: 3/22/25.The Resident's preferred activities are: Animals/Pets (Dogs, Visiting Resident Birds), Music (Oldies, Rock & Roll, Country, Hymns, Music Entertainment), Reading (Our Wisconsin, etc., Variety Newspapers), Games/Cards (Bingo Euchre), TV (Gameshow Network, Old Shows, Friends), Current Events (News/Weather on TV, Variety Newspapers), Sitting Outdoors/Fresh Air (Weather Permitting), Socializing/reminiscing With Others, Family Centered Functions. Date Initiated: 7/14/25. Focus: The resident has limited physical mobility. Date Initiated: 3/17/254. Revision on: 3/17/25.Goal: The resident will increase level of mobility through the next review date. Date Initiated: 3/17/25. Target Date: 10/9/25.Interventions:AMBULATION/LOCOMOTION - ASSIST - ONE. Date Initiated: 3/17/25. Revision on: 3/27/25.BED MOBILITY - ASSIST - ONE. Date Initiated: 3/17/25. Revision on: 3/17/25.TRANSFER - ASSIST - 2, Hoyer, lg (large) sling risk vs benefit completed on resident choosing to use different sling size than recommended by manufacturer. Date initiated: 7/2/25. Revision on: 7/11/25. Focus: At risk for behavior symptoms r/t (related to): (specify) end stage disease (Parkinson's). Date Initiated: 6/21/25. Revision on: 6/24/25.Goal: Will accept care and medications as prescribed. Date Initiated: 6/24/25. Target Date: 10/9/25. Maintain involvement with ADL (Activities of Daily Living) performance and social activities. Date Initiated: 6/21/25. Revision on: 6/24/25. Target Date: 10/9/25.Interventions:Administer medications per physician order. Date Initiated: 6/21/25. Revision on: 6/26/25.Behavior 1 aggressive. Intervention #1: redirection. Intervention #2: another staff member. Intervention #3: try later. Date Initiated: 6/21/25. Revision on: 6/26/25.Staff to take vitals as resident allows. Date Initiated: 6/25/26. Revision on: 6/26/25. Focus: Verbal/physical agitation/aggression (specify actions) r/t: cognitive impairment. Date Initiated: 7/3/25. Revision on: 7/3/25.Interventions:Administer medications per physician orders. Date Initiated: 7/3/25.Approach slowly and slightly to the side. Date Initiated: 7/3/25.Give resident clear, concise explanation of anything about to occur. Date Initiated: 7/3/25.If strategies are not working, leave (if safe to do so) and reapproach later. Date Initiated: 7/3/25.Involve in 1:1 recreational activity. Date Initiated: 7/3/25. Focus: The resident is at risk for behavioral problem. Resident had exhibited inappropriate sexual behavior such as grabbing, touching, verbal statements r/t: mild cognitive impairment. Date Initiated: 3/17/25. Revision on: 6/16/25.Goal: The resident will have no evidence of behavior problems by review date. Date Initiated: 3/17/25. Revision on: 3/17/25. Target Date: 10/9/25.Interventions:Anticipate and meet the resident's needs. Date Initiated: 3/17/25.Distract if able. Date Initiated: 6/16/25.Encourage resident to express feelings. Date Initiated: 3/17/25.Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Date Initiated: 6/16/25.Praise resident. Date Initiated: 6/16/25.Redirect as needed. Date Initiated: 6/16/25.Resident may not be able to remember passcode to phone due to DX (Diagnosis) of dementia. Passcode is [Resident's Passcode]. Date Initiated: 4/6/25. Focus: At risk for adverse effects r/t: use of antipsychotic medication. Date Initiated: 6/26/25. Revision on: 6/26/25.Goal: . To show minimal/no side effects of medications taken. Date Initiated: 6/26/25. Target Date: 10/9/25.Interventions:Antipsychotic Medication: Report adverse effects such as dry mouth, constipation, blurred vision, disorientation/confusion, difficulty urinating, hypotension, dark urine, yellow skin, nausea, vomiting, lethargy, drooling, EPS (Extrapyramidal Symptoms; tremors, increased agitation, restlessness, involuntary movement of mouth or tongue). Date Initiated: 6/26/25.AIMS (Abnormal Involuntary Movement Scale) testing per facility guidelines (upon admission, initiation of, change of, every 6 months, and PRN). Date Initiated: 6/26/25.Non-Pharm (Non-pharmacological) Interventions for behaviors:1. Address in a calm manner2. Attempt to orientate to place and time3. Allow resident to express feelings or frustrations and provide reassurance as needed4. Provide assistance as needed5. Family visits6. Offer activities of choice7. Provide emotional support to resident as needed8. Offer to close door and curtains to facilitate sleep. Date Initiated: 6/26/25.TARGET BEHAVIOR 1: Physically aggressive behavior (pinching, kicking, biting or hitting) Intervention #1: ensure safety leave, try again later. Intervention #2: try using different staff. Interventions #3: diversion, engage in conversation about his dog, bingo, music, therapy dog ([Name].). Date Initiated: 6/26/25. Revision on: 6/26/25.TARGET BEHAVIOR 2: Verbally aggressive or sexually inappropriate language. Intervention #1: Remain calm, don't react. Intervention #2: Try cares at a later time. Intervention #3: Try other staff. Date Initiated: 6/26/25. Revision on: 6/26/25. Focus: Cognitive loss as evidenced by confusion and agitation r/t (related to): Parkinson's disease. Date Initiated: 7/3/25. Revision on: 7/3/25.Interventions:Allow adequate time to respond. Do not rush or supply words. Date Initiated: 7/3/25.Approach/speak in a calm, positive/reassuring manner. Date Initiated: 7/3/25.Attempt to provide consistent routines/caregivers. Date Initiated: 7/3/25.Encourage low stress activities such as music, small group activities. Date Initiated: 7/3/25.Identify self when speaking to resident. Date Initiated: 7/3/25.Invite to participate in activities such as trivia, reminiscence, current events/newspapers. Date Initiated: 7/3/25.R8's Weight Documentation indicates R8 weighed 194 lbs. on 5/19/25.R8's Behavior Monitoring Documentation from May 2025 indicates R8 exhibited behaviors such as: yelling/screaming, abusive language, threatening behavior, rejection of care, pushing, and sexually inappropriate behavior on 6 out of 93 shifts in May 2025.A physician note dated 6/5/25 at 5:22 PM, written by DO O (Doctor of Osteopathic Medicine), states, in part: . Nursing reports that he has not had any essentially aggressive behaviors since medications changes were made. Patient has [sic] had episodes of confusion which has resulted in activation of his POA (Power of Attorney) in April. He has not tried leaving the facility within the last 6 weeks.R8's Weight Documentation indicates R8 weighed 190.5 on 6/16/25.On 6/17/25 at 21:53 (9:53 PM), a Behavior Note is written that states: Resident was very aggressive towards staff during cares, found walking in hall and unable to redirect, staff assisted as resident would allow with wheelchair to follow. Resident refused gait belt and became aggressive when staff tried. Resident did calm some and was able to eat dinner in dining room without incident. Resident went back to room and was watching television and seemed to be back to his baseline. Resident was later found to be exiting the building through the patio door. Resident was in sight by writer before exiting the building. Resident was walking with walker unassisted, appropriate clothing and footwear, staff assisted resident to wheelchair, and he calmly came back into facility. No other incidents this shift.On 6/19/25 at 16:21 (4:21 PM), a Psychosocial Assessment is completed that indicates R8 has no psychosocial symptoms related to communication or cognitive status. The assessment also states, in part: . 1. Mood or Behavior concerns since last assessment: Increased anger and inappropriate sexual comments with increased dementia and confusion. Additional Comments: POA-HC (Power of Attorney- Healthcare) will be asked to provide consent for psych (psychiatric) consult. D. Psychosocial status: 1. Check all those that apply: 1. Difficulty accepting placement and circumstances. 5. Participates in Living Center Programs 6. Pursues Indepedendent Activities. 7. Maintains Supportive Relationships. 1b. Comments: [Resident Name] doesn't understand why he can't go home and have his wife care for him. She is no longer able. He attends many activities including euchre, bingo, daily music, and special events. [Resident Name] continues to maintain relationship with his sister, brother, sister-in-law, and his wife.On 6/20/25 at 08:23 AM, a Quarterly Activity Participation Review is completed that indicates R8 participates in facility led small group activities daily, large group activities weekly, and 1:1s daily. The review also indicates R8 participates in daily independent activities and his favorite activities include cognitive (trivia, discussion, reading, word puzzles), entertainment (television, music, movies, visiting groups), games (board games, bingo, cards, video games, tablets), and social parties (parties, visiting w/ friends & family, social media, etc.).On 6/20/25 at 07:42 AM, an eINTERACT SBAR (Situation, Background, Assessment, Recommendations) Summary for Providers Note is written that states, in part: . Mental Status Evaluation: Increased confusion (e.g. disorientation) New or worsened delusions or hallucinations. Behavioral Status Evaluation: Verbal aggression Personality change. Nursing observations, evaluation, and recommendations are: resident has increased agitation and behaviors. Primary Care Provider Feedback:. monitor per policy update with further changes.On 6/20/25 at 14:07 (2:07 PM), a Clinical Follow Up Note is written that states: Resident is on follow up for: change in condition for increased agitation and behaviors. The current status is resident refused to allow nurses to get vitals even after several attempts. Resident is agitated and exit seeking, one on one at this time. monitor per policy.On 6/20/25 at 21:23 (9:23 PM) a Behavior Note is written that states: Resident is very aggressive towards staff tonight hitting grabbing yelling kicking and making inappropriate sexual comments very difficult to redirect.On 6/20/25 at 22:11 (10:11 PM) a Clinical Follow Up Note is written that states: Resident is on follow up for: change in condition for increased behaviors and agitation. The current status is resident is resting in wheel chair; has been one on one with DON (Director of Nursing) this shift due to exit seeking and behaviors. Resident hit, kicked, pinched staff swore at them. Resident given a snack; music played. Calm at this time. monitor per policy.On 6/20/25 at 22:45 (10:45 PM) a Behavior Note is written that states: this shift, resident has been agitated, aggressive, hitting, kicking, spitting on staff, redirection, one on one, music, snack, activity all provided. Resident had attempted to remove his shirt himself, would not allow staff to help, resident had shirt stuck around his wrists and hand, resident kept trying to pull shirt off and this may cause bruising.On 6/21/25 at 03:57 AM, a Behavior Note is written that states: Resident was restless and crawling out of bed tonight. Resident was incontinent of urine and changed both times. Resident was grabbing and was sexually inappropriate while staff was performing hygiene cares. Resident was dressed in a brief; gown and transferred to a w/c (wheelchair) and brought up front by the nurse's station to be under direct staff supervision.On 6/21/25 at 06:03 AM, a Clinical Follow Up Note is written that states: The current status is resident slid out of bed, head and chest on bed, legs on floor, kneeling. resident alert and confused at baseline. resident has been on a change in condition for increased agitation and behaviors. resident is calm at this time, sitting in wheelchair asking when it is time to go home. monitor per policy.On 6/21/25 at 07:14 AM, a Clinical Follow Up Note is written that states: Resident is on follow up for: resident on change in condition for increased behaviors and agitation. The current status is resident is hallucinating, hitting, kicking, pinching, swearing at staff. Resident is being sent to [Facility Name] ER (Emergency Room) for this change. sent to ER.On 6/21/25 at 08:10 AM, a Nursing Note is written that states: resident has been hallucinating, aggressive. This nurse called and got an order to eval (evaluate) and treat at [Facility Name] ER. resident POA (Power of Attorney) approved transfer. This nurse called sheriff dept (department) and requested [Emergency Medical Service Name] for transfer to [Facility Name]. [Emergency Medical Service Name] came, and resident was combative with them as well. resident hitting, kicking, spitting, swearing. resident alert but confused, does have diagnosis for mild cognitive impairment. resident was safely secured to cot and taken by EMS (Emergency Medical Services).On 6/21/25 at 10:41 AM, a Clinical Note is written that states: Resident is on follow up for: resident on change in condition for increased behaviors and agitation. The current status is Resident is currently being returned to facility by ambulance after being evaluated by [Facility Name], resident will be returning to facility with new orders for Risperidone Q (every) day. Continue to monitor and update MD as needed.R8's Behavior Monitoring Documentation from June 2025 indicates R8 exhibited behaviors such as: yelling/screaming, abusive language, threatening behavior, rejection of care, pushing, grabbing, and sexually inappropriate behavior on 22 out of 93 shifts in June 2025, with 6 of these shifts occurring between 6/17/25 and 6/21/25.R8's Physician Orders for June 2025 state, in part:Carbidopa-Levodopa (Treats Parkinson's disease by Oral Tablet 25-250 MG (Carbidopa Levodopa) Give 1 tablet by mouth three times a day related to PARKINSONS DISEASE WITHOUT DYSKENESIA, WITHOUT MENTIONS OF FLUCTUATIONS. Start Date: 4/5/25. D/C (Discontinue) Date: 6/24/25.Risperidone Oral Tablet 0.5 MG (Milligrams) (Risperidone) Give 1 tablet by mouth one time a day for Agitation. Start date: 6/22/25. Active Order.Risperidone Oral Tablet 0.25 MG (Risperidone) Give 1 tablet by mouth every 24 hours as needed for agitation. Give at HS (Bedtime) if needed for agitation. Start date: 6/21/25. D/C date: 7/7/25.On 6/21/25 at 14:00 (2:00 PM), a Behavior Note is written that states: Resident is attempting to pack his belongings, states he is leaving because staff stole his furniture. Nurse reassured resident that all of his furniture is still in his room. Resident began to get upset but was redirectable.On 6/21/25 at 15:44 (3:44 PM), a Nursing Note is written that states, in part: Narrative: resident is hitting, kicking, pinching, swearing at staff. resident is one to one at this time. POA gave verbal consent for risperidone. attempted to listen to music, activity, redirection, unsuccessful nurse is going up and down hall with resident. one on one.On 6/21/25 at 16:10 (4:10 PM), a Communication with the Emergency Dept of the hospital Note was written that states: Dr. [Name] at [Facility Name] ER gave a onetime order for a 0.5 risperidone by mouth.On 6/21/25 at 18:31 (6:31 PM), a Clinical Follow Up Note is written that states: Resident is on follow up for: Resident was sent to ER after 2 falls overnight and increased physical and aggressive behaviors. The current status is Resident started on Risperidone scheduled and PRN dose. Resident was aggressive with staff prior to dinner. Hitting, kicking at, verbally aggressive, inappropriate sexual comments. Continuous attempts to stand without staff assist or locking breaks [sic] on wheelchair. Staff was 1:1 with resident due to statements of wanting to leave building. ER contacted and one time dose of Risperidone given. Resident ate dinner and is in wheelchair. Mood has improved; aggressive behavior has decreased.On 6/21/25 at 21:30 (9:30 PM), an Administration Note is written that states, in part: risperidone Oral Tablet 0.25 MG. PRN Administration was: Ineffective. Resident continue with aggression but is improving. R8's Meal Intake Documentation indicates:Between 6/1/25 and 6/21/25, R8 ate 61 meals over 21 days, with 2 meals either refused or R8 was not available. R8 consumed 76-100% of 53 of meals, 51-75% of 6 of meals, 26-50% of 1 of meals, 0-25% of 1 of meal.(Of note: This documentation indicates R8 ate 76-100% of his meal for 87% of his meals eaten.)R8's Fluid Intake Documentation indicates:Between 6/1/25 and 6/21/25, R8 consumed an average daily fluid intake for this time period of 2,091 mL/day.R8's Activity Documentation Indicates:Between 6/1/25 and 6/21/25, R8 participated in 23 activities over 21 days. 10 were 1:1 activities with staff, 4 were independent activities initiated by staff but completed without staff, 8 were group activities, and 1 activity R8 was observed to be participating in, but did not include any staff involvement or participation. R8 had active participation in 20 of these activities, passive participation in 1 activity, and observation only in 2 activities.(Of note: This documentation indicates R8 had active participation in 87% of the activities in which he participated.) On 6/22/25 at 09:55 AM, a Nursing Note is written that states: Per DON and other staff - resident finally fell asleep at 0130 AM this morning after being awake for 46 hours. Resident only took an hour and 40-minute nap in that 46-hour period.On 6/22/25 at 10:40 AM, a Nursing Note is written that states, in part: Narrative: Resident started on Risperidone is sound asleep currently lying in bed, vitals are stable, resident did have cares performed and has been repositioned. No adverse effects noted. Resident able to answer yes/no questions.On 6/22/25 at 17:10 (5:10 PM), a Summary Note is written that states, in part: Resident summary. Resident started risperidone on 6/21 due to behaviors and aggression. Resident got one time dose, plus prn dose and scheduled dose today. Resident is requesting to stay in bed, is arousable and able to conversate with staff. No aggression noted.On 6/23/25 at 12:36 PM, a Behavior Note is written that states, in part: Resident started on Risperidone is sound asleep currently lying in bed, vitals are stable, resident did have cares performed and has been repositioned. Resident has become physically aggressive with staff every time attempted to get out of bed. Meals offered in bed; Resident has taken 2 containers of Boost (Nutrition Supplement) from writer with Meds. Has had a very poor appetite but has been drinking with straw w/o (without) problems.R8's Minimum Data Set with Assessment Reference Date 6/23/25, indicates R8 had a Brief Interview for Mental Status (BIMS) score of 8 out of 15, indicating moderate cognitive impairment. Section E indicates physical and verbal behaviors directed at others occurred 1-3 days in the past 7 days. Section GG indicates R8 was independent with eating and rolling left/right, required set up/clean-up assistance with oral hygiene, and required partial/moderate assistance with upper body dressing. Section GG also indicates R8 required substantial/maximal assistance with shower/bathe self, moving from sitting to lying, lying to sitting, sit to stand, chair/bed to chair transfer, toilet transfer, tub/shower transfer, and walking 10 feet. R8 was indicated to be dependent with toileting hygiene and lower body dressing.On 6/24/25 at 06:00 AM, a Behavior Note is written that states: New order for Risperidone on 6/22/25. No adverse effects from medication, no behaviors noted this shift.On 6/24/25 at 11:38 AM, an Orders - General Note from eRecord Note is written that states: Resident sleeping during AM med pass, when awoken, resident refused medications and went back to sleep.On 6/24/25 at 14:51 (2:51 PM), a Behavior Note is written that states: Resident refused meals on this shift as well as fluids and medications. Resident becomes [sic] combative and abusive with staff with cares and interactions. Reapproach, distraction, 1:1 ineffective.On 6/24/25 at 14:53 (2:43 PM), a COMMUNICATION - with Physician Note is written that states, in part: Situation: Resident refusing cares, medications, fluids and meals and becomes combative with staff during care. Spouse/POA wanted resident evaluated in ER due to decreased oral intake.On 6/24/25 at 17:57 (5:57 PM), an eINTERACT SBAR Summary for Providers Note is written that states, in part: . Functional Status Evaluation: Needs more assistance with ADLs (Activities of Daily Living) Behavioral Status Evaluation: Physical aggression Verbal aggression Personality change Other behavioral symptoms. Abdominal/GI Status Evaluation: Decreased appetite/fluid intake. Nursing observations, evaluation, and recommendations are: resident came back from ER with hospice order wife requesting [Hospice Provider Name] hospice. Primary Care Provider responded with the following feedback: A. Recommendations: monitor per policy.(Of note: This is the last documentation of staff reporting decreased appetite and fluid intake and needing more assistance with ADLs until 8/7/25).On 6/24/25 at 19:12 (7:12 PM), a Health Status Note is written that states, in part: Resident is currently resting in bed with eyes closed. Work of breathing is regular with equal chest rise and fall. Resident continues to have brief moments of agitation with cares but returns to sleeping soon after. Resident continues to refuse drink or beverage.On 6/25/25 at 04:54 AM, a Clinical Follow Up Note is written that states, in part: Resident is on follow up for: Overall decline in condition; resident has decreased food and fluid intake; increased assist with ADLs; increased behaviors. The current status is resting in bed. No display of pain noted.On 6/25/25 at 09:28 AM, a Behavior Note is written that states: New order for Risperidone on 6/22/25. No adverse effects from medication, no behaviors noted this shift. Resident pleasant and cooperative with cares, up in w/c for breakfast and ate 100%.R8's Weight Documentation indicates R8 weighed 177.5 lbs. on 7/1/25.(Of note: This documentation indicates a 6.82% weight loss over 2 weeks between 6/16/25 and 7/1/25, and the risperidone was started on 6/22/25).On 7/3/25 at 11:20 AM, a Psychosocial Assessment is completed that indicates R8 has psychosocial symptoms related to his cognitive status, stating [Resident Name] is confused and sometimes has thoughts and his relationship with his wife and also with staff members . The assessment also states, . 1. Mood or Behavior concerns since last assessment: yelling, hitting, spitting, verbal threats, swearing. 2. Is resident on any psychotropic medications? 1. Yes. 2b. If Yes to Psychotropic medications, list psychotropic medications and target behaviors: Risperdal (Risperidone) TARGET BEHAVIOR 1: Physically aggressive behavior (pinching, kicking, biting or hitting) TARGET BEHAVIOR 2: Verbally aggressive or sexually inappropriate language. 3. Mental Health Services. 1. No Need.On 7/9/25, a Physician Order was placed to admit R8 to hospice with the diagnosis of coronary artery disease.R8's Significant Change Minimum Data Set with Assessment Reference Date, 7/10/25, indicates R8 had a Brief Interview for Mental Status (BIMS) score of 6 out of 15, indicating severe cognitive impairment. Section GG indicates R8 requires supervision or touching assistance with eating and partial/moderate assistance with oral hygiene. Section GG also indicates R8 is dependent with toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, personal hygiene, and roll left/right, chair/bed to chair transfer, and tub/shower transfer. R8 could not attempt moving from sit to lying, lying to sitting, sit to stand, toilet transfer, and walking 10 feet.(Of note: This MDS indicates a decrease in R8's functional abilities with e

Based on observation, interview, and record review, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This has the potential to affect 39 of 39 residents.Surveyor observed food to have been removed from the original packaging and not dated with an expiration date, an open date, or a use by date. Evidenced by: Facility policy, entitled Food Storage, date revised 8/16/2022, states in part: .13. Frozen Foods: .c. All foods should be covered, labeled and dated. All foods will be checked to assure that foods will be consumed by their safe use by dates or discarded. Example - Undated food removed from original packaging On 8/4/25 at 9:35 AM, during the initial tour of the kitchen, Surveyor observed in the freezer the following: an opened package of mixed vegetables, out of original cardboard box, without a use by or expiration date; an opened package of diced carrots, out of original cardboard box, without a use by or expiration date; an opened package of peas, out of original cardboard box, without a use by or expiration date; and an opened package of yellow beans, out of original cardboard box, without a use by or expiration date. On 8/4/25 at 1:59 PM, Surveyor interviewed DM C and showed him the unlabeled and undated bags of frozen vegetables. DM C verified these opened bags of food were not labeled and indicated they should have been labeled and dated.

Based on observation, interview and record review, the facility did not ensure that each resident receives food and drink that is palatable and at a safe and appetizing temperature. This has the potential to affect 2 of 16 sampled residents (R4 and R22) and 13 residents who eat in the main dining room. R4 voiced concerns with his cold food not being cold enough.R22 voiced concerns with vegetables being mushy.Surveyor conducted 1 test tray for the main dining room which was not palatable. Evidenced by: Facility policy, entitled Food Storage, last revised 8/16/2022, includes, in part: . 12. Refrigerated food storage: b. TCS (time/temperature control for safety) foods must be maintained at or below 41 degrees Fahrenheit unless otherwise specified by the law. Periodically take temperatures of refrigerated foods to assure temperatures are maintained at or below 41 degrees Fahrenheit. Example 1 R4 admitted to the facility on [DATE]. R4's most recent Minimum Data Set (MDS), with a target date of 5/28/25, indicates a Brief Interview for Mental Status (BIMS) score of 11 out of 15, indicating R4's cognition is moderately impaired. On 8/5/25 at 10:03 AM, R4 indicated during Resident Council cold food isn't cold enough when he gets it. R4 eats in the main dining room.Example 2:On 8/4/25 at 10:55 AM, Surveyor interviewed R22 during the initial screening process. During the interview R22 was asked if he had any concerns with his meals. R22 indicated the vegetables look like they have been run through a washing machine. Example 3 - Test TrayOn 8/5/25 at 12:45 PM, Surveyor conducted a test tray from the main dining room. Surveyor took the temperature of the items on the test tray. The temperatures were as follows:Beef tips in gravy - 152.3 degrees FahrenheitNoodles - 134.1 degrees FahrenheitVegetable blend (corn, green beans, peas, carrots) - 136.8 degrees FahrenheitMilk - 53.3 degrees FahrenheitSurveyor tasted the food and drink on the tray. The hot food was hot enough, but the milk did not taste as cold as it should have been, as it was warm. The green beans in the vegetable blend were very soft and mushy. Surveyor could not pick them up while sticking the fork into the beans. Surveyor had to scoop up the beans by putting the fork under them due to the beans being so soft and mushy. The tray was not palatable and at a safe and appetizing temperature.While in the dining room waiting for the test tray, Surveyor observed glasses of milk and juice which were poured ahead of time sitting on a tray on the counter, not sitting in ice.Of note: 13 Residents eat their meals in the dining room.On 8/5/25 at 1:22 PM, Surveyor interviewed DM C (Dietary Manager) and asked what temperature milk should be when serving it. DM C indicated milk should be 40 degrees Fahrenheit or lower. Surveyor asked what the process is for serving drinks to residents at mealtime. DM C indicated staff pre-pour drinks ahead of time for room trays and put them on a tray, then put tray in a reach in cooler until serving them with the meal. DM C indicated for the dining room; staff usually fill a tub with ice and place gallons of milk and pitchers with juice in the tub and pour drinks to order. DM C also indicated sometimes staff use the left-over drinks that were pre-poured from the room trays for residents in the dining room. Surveyor told DM C the temperature of the milk from Surveyor's test tray was 53.3 and DM C stated the milk should have been 40 degrees or lower. DM C indicated he will have staff stop using pre-poured drinks that were left over from room trays for residents in the main dining room. Surveyor discussed the mushy green beans with DM C, and he indicated they should not have been mushy.

Based on interview and record review, the facility did not ensure the resident's right to request, refuse, and/or discontinue treatment and to formulate an advanced directive for 2 of 12 residents (R2 and R32) reviewed. R2 and R32's charts did not contain current copies of their advanced directive and/or did not contain evidence of advanced care planning, other than code status, for a time when they are not able to make their own healthcare decisions. Evidenced by:On 8/7/25 at 11:08 AM, ADON D (Assistant Director of Nursing) informed surveyor that they did not have an advanced directive policy.The facility admission Agreement, indicates, in part: Advanced Directives Policy and Record: Policy: It is the Center's policy to recognize and implement the resident's rights under state law to make decisions concerning medical care, including the right to accept or refuse medical treatment, and the right to formulate Advance Directives.Example 1R2 was admitted to the facility on [DATE].On 8/5/25 at 10:53 AM, During the record review portion of the initial pool process, surveyor was unable to locate a copy of R2's advanced directive/Power of Attorney for Health Care (POAHC) in his electronic medical record. On 8/5/25 at 11:38 AM, Surveyor reviewed R2's care plan which indicated he had an advanced directive in place. On 8/5/25 at 12:25 PM, Surveyor reviewed R2's admission agreement from the scanned documents in the electronic health record. The Record portion of the Advance Directives Policy and Record portion of the admission agreement, indicates, in part: Power of Attorney for Health Care. A column labeled Documents not yet received, but center was informed of document(s) in existence, includes a date of 3/7/23 and initials. Of note, resident had a previous admission with this facility.On 8/5/25 at 3:01 PM, Surveyor interviewed R2 who indicated he recalled someone asking about an advanced directive/POAHC when he came into the facility. R2 indicated that his mom said he had one because it had been discussed at the hospital, however, he could not remember if a copy ever made it to the facility.On 8/6/25 at 9:33 AM, Surveyor requested documentation of R2's advanced directive/POAHC.On 8/6/25 at 2:40 PM Surveyor interviewed SSD E (Social Services Director). During the interview SSD E indicated her process for advanced directives/POAHC is to try to get them from the hospital or family and scan them in the file. SSD E indicated she tries to get them before the resident gets to the facility because the admission agreement asks about it and that triggers her. SSD E indicated the admission agreement asks if we have it, what day we receive it, if it's activated and who it is. Another column says I don't have it, but they say they will bring it and then the date I was told that is initialed. SSD E indicated if the resident doesn't have one, she clicks that, talks to the resident and offers to create one and tells them it's not required but that she can help. SSD E indicated she asks the family repeatedly and checks during care conferences to see if she has it. If she doesn't have it she will ask about getting it. If they still haven't created one, she will ask again if they want help during the care conference.Surveyor asked SSD E if she had R2's advanced directive/POAHC. SSD E indicated she did not, but that she was able to get it from the [Hospital/Clinic Facility Name]. SSD E indicated the person that was here before her marked that he had one but that it wasn't here, and she hadn't gone back that far to check when she started. Surveyor asked SSD E if she checked for it during his last care conference. SSD E indicated she did not look back for his. Surveyor asked SSD E if she should have looked before his care conference. SSD E indicated she checked code status and took for granted that it was all in there from the social worker before. Surveyor asked SSD E if it is her intent for the process to be to check every advanced directive/POAHC prior to each care conference. SSD E indicated yes, and that this one was missed. Example 2R32 was admitted to the facility on [DATE].On 8/5/25 at 7:57 AM, During the record review portion of the initial pool process, surveyor was unable to locate a copy of R32's advanced directive/Power of Attorney for Health Care (POAHC) in his electronic medical record.On 8/5/25 at 5:00 PM, Surveyor requested documentation of R32's advanced directive/POAHC.On 8/7/25 at 9:00 AM, Surveyor interviewed SSD E (Social Services Director). During the interview SSD E indicated she had a copy of R32's POAHC in her file cabinet but it was not scanned into the electronic health record. SSD E indicated that R32's wife passed away in the spring of this year and she was originally the one listed on the POAHC and there was no alternate listed. SSD E indicated that his daughter wanted to be the POAHC, however, the paperwork was not completed correctly due to witnesses being family, so it was invalid. SSD E indicated she became aware of the daughter wanting to be the POAHC when she received new POAHC paperwork that someone left. Surveyor asked SSD E if she knew who left the paperwork and she indicated, I guess the daughter. SSD E indicated the paperwork looks like it was done in March 2024. SSD E indicated she thinks it may have been in R32's room for some time and does not recall when she received it, just that she found it on her desk one day. SSD E indicated the paperwork is dated before R32's wife passed. Surveyor asked SSD E if she reapproached R32 about POAHC once she found the paperwork and realized it was invalid due to who was listed as witnesses. SSD E indicated that shortly after R32's wife passed away she tried to talk to him about POA paperwork, but he initially said he was going home and wouldn't talk to me about it and said his daughter had it under control. Surveyor asked SSD E if she had any documentation of this discussion and she indicated she would check. Surveyor asked SSD E if it is accurate that R32 has been without a valid POAHC designee since his wife's passing. SSD E indicated, possibly, he is his own person. Surveyor asked SSD E what would happen if R32 became unresponsive and went to the hospital without a valid designee on his POAHC paperwork. SSD E indicated they would have to speak to his daughter. Of note, SSD E did not provide documentation of discussions with R32 regarding the invalid POA paperwork or discussions regarding the need to update a POAHC designee after R32's wife passed. On 8/7/25 at 10:13AM, SSD E brought in a copy of what she indicated was the invalid POAHC paperwork that is signed on 3/15/24. SSD E indicated that R32's wife passed away in January 2025, so it was probably March when she tried to talk to R32 about updating his POAHC. Surveyor asked SSD E if she should have reapproached again. SSD E indicated, probably, I mean yeah.

Based on interview and record review, the facility did not ensure care plans were reviewed and/or revised for 2 of 16 (R8 and R9) residents reviewed. Facility staff did not revise R8's care plan to address his hospice status and did not have the hospice agency care plan available for facility staff. R9's comprehensive care plan does not include a focus, goal or interventions for depression. Evidenced by: The facility policy titled, “Comprehensive Care Plan,” indicates, in part: Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment…Policy Explanation and Compliance Guidelines: …5. The comprehensive care plan will be reviewed and revised as appropriate by the interdisciplinary team after each comprehensive and quarterly MDS (Minimum Data Set) assessment, and as needed with changes in condition. 6. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed… Example 1: On 8/6/25 Surveyors reviewed R8's profile tab in his electronic health record which indicated a hospice organization was involved in R8's care. On 8/6/25 at 9:54 AM, Surveyor reviewed R8's hospice binder. A tab labeled Plan of Care (POC) does not contain any documents, and surveyor was unable to locate a hospice POC anywhere in the binder. Of note, R8 was on hospice prior to 7/7/25. Surveyors reviewed R8's comprehensive care plan and was not able to locate a hospice care plan. Surveyors did note the following under R8's nutrition at risk care plan: Focus: At risk for nutritional status change…Potential for wt loss r/t reduced oral intake, hospice care…Goal: Palliative Care… On 8/7/25 at 8:50 AM, Surveyor interviewed LPN J (Licensed Practical Nurse). During the interview, LPN J indicated if someone is on hospice it will show in their profile under external facilities. Surveyor asked LPN J if the facility utilized the hospice care plan separate from the facility care plan or if they are combined. LPN J indicated they put it on their care plan that the resident is on hospice. Surveyor asked LPN J where she would find the actual hospice care plan. LPN J indicated she truly didn't think she had ever seen one of hospice's care plans. Surveyor asked how they combine the care plans if she can't review it. LPN J indicated we talk and communicate then discuss it in care conferences. LPN J indicated that she does not put in the care plan and typically that is done by MDS Coordinator K (Minimum Data Set), DON B (Director of Nursing), or ADON D (Assistant Director of Nursing). LPN J indicated she utilizes the facility care plan for information. Surveyor and LPN J reviewed R8's facility care plan and LPN J indicated the only place she could locate any hospice information was under the nutrition at risk care plan. Surveyor asked LPN J if she would expect to see a hospice care plan. LPN J indicated, yes. On 8/7/25 at 9:15 AM, Surveyor interviewed ADON D and asked what the process is for care planning hospice. ADON D indicated, we have care conferences with hospice and combine cares. Surveyor asked ADON D if they combine care plans or keep them separate. ADON D indicated she was not sure if that was the process and referred surveyor to MDS Coordinator K. On 8/7/25 at 9:18 AM, Surveyor interviewed MDS Coordinator K. During the interview MDS Coordinator K indicated that she assists with making care plans. Surveyor asked MDS Coordinator K to review the hospice care planning process. MDS Coordinator K indicated they open the original baseline care plan, if it's a brand new patient, open that and answer all the questions and if you tell the care plan that the resident had a fall, for example, it will trigger a fall care plan. We go through all the diagnoses and ensure we have a care plan for everything and if they are on hospice they get a hospice care plan. Surveyor asked MDS Coordinator K how they incorporate the hospice agency care plan into the facility care plan. MDS Coordinator K indicated in their focus for care plans they have actual pain/hospice/palliative care and we can pick if they will be hospice. I compare the hospice care plan to ours and add what is needed. Surveyor asked MDS Coordinator K where they get the hospice care plans. MDS Coordinator K indicated there are books up front. Surveyor showed MDS Coordinator K R8's hospice binder, which she indicated was the book she was referring to, and MDS Coordinator K reviewed the binder and agreed there was not a hospice POC present. Surveyor asked MDS Coordinator K if she remembered if she compared the hospice care plan to the facility's and used it to update the care plan. MDS Coordinator K indicated, I honestly do not recall. Surveyor asked MDS Coordinator K how the nurses would know how to care for R8 without a hospice care plan. MDS Coordinator K indicated, they would come to us if they had questions and most of our hospice patients are cared for based on what we have in house and hospice is an added service. Surveyor asked MDS Coordinator K if R8 should have had a separate hospice care plan on the facility comprehensive care plan. MDS Coordinator K indicated, yes, and I fixed it yesterday. MDS Coordinator K indicated DON B came to her about it and R8's just got missed. MDS Coordinator K indicated he had one under nutrition but it needed to be more elaborate, it needed to be this is hospice, this is what he has. Example 2: R9 was admitted to the facility on [DATE] with diagnoses that include Major Depressive Disorder, Recurrent, Moderate and Mild Cognitive Impairment of Uncertain or Unknown Etiology. R9's most recent Minimum Data Set (MDS) Assessment, dated 4/24/25, indicates R9's Brief Interview for Mental Status (BIMS) score was 11 out of 15, indicating that R9 has mild cognitive impairment. R9's Physician Orders include, in part: --Paxil Oral Tablet 20 MG (Paroxetine HCl). Give 0.5 tablet by mouth one time a day for Depression, unspecified. Start Date: 6/26/25 --risperidone Oral Tablet (Risperidone) Give 0.5 mg (milligram) by mouth two times a day related to Other Symptoms and Signs involving Cognitive Functions and Awareness. Start Date 5/28/25 R9's Comprehensive Care Plan indicates: Focus: At risk for behavior symptoms. Date Initiated: 4/25/25. Revision on: 4/25/25. Goal: Will accept care and medications as prescribed. Date Initiated: 4/25/25. Target Date: 10/22/25. Will reduce risk of behavioral symptoms. Date Initiated: 4/25/25. Target Date: 10/22/25. Interventions: Behavior 1 rejection of care. Intervention #1: active listening for reason for rejection. Intervention #2: try again later. Intervention #3: try another caregiver. Of note, nowhere in R9's comprehensive care plan does it include that R9's has a diagnosis of depression, nor does it include resident specific goals or interventions. R9's Certified Nursing Assistant (CNA) Kardex Report indicates, in part: Mood/Behavior: *Behavior 1 rejection of careIntervention #1: active listening for reason for rejectionIntervention #2: try again laterIntervention #3: try another caregiver. Monitoring: *Monitor/Document/Report PRN (as needed) for following adverse effects of SEDATIVE/HYPNOTIC therapy: day time drowsiness, confusion, loss of appetite in the morning, increased risk of falls and fractures, dizziness. Resident Care: *Administer SEDATIVE/HYPNOTIC medications as ordered by physician. Monitor side effects and effectiveness Q-SHIFT (every shift). On 8/4/25 at 11:39 AM, Surveyor interviewed R9 and asked her if she ever felt sad or depressed. R9 stated that she did sometimes. Surveyor asked R9 if she ever refused the staff to assist her with cares. R9 stated that she never refused cares. Surveyor asked R9 if she ever refused medications. R9 stated that she never refused to take her medication. On 8/7/25 at 9:45 AM, Surveyor interviewed CNA F (Certified Nursing Assistant) and asked her what kind of behaviors that R9 displayed. CNA F stated that she didn't see R9 having any behaviors. Surveyor asked CNA F if R9 ever refused cares. CNA F stated that R9 would sometimes refuse to eat lunch if she ate a big breakfast, but that she never refused cares. Surveyor asked CNA F if R9 ever displayed signs of depression. CNA F stated that R9 liked to stay in her room and watch TV. Surveyor asked CNA F what side effects of R9's medication she would be monitoring for. CNA F stated she would have to check with the nurse. On 8/7/25 at 10:04 AM, Surveyor interviewed CNA G and asked her what kind of behaviors that R9 displayed. CNA G stated that R9 doesn't really have any behaviors, but that she prefers to stay in her room and at times will only eat one meal per day. Surveyor asked CNA G if R9 ever refused cares. CNA G stated no, she did not think that R9 ever refused cares. Surveyor asked CNA G if R9 ever displayed signs of depression. CNA G stated the isolation and refusal of meals that she had previously mentioned. Surveyor asked CNA G what kind of interventions worked for R9. CNA G indicated that she would offer R9 a snack if she refused lunch. Surveyor asked CNA G what side effects of R9's medication she would be monitoring for. CNA G stated she didn't know because the nurses are the ones that do that. On 8/7/25 at 10:31 AM, Surveyor interviewed RN H (Registered Nurse) and asked her what kind of behaviors that R9 displayed. RN H stated that at times R9 would refuse cares and refuse to come out of her room. RN H stated that R9 just liked to stay in her room and didn't like to be around other people, especially at mealtimes. Surveyor asked RN H what kind of interventions worked for R9. RN H indicated attempting redirection. Surveyor asked RN H what kind of side effects of R9's medication were they monitoring for. RN H stated that R9 took quite a list of behavioral medications so she would be watching for mental status changes and things like constipation. On 8/7/25 at 10:43 AM, Surveyor interviewed DON B (Director of Nursing) about monitoring R9's depression, medications, and interventions. DON B stated that they do a lot of redirection with R9, try to get her to come to activities and meals but that she is resistive to that and wants to hang out in her room by herself. Surveyor asked DON B how staff monitor for side effects of R9's medications. DON B stated the nurses watch every shift and note any behavior and monitor for depression symptoms. DON B indicated that the CNAs should monitor for any changes and notify the nurse. Surveyor asked DON B if a diagnosis of depression should be on R9's comprehensive care plan. Surveyor asked DON B how often interventions are reviewed for effectiveness. DON B stated that she reviews interventions at care plan review meetings quarterly and annually, and that she checks in with each resident twice per week or at least once per month to make sure their care plans match their needs. DON B stated yes, depression should be on R9's care plan. On 8/7/25 at 11:13 AM, ADON D (Assistant Director of Nursing) provided Surveyor with a history of changes made to R9's comprehensive care plan, which indicated that on 7/24/25, R9's depression focus, goals, and interventions had been resolved/cancelled. On 8/7/25 at 12:47 PM, Surveyor interviewed SSD E (Social Services Director) and asked her about R9's depression care plan being resolved. SSD E stated she had no idea why she would have done that, as she knows that R9 has a diagnosis of depression. SSD E indicated that sometimes she goes into a resident's care plan and updates the target behaviors but that she would not have intentionally deleted it. SSD E stated she had no clue how or why that happened and was not aware that she had deleted R9's depression care plan.

Based on observation, interview, and record review, the facility did not ensure that it was free of medication error rates of 5% or greater. There were 2 errors in 29 opportunities that affected 2 out of 7 supplemental residents (R23 & R25) included in the medication pass task, which resulted in an error rate of 6.9%. R23 received insulin from an insulin pen that had not been primed prior to use. R25 did not receive the correct dose of Vitamin D3. Evidenced by: The facility policy entitled, Medication Administration General Guidelines, dated 1/2025, states, in part: .Policy: Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices. Procedures:. Medication Administration: 1. Medications are administered in accordance with written orders of the prescriber. 9. Verify medication is correct three (3) times before administering the medication. a. When pulling medication package from med cart. b. When dose is prepared. c. Before dose is administered. Manufacturers' guidelines for insulin pen, entitled, Instructions for Use Humalog Kwik Pen injection for subcutaneous use 3 mL single-patient-use-pen (100 units per mL), revised 7/2023, manufactured by [NAME] Lily and Company, states, in part: . Priming your Pen: Prime before each injection. Priming your Pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. Example 1: R23 was admitted to the facility on [DATE] and has diagnoses that include Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease (a chronic condition where the body either doesn't produce enough insulin or can't properly use the insulin it produces, leading to high blood sugar levels), Long Term (current) use of insulin, and weakness. R23's Physician Orders include, in part: Humalog Injection Solution (Insulin Lispro). Inject 3 unit subcutaneously three times a day for inject before meals. Start Date: 4/8/25. No end date. R23's Medication Administration Record (MAR) for August 2025 indicates, in part:Humalog Injection Solution (Insulin Lispro). Inject 3 unit subcutaneously three times a day for inject before meals. Start Date: 4/8/25. On 8/5/25 at 8:06 AM, Surveyor observed LPN I (Licensed Practical Nurse) administer R23's insulin. LPN I did not prime the insulin pen before administering the insulin to R23. Surveyor asked LPN I if she had primed the insulin pen. LPN I stated that she primed the needle when the pen was first opened. LPN I stated she was taught to prime the pen to 2 units the first time it is used and after that it didn't need to be primed again with each use. On 8/7/25 at 10:41 AM, Surveyor interviewed DON B (Director of Nursing) and asked her if she would expect staff to prime an insulin pen before administering to ensure the correct dose is given. DON B stated yes, it was her expectation that insulin pens be primed at least 2 units each time. DON B indicated that she had provided education about priming insulin pens to LPN I and the other nurses. Example 2: R25 was admitted to the facility on [DATE] and has diagnoses that include Multiple Sclerosis, Primary Osteoarthritis, and Weakness. R25's Physician Orders include, in part: Vitamin D3 Tablet MCG (micrograms) 1000 unit (Cholecalciferol). Give 2 tablet by mouth one time a day for supplement. Start Date: 3/17/22. No end date. R25's Medication Administration Record (MAR) for August 2025 indicates, in part:Vitamin D3 Tablet MCG (micrograms) 1000 unit (Cholecalciferol). Give 2 tablet by mouth one time a day for supplement. Start Date: 3/17/22. On 8/5/25 at 7:48 AM, Surveyor observed LPN I administer medication to R25 which included Vitamin D3. Surveyor asked LPN I if she was giving one tablet or two. LPN I stated she was administering one tablet of Vitamin D3 to R25. On 8/5/25 at 8:47 AM, Surveyor reconciled medications that were administered to R25 to R25's MAR to find the Vitamin D3 was ordered for two tablets. Surveyor had observed the medication pass and confirmed with LPN I that she was giving one tablet of Vitamin D3. On 8/5/25 at 9:47 AM, Surveyor interviewed LPN I and asked about the Vitamin D3 that she had administered to R25. Surveyor showed LPN I R25's physician orders and asked LPN I if she had administered one tablet or two of Vitamin D3. LPN I indicated she thought she had given two. Surveyor asked LPN I if giving the wrong dose would be considered a medication error and LPN I indicated yes, that would be a medication error. On 8/7/25 at 10:41 AM, Surveyor interviewed DON B and informed her of the medication observation errors. DON B indicated she would expect medications to be administered according to physician orders.

Based on interview and record review the facility failed to ensure they followed standards of practice for an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use for 1 (R21) of 8 supplemental residents reviewed for antibiotic stewardship. R21 was diagnosed with a urinary tract infection. The physician ordered the antibiotic Bactrim DS (trimethoprim/sulfamethoxazole). The urine culture and susceptibility indicated the bacteria causing R21's urinary tract infection was resistant to Bactrim DS. After this result, R21's ordered antibiotic was not changed. Evidenced by: The facility's Antibiotic Stewardship Program policy, dated 11/18/22, states, in part: Policy: It is the policy of this facility to implement an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program. The purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use.4. The program includes antibiotic use protocols and a system to monitor antibiotic use . b. Monitoring antibiotic use: i. Monitor response to antibiotics, and laboratory results when available, to determine if the antibiotic is still indicated or adjustments should be made. iii. Antibiotic orders obtained from consulting, specialty, or emergency providers shall be reviewed for appropriateness . R21 was admitted to the facility on [DATE] and has diagnoses that include: congestive heart failure (heart does not adequately pump blood), weakness, and type 2 diabetes. On 7/7/25, a urinalysis was collected from R21 for new or marked increase in incontinence, urgency, and frequency. The urinalysis resulted on 7/8/25, and a physician ordered Bactrim DS for R21. On 7/9/25, a urine culture and susceptibility resulted showing greater than 100,000 CFU (Colony Forming Units) of Escherichia coli (bacteria). The susceptibility indicated this bacterium was resistant to Bactrim DS, the antibiotic ordered to treat this infection. On 8/6/25 at 2:40 PM, Surveyor interviewed ADON D (Assistant Director of Nursing). Surveyor referenced R21 being ordered on Bactrim DS on 7/7/25, Surveyor asked ADON D what symptoms R21 was experiencing. ADON D indicates, altered mental status, urinary frequency, and restlessness. Surveyor asked ADON D if the infectious organism found in R21's urine culture was resistant to Bactrim DS. ADON D reviewed the culture and susceptibility results and states, yes. Surveyor asked ADON D if any discussions were had with the ordering physician regarding R21's resistance to this antibiotic. ADON D indicates that the culture and susceptibility was sent to him, but there are no notes regarding any discussion. Surveyor asked ADON D why it is important to use a different antibiotic if the bacteria is found to be resistant to the ordered antibiotic. ADON D indicates, so the antibiotic actually kills the bacteria.

Based on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately for 2 of 3 residents reviewed for abuse (R1 and R2). An allegation of abuse was made by CNA G (Certified Nursing Assistant) regarding CNA F, five days after the alleged incident occurred. CNA C had knowledge of an allegation of abuse involving CNA F and R2, and this was not reported. Laundry/Hskp D (Laundry/Housekeeper) witnessed and had knowledge of a potential abuse situation with CNA F and did not report this to anyone. Findings include The facility's policy, titled Abuse Prevention Program states, in part: *Verbal abuse means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. *Staff are to report suspected violations to their supervisor immediately, who in turn will notify the administrator. The administrator or designee will report to the state survey agency alleged abuse (this includes sexual assault) no later than two hours of the allegation. Results of the investigation will be reported to the state survey agency within 5 working days of the initial allegation. *Investigation: the facility's immediate response is to protect the alleged victim period to protect the alleged victim, the facility has clear delineated roles of those responsible for investigating and will respond to ensure protection of the alleged victim, identify any other alleged victims, and ensure the safety of all other residents and the integrity of the investigation. Example 1 R1 was admitted to the facility on [DATE] and has diagnoses that include vascular dementia. R1's most recent Minimum Data Set (MDS), dated [DATE], includes a Brief Interview for Mental Status (BIMS) score of 3, indicating R1 is severely cognitively impaired. A facility self-report indicates that on 2/7/25, CNA G (Certified Nursing Assistant) reported that CNA F had held R1 down during cares on 2/2/25 and stated, If you weren't such a f***ing b***h, we wouldn't have to do this and stated multiple times to R1 to grow up. According to CNA G, she was with CNA F at the time of the allegation assisting with cares. CNA F was not in the building at the time of the allegation, but was suspended pending the outcome of the investigation. During the investigation the facility did the following: *Starting 2/7/25, conducted skin checks and monitoring of R1 to determine any ill-effects, which did not result in any physical or emotional distress. R1 did not recall the incident or if it happened. *CNA G was educated on 2/7/25 about reporting immediately. Additionally, she and the rest of the facility staff (all disciplines) were educated on the facility's abuse policy on 2/7/25. *Some staff (including CNA F and CNA G) and residents were interviewed. No other concerns were brought forward or identified. *CNA F denied the allegation occurred. *Local law enforcement was notified and responded, with no criminal findings or wrong doing identified. *The facility stated they were unable to substantiate abuse as there was no physical or psychological harm to R1 and were unable to confirm CNA G's allegation. The facility indicated CNA F and CNA G had difficulty working together due to historical personal reasons. *CNA F was allowed to return to work on 2/15/25 following abuse policy re-education and customer service re-training. It should be noted that CNA F worked 2/3/25, 2/6/25, and 2/7/25 before the allegation was made known to facility management. Example 2 R2 was admitted to the facility on [DATE]. His most recent MDS, dated [DATE], includes a BIMS score of 15, indicating R2 is cognitively intact. On 2/19/25 at 12:09 PM, Surveyor interviewed CNA C who stated that he had heard CNA F yelling inappropriately at R2. CNA C stated that maybe 3 weeks ago he was sitting at the nurse's station and could hear CNA F yelling in R2's room, but could not make out what she was saying. CNA F then exited the room. According to CNA C, as CNA F was exiting the doorway or R2's room, she said He needs to grow the f*** up .I'm done with his bulls***. CNA C stated he believe R2 could hear what CNA F said and was concerned. CNA C said he then went to R2's room to check on him and he (R2) appeared to be upset. When asked if he reported this incident to the management, CNA C stated he did not because LPN H (Licensed Practical Nurse) was in the hallway passing medications and he assumed that she heard the incident. Surveyor contacted LPN H on 2/19/25 at 12:29 PM via phone. LPN H did not have any details for Surveyors and indicated she was unaware of any incident regarding R2 or CNA F. It should be noted that CNA C was not interviewed or questioned during the investigation of the allegation involving R1. On 2/19/25 at 12:30 PM, Surveyor spoke with CNA E (Certified Nursing Assistant). Surveyor asked CNA E, have you observed a staff member verbally or physically abusing a resident. CNA E stated, yes 3-4 weeks ago. Surveyor asked CNA E to share what she observed. CNA E stated, while at the nurses station she observed CNA F talking down to a resident and calling him names. CNA E stated, sometimes CNA F will joke with R2 and tell him, You're being an ass today. On this specific day CNA E stated, she observed CNA F call R2 an ass. CNA E stated, on this day, it sounded like she was having a bad day and was not joking. Surveyor asked CNA E, how did R2 respond to CNA F. CNA E stated, R2 gets frustrated with CNA F and does not like her. CNA E stated, when R2 gets upset he won't talk to us and will get a ride back to his room. Surveyor asked CNA E, is R2 able to leave the situation on his own. CNA E stated, no. CNA E stated, R2 can't leave the situation if he wants to as he cannot propel his wheelchair. CNA E has observed CNA F get frustrated when CNA F helps him with cares. Surveyor asked CNA E, has R2 had any change in his behavior since this incident. CNA E stated, no. CNA E added, R2 is, Pretty forgiving and bounces back like nothing ever happened. CNA E stated, this incident occurred on a Tuesday or Thursday within the last 3-4 weeks when management was here. Surveyor asked CNA E, what would this be considered. CNA E stated, Verbal Abuse. Surveyor asked CNA E if she reported this incident to the facility. CNA E stated, 'The nurse (name unknown) was at the nurses station and she heard it. CNA E stated, all staff got educated regarding no swearing after this. (Note, this was due to a Self-Report regarding a different allegation of abuse against CNA F.) Both CNA C and CNA E had knowledge of and witnessed abuse occuring with CNA F and did not report this to facility management. Example 3: On 2/19/25 at 11:05 AM, Surveyor spoke with Laundry/Hskp D (Laundry/Housekeeper). Surveyor asked Laundry/Hskp D, have you observed a staff member verbally or physically abusing a resident. Laundry/Hskp D stated, in her opinion, yes. Surveyor asked Laundry/Hskp D what she observed. Laundry/Hskp D stated, she has observed CNA F (Certified Nursing Assistant) shooting her mouth off and running down the hall saying fuck, fuck, fuck in front of residents. Surveyor asked Laundry/Hskp D, did you report this to the facility. Laundry/Hskp D stated, she saw DON B (Director of Nursing) walk out of her office immediately after this happened and Laundry/Hskp D stated, DON B heard CNA F swearing that is why she did not report this. Surveyor asked Laundry/Hskp D, what is the CNA's name. Laundry/Hskp D stated, she does not know here name. Surveyor asked Laundry/Hskp D to describe her. Laundry/Hskp D stated, she has short brown hair, is in her 20's, used to work in the kitchen before she started working as a CNA, and is not currently working in the facility today. Surveyor asked Laundry/Hskp D, when did you witness this. Laundry/Hskp D stated, it occurred less than 1 week ago. CNA F worked 2/15/25, 2/16/25, and 2/17/25 according to facility records. On 2/19/25 at 11:25 AM, Surveyor spoke with DON B (Director of Nursing). Surveyor asked DON B, have you ever heard a staff member swearing in front of residents as they are walking down the hall. DON B stated, there was one day she heard somebody say, Oh shit. DON B was unable to determine which staff member made the statement. DON B stated, if we can't prove it we just re-educate all staff. DON B stated, swearing is not permitted. DON B added, the first time an employee swears they are written up; the second time the staff member is fired. Surveyor asked DON B, have you ever heard CNA F swearing. DON B stated, they (staff) don't do it around me. DON B stated, she has not ever witnessed anybody swear on the floor. Surveyor asked DON B, if staff were to swear in front of a resident what would that be considered. DON B stated, Abuse. Surveyor shared Laundry/Hskp D's observation of CNA F swearing as she was walking down the hall. Surveyor asked DON B, what is your expectation for Laundry/Hskp D and all staff when they witness abuse. DON B stated, it's her expectation that staff report this to her immediately. DON B stated, staff should not assume that someone else coming out of their office heard it. DON B stated, CNA F is loud, vocal, and comes off strong. DON B added, it's her tone, she's rough. On 2/19/25 at 12:00 PM, 1:10 PM, and approximately 2:30 PM, NHA A (Nursing Home Administrator) stated, if it's another incident(s) we have a clear path. NHA A stated, Laundry/Hskp D (Laundry/Housekeeper) and CNA E should have immediately reported these allegation of verbal abuse. NHA A stated, she relies on staff to report observations of abuse to her so that she may follow up and do her due diligence and expects staff to report to her, a charge nurse or other management immediately after a resident is safe. NHA A stated, she confirmed the date of Laundry/Hskp D's observation of abuse was on 2/17/25. This was after the facility educated staff regarding abuse. (It is important to note, due to Laundry/Hskp D's observation of potential verbal abuse on 2/17/25, there is current non-compliance regarding abuse reporting.)

Based on interview and record review, the facility did not have evidence that all alleged violations of abuse were thoroughly investigated for 2 of 3 residents (R1 and R2). An allegation of abuse was made by CNA G (Certified Nursing Assistant) regarding CNA F five days after the alleged incident occurred with R1. The facility did not interview all staff, who had knowledge of other allegations. CNA C and CNA E had knowledge of an allegation of abuse involving CNA F and R2, and this was not investigated. Housekeeper D witnessed and had knowledge of a potential abuse situation with CNA F, and this was not investigated. Findings include: The facility's policy, titled Abuse Prevention Program states, in part: *Verbal abuse means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. *Staff are to report suspected violations to their supervisor immediately, who in turn will notify the administrator. The administrator or designee will report to the state survey agency alleged abuse (this includes sexual assault) no later than two hours of the allegation. Results of the investigation will be reported to the state survey agency within 5 working days of the initial allegation. *Investigation: the facility's immediate response is to protect the alleged victim period to protect the alleged victim, the facility has clear delineated roles of those responsible for investigating and will respond to ensure protection of the alleged victim, identify any other alleged victims, and ensure the safety of all other residents and the integrity of the investigation. Example 1 R1 was admitted to the facility on [DATE] and has diagnoses that include vascular dementia. R1's most recent Minimum Data Set (MDS), dated [DATE], includes a Brief Interview for Mental Status (BIMS) score of 3, indicating R1 is severely cognitively impaired. A facility self-report indicates that on 2/7/25, CNA G (Certified Nursing Assistant) reported that CNA F had held R1 down during cares on 2/2/25 and stated, If you weren't such a f***ing b***h, we wouldn't have to do this and stated multiple times to R1 to grow up. According to CNA G, she was with CNA F at the time of the allegation assisting with cares. CNA F was not in the building at the time of the allegation, but was suspended pending the outcome of the investigation. During the investigation the facility did the following: *Starting 2/7/25, conducted skin checks and monitoring of R1 to determine any ill-effects, which did not result in any physical or emotional distress. R1 did not recall the incident or if it happened. *CNA G was educated on 2/7/25 about reporting immediately. Additionally, she and the rest of the facility staff (all disciplines) were educated on the facility's abuse policy on 2/7/25. *Some staff (including CNA F and CNA G) and residents were interviewed. No other concerns were brought forward or identified. *CNA F denied the allegation occurred. *Local law enforcement was notified and responded, with no criminal findings or wrongdoing identified. *The facility stated they were unable to substantiate abuse as there was no physical or psychological harm to R1 and were unable to confirm CNA G's allegation. The facility indicated CNA F and CNA G had difficulty working together due to historical personal reasons. *CNA F was allowed to return to work on 2/15/25 following abuse policy re-education and customer service re-training. She worked 2/15/25, 2/16/25 and 2/17/25 according to facility records. It should be noted that CNA F worked 2/3/25, 2/6/25 and 2/7/25 before the allegation was made known to facility management. Additionally, the facility did not interview or get statements from all nursing staff. CNA C had details of an additional allegation involving R2 and CNA F (see example 2). Example 2 R2 was admitted to the facility on [DATE]. His most recent MDS, dated [DATE], includes a BIMS score of 15, indicating R2 is cognitively intact. On 2/19/25 at 12:09 PM, Surveyor interviewed CNA C who stated that he had heard CNA F yelling inappropriately at R2. CNA C stated that maybe 3 weeks ago he was sitting at the nurse's station and could hear CNA F yelling in R2's room, but could not make out what she was saying. CNA F then exited the room. According to CNA C, as CNA F was exiting the doorway or R2's room, she said He needs to grow the f*** up .I'm done with his bulls***. CNA C stated he believe R2 could hear what CNA F said and was concerned. CNA C said he then went to R2's room to check on him and he (R2) appeared to be upset. When asked if he reported this incident to the management, CNA C stated he did not because LPN H (Licensed Practical Nurse) was in the hallway passing medications and he assumed that she heard the incident. Surveyor contacted LPN H on 2/19/25 at 12:29 PM via phone. LPN H did not have any details for Surveyors and indicated she was unaware of any incident regarding R2 or CNA F. It should be noted that CNA C was not interviewed or questioned during the investigation of the allegation involving R1. On 2/19/25 at 12:30 PM, Surveyor spoke with CNA E (Certified Nursing Assistant). Surveyor asked CNA E, have you observed a staff member verbally or physically abusing a resident. CNA E stated, yes 3-4 weeks ago. Surveyor asked CNA E to share what she observed. CNA E stated, while at the nurses station she observed CNA F talking down to a resident and calling him names. CNA E stated, sometimes CNA F will joke with R2 and tell him, You're being an ass today. On this specific day CNA E stated, she observed CNA F call R2 an ass. CNA E stated, on this day, it sounded like CNA F was having a bad day and was not joking. CNA E stated, this incident occurred on a Tuesday or Thursday within the last 3-4 weeks when management was here. Surveyor asked CNA E, what would this be considered. CNA E stated, Verbal Abuse. Surveyor asked CNA E if she reported this incident to the facility. CNA E stated, 'The nurse (name unknown) was at the nurses station and she heard it. CNA E stated, all staff got educated regarding no swearing after this. (Note, this was due to a Self-Report regarding a different allegation of abuse against CNA F.) Both CNA C and CNA E had knowledge of and witnessed abuse occurring with CNA F, and this was not investigated. Example 3: On 2/19/25 at 11:05 AM, Surveyor spoke with Laundry/Hskp D (Laundry/Housekeeper). Surveyor asked Laundry/Hskp D, have you observed a staff member verbally or physically abusing a resident. Laundry/Hskp D stated, in her opinion, yes. Surveyor asked Laundry/Hskp D what she observed. Laundry/Hskp D stated, she has observed CNA F (Certified Nursing Assistant) shooting her mouth off and running down the hall saying f**k, f**k, f**k in front of residents. Surveyor asked Laundry/Hskp D, did you report this to the facility. Laundry/Hskp D stated, she saw DON B (Director of Nursing) walk out of her office immediately after this happened and Laundry/Hskp D stated, DON B heard CNA F swearing that is why she did not report this. Surveyor asked Laundry/Hskp D, what is the CNA's name. Laundry/Hskp D stated, she does not know here name. Surveyor asked Laundry/Hskp D to describe her. Laundry/Hskp D stated, she has short brown hair, is in her 20's, used to work in the kitchen before she started working as a CNA, and is not currently working in the facility today. Surveyor asked Laundry/Hskp D, when did you witness this. Laundry/Hskp D stated, it occurred less than 1 week ago. On 2/19/25 at 11:25 AM, Surveyor spoke with DON B (Director of Nursing). Surveyor asked DON B, have you ever heard a staff member swearing in front of residents as they are walking down the hall. DON B stated, there was one day she heard somebody say, Oh shit. DON B was unable to determine which staff member made the statement. DON B stated, if we can't prove it we just re-educate all staff. DON B stated, swearing is not permitted. DON B added, the first time an employee swears they are written up; the second time the staff member is fired. Surveyor asked DON B, have you ever heard CNA F swearing. DON B stated, they (staff) don't do it around me. DON B stated, she has not ever witnessed anybody swear on the floor. Surveyor asked DON B, if staff were to swear in front of a resident what would that be considered. DON B stated, Abuse. Surveyor shared Laundry/Hskp D's observation of CNA F swearing as she was walking down the hall. Surveyor asked DON B, what is your expectation for Laundry/Hskp D and all staff when they witness abuse. DON B stated, it's her expectation that staff report this to her immediately. DON B stated, staff should not assume that someone else coming out of their office heard it. On 2/19/25 at 12:00 PM, 1:10 PM, and approximately 2:30 PM, NHA A (Nursing Home Administrator) stated, if it's another incident(s) we have a clear path. NHA A stated, Laundry/Hskp D (Laundry/Housekeeper) and CNA E should have immediately reported these allegation of verbal abuse. NHA A stated, she relies on staff to report observations of abuse to her so that she may follow up and do her due diligence and expects staff to report to her, a charge nurse or other management immediately after a resident is safe. NHA A stated, she confirmed the date of Laundry/Hskp D's observation of abuse was on 2/17/25. This was after the facility educated staff regarding abuse. Laundry/Hskp D had knowledge of and witnessed abuse occurring with CNA F, this was not investigated by the facility.

Based on interview and record review, facility staff did not adequately assess and treat pain and provide necessary care and services to attain or maintain the highest practicable physical well-being for 1 of 3 residents (R1) reviewed for pain. The facility failed to re-evaluate the effectiveness of R1's pain medication within one hour of being administered, failed to offer non-pharmacological interventions related to pain management, and failed to consult with R1's Medical Doctor when her pain rating was consistently above her goal rate of 2 out of 10. This is evidenced by: Facility did not provide a policy related to pain rating and pain assessment. R1 was admitted to the facility on [DATE] with diagnoses including, but not limited to: Type 2 diabetes, pain in right knee, pain in left knee, and other chronic pain. On 8/27/24 at 10:08 AM, Surveyor interviewed RR E (Resident Representative). RR E reported to Surveyor that R1 was not being given pain medications overnight. Additionally, RR E states that R1 has called her several times in pain and she feels R1's pain is not being properly controlled. On 8/27/24 at 11:29 AM, during an interview, R1 indicated the facility could be doing more for her pain management and that she is often in a lot of pain. R1's Significant Change in Status Minimum Data Set (MDS), dated [DATE], indicates a Brief Interview for Mental Status (BIMS) of 15, indicating she is cognitively intact. The MDS states R1 frequently experiences pain, affects R1's sleep, and interferes with R1's day-to-day activities almost constantly. R1 rated her pain at a 10 on a scale from 00-10 at the time of the pain assessment. Acetaminophen Oral Tablet (Acetaminophen). Give 650 mg by mouth every 4 hours as needed for Pain. Start date: 1/28/24. Hold date from 8/4/24 to 8/7/24. Discontinue date of 8/22/24. Acetaminophen Oral Tablet (Acetaminophen). Give 325 mg by mouth every 4 hours as needed for Pain. Start date: 1/28/24. Hold date from 8/4/24 to 8/7/24. Discontinue date of 8/22/24. ICE RIGHT SHOULDER 3 TIMES A DAY FOR 3 DAYS three times a day for 3 days. Start date: 8/3/24. End date: 8/6/24. Indicate level of pain using pain scale or PAINAD (Pain Assessment in Advanced Dementia Scale). If pain >(greater than) goal of 2, or s/s of pain noted, offer non-pharmacological pain interventions/medications/treatments prn (as needed). Three times a day. Start date: 1/29/24. Progress note dated 8/2/24 at 6:40 PM, indicates that staff were transferring the resident from her wheelchair to her bed, when the Hoyer lift (full body lift) malfunctioned, causing the resident to fall. Resident was sent to the emergency room at this time. Hospital discharge paperwork dated 8/2/24, indicates the resident was diagnosed with a closed, nondisplaced comminuted (broken into multiple pieces) fracture of shaft of right humerus (upper arm bone). R1's Physician Orders include, in part: 8/3/24: ICE RIGHT SHOULDER 3 TIMES A DAY FOR 3 DAYS three times a day for 3 days. End date: 8/6/24. 8/4/24: Hydrocodone-Acetaminophen Oral Tablet 5-325 MG (Hydrocodone-Acetaminophen) Give 2 tablets [sic] by mouth every 6 hours for pain for 3 days. 8/3/24: Hydrocodone-Acetaminophen Oral Tablet 5-325 MG (Hydrocodone-Acetaminophen) Give 1 tablet by mouth every 4 hours as needed for right shoulder pain. Hold date from 8/4/24 to 8/7/24. Discontinue date 8/8/24. 8/8/24: Oxycodone-Acetaminophen Oral Tablet 5-325 MG (Hydrocodone-Acetaminophen). Give 1 tablet by mouth every 4 hours as needed for pain. Discontinue date 8/13/24. 8/13/24: Percocet Oral Tablet 7.5-325 MG (Oxycodone with Acetaminophen). Give 1 tablet by mouth every 4 hours as needed for pain related to other chronic pain. Discontinue date: 8/15/24. 8/15/24: Percocet Oral Tablet 5-325 MG (Oxycodone with Acetaminophen). Give 1 tablet by mouth every 4 hours as needed for pain control. Discontinue date: 8/16/24. 8/15/24: Percocet Oral Tablet 5-325 MG (Oxycodone with Acetaminophen). Give 2 tablet by mouth every 4 hours as needed for pain control. Discontinue date: 8/16/24. 8/16/24: Percocet Oral Tablet 5-325 MG (Oxycodone with Acetaminophen). Give 2 tablet by mouth every 4 hours as needed for pain control. Discontinue date: 8/22/24. 8/22/24: Percocet Oral Tablet 5-325 MG (Oxycodone w/ Acetaminophen ) Give 1 tablet by mouth three times a day for pain. Discontinue date: 8/22/24 at 8:21 PM. 8/22/24: Percocet Oral Tablet 5-325 MG (Oxycodone with Acetaminophen). Give 2 tablet by mouth every 4 hours as needed for pain control. 8/22/24: Acetaminophen Oral Tablet (Acetaminophen). Give 325 mg by mouth every 4 hours as needed for Pain. 8/23/24: Tramadol HCL Oral Tablet 50 MG (milligrams) (Tramadol HCL) Give 1 tablet by mouth two times a day for pain for 14 days. R1's Medical Record includes, in part: 8/3/24 AM- 10/10 pain reported 8/4/24 AM- 10/10 pain reported 8/5/24 AM- 8/10 pain reported 8/5/24 PM- 10/10 pain reported 8/6/24 AM- 8/10 pain reported 8/7/24 AM- 7/10 pain reported 8/7/24 PM- 8/10 pain reported 8/9/24 AM- 10/10 pain reported On 8/9/24, R1 reported a pain scale of 10 out of 10 to the AM shift. According to the Medication Administration Record (MAR), at 12:44 AM, R1 was administered 1 tablet of Oxycodone-Acetaminophen as ordered and reports a pain scale of 7 out of 10 at the time of administration. R1's pain was Re-evaluate at 3:19 AM with a pain rating of 1. (Of note R1's pain was not re-evaluated within an hour or receiving her pain medication). At 7:50 AM, R1 was also administered 1 tablet of Oxycodone-Acetaminophen as ordered and reports a pain scale of 10 out of 10 at the time of administration. No re-evaluation of R1's pain was done. At 12:25 PM, R1 was administered 1 tablet of Oxycodone-Acetaminophen as ordered and reports a pain scale of 10 out of 10 at the time of administration. R1's pain was Re-evaluated at 3:25 PM with a pain rating of a 5. (Of note R1's pain was not re-evaluated within an hour or receiving her pain medication). At 4:09 PM, R1 was administered 1 tablet of Oxycodone-Acetaminophen as ordered and reports a pain scale of 7 out of 10 at the time of administration. R1's pain was Re-evaluated at 4:40 PM with a pain rating of a 5 out of 10. At 8:39 PM, R1 was administered 1 tablet of Oxycodone-Acetaminophen as ordered and reports a pain scale of 10 out of 10 at the time of administration. R1's pain was re-evaluated at 9:57 PM with a pain rating of a 5. (Of note R1's pain was not re-evaluated within an hour or receiving her pain medication) 8/10/24 AM- 10/10 pain reported On 8/10/24 at 5:26 AM, R1's Nurse note states in part: .Tizanidine HCL (hydrochloride) oral tablet 2mg give 2mg by mouth every 8 hours as needed for muscle spasms separate from Percocet dose by at least 2 hours . 8/13/24 AM- 8/10 pain reported 8/14/24 AM- 10/10 pain reported 8/15/24 PM- 10/10 pain reported 8/16/24 PM- 8/10 pain reported On 8/16/24, R1 reported a pain scale of 8 out of 10 to the PM shift. According to the MAR, R1 was administered 2 tablets of Percocet as ordered at 18:08 (6:08 PM) and reports a pain scale of 10 out of 10 at the time of administration. R1's pain was re-evaluated at 10:10 PM with a pain rating of 7, PRN administration was: effective, short duration. (It is important to note that her pain goal is to be under 2 out of 10). 8/16/24 NOC (overnight/night shift)- 10/10 pain reported. According to the MAR, R1 was administered 2 tablets of Percocet as ordered at 23:21 (11:21 PM) and reports a pain scale of 10 out of 10 at the time of administration. R1's pain was re-evaluated at 12:17 AM with a pain rating of 6. PRN administration was: effective (It is important to note that her pain goal is to be under 2 out of 10). On 8/17/24, R1 reported a pain scale of 8 out of 10 to the AM shift. According to the MAR, at 11:26 AM, R1 was administered 2 tablets of Percocet as ordered and reports a pain scale of 8 out of 10 at the time of administration. R1's pain was re-evaluated at 1:37 PM with a pain rating of 4 PRN administration was: effective. (Of note R1's pain was not re-evaluated within an hour or receiving her pain medication) 8/17/24 PM- 8/10 pain. According to R1's MAR, R1 was administered 2 Percocet as ordered at 16:02 (4:02 PM) and reports a pain scale of 8 out of 10 at the time of administration. R1's pain was re-evaluated at 5:46 PM with a pain rating of 4 PRN administration was: effective Of note R1's pain was not re-evaluated within an hour or receiving her pain medication). R1 then received 325 MG of acetaminophen as ordered at 18:12 (6:12 PM) with a pain scale reported as 9 out of 10. R1's pain was re-evaluated at 7:09 PM with a pain rating of 6 PRN administration was: effective. (It is important to note that her pain goal is to be under 2 out of 10). 8/18/24 AM- 10/10 pain reported. 8/19/24 AM- 10/10 pain reported. On 8/19/24, R1 reported a pain scale of 10 out of 10 to the AM shift. According to the MAR, at 3:00 AM, R1 was administered 2 tablets of Percocet as ordered and reports a pain scale of 7 out of 10 at the time of administration. R1's pain was Re-evaluated at 4:48AM, with a pain rating of 2. (Of note R1's pain was not re-evaluated within an hour or receiving her pain medication). At 7:54 AM, R1 was also administered 2 tablets of Percocet as ordered and reports a pain scale of 10 out of 10 at the time of administration. R1's pain was re-evaluated at 9:13 AM with a pain rating of 4. PRN administration was: effective. (It is important to note that her pain goal is 2 out of 10). 8/21/24 AM- 7/10 pain reported. On 8/21/24, According to the MAR, at 3:28 AM, R1 was administered 2 tablets of Percocet as ordered and reports a pain scale of 7 out of 10 at the time of administration. R1's pain was re-evaluated at 5:23 AM, pain rating of 0. (Of note R1's pain was not re-evaluated within an hour or receiving her pain medication.) At 7:39 AM, R1 was also administered 2 tablets of Percocet as ordered and reports a pain scale of 9 out of 10 at the time of administration. No follow up pain evaluation was completed for R1 after receiving this dose. At 12:11 PM, R1 was administered 2 tablets of Percocet as ordered and reports a pain scale of 10 out of 10 at the time of administration. R1's pain was re-evaluated at 1:06 PM with a pain rating of 4. 8/22/24 AM- 10/10 pain reported 8/23/24 AM- 10/10 pain reported On 8/23/24, According to the MAR, at 12:19 AM, R1 was administered 2 tablets of Percocet as ordered and reports a pain scale of 8 out of 10 at the time of administration. R1's pain was re-evaluated at 2:30 AM with a pain rating of 0. (Of note R1's pain was not re-evaluated within an hour or receiving her pain medication) R1 reports a pain scale of 10 out of 10 to the PM shift. At 4:08 PM, R1 was also administered 2 tablets of Percocet as ordered and reports a pain scale of 10 out of 10 at the time of administration. R1's pain was re-evaluated at 4:33 PM with a pain rating of 5. At 8:11 PM, R1 was administered 2 tablets of Percocet as ordered and reports a pain scale of 9 out of 10 at the time of administration. R1's pain was re-evaluated at 8:59 PM with a pain rating of 3. On 8/23/24 at 2:03 PM, a Progress Note was written, categorized as a Summary Note, which state that the resident's pain is controlled with scheduled and PRN pain medications. (It is important to note that R1's documentation provided to surveyor did not show the use of non-pharmacological interventions related to pain management such as ice, heat, repositioning, distraction etc.,) Of note: Progress notes do not identify a notification to the physician or any further assessment or intervention after repeated reports of 10 out of 10 pain. 8/24/24 AM- 10/10 pain reported 8/25/24 AM- 9/10 pain reported (Of note: According to the physician order for pain scale every shift, R1 has a pain goal of less than 2. Also, on 8/23/24, R1 rated her pain 8 or higher on consecutive shifts. Record review shows that since returning to the facility, R1 has experienced 8 out of 10 pain at least once a day for 18 out of 22 days between 8/3/24 to 8/25/24.) According to the MAR, on 8/27/24 at 12:35 PM, R1 was administered 2 tablets of Percocet as ordered and reports a pain scale of 9 out of 10 at the time of administration. R1's pain was re-evaluated at 2:14 PM, with a pain rating of 4. (It is important to note that facility staff did not re-evaluate resident pain within one hour and they did not meet her pain goal of 2 out of 10). At 4:40 PM, R1 was also administered 2 tablets of Percocet as ordered and reports a pain scale of 10 out of 10 at the time of administration. R1's pain was re-evaluated at 7:31 PM with a pain rating of 6. When the staff member reapproached R1 to assess pain medication effectiveness, R1 reports a pain scale of 9 out of 10. R1's August 2024 MAR indicates that her prescribed Tramadol was administered as ordered without a pain scale associated with its administration. On 8/27/24 at 11:11 AM, Surveyor interviewed PA F (Physician Assistant) who indicated that he would want to be notified of a patient with uncontrolled pain. PA F also indicated that the injury sustained by R1 is known to be very painful and take at least 6-8 weeks to heal, and sometimes even 12 weeks. PA F stated that as a result of R1's injury he placed an order that R1 cannot be transferred utilizing a Hoyer lift. (Of note: due to this order, R1 has been unable to get out of bed since the injury due to no suitable, safe alternatives for transfer in and out of bed). On 8/27/24 at 3:20 PM, Surveyor interviewed LPN C (Licensed Practical Nurse). Surveyor asked LPN C what she does if a resident reports a pain scale of 10 out of 10 pain. LPN C states, she gives them ordered pain medication and reassesses the resident in around 30 minutes. LPN C states she would also try repositioning and other non-pharmacological interventions as well as any PRN medications due to the severity of the pain. LPN C indicated that she did not document the type of non-pharmacological intervention or if the intervention was effective. Surveyor asked LPN C what her process is if a resident reports an additional pain scale of 10 out of 10. LPN C states she would continue with ordered interventions and notify the physician of the resident's uncontrolled pain. (Of note: there was only one non-pharmacological physician order that was effective for three days 8/3/24-8/6/24). On 8/27/24 at 3:40 PM, Surveyor interviewed RN D (Registered Nurse). Surveyor asked RN D what she does if a resident reports a pain scale of 10 out of 10 pain. RN D states, she would complete an assessment and assess for additional visual cues of pain and where the pain is located, look to see what medications they have ordered both scheduled and PRN, and offer non-pharmacological interventions since oral medications would not work immediately. RN D also states she should follow up with the resident around 30 minutes after administration of medication to assess effectiveness. Surveyor asked RN D what her process is if a resident reports an additional pain scale of 10 out of 10. RN D states, she should contact the physician and consider sending them for evaluation in the emergency room for uncontrolled pain. RN D also states that she should notify the physician that the resident has received all ordered pain medications without relief of severe pain. On 8/27/24 at 4:30 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B what her expectations are for staff when a resident reports a pain scale of 10 out of 10. DON B states she would expect staff to administer ordered pain management medications and non-pharmacological interventions. She would also expect staff to follow-up with the resident within an hour to reassess pain. Surveyor asked DON B, what she expects from staff if a resident reports an additional pain scale of 10 out of 10 after initial interventions have time to become effective. DON B states, she would expect them to ask the resident if they want to be further evaluated in the emergency room for uncontrolled pain. DON B also states she would expect a physician to be contacted. The facility failed to re-evaluate the effectiveness of R1's pain medication within one hour of being administered, failed to offer non-pharmacological interventions related to pain management, and failed to consult with R1's Medical Doctor when her pain rating was consistently above her goal rate of 2 out of 10.

Based on interview and record review, the facility failed to submit accurate data to Centers for Medicare and Medicaid Services (CMS) mandatory Payroll Based Journal (PBJ) for Quarter 4 2023, Quarter 1 2024, and Quarter 2 2024. This had the potential to affect all 38 residents. Findings: On 07/22/24 at 1:21 PM, Surveyor interviewed Business Office Manager (BOM) G about the low weekend staffing data and no Registered Nurse (RN) that was triggered in the PBJ report. Surveyor asked for the information that was submitted. On 07/23/24 at 9:46 AM, Surveyor interviewed BOM G and asked for the information submitted for the PBJ. BOM G replied, I thought that you already had that information, so I wasn't sure if I needed to print that out or not. Surveyor replied, I need to see what you submitted in order to know why it was triggered. BOM G replied, Yes, I will do that. On 07/23/24 at 10:23 AM, BOM G provided Surveyor with PBJ submitter Final File Validation Report to review. On 07/23/24 at 2:45 PM, Surveyor requested timecard punches and schedules from BOM G for the dates missing on the PBJ report. On 07/24/24 at 8:03 AM, Surveyor interviewed the Nursing Home Administrator (NHA) A regarding PBJ submission to CMS. NHA A replied, Our facility had switched from Kronos to Smartlink for time punches. This new system had a lot of new features, but you had to input all of the data up front to make the system work properly. Surveyor informed NHA A that the timecard punches were requested yesterday and that should clear up a few things. NHA A replied, Well, maybe, our agency staff were not punching properly so they would not get recognized as working 8 hours that day. On 07/24/24 at 8:09 AM, NHA A provided Surveyor with daily punches and schedules requested. Surveyor noted that there were holes in the daily punches, and it did not correlate with the facility schedules provided. On 07/24/24 at 8:31 AM, Surveyor reviewed the facility assessment which states: It is the goal of [NAME] Health Services (LHS) to maintain the highest level of care possible for our resident population. As such LHS remains committed to staff ratios that meet and exceed industry standards. Our current budgeted census is 3.0. The following is a breakdown of an average days staff ratios: Day shift nurses: 2 Day shift Certified Nursing Assistants (CNA): 4 Eve shift nurses: 2 Eve shift CNA: 3 Night shift nurses: 1 Night shift CNA: 2. On 07/24/24 at 10:08 AM, Surveyor met with NHA A, Director of Nursing (DON) B, and [NAME] President of Success (VPS) H regarding staffing discrepancies. When reviewing the staff schedules with the timecard punches, NHA A was able to show Surveyor that the facility was short 8 hours RN coverage on 08/20/23 and 10/28/23. All of the other dates questioned by the offsite PBJ data were accounted for. VPS H replied, We had issues pulling agency hours from our program. It would show that the agency staff are here but would not formulate the number of hours worked. When this was recognized we did whole system sweep to correct this issue. VPS H showed Surveyor an email dated 03/05/24 that was sent out to all North Shore facilities that read, For 8 hr. RN coverage we extended nurse hours from 8 to 8.5 and for weekend staffing we do not have our administrative nurses working which lowers our overall coverage. 24-hour nursing coverage please look to see if we had agency on or admin staff that may have not been caught in PBJ reporting. On 8/5/24, Surveyor interviewed VPS H who had provided electronic documents showing PBJ entries for April, May, and June (Quarter 3) for all disciplines on the 1702D report. VPS H stated that the facility does audits of the 1702D PBJ report with a system check for Smartlink time entries for accurate submission for each building. The facility ensures manual entry of management RN hours so that it gets calculated for the total RN hours. VPS H indicates all weekend hours are in line with facility assessment staffing needs and do not show any low weekend staffing hours on the Quarter 3 audits. This is being cited as past noncompliance with the completed date of 03/05/24.

Based on interview and record review, the facility did not ensure each resident's drug regimen was free from unnecessary drugs. This occurred for 1 of 3 sampled residents (R6) who is prescribed a prophylactic antibiotic without adequate indications for its use. R6 returned from the hospital with an order for a prophylactic antibiotic (Cephalexin). No diagnosis was listed for this order. No stop date was listed for this order. This is evidenced by Facility policy and procedure entitled Antibiotic Stewardship Program, dated 11/18/22, states in part: Prescriptions for antibiotics shall specify the dose, duration, and indication for use. R6 was admitted to the facility with diagnoses that include chronic respiratory failure, respiratory failure with hypoxia, hypertension, congestive heart failure, chronic kidney disease, and Alzheimer disease. R6's Quarterly Minimum Data Set (MDS) assessment, dated 5/3/24, indicated that R6 had a Brief interview for Mental Status (BIMS) of 7 indicating severe cognitive impairment. R6's physician orders revealed an order dated 02/26/24. for Cephalexin Oral Tablet (Cephalexin) Give 125 mg by mouth one time a day for prophylactics. R6's care plan states in part: Has history of UTI . Monitor for side effects from antibiotic therapy and report to physician if present, . Has/At risk for respiratory impairment related to: ACUTE AND CHRONIC RESPIRATORY FAILURE WITH HYPOXIA, pneumonia . R6's pharmacy review, dated 06/29/24, states in part: Cephalexin 125 mg per day - no stop date letter/clarification. On 07/23/24 at 12:30 PM, Surveyor interviewed Assistant Director of Nursing (ADON) F and requested further information related to the reason R6 is on a prophylactic antibiotic. On 07/23/24, ADON F provided documentation from R6's hospital discharge summary, dated 01/31/24, which states in part: Discharge medications include . Cephalexin 250 mg tablet, 125 mg, Oral, NIGHTLY. Review of R6's Medication Administration Record (MAR) reveals that Cephalexin 250 mg tablet 125 mg oral, nightly was started on 01/31/24. R6 has continued to receive this medication nightly since that date. On 07/24/24 at 8:32 AM, Surveyor interviewed ADON F who stated the resident was hospitalized for pneumonia and then after a short time was hospitalized again for pneumonia, but other than that they see no further information or indications for use of the prophylactic antibiotic.

Based on random observation, interview and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and help to prevent the development and transmission of communicable diseases and infections. Staff did not perform hand hygiene when warranted when providing cares for 3 of 3 residents (R24, R27, and R3). Staff did not perform sanitizing of durable medical equipment to prevent the spread of infection when warranted between 2 residents (R3 and R24). This is evidenced by: The facility policy entitled Hand Hygiene revised on 11/02/22 states in part . All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. Either soap and water or alcohol-based hand rub before applying and after removing personal protective equipment, including gloves, before and after handling clean or soiled linens, and after handling items potentially contaminated with blood, body fluids, secretions or excretions. The facility was unable to provide a policy on sanitization of mechanical lifts between residents. Example 1 On 07/23/24 at 6:51 AM, Surveyor observed Certified Nursing Assistant (CNA) D perform incontinence care on R27 with gloved hands. CNA D removed urine-soaked incontinent product, washed R27's frontal peri area without removing gloves and/or conducting hand hygiene. CNA D proceeded to open closet door to obtain clean clothing and assist with lower body dressing. CNA D then held R27's right hand with contaminated gloved hand. CNA D assisted R27 to sit on edge of bed to dress into a clean shirt. After supporting R27 to stand up, CNA D took urine-soaked incontinent product that was stuck to R27's buttocks and placed in garbage. Without removing contaminated gloves or conducting hand hygiene, CNA D cleansed R27's buttocks, pulled up clean incontinent product and pants with same contaminated gloves. On 07/23/24 at 12:38 PM, Surveyor interviewed CNA D regarding observation of no hand hygiene and glove change after conducting incontinence care and before touching resident and resident's clean clothing. CNA D stated, I must have been flustered and forgot. Example 2 On 07/23/24 at 10:27 AM, Surveyor observed CNA C perform incontinence care on R24. CNA C unsecured urine-soaked incontinent product, and cleansed R24's frontal peri area. CNA C proceeded to roll R24 onto left side, cleanse R24's buttocks and remove urine saturated incontinent product. Without removing contaminated gloves or conducting hand hygiene, CNA C placed a clean incontinent product securing it into place, pulled up R24's pants, secured mechanical lift sling and transferred R24 back to reclining wheelchair with the contaminated gloves. Example 3 On 07/23/24 at 10:53 AM, Surveyor observed CNA E perform incontinence care on R3. CNA E removed urine-soaked incontinent product and placed a clean incontinent product securing it into place. Without removing contaminated gloves or conducting hand hygiene, CNA E pulled up R3's pants, secured mechanical lift sling and transferred R3 back to wheelchair. On 07/23/24 at 10:57 AM, Surveyor interviewed CNA C and CNA E regarding observations of lack of hand hygiene following incontinence care for R24 and R3. Both CNA C and CNA E stated the expectation would be to remove dirty gloves and conduct hand hygiene. CNA C and CNA E confirmed this was not completed per facility policy. On 07/23/24 at 1:32 PM, Surveyor interviewed Director of Nursing (DON) B and Assistant Director of Nursing (ADON) F regarding observation of lack of hand hygiene/glove change following incontinence care. Both DON B and ADON F acknowledged the expectation would be to remove gloves and conduct hand hygiene after incontinence care. Example 4 On 07/23/24 at 10:27 AM, Surveyor observed CNA E remove mechanical lift, which had a vinyl bag with tub of sanitization wipes inside secured to lift, from hallway storage area and bring to R24's room to assist CNA C in performing incontinence care for R24. Surveyor did not observe sanitizing of mechanical lift prior to or following transfer of R24 to and from wheelchair to bed and back to wheelchair. CNA E brought mechanical lift back to hallway storage area. Surveyor conducted constant observation of mechanical lift. On 07/23/24 at 10:53 AM, Surveyor observed CNA E take same mechanical lift to R3's room to perform incontinence care. Surveyor did not observe sanitization of mechanical lift prior to or after transferring R3 to and from wheelchair, to bed and back to wheelchair, and placing the lift in the hallway storage area. On 07/23/24 at 10:57 AM, Surveyor interviewed CNA C and CNA E regarding observations of lack of sanitizing mechanical lift between R24 and R3. Both CNA C and CNA E stated the expectation would be to sanitize lifts between residents. CNA C and CNA E confirmed this was not completed. On 07/23/24 at 1:38 PM, Surveyor interviewed DON B and ADON F regarding observation of lack of sanitization of mechanical lifts between residents. Both acknowledge the expectation would be to sanitize each lift between resident use.

Based on interview and record review, the facility did not immediately report alleged violations of abuse to the State Agency and local law enforcement for 2 of 3 reportable incidents (R8 and R9). On 3/21/24, R8 reported that he was unable to find the cash that he kept in his room. R8 indicated that there was a grand that he was unable to locate. NHA A failed to report this Suspicion of a Crime to local law enforcement and the State Agency. On 3/16/24, R9's daughter called the facility to report that R9's wedding ring was missing. NHA A failed to investigate the allegation or report this Suspicion of a Crime to local law enforcement and the State Agency. This is evidenced by: The facility's policy and procedure, Abuse, Neglect, Exploitation Policy, last revised 7/15/22, states in part, the following: Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. VII. Reporting/Response. A. The facility will have written procedures that include: 1. Reporting of alleged violations to the Administrator, state agency, adult protective services, and to all other required agencies (e.g., law enforcement when applicable) within specified timeframe's. Example 1 R8 was admitted to the facility on [DATE] with diagnoses that include, in part . COPD (chronic obstructive pulmonary disease), acute and chronic respiratory failure with hypoxia, Type 2 diabetes mellitus, and heart failure. R8's Admission Minimum Data Set (MDS) dated [DATE] indicates R8 has a Brief Interview of Mental Status) of 12, indicating mild cognitive impairment. R8's does not have an Activated Healthcare Power of Attorney (AHCPOA) and is his own decision maker. On 3/21/24, a grievance form was completed stating in part . R8 stated that he can't find cash that he keeps in his room. He said that he hid it in a new place and now can't find it. R8 was asked by staff how much he had been keeping in his room and R8 stated, a grand. On 4/24/24 at 10:55 AM, Surveyor interviewed NHA A (Nursing Home Administrator) and VPS C (Vice President of Success). Surveyor asked what the facility did with R8's concern of missing money. VPS C stated that the resident found the money the next day. Surveyor asked NHA A and VPS C if R8 reporting a large amount of money missing should have been reported to the State Agency and law enforcement. NHA A stated, yes. VPS C indicated, he (R8) found the money the next day, but (VPS C) cannot say that it was within 24 hours of R8 reporting it to us missing. VPS C indicated he did not keep a timeline of when it was reported and when it was found. Example 2 R9 was admitted to the facility on [DATE] with diagnosis that include, in part . unspecified dementia, anxiety disorder, insomnia, and chronic kidney disease. R9's Quarterly Minimum Data Set (MDS) dated [DATE] indicates that R9 has a Brief Interview of Mental Status (BIMS) of 5, indicating severe cognitive impairment. R9 has an Activated Healthcare Power of Attorney (AHCPOA). On 3/16/24, a grievance form was completed stating in part . R9's daughter reported that her mom's wedding ring is missing. She noticed it about 3 weeks ago and again today that her mom is wearing a bingo prize ring. When she asked R9 where her wedding ring is, she was unsure. R9's daughter looked but couldn't find it in her room. On 4/24/24 at 10:55 AM, Surveyor interviewed NHA A (Nursing Home Administrator) and VPS C (Vice President of Success). Surveyor asked NHA A and VPS C about R9's missing wedding ring. VPS C states that R9 has a history of misplacing items, and it was believed that she had thrown the ring away. Surveyor asked VPS C and NHA A if this was something that should have been reported to the State Agency and Law Enforcement. NHA A stated, yes. VPS C stated, even though we know she has a history of throwing items away and this was the likely conclusion. Surveyor asked VPS C if the item could have been misappropriated. VPS C stated the likely cause was R9 throwing away the item. The facility completed grievance forms on the missing money and missing items, but did not report these concerns to the State Agency or law enforcement per the regulatory requirements.

Based on observation, interview, and record review, the facility did not maintain a safe and sanitary environment in which food is stored and distributed in accordance with professional standards for food service safety. This has the potential to affect all 33 residents who reside in the facility. Surveyor observed DA F (Dietary Aide) during dishwashing. Surveyor observed DA F go from working with dirty dishes to clean dishes four times without washing hands in between. Evidenced by: The facility policy titled, Cleaning Dishes Dish Machine, with a reviewed date of 7/13/22, includes, in part: Policy Explanation and Compliance Guidelines .2. The person loading dirty dishes will not handle the clean dishes unless they change into a clean apron and wash hands thoroughly before moving from dirty to clean dishes .10. Inspect for cleanliness and dryness and put dishes away if clean (be sure clean hands or gloves are used) On 4/5/23 at 9:35 AM, Surveyor observed DA F rinsing and placing dirty dishes in the dishwasher. Surveyor observed DA F then start putting clean dishes away. Surveyor observed DA F go back and forth from dirty to clean dishes four times and not washing hands in between. Surveyor observed DA F take a rag in a sanitizing bucket, squeeze the rag, and then immediately start putting away clean dishes. DA F indicated to Surveyor dirty and clean dishes should be separate. Surveyor observed DA F not wearing an apron while scrapping food off dirty dishes. On 4/6/23 at 10:36 AM, DM G (Dietary Manager) indicated staff should wash their hands when going from dirty to clean dishes. DM G indicated he will provide education to staff.

Based on observation, interview and record review, the facility has not established an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections, this has the potential to affect all 33 residents (R) in the facility. The facility's staff infection control line list contained missing and/or incorrect information. Dietary Aide H returned to work sooner than current infection control standards of practice recommend. The facility's monthly infection control rates were not calculated according to current standards of practice and rates were not segregated for specific infection types. Staff administered R86's eye drops without gloves or proper hand hygiene. Surveyor observed DA F (Dietary Aide) touch her face mask twice and then touch the top of a drink pitcher without washing her hands. This is evidenced by: The facility policy titled, Infection Surveillance, with a revised date of 3/8/23, includes, in part: Policy: A system of infection surveillance serves as a core activity of the facility's infection prevention and control program. Its purpose is to identify infections and to monitor adherence to recommended infection prevention and control practices in order to reduce infections and prevent the spread of infection . Policy Explanation and Compliance Guidelines: 1. The Infection Preventionist serves as the leader in surveillance activities, maintains documentation of incidents, findings, and any corrective actions made by the facility and reports surveillance findings to the facility's Quality Assessment and Assurance Committee, and public health authorities when required .5. Surveillance activities will be monitored facility-wide, and may be broken down by department or unit, depending on the measure being observed. A combination of process and outcome measures will be utilized. 6. The facility will collect data to properly identify possible communicable diseases or infections before they spread by identifying: a. Data to be collected, including how often and the type of data to be documented, including: i. The infection site, pathogen (if available), signs and symptoms, and resident location, including summary and analysis of the number of residents (and staff, if applicable) who develop infections: .iii. The identification of unusual or unexpected outcomes, infection trends and patterns .8. Monthly time periods will be used for capturing and reporting data. Data will be used to show comparisons over time and will be monitored for trends .12. Formulas used in calculating infection rates will remain constant for a minimum of one calendar year and will require discussion in QAA/QAPI meetings before changes in the formulas are made. The facility policy titled, Employee Work Restrictions - Infectious Diseases, with a revised date of 3/8/23, includes, in part: Policy: It is our policy to take appropriate precautions to prevent transmission of infectious agents . Policy Explanation and Compliance Guidelines: .3. If the employee presents an infectious disease to the center leadership, it is the responsibility of the employee's supervisor, or the supervisor on duty, to make determinations regarding work-restrictions, depending on the circumstances. The designated Infection Preventionist may be consulted to provide guidance in decision-making .5. Employees who are restricted from work shall remain away from work until no longer contagious or cleared by a medical provider as needed or recommended by the Infection Preventionist if available . The facility provided page 10 of the Wisconsin Department of Health Services, Prevention and Control of Acute Gastroenteritis Outbreaks In Wisconsin Long-Term Care Facilities.Staff should exclude themselves from resident care and food service duties at the onset of symptoms, including nausea, vomiting, abdominal pain, and/or diarrhea. Such exclusions shall remain in effect until the employee is asymptomatic and free of diarrhea and vomiting for 48 hours .Any food service employee experiencing symptoms of acute gastrointestinal illness resembling norovirus shall be excluded from working until 48 hours after symptoms end. The facility document, titled, Infection Control Quick Reference Guide for IFP, includes, in part: .Items to update monthly: Incident rate worksheet: # of infections/Total resident days x 1000 = incident rate %. Monthly summary of trends: .Type of infections . Example 1: Surveyor was provided with an employee IC (Infection Control) line list titled, Employee Infection Report, dated March 2023. The line list contains the following columns: Employee Name; Type of Infectious Illness; Onset Date and Time; Symptoms; Treatment and/or Antibiotic & Start Date; Precaution Type and Start Date; Well date and Time; Return to Work; Additional Comments; and Record by (Initials). There are 7 employees with symptoms listed on the line list. There is no information documented for all 7 employees regarding well date and return to work dates. On 4/5/23 at 9:41AM, Surveyor was provided with a piece of paper with the following hand written information: Scheduler/CNA I (Certified Nursing Assistant) Positive 3/20 no s/s (Signs/Symptoms) - routine testing Test 3/25 negative - Day 5 Test 3/27 negative Return to work 3/28. The March 2023 Employee IC line list indicates the following for Scheduler/CNA I: Onset Date & Time: 3/24/23 Symptoms: Fever/cough Additional Comments: Covid + Type of Infectious Illness; Treatment &/or Antibiotic & Start Date; Precaution Type and Start Date; Well date & Time; Return to Work; and Recorded by (Initials) are all blank. On 4/5/23 at 3:19 PM Surveyor interviewed IP C and asked if she knew which date, 3/20/23 or 3/24/23, for Dietary Aide H is correct for when she was positive for COVID. IP C indicated she believed the document that says 3/20 is correct because DON B wrote that document out. Surveyor asked IP C if the line list information should be accurate. IP C indicated, yes. Surveyor asked IP C if the return-to-work dates and wellness dates should be filled in on the line list. IP C indicated, yes. On 4/6/23 at 8:42 AM, Surveyor interviewed Scheduler/CNA I and asked what she recalled about when she tested positive for COVID this month. Scheduler/CNA I indicated, I was asymptomatic, my son was with his grandma over the weekend. She called me at like 7 am or 8am on Monday 3/20 and told me she was positive. So, I tested at home at 8:30ish on a home test and it was positive. I called DON B (Director of Nursing) and she asked me to come in and test here, which I did, around 9 am. I tested outside. Surveyor asked Scheduler/CNA I if she ever developed symptoms. Scheduler/CNA I indicated, no. Surveyor asked Scheduler/CNA when she returned to work. Scheduler/CNA I indicated, 3/27. Of note, Surveyor reviewed schedules and punch details and there was greater than 48 hours between last date worked and positive test for Scheduler/CNA I. Surveyor requested RTW (Return to Work) dates for all employees on the March 2023 line list, this information was not included on the line list to track when staff are able to return to work. Example 2: The original March 2023 Employee IC line list received from the facility indicated the following for Dietary Aide H: Onset Date & Time: 3/11/23 Symptoms: vomiting Additional Comments: covid neg (negative) Type of Infectious Illness; Treatment &/or Antibiotic & Start Date; Precaution Type and Start Date; Well date & Time; Return to Work; and Recorded by (Initials) are all blank. The updated line list indicates a RTW date of 3/12/23 for Dietary Aide H. On 4/6/23 at 9:00AM, Surveyor reviewed the above information regarding Dietary Aide H with DON B (Director of Nursing). DON B indicated this illness was related to food and that Dietary Aide H was working on getting a letter from her doctor. DON B indicated Dietary Aide H was available for interview at that time and had her come to the conference room. Surveyor asked Dietary Aide H what she could recall regarding her illness noted on 3/11/23. Dietary Aide H indicated; she went to the doctor on 3/15 about this. She tested covid negative and the doctor stated that it may be food related. Dietary Aide H indicated she contacted her doctor today to get a note. Surveyor asked Dietary Aide H if she had other symptoms. Dietary Aide H indicated, oh yes, hot flashes and I did not feel good. Surveyor asked Dietary Aide H, if at the time she returned to work on 3/12, did she have approval from a physician to return to work. Dietary Aide H indicated, no. Surveyor asked DON B with GI (Gastro intestinal) symptoms and a covid negative test do they use GI criteria for RTW dates. DON B indicated, yes. DON B indicated Dietary Aide H came back too soon. Surveyor asked DON B how long Dietary Aide H should have been off work. DON B indicated, without a doctor's note, 48 hours past symptom end time. Example 3 On 4/5/23 at 8:39 AM, Surveyor was provided with the following monthly IC (Infection Control) rates, hand-written on a piece of paper: April 22 - 129%; May 22 - 96.8%; Jun 22 - 366.7%; [DATE] - 322.6%; [DATE] - 322.6%; [DATE] - 233.3%; [DATE] - 548.4%; [DATE] - 133.3%; [DATE] - 193.5%; [DATE] - 193.5%; [DATE] - 285.7%; [DATE] - 290.3%. On 4/5/23 at 9:57 AM Surveyor interviewed IP C (Infection Preventionist) and asked who calculates the monthly IC rates. IP C indicated, the previous NHA (Nursing Home Administrator) was calculating the rates and she was a nurse. IP C indicated that she learned how to do this so she will be doing it moving forward. On 4/5/23 at 3:14 PM Surveyor interviewed IP C and asked how she was trained to calculate IC rates. IP C indicated she takes the number of antibiotics for the month/ (divided by) the number of days in the month x 1000. Surveyor asked IP C if she calculates segregated rates based on infection type. IP C indicated she was not sure and that the previous NHA (Nursing Home Administrator) completed that at QAPI (Quality Assurance Plan & Improvement). Surveyor asked IP C how the rates that were provided were calculated. IP C indicated the rates were all infections rolled into one rate. On 4/5/23 at 3:52 PM, Surveyor interviewed DON B and asked how monthly IC rates are calculated. DON B indicated, they use the number of infection/resident days x 1000 and include all infections at once. Surveyor asked DON B if they have segregated rates per infection. DON B indicated, no. Of note: On 4/5/23 at 3:44 PM Surveyor interviewed DON B and clarified that she is overseeing the program while training IP C. DON B indicated this was correct. The facility is not calculating their infection rates by the type of infection (segregated) per standards of practice. 41788 Example 4 The facility policy, entitled Eye Drops, dated 1/23. States, in part: . POLICY- To administer ophthalmic solution into eye in a safe and accurate manner. EQUIPMENT- .Gloves . PROCEDURE- .8. With a gloved finger, gently pull down lower eyelid to form pouch, while instructing resident to look up . R86 was admitted to the facility on [DATE], and has diagnoses that include osteoarthritis, osteoporosis, and anxiety. R86's Admission Minimum Data Set (MDS) Assessment, dated 3/28/23, shows R86 has a Brief Interview of Mental Status (BIMS) score of 10 indicating R86 has moderate cognitive impairment. On 4/5/23, at 7:23 AM, Surveyor observed LPN E (Licensed Practical Nurse) administer artificial tears into R86's eyes without gloves on and proper hand hygiene. On 4/5/23, at 7:39 AM, Surveyor asked LPN E if gloves should be worn while administering eye drops and LPN E indicated that she never wears gloves while administering eye drops. Surveyor asked LPN E what the facility policy indicates for proper administration of eye drops and LPN E indicated not knowing but she knows there is a five-minute wait in between administering more than one eye drop. On 4/5/23, at 4:50 PM, Surveyor asked DON B (Director of Nursing) if it is her expectation for a nurse to wear gloves and conduct proper hand hygiene while administering eye drops. DON B indicated yes. Surveyor asked DON B if it would be expected that hand hygiene be conducted before and after glove use and DON B indicated yes. 44552 Example 5: The facility policy titled, Hand Hygiene, with a reviewed date of 11/2/22, includes, in part: Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Policy Explanation and Compliance Guidelines: 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice . On 4/4/23 at 9:43 AM, during initial kitchen walk through, Surveyor observed DA F (Dietary Aide) touch her face mask twice by putting it up and down over her mouth and nose. Surveyor observed DA F immediately touch the top of a drink pitcher after touching her face mask. DA F did not wash her hands after touching her face mask. On 4/6/23 at 10:36 AM, DM G (Dietary Manager) indicated staff should wash their hands after touching their face mask. DM G indicated he will provide education to staff.

Based on interview and record review, the facility must develop policies and procedures to ensure that residents and/or resident responsible party receives education regarding the benefits and potential side effects of the immunization prior to offering the immunization and documentation is noted in the medical record on whether the resident received or declined the immunization. This affected 1 of 5 residents (R9) reviewed for pneumococcal immunizations of 16 sampled residents. R9 did not have the pneumococcal immunization and no documentation in R9's record. This evidenced by: The facility policy, entitled, Pneumococcal Vaccine (Series), with a revised date of 2/20/23, states, in part: Policy: It is our policy to offer our residents and staff immunization against pneumococcal disease in accordance with current CDC (Centers for Disease Control) guidelines and recommendations. Policy Explanation and Compliance Guidelines: 1. Each resident will be assessed for pneumococcal immunization upon admission .2. Each resident will be offered a pneumococcal immunization unless it is medically contraindicated or the resident has already been immunized. Following assessment for any medical contraindications, the immunization may be administered in accordance with the physician-approved standing orders. 3. Prior to offering the pneumococcal immunization, each resident or the resident's representative will receive education regarding the benefits and potential side effects of the immunization . 4. Consent shall be documented prior to the administration of the vaccine [sic] The resident/representative retains the right to refuse the immunization. Refusals should be documented . 12. The resident's electronic health record shall include documentation that indicates at a minimum, the following: a. The resident or resident's representative was provided education regarding the benefits and potential side effects of pneumococcal immunization. b. The consent was received or immunization was declined. c. The resident received the pneumococcal immunization or did not receive due to medical contraindication or refusal . Example 1: R9 was admitted to the facility 8/22/22. There is no documentation that R9 was provided education on the risk and benefits of the pneumococcal immunization or that the immunization was offered, received, or declined. On 4/5/23 at 9:41 AM, Surveyor interviewed IP C (Infection Preventionist) and asked what the process is for resident immunizations in the facility. IP C indicated, we have an admission packet that has all the immunization vaccine consents or declinations in it and this should be completed during the admission process. Surveyor asked IP C if there is a process for double checking these are completed. IP C indicated, a second nurse is supposed to go through the packet when it is completed and check that everything is complete. I'm not sure what happened to R9's. Surveyor asked IP C if R9 should have been offered the pneumococcal vaccination on admission. IP C indicated, yes. Surveyor asked IP C if a consent or declination should have been completed for R9. IP C indicated, yes. R9 has no evidence of being offered, having declined, or received any pneumococcal immunizations.

Based on interview and record review, the facility did not ensure all staff who provide care to the residents were fully vaccinated for COVID-19. This had the potential to affect all 33 residents. Cook D, with a date of hire of 7/14/22, was not fully vaccinated for COVID-19 while working in the facility and did not have a temporary delay or exemption from receiving the COVID-19 vaccination. This is evidenced by: The facility policy, Employee COVID-19 Vaccinations, with a revised date of 10/24/22, indicates, in part: Policy: It is the policy of this facility to ensure that all eligible employees are vaccinated against COVID-19 as per applicable Federal, State and local guidelines . Compliance Guidelines: 1. The facility will ensure that all eligible employees are fully vaccinated against COVID-19, unless religious or medical exemptions are granted as per CMS (Centers for Medicare and Medicaid Services) guided time frames .4. The facility will ensure that all eligible employees (except for staff who have pending requests for, or who have been granted exemptions to the vaccination requirements, or staff for whom COVID-19 vaccination must be temporarily delayed, as per CDC (Centers for Disease Control) recommendations, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the facility and/or its residents. If a second dose is required, the employee should receive the second dose when due. If employee fails to complete the primary vaccination series, the facility will remove employee from the schedule pending application for vaccine exemption, if requested . On 4/5/23, Surveyor reviewed the staff COVID vaccination list received from the facility. Eight employees are listed as Refused. On 4/5/23, Surveyor interviewed IP C (Infection Preventionist) and asked for clarification on what Refused meant on the COVID vaccination list. IP C indicated that the staff had refused the vaccination on the exemption form. Surveyor asked to see the exemption forms for the 8 staff members listed as refused. On 4/5/23, Surveyor reviewed the exemption forms, titled, Staff Declination of COVID-19 Vaccination, received for the 8 staff members listed as refused. The form includes, in part: I decline COVID-19 Vaccination for: Medical Exemption; Religious Exemption; Neither of the above, but I am refusing vaccination. The 8 employees listed as refused have marked the third option: Neither of the above, but I am refusing the vaccination. On 4/5/23 at 3:40 PM, Surveyor interviewed IP C and asked what guidance the facility is following regarding the refusals of the COVID vaccination vs medical or non-medical exemptions. IP C indicated that the forms had all been completed prior to her coming to the facility and that she was unsure. Surveyor noted Cook D had a date of 4/4/23 next to her signature on the form and asked IP C if the refusal was completed yesterday. IP C indicated, I noted when reviewing the vaccine matrix that she still didn't have her information, so I talked to her yesterday and she stated she was refusing the vaccine. On 4/5/23 at 4:03 PM Surveyor interviewed DON B (Director of Nursing) and asked what guidance the facility is following regarding the refusals of the COVID vaccination vs medical or non-medical exemptions. DON B indicated, I'm not sure, I thought they had to have one or the other. DON B indicated that the NHA A (Nursing Home Administrator) may know more and had him come join the interview. Surveyor asked NHA A if he knew what guidance was being used to allow staff to have a refusal of the COVID vaccine without a medical or non-medical exemption. NHA A was shown a form with the refusal checked. NHA A indicated he did not know as the form is not their form and that he was not aware that there were staff in the facility who did not have the proper exemptions. NHA A requested to check into this further as the correct form is supposed to go through HR and get an approval so they may have copies he can obtain. On 4/6/23 at 7:38 AM Further information was provided by NHA A (Nursing Home Administrator) regarding the completed exemption forms that were provided to Surveyor. Per NHA A, the forms originally provided are not up to date nor are they current facility forms. The up-to-date forms have a deadline noted on them of 12/6/21 and are sent to HR (Human Resources) for approval and the approvals, with dates, are then attached. NHA A provided the updated forms for 7 of the 8 employees reviewed to Surveyor. Per NHA A, they were not able to locate one for Cook D and will be taking care of this today. Of note, the facility was in outbreak during this survey.

Based on interview and record review, the facility did not ensure that each resident was free from physical abuse for 2 of 5 residents reviewed for abuse (R4 and R5). R6 was inappropriately touching R4, R5, and an unknown/unidentified female resident. Facility staff documented R6's interventions to keep him from touching female residents as not effective. The facility did not attempt to implement additional interventions to keep their female residents safe. DON B (Director of Nursing) is unaware of the 6/25/22 documented incident of R6 kissing an unknown/unidentified female resident with his hand down her shirt. As evidenced by The facility policy, Abuse Prevention Program, dated March 2018, indicates, in part as follows: Our residents have the right to be free from abuse .The objective of the Abuse policy is to comply with the seven-step approach to abuse, neglect and exploitation detection and prevention Overview of the seven components .Identification, Investigation, Protection, Reporting/Responding 3. Prevention: Abuse Policy Requirement: It is the policy of this facility to prevent and prohibit all types of abuse and neglect by the following measures including, but not limited to: Providing a safe environment .Determining resources needed to care for residents though the use of a facility assessment and ongoing QAPI. Supporting as much as possible, the resident's right to consensual sexual relationships. The facility will assume for the safety of a resident deemed incapable of decision making that the resident is incapable of declining to participate in the sexual act or lacks the ability to understand the nature of the sexual act and therefore, the act would constitute sexual abuse. If the resident appears to desire to pursue a consensual sexual relationship, the Social Worker will contact the POA/Legal Guardian, primary physician, Ombudsman for a care conference. Mental health practitioner and members of the Interdisciplinary team may also be utilized. This will be documented in the progress notes and the care plan as needed. 7. Reporting / Responding: Abuse Policy Requirement: The facility must report alleged violations related to mistreatment, exploitation, neglect, or abuse .Staff are to report suspected violations to their supervisor immediately, who in turn will notify the Administrator. Example 1 R4 was admitted to the facility 4/21/20 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's MDS (Minimum Data Set) BIMS (Brief Interview of Mental Status) score is 8/18, indicating R4 is moderately cognitively impaired. R6 was admitted to the facility 9/14/20 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R6's Minimum Data Set (MDS) Brief Interview Mental Status's (BIMS) score is 7/15, indicating he is severely cognitively impaired. R6's care plan indicates he is independent with ambulation (1 assist when needed). On 6/1/22 at 4:30 PM, AD K (Activity Director) documented the following statement: This staff member was coming down the hall and heard a resident (that has since been discharged ) yelling, Teacher, teacher! He is trying to touch grandma. She was heading towards the nurse's station. I asked (resident name) who and where. She pointed towards the Fire Side room and said, He is. This staff turned and saw R6 with his hand on R4's thigh. I approached and said, (R6's name), that is inappropriate he removed his hand immediately. Before removing his hand, R4 was actively attempting to push R6's hand off her leg. R6's attention was easily removed from R4 and redirected to me. He turned to look at me and said Well, then can I hold your hand? I agreed to that and held his hand. He then said, Can I hold your boobs? I replied, no, that is inappropriate. Let's move over here to watch TV (television). R6 said okay and I moved him to see the TV. I went to find the closest nurse and told him that R6 had his hand on R4's thigh, and I was going to facilitate a group. On 6/1/22 at 11:30 PM, R6's Progress Notes indicate the following: R6 is on follow up for: 6/1/22 Resident was reported to have inappropriate touching with another resident in the day room (R4). Staff intervened and he was moved from the day room to near the nurse's station for monitoring. The status is R6 has been resting in bed with occasional staff assist to the restroom, then back to bed. No interactions with other residents have occurred through the night. Continuing to monitor. Following this incident, the facility completed the Resident-To-Resident Altercation Flowchart and determined the following: Did the resident (R6) act willfully: Yes; Did the other resident suffer pain, physical injury, or psychological or emotional harm as a result of the altercation? No, the flowchart indicates Do not report. Document an immediate assessment showing no harm to the other resident. Assess - Care Plan - Intervene Goal: Prevent reoccurrence and keep other residents safe. Did behavior continue? No - Stop. On 8/17/22 at 1:47 PM, Surveyor spoke with R4. Surveyor asked R4 if she feels safe at the facility. R4 stated, yes. Surveyor asked R4 has any resident touched you inappropriately. R4 stated, no. Surveyor asked R4 if she has any concerns regarding her care. R4 stated, no. 6/2/22 at 9:30 AM, a Progress Note indicates the following: R6 is on follow up for: alleged abuse 6/1/22. The current status is resident stable. VSS (vital signs stable). Example 2 R5 was admitted to the facility 1/8/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R5 is severely cognitively impaired. On 6/17/22 at 6:15 PM, a Progress Note indicates the following: Behavior/Mood: R6 rubbing on another resident (R5) trying to be sexually inappropriate, resident cornered the RN (Registered Nurse) and stated, let me play with it, and tried to grab her front. What was the resident doing prior to or at the time of behavior/mood: trying to be alone in family room with another resident? Interventions implemented: redirect, state educationally that his behavior was not acceptable. Effectiveness of the interventions: not effective, resident continues to try to grope women residents and female staff. Note, staff is documenting that interventions are not effective; however, the facility did not attempt to implement other interventions to keep their female residents safe. On 8/17/22 at 1:33 PM, Surveyor spoke with CNA F (Certified Nursing Assistant). Surveyor asked CNA F, do any residents touch other residents inappropriately. CNA F stated that R6 touches R5. CNA F stated R5 and R6 are in a relationship. CNA F stated, that is a bad idea however, the family approved of it (with the limitation of holding hands only, see above). CNA F stated, we're supposed to redirect if it happens. CNA F stated, she is aware that there was an occurrence where R6 was holding R5's hands and then put his hand down her pants. On 8/17/22 at 1:42 PM, Surveyor spoke with CNA G. Surveyor asked CNA G, do any residents touch other residents inappropriately. CNA G stated, yes, R6 touches R5 inappropriately. CNA G stated, in late June or early July he had his hand down her shirt (Note, this may be the 6/25/22 documented incident). Surveyor asked CNA F, how did R5 react. CNA F stated, I don't think she minded it. Surveyor asked where this occurred. CNA G stated, in the day room by the front door. CNA G stated, her family and APOAHC (Activated Power of Attorney for Health Care) was okay with them holding hands only. CNA G added, R5 was kind of encouraging R6. R5 wanted to go to R6's room. CNA G stated, that is unacceptable and did not occur. On 6/20/22 at 3:47 PM, the facility documented the following correspondence with R5's APOAHC (Activated Power of Attorney for Health Care). R6's APOAHC spoke with writer, DON B (Director of Nursing). Stated she spoke with resident and educated her on what was appropriate and not appropriate with her relationship with a male resident (R6). POA stated she was aware that male resident may not be able to control self and asks that we monitor situation. States she is okay with holding hands and them being around each other but wishes we direct if there is any kissing our [sic] touching of private parts. At this time, she sees no harm and believes it would cause more harm at this time if they were to be separated. On 8/17/22 at 2:03 PM, Surveyor spoke with R5. Surveyor asked R5 her name. R5 was unable to recall her name. Surveyor asked R5, do you feel safe at the facility. R5 stated yes. Surveyor asked R5 has anybody touched you inappropriately. R5 stated, a neighbor boy. Surveyor asked R5 his name. R5 stated, she does not remember his name. R5 added, I'm old enough to handle that. Example 3 On 6/25/22 at 6:47 PM, a Progress Note indicates the following: R6 was caught kissing with his hand down another females [sic] (resident unknown) residents' shirt in the Meadowview hallway. Both residents were told that this was inappropriate behavior. Residents proceed to hold hands with the female resident without further inappropriate touching. On 7/16/22 at 12:16 PM, Progress Notes indicate the following: R6 had some inappropriate sexual comments towards staff with cares and was easily redirected. Note, this is the last documentation re: inappropriate contacted with residents or staff. Staff should be made aware that comments to staff may be an indicator of upcoming incidents with female residents. On 8/17/22 at 2:59 PM, Surveyor spoke with DON B (Director of Nursing). Surveyor asked DON B. Who is the resident involved in each of the above examples: DON B stated, 6/1/22: R4, 6/17/22: R5, 6/25/22: DON B stated she was not aware of this incident documented on 6/25/22 and does not know the female resident involved in this incident? Surveyor asked DON B, do you expect staff to report these incidents to you. DON B stated, yes. Surveyor asked DON B, should staff have reported this incident to you. DON B stated, absolutely. DON B stated that R6 is on [MEDICATION(S)] to decrease his urges. Surveyor shared with DON B that CNA F indicated there was an incident while R6 and R5 were holding hands that R6 put his hand down R5's pants. It is important to note this is not documented.

Based on interview and record review the facility did not report alleged violations of abuse to the State Agency for 1 of 5 sampled residents (R1). LPN H (Licensed Practical Nurse) stated to Surveyor, approximately 4-5 months ago, former DON J (Director of Nursing) approached her stating that R1 just told her, [OBSCENITY] you! and DON J stated to R1, No, [OBSCENITY] you! LPN H stated, DON J stated to her that she should not have said that to R1. Immediately after this DON J was on her cell phone. LPN H incorrectly assumed that DON J was reporting this to the former Nursing Home Administrator (NHA), which she did not. The facility has no documentation of this incident. This is evidenced by: The facility's policy, Abuse Prevention Program, dated March 2018, documents in part, the following: Our residents have the right to be free from abuse, neglect . This includes but is not limited to verbal abuse. 7. Reporting / Responding: Abuse Policy Requirement: The facility must report alleged violations related to mistreatment, exploitation, neglect, or abuse: including neglect or abuse . Allegations must be reported to the Administrator / designee immediately. R1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Minimum Data Set (MDS) dated [DATE], Brief Interview of Mental Status (BIMS) score is 11/15, indicating he is moderately cognitively impaired. R1 is his own person. On 8/17/22 at 9:10 AM, Surveyor spoke with R1. R1 does not recall the incident. On 8/17/22 at 11:43 AM, Surveyor spoke with LPN H (Licensed Practical Nurse). Surveyor asked LPN H are you aware of any staff members that have yelled at a resident(s). LPN H stated, yes, the former DON J. LPN H stated, about 4-5 months ago at most, she was sitting at the nurse's station when former DON J approached her and stated that R1 just told her, [OBSCENITY] you! and DON J stated to R1, No, [OBSCENITY] you! LPN H stated, DON J stated to her that she should not have said that to R1. LPN H stated, because DON J recognized that she should not have done this, she thought DON J reported the incident to the former NHA (Nursing Home Administrator), as she was on her cell phone right after telling LPN H about this occurrence. On 8/17/22 at 11:53 PM and 12:24 PM, Surveyor spoke with BOM C (Business Office Manager). Of note, BOM C was the acting NHA from 5/12 - 8/14/22. Surveyor asked BOM C regarding former DON J's employment at the facility. BOM C stated, DON J was terminated from the facility on 5/3/22 due to unprofessionalism with staff and concerns regarding job performance. Surveyor asked BOM C if she is aware of any staff members swearing at residents. BOM C stated, she heard hearsay regarding DON J using profanity with a resident (R1) but was also told this was a resident that could kid around. Surveyor asked BOM C, what is the resident's name. BOM C stated, (R1's name). Surveyor asked BOM C do you know when this incident occurred. BOM C stated, she does not have any idea of the date. BOM C stated this occurred when the former NHA was still at the facility. Surveyor asked BOM C is there a soft file, documentation, or any follow-up up related to this allegation. BOM C stated, no. Surveyor asked BOM C who shared this information with you. BOM C stated, it was so long ago she doesn't remember who told her about it. Surveyor asked BOM C if a staff member swears at a resident what is that considered. BOM C stated, It's probably abuse. Surveyor asked BOM C who is the grievance officer. BOM C stated, the NHA. Surveyor asked BOM C, did anybody follow up regarding this allegation. BOM C stated, No. Surveyor asked BOM C, should this allegation have been followed-up on. BOM C stated, Yes. On 8/17/22 at 12:00 PM, Surveyor spoke with NHA A (Nursing Home Administrator). NHA A started working at the facility on 8/15/22. Surveyor asked NHA A, do you have a soft file, documentation, or any follow-up regarding this incident. NHA A stated, no. Surveyor asked NHA A, what is your expectation for allegations of abuse. NHA A stated, staff need to report that to whoever is in charge immediately. Surveyor asked NHA A, should this incident have been reported immediately to the former NHA (Nursing Home Administrator). NHA A stated, yes.

Based on interview and record review, the facility did not ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (R1). The facility was aware R1 was being transferred by family and did not provide the supervision necessary to help prevent accidents which resulted in a fall with major injury. Findings include R1 was admitted to the facility on [DATE] and had diagnoses that included dementia and coronary [CONDITION(S)]. Her most recent MDS (Minimum Data Set) shows a BIMS (Brief Interview for Mental Status) score of 3, which indicates R1 was severely cognitively impaired. Upon admission to the facility, R1 was prescribed [MEDICATION(S)] (Apixiban) for coronary [CONDITION(S)] and, according to facility records, had taken it twice per day regularly until she left the faciity on [DATE]. R1 was assessed as a fall risk upon admission. Her care plan states, as of 5/29/21, that she requires an assist of 2 for all transfers. On 6/30/21, R1 experienced an unwitnessed fall. A facility note documents, At 1703 (5:03PM) resident's call light was alarming and son came out of room stating his mom was on the floor. When entering the room resident was sitting on floor outside of bathroom with back facing the bathroom door and approximately 1 foot away from door. Walker was next to the tv sitting sideways. Wheelchair was in front of the tray table with supper tray on it not touched. Bed mat on floor next to bed with tray table pushed up to edge of mat. Resident's right leg was straight and left leg was rotated outward and slightly bent at knee. Resident was complaining of pain in left hip/upper leg area. Writer called RN in to also assess. Decided to call 911 to have evaluation and treat at the hospital. Writer was holding resident up from behind and son was in the bathroom with hand on resident's back. Resident kept making comments that she should not have fallen. Son kept making comments while writer and other nurse was in the room of how he should have left her in the wheel chair so she didn't fall. Resident exited facility by ambulance at 1735 (5:35 PM). The admission note from the local ED (Emergency Department) states that, according to a nurse at the nursing facility, R1 sustained a fall when her son was attempting to help her transfer to the restroom. X-rays were taken and R1 was found to have a fracture of the proximal left femur. R1 was transferred to another hospital on 6/30/21. On 7/1/21, a PA (Physician's Assistant) in orthopedic surgery noted the nature of the fracture to be unstable in nature and the risks of not performing surgery were greater than the risks of surgically repairing the fracture. The facility's post fall investigation highlights the following: *The fall was unwitnessed, but the facility believes R1's son was a witness to the fall. *R1's son later told the facility that he left the facility and when he returned he found his mother (R1) on the floor. The facility documents that nobody saw R1's son leave, he would have been screened in twice if he entered the building twice, and the door was locked and would have needed assistance to get back in. *Prior to the fall on 6/30/21, multiple facility staff had witnessed R1's son transferring R1 on his own without asking for assistance. *Staff stated they had seen R1's son out in the parking lot of the facility consuming beverages out of a [NAME]. *R1's son may have a cognitive deficit. The investigation states, R1's APOA notified administrator and social services director multiple times that her brother (R1's son), is a developmentally disabled adult, which could contribute to the repeated directions from staff to request assistance when resident desires to be transferred and is ignored by R1's son. *The facility initially expected R1 to return to the facility and the post fall intervention, which was also placed on R1's comprehensive care plan and CNA (Certified Nursing Assistant) care plan, reads, Pad alarms placed in resident's wheelchair and recliner to alert staff when family members attempt to transfer her without requesting assistance with the staff. *The investigation concludes by stating, Based on the investigation, it is reasonable to believe the son may have tried to assist with the resident's transfer given the information that was collected. On 7/20/21 at 12:30 PM, Surveyor interviewed R1's son, FM D (Family Member). FM D stated he came to the facility around 3:00 PM on 6/30/21 and then left at 4:00 PM. FM D stated he then returned at 5:00 PM. When asked if the door is always locked at the facility when he visits, FM D stated it is always locked, but he could not remember the staff who let him in at 5:00 PM when he returned, nor could he provide a description of the staff member. On 7/20/21, Surveyors interviewed the following staff: 11:00 AM, LPN D (Licensed Practical Nurse) is the nurse who initially reported to the scene of the fall and confirmed that FM D had made the statement, I shouldn't have moved her from her chair. 12:15 PM, CNA F stated she never saw FM D transfer R1 by himself but the nurses in the facility had told her (CNA F) prior to the fall on 6/30/21 (exact date and time unknown) to make sure R1's family doesn't perform any transfers without staff present. 12:41 PM, RN G (Registered Nurse) stated she was the nurse working the PM shift on 6/30/21 and assessed R1 after she had fallen. RN G stated she was aware FM D had transferred R1 by himself and the facility had educated FM D in the past about performing transfers by himself without staff knowledge. RN G stated she had not witnessed FM D transferring R1 in the past, but had, on other days, walked past R1's room and observed R1 in different locations in the room knowing that no other staff had been in to assist R1. RN G also stated she had been sitting at the nurse's station at the time of the fall and she would have noticed if FM D left the building as the nurse's station is close to the entrance. RN G stated she did not see FM D leave or re-enter the building. Additionally, RN G stated she believed FM D to have some sort of disability as he did not seem to understand why the facility was telling him not to conduct transfers alone or other issues she had observed, such as opening windows when specifically told not to do so. 1:04 PM, CNA H stated that on one occasion (unsure of the exact date), FM D had been in the building without wearing a facemask, so she went into R1's room to notify him that he needed to wear a mask. When CNA H entered, she witnessed FM D in the act of lifting R1 out of her recliner by himself. Upon seeing CNA H enter the room, FM D then placed her back in her recliner. CNA H stated she didn't say anything to FM D specifically about the transfer and she did not tell any other nursing staff about the incident as she was unsure as to if FM D was allowed to conduct the transfer himself. CNA H stated she did tell the facility about the incident when she was questioned as part of the 6/30/21 post-fall investigation. 1:33 PM, CNA I stated on one occasion a few days before the 6/30/21 fall (unsure of the exact date), she answered the call light for R1's room and when she arrived, R1 was in the bathroom with FM D. CNA I stated no staff had assisted R1 to the bathroom and FM D stated he had moved her to the bathroom himself but needed some help getting her out. CNA I stated she told a nurse about the incident, but could not remember the name of the nurse she talked to. CNA I stated the nurse talked about some sort of risks and benefits for the son, but she (CNA I) was unsure what happened after that. In addition, CNA I wrote a statement during the 6/30/21 post-fall investigation that read, I had entered the room at 4:50 PM to pass trays. Resident was in wheelchair, but I had left her in recliner after her shower. No CNA had transferred her from recliner at all. 1:35 PM, CNA K stated he witnessed FM D walking R1 to the bathroom by himself. CNA K stated that he offered to help at that moment and FM D agreed. CNA K stated R1 had just been toileted by staff prior to the incident. 1:36 PM, CNA J stated that every time FM D was at the facility he would transfer R1 by himself and had witnessed it on multiple occasions. CNA J also witnessed one of R1's daughters transferring R1 by herself. According to CNA J, the daughter told CNA J that she knew she should not be transferring her (R1). CNA J stated she then told the daughter to let staff do the transfers. The facility was unable to provide any details or documentation of these incidents or any education or follow up for either the staff or the family. No staff were able to provide details on when they observed the transfers by FM D or were aware of any additional approaches or interventions on how to monitor R1 or ensure FM D or other family was not continuing to transfer R1 alone. On 7/20/21 at 2:00 PM, Surveyor interviewed SSD C (Social Services Director). SSD C stated that before R1 was even admitted to the facility, the previous facility had told her (SSD C) FM D frequently transferred R1 without assistance. In addition, SSD C stated R1's APOA had told her (SSD C) before R1 was admitted FM D was developmentally disabled and had went as far as to say FM D had mental issues. Also, SSD C stated FM D absolutely had cognition issues. During this conversation, NHA A (Nursing Home Administrator) stated she had started a risks and benefits form for the family on 7/1/21, but had not finished it. On 7/20/21 at 2:30 PM, Surveyor interviewed DON B (Director of Nursing). DON B stated that although she never witnessed FM D transferring R1, she (DON B) had been notified on multiple occasions that R1 had been moved without the assistance of any staff. DON B stated that she had had phone conversations with the family about not transferring R1 without assistance but did not have any documentation and was not specific on when this occurred. Additionally, DON B stated the chair alarms put into place after R1's 6/30/21 fall would have been beneficial before 6/30/21 in notifying staff when R1 was being transferred by family. DON B told Surveyor there had been no additional plan as to how to monitor or supervise FM D or any other family member to prevent further attempts to transfer R1. R1's care plan does not address her family or FM D providing cares or transfers without staff present. The facility was aware that R1 was a fall risk, required extensive assistance, and R1's family repeatedly transferred her inappropriately despite repeated verbal cues to wait for staff assistance. The facility did not create a plan of care or ensure appropriate supervision of R1 to address the family's frequent attempts to transfer R1 alone. R1 was transferred by FM D which resulted in a fall with fracture.

Based on observation, record review, and interview, the facility did not ensure, based on a comprehensive assessment of a Resident, that a Resident receives care, consistent with professional standards of practice, to prevent pressure injuries and does not develop pressure injuries unless the individuals clinical condition demonstrates that it was unavoidable and a Resident with pressure injuries receives necessary treatment and services to promote healing, prevent infection, and prevent new ulcers from developing for 1 of 1 Residents (R3) with pressure injuries out of a total sample of 11. R3 developed a stage 2 - pressure injury (PI) to her right hip, left heel, and an unstageable pressure injury to her right sacral region, after experiencing a significant weight loss. Interventions were not put into place until PI's were already developed. This is evidenced by: The Role of Nutrition in Pressure Ulcer Prevention and Treatment: National Pressure Ulcer Advisory Panel White paper, Dated 2009, states in part: .Nutrition and Pressure Ulcers, although limited evidence - based research is available, general consensus indicates that nutrition is an important aspect of a comprehensive care plan for prevention and treatment of [REDACTED]. Adequate calories, protein, fluids, vitamins, and minerals are required by the body for maintaining tissue integrity and preventing tissue breakdown .compromised nutritional status such as unintentional weight loss, undernutrition, protein energy malnutrition (PEM), and dehydration deficits are known risk factors for pressure ulcer development (1, 18). Other nutrition - related risk factors associated with increased risk of pressure ulcers include low body mass index (BMI), reduced food intake, and impaired ability to eat independently .poor outcomes are associated with undernutrition including the risk of morbidity and mortality, hence the need to quickly identify and treat undernutrition.The type and amount of food/fluid ingested daily should be reviewed periodically to ensure the individual actually ingests enough calories based on estimated needs. It is also important to examine the reasons for the intake being decreased. Oral nutritional supplements, enhanced foods, and food fortifiers can be used to combat unintended weight loss and undernutrition . The facility policy entitled, Pressure Ulcer Prevention & Treatment, dated 04/04/2016, states in part: 1.1 Based on the comprehensive assessment of a resident/patient, the center must ensure that - 1. A resident/patient who enters the center without pressure ulcers does not develop pressure ulcers, unless the individual's clinical condition demonstrates that they were unavoidable; and 2. A resident/patient having pressure ulcers receives necessary treatment and services to promote healing, prevent infection, and prevent new ulcers from developing ., 2.1 the intent of this policy is that the resident/patient does not develop pressure ulcers unless clinically unavoidable and that the center provides care and services to: Promote the prevention of pressure ulcer development, promote the healing of pressure ulcers that are present ; and prevent development of additional pressure ulcers.3.3 Braden scale, for predicting pressure ulcer risk factors, will be completed within eight hours of admission, weekly for the first four weeks after admission, then quarterly and with any significant change of condition .3.5 Please refer to Policy number FS-32/A for Nutritional Component. The facility policy entitled, Wound protocol - Recommended Dietary Interventions for Pressure Ulcers, (policy FS - 32/A), dated 12/01/07, states in part: Research supports an association between malnutrition and pressure ulcer development and a strong relation between nutritional status and ulcer healing. Example 1: R3 was admitted to the facility, on 02/09/2017, and had [DIAGNOSES REDACTED]. 3/6/17 R3 weighed 104 lbs. 4/10/17 R3 weighed 101 lbs. 5/1/17 R3 weighed 102.0 lbs. 5/8/17 R3 weighed 98.0 lbs. 5/15/17 R3 weighed 96.0 lbs. 5/22/17 R3 weighed 93.0 lbs. 5/29/17 R3 weighed 89.0 lbs. 5/30/17 R3 weighed 87.0 lbs. 6/1/17 R3 weighed 84.0 lbs. and was admitted to Hospice on 6/2/2017. 6/12/2017 R3 weighed 83.0 lbs. Between 5/1/17 and 5/31/17, R3 ate 50% or less of meals for 50 out of 93 meals, which is over half of R3's meals where she consumed 50% or less of her small portions. Resident had a severe weight loss in May of up to 4 - 5 pounds every one to two weeks for a total of 18 pounds in a month. R3's weight decreased from 102 lbs., on 5/1/17, to 84.0 lbs., on 6/1/17, that is a 18 - pound or 17.64% weight loss. Also during this time, R3's estimated daily fluid needs were to be between 1295ml to 1511ml a day. R3 hit her fluid needs 4 out of 31 days in the month of May. During this time frame, no new interventions are implemented to prevent weight loss or lessen R3's weight loss. 06/07/2017, at 2:45 PM, Focus note states, in part: physical functioning: Assist x2 staff for cares and transfers. She is able to self propel her wheelchair around facility. Resident has not been ambulating. Nutrition/Hydration: weight 84# .Meal intake 26-50% fluid intake 600 -1000cc . R3's weight loss put her at greater risk for pressure ulcer development. Nevertheless, her Braden assessments on 6/8/17 and 6/12/17 showed a score of 18, slight risk. R3's significant change MDS, dated [DATE], indicates R3 has a BIMS of 09, which indicates moderately impaired cognitive function. This MDS also indicates R3 continues to need extensive 2 person physical assist with bed mobility, transfers, and ambulation. R3 needs extensive physical assistance of 1 with meals and R3 does not have a lower extremity impairment at this time. This MDS also indicates R3 does not have pressure injuries at this time, but continues to be at risk for pressure injuries and that R3 has had weight loss without a physician prescribed regimen. R3's care plan indicates the following, with respect to skin integrity indicates: 2/9/17 - administer meds/vitamins as ordered. 2/12/17 - keep skin clean and dry. Use lotion on dry skin as ordered/desired/needed. 4/14/2017 - monitor soaker pad placement is correct as patient allows. 06/11/2017 - offer to lay down after meals. R3 developed three pressure injuries, beginning 6/12/17, as follows: Right Buttock Stage 2 6/12/17 - right buttock stage 2 (Length) 1.2 x1.2 (Width) x0.1 (depth) centimeters Facility revised R3's care plan to include an alternating air pressure mattress for bed. (Prior mattress recommended for prevention and treatment of [REDACTED]. 6/12/2017 - ROHO cushion for wheelchair 6/19/17 - right buttock stage 2 measured 0.3 x 0.5 x 0 cm 6/26/17 - right buttock stage 2 measured 0x0x0 cm - identified as closed 7/3/17 - right buttock stage 2 measured 0x0x0 cm - identified as closed 7/10/17- right buttock stage 2 measured 0x0x0 cm - identified as closed 7/17/17- right buttock stage 2 measured 0x0x0 cm - identified as closed On 7/7/17, R3 was sent to the ER (emergency room ) related to a fall and had a CT scan performed and sent back to facility. Right Sacral wound unstageable 7/9/2017 - 4 x 5 x 0 identified as a Deep tissue injury On 7/9/17, R3 was noted to have reddened area to right buttock measuring 4 cm x 5 cm area slight purple discoloration and was blanchable. (Right buttock is referring to sacral wound). Facility revised the care plan to include Reposition to left side and back as resident allows (Intervention placed on care plan after R3 had already developed an area to right sacral region) On 7/10/17, area measured 3 cm x 2.5 cm with small scabbed area to distal end of reddened area. This area looked to be shearing. Intervention to lift with slip sheet off bed with repositioning. Facility revised the care plan to include: Resident will at times reposition self. Slide sheet for repositioning, lifting off bed. On 7/14/17, physician returned update with order for skin prep and to continue to monitor. 7/16/20 - 3 x 2.5 x 0.1 remains identified as a deep tissue injury with 100% open area covered with black/brown scab like tissue, periwound bright red and blanchable, worsening (TX cleanse wound, skin prep surrounding tissue, apply [MEDICATION NAME] and a [MEDICATION NAME] dressing every three days). On 7/17/17, R3 noted to have blackened area measuring 2 cm x 2 cm x 0.1 cm in center of upper reddened area (right sacral wound). Periwound blanchable. Area cleansed, skin prepped, [MEDICATION NAME] to wound bed and [MEDICATION NAME] placed over area. Duoderm placed to lower area for protection. Area continues to be blanchable (right buttock area). On 7/18/17 physician okayed order for [MEDICATION NAME] and [MEDICATION NAME] to area. 7/19/2017 - Care plan revised to include Risk and Benefit completed with POA on resident repositioning self 07/23/2017 - 2 x 2 x 0 identified as unstageable, slough present- sloughy with tan tissue noted throughout. 07/24/2017 - Care plan revised to include Reposition resident every 1.5 hours (Please note no prior repositioning schedule noted on R3's care plan) Left foot/heel Blister 07/01/2017 - Care plan revised to include leg protectors as the resident will allow 07/13/2017 - 8.5 x 7.5 x 0 identified as a stage 2 - blister filled with serous (clear yellow tinged) fluid, periwound bright red/blanchable On 7/13/17, large blistered area to medial aspect of left heel. Area filled with clear serous fluid, measuring 8.3 cm x 7.5 cm. immediate care plan intervention was to remove socks while in bed, float heels on pillows and to place pillow between legs to prevent heels from touching due to R3 rubbing feet together and causing possible shearing. Treatment skin prep area and heel twice daily Facility revised the care plan to include float left heel when in bed. Place pillow between legs to keep feet from rubbing together. (This intervention was placed on R3's care plan after development of stage 2 to heel) On 7/18/17, left heel area opened, order changed to skin prep and cover with non-adhesive pad and wrap with gauze wrap. 07/19/17 - left heel area reassessed and found to be a stage 2 pressure injury, Heel boots put into place to protect and prevent further breakdown. Care plan was revised to include: Heel boots to bilateral feet while in bed. (No prior interventions to float heels noted on R3's care plan prior to 7/13/17) 07/20/2017 - 8.5 x 7.5 x 0 - stage 2, blister no longer intact, fluid drained 07/24/17 - 9 x 7 x 0 - stage 2, blister area opened with dermal tissue, 2 small areas of eschar noted 0.3cm x 1 cm to ankle bone and 0.7 cm x 0.9 cm to side of foot on 1st metatarsal bone, moderate amount of serosanguineous drainage. Identified as worsening Right Hip stage 1 07/24/2017 - 0.4cm x 3 cm x 0 cm - identified as a stage 1. 07/20/2017, physician note states, in part: .staff does note that she has had a couple of skin issues since she was taken to the ER for a fall around 07-13-17 .Since then, she has had a skin sore on her sacral spine that is being treated with dressings and [MEDICATION NAME]. She also has small skin breakdown on the right hip . I also note she has had a serous blister on her left ankle likely from her ankles resting together. She is very active and moves about in her bed so positioning for pressure relief is difficult, and she will move herself into her own desired position after positioning .she does have some dry mucous membranes and thickened secretions .on her lower back, she does have about a 2 cm round ulcer consistent with deep tissue damage possibly from transfers occurring in her trip to the hospital and multiple transfers through EMS and hospital and CT scan .Right hip has small superficial skin breakdown, less than 2 cm area. Left ankle: she has a large area on the medial malleolus area and recently had a serous blister that has spontaneously ruptured . 2. Dementia. Seems to be worsening and permitting her from interacting normally, eating well, or taking medications . On 7/21/17, IDON B signed Risk and Benefit form, with R3's POA, dated 07/19/2017 @10:35 AM, which indicates the following: Repositioning patient every 2 hours off open areas to prevent further breakdown. Resident will move from recommended position to a position of comfort on right side .Open areas potentially worsen, which could lead to infection and/or death, spoke with activated POA over the phone and she stated understanding. (please note this was done after R3 has already developed an unstageable to right sacral area, Stage 2 to right buttock/hip area and stage 2 to left heel.) 07/24/2017, at 12:30 PM, Surveyor observed R3's wound care being performed by IDON B and RN M. R3's left heal measured 9 cm x 7 cm with two eschar areas measuring 0.3 cm x 1 cm and 0.7 cm x 0.9 cm. IDON B indicated left heel wound edges were macerated and more odorous with yellow green ting drainage in moderate amount on old dressing. Duoderm on right hip had a wrinkle present, when IDON B removed duoderm, new area present on R3's right hip. IDON B indicated area is a stage 1 measuring 0.4 cm x 3 cm. Right sacral unstageable observed, periwound inflamed and red, tan slough throughout wound bed and measuring 2 cm x 2 cm, no depth. 7/25/17 - fax sent to physician states: due to Residents continued decline in condition may we have statement that current skin breakdown is unavoidable? Physician response: Due to patients current condition and progressive decline, current skin breakdown is unavoidable. On 07/26/17, at 5:00 PM, Surveyor interviewed IDON B regarding R3's PIs. IDON B indicated R3 had a regular mattress prior to alternating pressure mattress. IDON B indicated floating heels is part of the facilities practice, but wasn't in R3's care plan to do it, but can't say CNAs weren't doing it. IDON B indicated as soon as heel injury occurred, CNAs had to float heels. IDON B indicated staff tried to reposition as much as possible, as R3 was difficult to reposition, as she would reposition herself a lot. IDON B indicated Risk and Benefits not done right away due to stage 2 resolving, then developed other areas. IDON B indicated everyone has a wheel chair cushion and that R3 had a cushion prior to 6/12, unable to tell Surveyor what type of cushion R3 had. IDON B unable to verify what stage PI R3's Posey boots can be used for.

Based on record review and interview, the facility did not ensure residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range, unless this is not possible for 2 of 5 Residents reviewed for weight loss (R3 & R11 ) of a total sample of 11 Residents. R3 had a significant weight loss between [DATE] and [DATE]. During that time, the facility staff failed to identify the weight loss while it was occurring, failed to consult and update the physician, failed to consult the Registered Dietitian, and failed to implement interventions while R3 was losing weight. The facility did not intervene until R3 had experienced a significant weight loss of 18 pounds. R11 had a significant weight loss of 8 pounds/5.3% between [DATE] and [DATE] and 16 pounds/10.6% between [DATE] and [DATE]. There is no evidence the facility monitored R11's intakes, as stated in R11's care plan. There is no evidence the facility followed thru on RD C's recommendations to weigh R11 weekly, switch milk to whole milk at meals, and offer nutra juice with breakfast, ice cream, pudding, cookies, etc for snacks. There is no evidence RD C followed up with resident and need for further nutritional intervention until [DATE]. This is evidenced by: The facility policy entitled, Resident/Patient Heights and Weights, (no date) states, in part: All residents and patients will be weighed upon admission and as the policy directs to provide a baseline and ongoing record for monitoring stability of weight as an indicator of nutritional status and medical condition over a period of time. Nursing department staff and Dietitian will cooperate to prevent, monitor and intervene for undesirable weight variances for our residents and patients .Procedure .2. Upon day of admission, the nursing department staff will weigh resident on the appropriate scale .weekly thereafter for 4 weeks and then monthly unless otherwise ordered by the physician or recommended by the Dietitian. 3. Frequency of subsequent weights will be determined by the Dietitian in cooperation with the Interdisciplinary team or by the Physician, based on Residents medical condition. Weight frequency will be scheduled in Tasks in the EMR and documented in the Nutritional Care plan. 4. Weight will be documented in the EMR .5. Weekly or daily weights are recommended if any of the following are present: a. sudden, unplanned weight loss. b. significant unplanned weight loss in 30 days. c. decreased meal intake for a period >48 hours. d. gradual, unplanned weight loss over multiple months .7. Any weight change of 5 pounds or greater within 30 days will be retaken within 24hrs. for verification .8. If re-weight verifies a significant, unplanned weight change, this is communicated in writing to the Resident's physician, POA, Dietitian and any others deemed necessary by the interdisciplinary team. This weight change will be assessed and reviewed by the Dietitian in cooperation with the interdisciplinary team and appropriate interventions will be implemented, reviewed and revised as needed. Care plan to be updated with interventions provided .14. In addition to above, Dietitian or designee will monitor triggered weight changes in the Weights and Vitals tab in the EMR and document progress notes to clear these alerts .Responsibilities: Dietitian monitors compliance with policy by ensuring accuracy of heights and weights and providing documentation as needed with significant weight changes. Updates care plan as appropriate .Dietary Manager in cooperation with Dietary and Interdisciplinary Team, ensure that care plan and tray card reflect current interventions for weight changes .Nursing Department ensures that weights are documented as scheduled and notifies Physician and Dietitian of significant, unplanned weight changes. Makes changes to Nutrition Care plan as appropriate . A Significant weight change is defined as a 5% weight change over 30 days, 7.5% weight change over 90 days or a 10% weight change over 180 days. Example 1 R3 was admitted to the facility, on [DATE], and had [DIAGNOSES REDACTED]. R3 weighed 91 pounds upon admission. R3's nutritional care plan indicates as follows: Resident has potential problem related to acute kidney failure, [MEDICAL CONDITIONS], and GERD. The following interventions are indicated: [DATE] - Diet texture general, diet type regular. Fluids thin [DATE] - provide adaptive utensil [DATE] - prompt/cue to eat [DATE] - weight at same time of day and record [DATE] - see tray card for specific food preferences. [DATE] - give small portions [DATE] - provide Ensure plus (8oz) for a 2pm snack, and V-8 juice (5.5oz) for 10 am snack [DATE] - provide nutritional supplement with med pass [DATE] - Eats in dining room [DATE] - bell at place setting on dining room table, if needs help she can ring the bell for help. [DATE] - Eating Assist one, (R3's eating independent from [DATE] - [DATE]) [DATE] - R3 weighed 91 lbs. [DATE] - R3 weighed 104 lbs. [DATE] 12:10 PM - R3 weighed 101.0 lbs. [DATE] 12:43 PM - R3 weighed 103.0 lbs. [DATE] - R3 was readmitted to facility after a 14 day inpatient stay at SBS. [DATE] 11:34 AM - Dietary note states in part: .Weight Warning Value: 103.0 .Resident was hospitalized , welcomed weight gain, will continue to monitor. [DATE] - order received to restart [MEDICATION NAME] 1 packet daily to promote wound healing. [DATE] 10:10 AM - R3 weighed 102.0 pounds [DATE] - morning meeting form indicates R3's weight is up to 102 pounds. [DATE], at 10:10 AM - Dietary note states, in part: .Weight warning: Value: 102.0 .increased [MEDICAL CONDITION]. [DATE] 1:59 PM - R3 weighed 98.0 pounds (compared to weight on [DATE] of 102.0, a 4 pound or 3.9% weight loss in 7 days. No documentation of new intervention being initiated, no physician, RD, or POA notification.) [DATE] - morning meeting form indicates R3 is down to 98 pounds and staff is aware. [DATE], 12:33 PM - progress note indicates R3 was seen by physician and no changes were made. Does not indicate if physician reviewed weights. [DATE] at 06:53 - R3's Hydration Risk Eval and Assessment indicates: R3 has cognitive impairment, poor decision making, usual fluid intake less than 1200 cc per day, dependent on staff for fluids, receives scheduled laxatives daily, and has a low BMI. Summary: Resident is legally blind, relies on staff to provide fluids. Staff encourages resident's fluid intake. Section for physician notification, family/health care agent notification, and Dietary Manger/Dietitian notification are blank. [DATE], 6:53 AM - Nutritional Risk Evaluation done by LPN H indicates R3 is able to feed self with staff set up and assist. [DATE], 1:59 PM - R3 weighed 96.0 lbs. (compared to weight on [DATE], shows 7 lbs. or 6.8% weight loss in 22 days, or since [DATE], R3 lost 6 lbs. or 5.88% in 14 days from R3's stabilized weight, which represents a severe weight loss. No documentation of new intervention being initiated, no physician, RD, or POA notification.) [DATE], 3:29 PM - R3's Quarterly Dietary Screening, done by DM D, indicates the following: most recent weight 96.0, on [DATE], no recent unplanned weight change, no [MEDICAL CONDITION], current diet no salt packet, general diet and usual appetite is ,[DATE]%. R3 is not on a fluid restriction and average fluid intake is less than 1200 mls. This screening also indicates R3 prefers small portions and that she received Ensure 8oz daily and mighty shake 4oz daily, and that R3 needs limited assistance with eating. This screen also indicates R3 uses a lipped plate with dark placemat, and that R3 has open wounds that are not pressure injuries. Pertinent medications: [REDACTED]. Summary: Quarterly screen: .MNA score of 8 indicates resident is at risk of malnutrition . R3's Quarterly MDS assessment, dated [DATE], indicated that R3 had a BIMS of 13, indicating she was cognitively intact. This MDS showed R3 is at risk for PI development and had no current PI's. R3 was indicated to have had weight loss without being on a physician prescribed regimen. MDS also indicates that R3 needs extensive 2-person physical assistance in bed mobility, transfers, and ambulation and has impairment to one side of her lower extremities. It also indicates that R3 was independent after setup assist with meals. (Please note it's marked on R3's MDS that she had a weight loss without a physician prescribed regimen, therefore the facility identified R3 as having a weight loss, yet there is no documentation that any new interventions were put in place to counter act R3's weight loss. There is no documentation to show that the RD or physician was notified) [DATE], 1:59 PM, R3 weighed 93.0 lbs. (Compared to [DATE]'s weight of 103.0. R3 has lost 10 pounds or 9.70% in approx. (approximately) one month, 5 pounds or 5% in 2 weeks and has lost 9 lbs. or 8.82% since [DATE]. No documentation of care plan evaluation or new interventions being initiated, no physician or RD notification, no re-evaluation of nutritional needs documented.) [DATE] - morning meeting form indicates R3 is within her goal range. [DATE], 1:42 PM - R3 weighed 89.0 lbs. (Since [DATE], R3 has lost 13 pounds or 12.74%, and in one week R3 has lost 4 pounds or 4%. There is no documentation of care plan evaluation, implementation of new intervention, physician or RD notification or re-evaluation of nutritional needs.) [DATE] - morning meeting form indicates R3 is down for a re-weight. (Facility is aware R3's weight has decreased but there is no documentation of physician notification or RD notification as well as no documentation of care plan review or revision.) [DATE], 11:50 AM - R3 weighed 87.0 lbs. (Since [DATE], R3 has lost 15 lbs. or 14.70% with no documentation of new interventions being initiated, physician or POA notification.) [DATE], 08:52 AM - Dietary note states, in part: .Weight Warning: Value 89.0 .re-weight requested. (There is no indication that a re-weight was taken.) (Please note, no documentation was provided to Surveyor to show that R3 received mighty shake or Ensure supplements during the month of [DATE].) Between [DATE] to [DATE], R3 ate 50% or less of meals for 50 out of 93 meals, which is over half of R3's meals. R3's weight decreased from 102 pounds, on [DATE], to 84.0 lbs., on [DATE]. This is an 18 lb. or 17.64% weight loss. During this time frame, no new interventions were implemented to prevent weight loss or lessen R3's weight loss. All interventions were placed reactively after R3 had already lost 18 lbs. or 17.64%, since [DATE]. In addition, there is no documentation of an RN assessment regarding R3's weight change during this time period. [DATE] - Morning meeting form indicates R3 is down for update on weight. A Fax was sent on [DATE] to update R3's physician on Patient weight today was 84 lbs. when weight was completed on [DATE] 87lbs. Weight list sent. Weight goal is currently ,[DATE] lbs. Currently receiving [MEDICATION NAME] once daily to help with her wound healing. Eats regular portioned meals and eats ,[DATE]% but does eat ,[DATE]% on occasion. Also refuses meals at times. Accepts snacks. (Please note, although a weight list was sent, the fax does not identify that R3 has lost 18 lbs. in the last month or that she is down 17.64% of her body weight.) [DATE], 9:06 AM - R3 weighed 84 lbs. (R3 has lost 5 lbs. in 2 weeks or 5.6% and R3 has lost a total of 18 lbs. or 17.64% of her body weight in one months' time, no re-evaluation of nutritional needs, no care plan re-evaluation or revision.) [DATE], 5:18 PM - progress note states, in part: (physician name) reviewed weights. No change at this time due to hospice consult ordered . [DATE] - R3 becomes Hospice [DATE], at 5:32 PM - weight change note states, in part: .Warning weight: Value 84.0 .RDN Note: Resident triggered for an 18# or 17% weight loss in one month. Resident weighed 102#, on [DATE], with most recent weight of 84#, on [DATE]. Recommendations include weight to be completed to confirm weight loss, noted weight trending down on ,[DATE] and ,[DATE]. Current weight is 15.9 or underweight category. She has no [MEDICAL CONDITION] present and she has a skin tear and wounds on her lower left leg and a healing wound on her right leg. Resident admitted to Hospice on [DATE] with a comfort focus. Meal intakes have declined to an average of ,[DATE]% of small portioned meals. She currently receives a 4 oz might shake once daily with med pass and an 8 oz Ensure plus snack. Recommend increasing to a 4 oz might shake BID with med pass as accepted dt (due to) significant weight loss over the last month. RD will monitor and make recommendations as deemed fit. [DATE], at 2:45 PM - Focus note states, in part: physical functioning: Assist x2 staff for cares and transfers. She is able to self-propel her wheelchair around facility. Resident has not been ambulating. Nutrition/Hydration: weight 84# .Meal intake ,[DATE]% fluid intake [PHONE NUMBER]cc. [DATE], at 08:30 - Nutritional Risk Evaluation, done by LPN H, indicates R3 had unplanned weight lost of 5% in 30 days or 10% in 180 days and also indicates R3 is able to feed self with staff set up and assist. R3's significant change MDS, dated [DATE], indicates R3 has a BIMS of 09 which indicates moderately impaired cognitive function. This MDS also indicates R3 continues to need extensive 2 person physical assist with bed mobility, transfers, and ambulation. R3 needs extensive physical assistance of 1 with meals and R3 does not have lower extremity impairment at this time. This MDS also indicates R3 does not have PIs at this time but continues to be at risk for PIs and that R3 has had weight loss without a physician prescribed regimen. [DATE], 10:51 AM - R3 weighed 83.0 lbs. [DATE], at 1:31 PM, Nursing note states: Resident will trial a 3 day mechanical soft diet due to ill-fitting dentures. [DATE] - R3 develops a stage 2 PI to her right hip. [DATE], at 9:14 AM, progress note states, in part: Dr. (physician name) was here to see Resident . [DATE], at 10:24 AM - weight change note states, in part: Weight warning: Value 83.0 .added mighty shakes BID for weight loss. [DATE], at 10:36 AM - Progress note states, in part: .Nutritional assessment/screening summary: RDN review - significant change in condition: Resident was admitted to hospice care on [DATE]. Diet order remains a regular diet with no added salt, regular texture, and thin liquids. Weight has significantly declined over the last month from 102#, on [DATE], to 84# on [DATE], which indicates an 18# or 17.6% weight loss in the last month. Current BMI is 15.7 or underweight category, she is below her baseline goal weight of ,[DATE]#. Meal intakes have declined to an average of ,[DATE]% of small portioned meals. Mighty shakes were increased to BID with med pass along with and 8 oz Ensure plus for PM snack and [MEDICATION NAME] once daily for adequate calories and protein for weight gain and wound healing. Fluid intakes average between [PHONE NUMBER] cc per day according to documentation, noted one day was 1760 cc she recently developed a superficial stage 2 PI on her right buttock for which she is receiving nutritional supplements to aide with healing .continue with supplements and encourage oral intakes for adequate nutrition. RD will continue to monitor status. (No documentation was provided to Surveyor to show that R3 received mighty shake or Ensure supplements during the month of [DATE].) [DATE] - R3 develops an unstageable sacral ulcer [DATE] - R3 develops a stage 2 left heel ulcer On [DATE] - R3 expired On [DATE], at 12:35 PM, Surveyor interviewed CNA N. CNA N indicated that once a weight is obtained, she puts it in the computer, unless it's a re-weigh, then the weight is given to the nurse. CNA N indicated that, when putting a weight in the computer, only the computer on the wall will show one previous weight for a Resident. CNA N indicated to Surveyor that the weight has to be 5 lbs. different before needing a re-weight. CNA N indicated that the nurses go through weights and have the CNAs re-weigh. CNA N indicated that Nurses go through weights on the same day, weekly weights on Mondays, and the first of the month everyone is done. CNA N indicated that if a Resident's weight is off, only by a pound or two, she would not say anything because they're (nurses) going to look at them anyways. CNA N indicated the last time she weighed R3, R3 had a weight loss, could not remember when. CNA N indicated that CNAs would give supplements to R3. CNA N indicated nurses were aware R3 refused supplements. CNA N indicated she stopped telling the nurse about R3 declining supplements, but could not remember when that was. On [DATE], at 1:25 PM, Surveyor interviewed CNA O. CNA O indicated weights are put in the computer by CNAs and that nurses kind of watch for weight differences and tell CNAs when to get a re-weight. CNA O indicated she doesn't notice weight changes. CNA O indicated CNAs would give Ensure to R3 and that R3's meal intakes varied. Somedays, R3 would eat wonderfully and other days wouldn't. CNA O indicated she would notify the Charge Nurse when R3 didn't eat. CNA O indicated that R3 loved to refuse Ensure a lot. CNA O indicated she would report to Charge Nurse when R3 refused and let them deal with it. CNA O indicated, the last couple of months, R3 did not take her Ensure and that she reported it to whomever was on. CNA O indicated she would report meal intakes of ,[DATE]% and ,[DATE]%. On [DATE], at 1:50 PM, Surveyor interviewed LPN I regarding R3. LPN I indicated CNAs put intake information into computer and Dietary monitors it. LPN I indicated, that on a daily basis, the nurses do not check intakes and that sometimes CNAs will let them know if a resident didn't eat. LPN I indicated if weight is flagged, then Dietary reports needing re-weight in morning meeting. LPN I stated, It's not flagged on our computer system that we see. LPN I indicated she couldn't recall R3 not drinking supplements in May. LPN I indicated nurses gave R3 [MEDICATION NAME] and mighty shakes and that R3's Ensure would come out on the 2 PM snack cart. LPN I stated, no, indicating no CNAs reported supplement refusal to her. LPN I indicated CNAs have not reported meal refusal or decrease in meal intake to her. LPN I indicated R3's diet was not changed. LPN I stated, .did we think she was getting thin, yes, did not see that much of a weight loss, when asked if aware of R3 having weight loss in May. LPN I indicated R3 should have been placed on board for change of condition and expected physician to be notified. LPN I stated, yes, indicating nurses have access to weights. LPN I indicated she never reviews weights, only gets the re-weights. On [DATE], at 2:05 PM, Surveyor interviewed LPN H. LPN H indicated CNAs chart intakes or PM Nurses do, or whoever picks up trays or is assigned to the main dining room. LPN H indicated that DM D monitors refusals. LPN H indicated, that unless she is told, she doesn't know if a resident is refusing consistently. LPN H indicated she doesn't go into the charting to look for that. LPN H indicated nurses monitor supplements if they are in the MAR, otherwise, CNAs chart on supplements that come out on the snack carts. LPN H indicated DM D monitors snack intakes. LPN H doesn't recall R3 needing a diet change. LPN H indicated that DM D monitors weights when it flags and then lets us (nurses) know to re-weight; if weight still not good, then physician is updated. LPN H indicated CNAs don't notify nurses of weight changes as CNAs never know if there is a change. LPN H stated, No, indicating she was not aware R3 had weight loss in May and indicated R3 started to decline in May. LPN H indicated Ensure came out on snack cart and did not visually see R3 receive it. LPN H indicated [DATE] care plan change to 1 assist with meals is due to R3 couldn't see her food anymore. On [DATE], at 11:00 AM, Surveyor interviewed LPN H. LPN H indicated she was aware R3 refused supplements. LPN H stated, No, indicating she did not update the DM or RD of R3's refusal. LPN H indicated when R3 came back from SBS she did not have orders for supplements. On [DATE], at 1:35 PM, Surveyor interviewed RN M. RN M indicated that everyone monitors intakes and that during the meeting, in the morning, DM D indicates who's flagged; when she's the Charge Nurse they look at meal intakes; who flags regarding choking or meal intake problems. RN M indicated DM D and RD C talk about weights and intakes every morning meeting. RN M indicated that they become aware of refusal when CNAs notify us and supervisor in dining room. RN M indicated CNAs have a list of supplements to be given and are provided at certain times. RN M indicated DM D discusses weights in morning meeting . RN M could not recall if R3 was discussed in morning meeting. RN M stated, We all kind of do, when asked who monitors weights. RN M indicated she does not go in and check weights everyday unless a concern. RN M indicated daily weights are looked at daily, by DM D, due to being triggered and that DM D notifies nursing, unless CNA reports weights. RN M is unaware of getting weight triggers. On [DATE], at 12:55 PM, Surveyor interviewed RD C. RD C indicated oral intakes are checked after meals by CNAs and then put into chart. RD C indicated she and the DM monitor intakes based on nutritional needs. RD C indicated intakes are monitored when CNAs let nursing know of poor intake or if weight loss occurs. RD C indicated she looks at a Resident when asked to look at them or notice a trend in their diet. RD C indicated in the morning meeting, every week, they bring up intakes and weights; then look at those intakes and weights that are brought up and go through to see who triggers for weight loss. RD C indicated triggers means the weights and vitals tab will trigger if weight is a certain percentage, either 3%, 5%, or 10% weight changes from admit, last 30 days, or 180 days. RD C indicated the only other way she would know about a weight loss would be if someone notified her due to DM D monitors weights daily. RD C indicated not everyone will trigger, as it depends on how they are weighed daily, weekly, or monthly. RD C indicated the computer is the main trigger for weight loss for staff. RD C indicated she would expect staff to get physician and family involved if a resident consistently refuses meals or consumes less than 50% and expect staff to notify her. RD C expects staff to notify her if a resident refuses supplements. RD C indicated she was not aware of R3 refusing supplements. RD C indicated dietary supplements are given at meal times, unless Physician order [REDACTED]. RD C stated, Most definitely, indicating the weight loss for R3 should have been noticed., RD C stated, yes, indicating there should have been interventions during R3's weight loss and that RD C expected the physician to be notified. [DATE], at 10:38 AM, Surveyor interviewed DM D regarding R3's weight loss. DM D indicated a weight change note was done, on [DATE], by the RD due to triggering. DM D can't recall R3 triggering for her weight loss. DM D indicated intervention should have been put in place, prior to [DATE] RD note. DM D indicated that unplanned significant weight loss is 5 lbs. or greater in 30 days. DM D stated, yes, indicating that R3's weight loss is considered a significant weight loss. DM D indicated she overheard that R3 would refuse Ensure and [MEDICATION NAME] at times and would expect refusals to be documented. DM D indicated she expected to be notified of supplement refusals, as she would then refer to RD for recommendations. DM D stated, no, indicating no one reported R3's supplement refusals to her. DM D indicated CNAs put weights in and Nurses will sometimes, if a re-weight. DM D indicated she also documents weights. DM D indicated she looks at weights on a daily basis, looks at flags in the weight and vitals tab, which triggers if weight loss or gain. Triggers occur if percentage is enough to make a difference of 3%, 5% or 10%. It will flag and the RD helps monitor weights on site and off site. DM D stated R3 dropped in May then slowly continued. RD M stated, It should have flagged and we should have looked at updating the doctor. DM D indicated she did not see a weight change note in the progress notes, after [DATE], and indicated if R3 was flagging, would have taken it to Quality Assurance meeting in the morning daily meeting and let nurses know. DM D indicated she couldn't see any weight loss that would have flagged (while looking in R3's chart). DM D indicated R3 was on weekly weights due to [MEDICAL CONDITION]. DM D stated, yes, indicating she expects nurses to update physician with weight loss. On [DATE], at 2:30 PM, Surveyor interviewed NHA A, IDON B, RD C, MDS K, and CC J. NHA A indicated CNAs and Nurses document meal intakes. IDON B indicated CNAs document meal intakes and we do assessments based on documentation. CC J indicated DM D and RD C monitor meal intakes. IDON B indicated to re-approach and offer something else and update physician, if refusing, with how often refusing meals. IDON B indicated [MEDICATION NAME] is given by the nurse, as well as mighty shake, and snacks are documented by CNA. MDS K indicated refusals to be reported to nurse, nurse to try and monitor, as well as document refusal and tell Dietary. IDON B indicated DM D monitors weights and RD C indicated she also monitors weights. NHA A indicated weights are monitored daily during QAPI. MDS K indicated nurses should monitor weights and that she doesn't get flagged like Dietary does. IDON B indicated she was not aware R3 wasn't taking supplements prior to becoming Hospice, only aware after became Hospice. MDS K indicated she was not aware R3 had a 18 lb. weight loss. RD C indicated she was aware of the 18 lb. weight loss, as of ,[DATE], otherwise was not aware of weight loss, between ,[DATE] - [DATE], and RD C was not aware R3 was not taking supplements. NHA A indicated that DM D should monitor weights. CC J indicated weights should be monitored by a combination of nursing, dietary and herself. CC J indicated clarification first 5% weight loss occurred on [DATE]. RD C indicated that DM D should notify her and she does the assessment. CC J indicated no answer, to that question, when asked if a systems failure. CC J stated, rely on computer to show weight loss. RD C indicated to Surveyor during this time, that there is no documentation to show that R3 received supplements during the month of [DATE]. Example 2 R11's [DIAGNOSES REDACTED]. R11 is not his own decision maker. R11's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of [DATE] indicated R11 is cognitively intact, eats independently with set up, weighs 150 pounds, and has no weight loss. R11's MDS with an ARD, of [DATE], indicated R11 has moderate cognitive impairment, eats independently with set up, weighs 135 pounds, and has no weight loss. R11's MDS with an ARD, of [DATE], indicated R11 has moderate cognitive impairment, eats independently with set up, weighs 134 pounds, and has weight loss. R11's Nutritional Care Plan, initiated [DATE], included the following interventions: Diet texture - regular, initiated [DATE] Eats in own room - initiated [DATE] Eating - independent, initiated [DATE] Eating - provide supplement; plus 2, 60 cc's (Cubic Centimeters) BID (twice a day), initiated [DATE] Eating - provide supplement; plus 2 60 cc's Qday (every day), initiated [DATE] Eating - Provide supplements/snacks, initiated [DATE] Fluids - No restrictions, initiated [DATE] Give small portions and offer an alternative if resident does not care for what is on the care plan, initiated [DATE] Provide and serve supplements as ordered: Hi Cal (high calorie) Cookie at 2 PM every day, initiated [DATE] and resolved [DATE] Provide, serve diet as ordered. Monitor intake and record q (every) meal. Initiated [DATE] Weigh at same time of day and record: Monthly. The resident is weighed standing, using w/c (wheelchair) scale, initiated [DATE] R11's medical record included the following weights: [DATE] - 150 pounds [DATE] - 140 pounds [DATE] - re-weight - 142 pounds [DATE] - 139 pounds [DATE] - 135 pounds [DATE] - 134 pounds It is important to know, that between [DATE] and [DATE], R11 had an 8 pound/ 5.3% weight loss and, between [DATE] and [DATE], R11 had a 16 pound/10.6% weight loss. [DATE] - 31, 2017 - R11's medical record showed R11 was offered snacks 78 times, refusing 39 times, accepted 0 - 25% = 2 times, accepted 26 - 50% = 1 time, accepted 51 - 75% = 1 time, and accepted 76 - 100% = 35 times. [DATE] - 30, 2017 - R11's medical record showed R11 was offered snacks 81 times, refusing 44 times, accepted 0 - 25% = 2 times, accepted 26 - 50% = 1 time, and accepted 76 - 100% = 34 times. [DATE] - 30, 2017 - R11's medical record showed R11 was offered snacks 90 times, refusing 43 times, accepted 0 - 25% times = 1 time, accepted 26 - 50% = 2 times, accepted 51 - 75% = 3 times, and accepted 76 - 100% = 41 times. R11's MAR (Medication Administration Record) included, in part, the following order: Plus 2 med pass supplement one time a day for supplement, 60 cc's mix with milk at breakfast. Start date [DATE]. D/C (Discontinue) [DATE]. March, 2017 MAR indicated [REDACTED]. April, 2017 MAR indicated [REDACTED]. [DATE] - 5, 2017 MAR indicated [REDACTED]. R11's MAR indicated [REDACTED] Plus 2 med pass supplement two times a day for supplement, 60 cc's. Start date [DATE]. D/C [DATE]. [DATE] - 31, 2017 MAR indicated [REDACTED]= 5 times, accepted 50% = 1 time, there are 47 times R11's intake of the supplement was not documented. [DATE] - 26, 2017 MAR indicated [REDACTED]= 2 times, accepted 50% = 6 times, there are 21 times R11's intake of the supplement was not documented. R11's Nutrition - Amount Eaten documentation in the medical record included, in part, the following information: February, 2017, Refused 1 time, ate 0 - 25% = 42 times, 26 - 50% = 18 times, 51 - 75% = 12 times, and 76 - 100% = 10 times. March, 2017, Refused 3 times, ate 0 - 25% = 36 times, 26 - 50% = 23 times, 51 - 75% = 10 times, and 76 - 100% = 20 times. April, 2017, Refused 2 times, ate 0 - 25% = 44 times, 26 - 50% = 24 times, 51 - 75% = 8 times, and 76 - 100% = 4 times. May, 2017, Refused 1 time, ate 0 - 25% = 46 times, 26 - 50% = 19 times, 51 - 75% = 14 times, and 76 - 100% = 7 times. R11's Progress Notes included, in part, the following entries: * [DATE], 1:02 PM, Nursing Note: Resident has had an 8# (pound) weight loss + 5% weight los