Every finding on record at Legacy Heights Nursing and Rehab, LLC

Based on facility policy review, record review, observations and interviews, it was determined that the facility failed to ensure ice machines were maintained in a clean condition to minimize the risk for food borne illness in one of two ice machines observed. Based on facility policy review, record review, observations and interviews, it was determined that the facility failed to ensure ice machines were maintained in a clean condition to minimize the risk for food borne illness in one of two ice machines observed. The findings include: During an observation on 07/31/2025 at 12:15 PM, Dietary Aide (DA) #1 used a white paper towel to wipe the interior of the ice machine. An unknown tan and gray substance transferred to the paper towel. During an interview on 07/31/2025 at 12:15 PM, DA #1 stated the substance should not be there. DA #1 indicated that it looked like dirt, and that the ice machine should be cleaned with vinegar. During an interview on 07/31/2025 at 12:20 PM, the Administrator reported Housekeeping/Laundry #2 was responsible for cleaning the ice machine. During an interview on 07/31/2025 at 12:22 PM, Housekeeping/Laundry #2 indicated that the ice machine was cleaned two times a week, sometimes more, and that the ice machine was last cleaned two days ago. They also indicated that the ice machine was deep cleaned every week. The Housekeeping and Laundry Supervisor observed the white paper towel with the tan and gray debris and reported that the substance looked like mold. During an interview on 07/31/2025 at 12:58 PM, the Maintenance Director (MD) indicated the ice machine was cleaned once a month, when they cleaned and checked the mechanical components on top of the ice machine. The MD indicated that he also looked for dust and build up. During an interview on 07/31/2025 at 1:15 PM, the Administrator indicated that the ice machine should be cleaned immediately and disinfected. The Administrator also indicated that the Housekeeping and Laundry Supervisor was trained on how to clean the ice machine but did not know what the training entailed. The Administrator indicated that the ice from this ice machine was used to distribute ice to the residents in the facility and that all of the ice used on the halls had been disposed of. Review of a document titled Ice Machine Cleaning Log, dated July 2025, revealed the following dates: 7/1/2025, 7/4/2025, 7/8/2025, 7/11/2025, 7/15/2025, 7/18/2025, 7/22/2025, 7/25/2025 and 7/29/2025 which had a comment of Cleaned and showed a check mark with initials of the Housekeeping and Laundry Supervisor. A review of a facility policy titled, Infection Prevention and Control Program, dated 11/22/2017 , indicated the facility would have a system of surveillance designed to identify possible communicable diseases or infection before they can spread to other persons in the facility.

Based on observation and interview, the facility failed to ensure food items stored in the refrigerator were covered, sealed, and dated, kitchen walls, door frames and baseboards were free of rotten wood, chipped walls were replaced, dietary staff washed their hands when contaminated to decrease the potential for food borne illness for residents who received food from 1 of 1 kitchen, 2 of 2 ice machines were maintained in a clean and sanitary condition and dietary staff washed their hands and changed their gloves before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. The failed practices had the potential to affect 82 residents who received meals from the kitchen (total census: 82). The findings are: 1. On 04/14/2024 at 10:15 AM, 17 individual 4 ounce (oz) containers of lemon flavor with other natural sweeter flavors added were on a shelf in the storage room. There was no received date on the box. 2. On 04/17/2024 at 03:45 PM, there was a pink residue in the interior surface of the ice machine located in the kitchen. The Surveyor asked the Dietary Supervisor to wipe the right interior side of the ice machine where pink residue was found. She used a tissue to wipe the area, which had a pinkish residue on it and the pink substance easily transferred to the tissue paper. The Surveyor asked the Dietary Supervisor to describe the residue that was on the tissue, who uses the ice machine, and how often was it cleaned. The Dietary Supervisor stated, Pinkish, and we use it in the kitchen to fill beverages served to the residents at mealtimes. 3. On 04/16/2024 at 03:46 PM, the cabinet below the deep fryer had 5 pilots, the pilots and the bottom of the cabinet which were covered with a buildup of greasy. The Surveyor asked the Dietary Supervisor how often they cleaned it. She stated, It is cleaned every week, but it has not been. 4. On 04/16/24 at 03:47 PM, Dietary Employee (DE) #1 picked up a box of gloves, pulled the gloves out of the box and placed them on his hands, contaminating them. Without washing his hands and changing gloves, he picked up a clean blade and attached it to the base of the blender to be used in pureeing the food items to be served to the residents who received pureed diets. The Surveyor asked DE #1, What should you have done after touching dirty objects and before handling clean equipment? DE #1 stated, I should have washed my hands. 5. On 04/16/2024 at 03:49 PM, there was a pink residue in the interior surface of the ice machine located behind the nurse's station on Station 3. The Dietary Supervisor asked DE #2 to wipe the left and the right interior side of the ice machine where pink residue was found. He used tissues to wipe the areas, which had a pinkish residue on them. The pink substance is easily transferred to the tissue paper. The Surveyor asked the Dietary Supervisor to describe the residue that was on the tissue, who uses the ice machine, and how often it was cleaned. The Dietary Supervisor stated, Pinkish and the housekeeping cleans it once a week. That's the ice machine the CNAs use for the water pitchers in the residents' rooms. 6. On 04/16/2024 at 04:15 PM, an opened box of bacon was on a shelf in the refrigerator. The box was not covered or sealed. 7. On 04/16/2024 at 04:16 PM, during observation the following food items on a shelf in the freezer were not covered or sealed. a. A box of biscuits. b. A box of hamburger patties. c. A box of biscuit dough. d. A box of garlic bread. e. A box of garlic biscuits. 8. On 04/16/2024 at 04:29 PM, the following observations were made in the kitchen. a. The exit door frame from the kitchen leading to the hall was chipped, exposing the metal. b. The board against the wall of the door frame was loose. c. The bottom of the door frame was rotten, exposing the metal. d. The wall paint between the plate warmer and the steam table was peeling, exposing the cement. e. The wall on the right side of the steam table was chipped, exposing the sheet rock. f. The wall paint below the dish washing machine was peeling, exposing the cement. The area had sage color on it. 9. On 04/16/2024 at 05:02 PM, DE #1, who was on the tray line assisting with supper meal, was observed to pick up tray cards, packet of individual crackers and place them on the trays. Without washing his hands, he picked up the plates to be used in portioning the food items to be served to the residents for supper with his fingers inside of them on the trays. The Surveyor asked DE #1 what should have been done after touching dirty objects and before handling clean equipment. DE #1 stated, I should have washed my hands. 10. On 04/16/2024 at 05:09 PM, DE #2, who was on the tray line assisting with the supper meal, picked up cartons of supplements, cans of soft drinks, ice cream cartons and placed them on the trays. Without washing his hands, he picked up glasses that contained beverages by their rims and placed them on the trays to be served to the residents at the supper meal. At 05:14 PM, the Surveyor asked DE #2 what should you have done after touching dirty objects and before handling clean equipment. DE #2 stated, I should have washed my hands. 11. On 04/16/2024 at 08:00 AM, DE #3 opened a cabinet and placed clean bowls in it. Without washing her hands, she picked up bowls to be used in portioning the food items to be served to the residents for lunch with her fingers inside of them. At 11:30 AM, the Surveyor asked DE #3 what should have been done after touching dirty objects and before handling clean equipment. DE #3 stated, I should have washed my hands. 12. On 04/17/2024 at 10:25 AM, DE #5 placed 15 servings of brownie into a blender, then removed a gallon of milk from the refrigerator. DE #5 removed the lid from the gallon of milk and poured some on the brownie, added 3.5 tablespoon of thickener and pureed. Without washing her hands, DE #5 picked up a bowl from the counter with her fingers inside of it to be used in portioning dessert. When DE #4 was ready to transfer pureed dessert into a bowl to be served to the residents who required pureed diets for lunch, the Surveyor immediately asked DE #5, what should you have done after touching dirty objects and before handling clean equipment? DE #5 stated, I should have washed my hands. 13. On 04/17/2024 at 11:01 AM, DE #4 opened a box of frozen bread sticks. Without washing her hands, she removed gloves from the glove box and placed them on her hands, she picked up bread sticks from the original box with her contaminated gloved hands and placed them on the trays to be baked and served to the residents for the lunch meal. 14. On 04/17/2024 at 11:33 AM, a container of baking powder was in the cabinet with an expiration date of 12/13/2023. 15. The facility policy titled, Hand Washing, provided by the Dietary Supervisor on 04/18/2024 at 07:54 AM documented, .Staff will wash hands and exposed portions of their arms: .To remove contamination after entering the kitchen, .during food preparation, .before donning gloves for working with food, and after engaging in other activities that contaminate the hands .

Based on observation and interview, the facility failed to ensure a medication cart was locked while unsupervised, and that controlled narcotics were contained in a locked and permanently affixed container. The findings are: On 04/17/2024 at 03:00 PM, the Surveyor observed the refrigerated plastic emergency kit located in the Station 1 refrigerator containing (5) 2 milligram (Mg)/1 milliliter (mL) oral Lorazepam syringes and (1) 2 Mg/1 mL injectable Lorazepam syringe was not in a locked and affixed container. Lorazepam is a controlled substance which can cause paranoid or suicidal ideation and impair memory, judgment, and coordination. Combining with other substances, particularly alcohol, can slow breathing and possibly lead to death. On 04/17/2024 at 03:13 PM, the Surveyor observed the medication cart on Station 2 to be unlocked and unattended. On 04/17/2024 at 03:14 PM, the Surveyor asked Licensed Practical Nurse (LPN) #1, Is the refrigerated emergency kit containing Lorazepam in a permanently affixed and locked container? LPN #1 stated No. The Surveyor asked, Should the medication cart on Station 2 be unlocked and unattended? LPN #1 stated No, it should not be. On 04/17/2024 at 03:56 PM, the Director of Nursing (DON) confirmed the medication cart on Station 2 was left unlocked and unattended. On 04/17/2024 at 04:16 PM, the Assistant Director of Nursing (ADON) confirmed the refrigerated emergency kit containing Lorazepam was not in an affixed and locked container. On 04/17/24 at 04:27 PM, the DON reported the facility did not have a Medication Storage Policy. A document provided by Human Resources on 04/18/2024 at 08:28 AM titled, Charge Nurse Job Description showed, .responsibilities .ensure proper .storage of medications and controlled substances .

Based on observation, interview and record review, the facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents for 1 of 2 meals observed. This failed practice had the potential to affect 7 residents who received pureed diets from 1 of 1 kitchen. The findings are: 1. The menu for supper documented that the residents who received pureed diets were to receive two #8 scoops (totaling 1 cup) of pureed pimento cheese sandwich. 2. On 04/16/2024 at 05:06 PM, Dietary Employee (DE) #2 used a 4-ounce spoon to serve a single scoop (totaling 0.5 cups) of pureed pimento cheese sandwich to the residents on pureed diets, instead of two #8 scoops as specified on the menu. 3. On 04/17/2024 at 11:38 AM, the Surveyor asked DE #2 what spoon size she used to serve pureed pimento cheese and how many servings she had served to the residents who required pureed diets. DE #2 stated, I used 4-ounce spoon and gave a serving each.

Based on observation and interview, the facility failed to ensure the pureed food items were blended to a smooth, lump free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 1 of 1 meal observed. The failed practice had the potential to affect 7 residents who received pureed diets. The findings are: 1. On 04/17/2024 at 07:40 AM, a pan of pureed sausage was on the steam table. The consistency of the pureed sausage was gritty and not smooth. The Surveyor asked Dietary Employee (DE) #5 to describe the consistency of the pureed sausage. DE #5 stated, It was a little gritty. I should have pureed it a little longer. 2. On 04/17/2024 at 10:45 AM, DE #5 used a 6-ounce scoop to place 7 servings of lasagna into a blender, added beef broth and pureed. At 10:47 AM, DE #5 poured the pureed lasagna into a pan and placed it on the steam table. The consistency of the pureed lasagna was lumpy and not smooth. There were pieces of intact noodle visible in the mixture. 3. On 04/18/2024 at 07:50 AM, the Surveyor asked DE #5 to describe the consistency of pureed lasagna. DE #5 stated, I should have pureed it longer.

Based on observation and interview, the facility failed to ensure 1 of 3 shower rooms were clean. The findings are: On 04/15/2024 at 02:17 PM, a brown substance was smeared on the floor in the bathroom on the Medicare Hall. On 04/15/2024 at 02:19 PM, Certified Nursing Assistant (CNA) #4 walked into the shower on the Medicare Hall. She was asked, What's the brown substance on the shower floor? She stated, I'm sure it's bowel movement. On 04/17/2024 at 09:56 AM, the Director of Nursing (DON) was asked, How often should the shower room be cleaned? She stated, After use and between residents. On 04/17/2024 at 10:06 AM, the Administrator was asked, How often should the shower room be cleaned? She stated, Soils should be cleaned after every shower, and deep cleaned at the end of the day. She was asked, Should there ever be feces on the shower room floor if the shower is not in use? She stated, No it should be cleaned up as soon as the resident has left the shower room.

Based on interview and record review, the facility failed to ensure all medications were documented on the discharge summary for 1 (Resident #184) when discharging from the facility. The findings are: A review of the Admission Record, indicated the facility admitted Resident #184 with a diagnosis Acute systolic (congestive) heart failure. The Discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/21/2024 revealed Resident #184 had a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. On 04/17/2024 at 03:11 PM, the Administrator was asked, Did you have any residents receive the wrong medication upon discharge last month? She stated, Yes I believe her name was [Resident #184]. I don't do the discharges, but the care giver called up here and said [Resident #184] had someone else's medication and she was going to be bringing the medication back up here. I think she gave the medication to [Licensed Practical Nurse (LPN) #2] on Station 1. On 04/17/2024 at 03:39 PM, the discharge summary was reviewed. There was no documentation indicating what medications were sent home with the resident on 03/20/2024. On 04/17/2024 at 03:43 PM, the Director of Nursing (DON) was asked, What is the process for getting a residents medication ready for discharge? She stated, The nurse goes over the resident's orders then she pulls the medications. The Surveyor asked, Is there a discharge summary of all the medications that were sent home with [Resident #184]? She looked in the computer and pulled up a copy of the physician orders. She was asked, What medications were sent home with [Resident #184] that didn't belong to the resident? She stated, I'm not sure. On 04/17/2024 at 04:21 PM, LPN #2 was asked, What's the process for discharging a resident home with medication? She stated, The night shift pulled the PM meds [medications], and I pulled the AM meds. I put them all together and I put them in a bag. The Surveyor asked, Did you check the medications? She stated, No, I just put them in the bag since the night shift had already pulled them. The Surveyor asked, Why is it important that you check the medications against the physician orders? She stated, I should have. The discharge person does all the paperwork and the reconciliation form, and we just pull the meds. I just took for granted that everything was correct. The Surveyor asked, What could happen if a resident is discharged with the wrong medication? She stated, The caregiver called me and told me that [Resident #184] had the wrong medication, and she would bring them up here. She was asked, After this incident happened, were you in-serviced? She stated, Personally, no they didn't. The DON didn't know about it. I told the Administrator. It was an absolutely a freak mistake. On 04/17/2024 at 03:47 PM, the Administrator was asked, When were you made aware that the nurse had discharged [Resident #184] home with another resident's medication, and did you provide an in-service for the nurses? She stated, No I didn't. I just talked to LPN #2, and she told me that they were bringing the medications back up here.

Based on interview and record review, the facility failed to ensure 1 (Resident #184) did not receive medications that were not prescribed to them upon discharge. The findings are: A review of the Admission Record, indicated the facility admitted Resident #184 with a diagnosis of Acute systolic (congestive) heart failure. The Discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/21/2024 revealed Resident #184 had a Brief Interview of Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. On 04/17/2024 at 03:11 PM, the Administrator was asked, Did you have any residents receive the wrong medication upon discharge last month? She stated, Yes, I believe [the resident] name was [Resident #184]. I don't do the discharges, but the care giver called up here and said [Resident #184] had someone else's medication and she was going to be bringing the medication back up here. I think she gave the medication to [Licensed Practical Nurse (LPN) #2] on Station 1. On 04/17/2024 at 03:39 PM, the discharge summary was reviewed. There was no documentation indicating what medications were sent home with the resident. On 04/17/2024 at 03:43 PM, the Director of Nursing (DON) was asked, What is the process for getting a residents medication ready for discharge? She stated, The nurse goes over the resident's orders then she pulls the medications. The Surveyor asked, Is there a discharge summary of all the medications that were sent home with [Resident #184]? She looked in the computer and pulled up a copy of the physician orders. She was asked, What medications were sent home with [Resident #184] that didn't belong to her? She stated, I'm not sure. On 04/17/2024 at 04:21 PM, LPN #2 was asked, What's the process for discharging a resident home with medication? She stated, The night shift pulled the PM meds [medications], and I pulled the AM meds. I put them all together and I put them in a bag. The Surveyor asked, Did you check the medications? She stated, No, I just put them in the bag since the night shift had already pulled them. The Surveyor asked, Why is it important that you check the medications against the physician orders? She stated, I should have. The discharge person does all the paperwork and the reconciliation form, and we just pull the meds. I just took for granted that everything was correct. The Surveyor asked, What could happen if a resident is discharged with the wrong medication? She stated, The caregiver called me and told me that [Resident #184] had the wrong medication, and she would bring them up here. She was asked, After this incident happened, were you in-serviced? She stated, Personally no they didn't. The DON didn't know about it. I told the Administrator. It was an absolutely a freak mistake. On 04/17/2024 at 03:47 PM, the Administrator was asked, When were you made aware that the nurse had discharged [Resident #184] home with another resident's medication, and did you provide an in-service for the nurses? She stated, No I didn't. I just talked to [LPN #2], and she told me that they were bringing the medications back up here.

Based on observation, interview, and record review, the facility failed to ensure foods stored in the kitchen freezer, refrigerators, and dry storage area were labeled and dated when received and/or opened; foods in resident refrigerators on the halls were labeled and dated; cookware was cleaned and sanitized between uses; 1 of 2 ice machines was maintained in a clean and sanitary condition to prevent potential contamination of residents' beverages, and to prevent potential food borne illness for residents who received meals from 1 of 1 Kitchen. These failed practices had the potential to affect 73 residents who received meal trays and beverages from the Kitchen as documented on a Diet list provided by the Administrator on 1/20/23. The findings are: 1. On 01/17/23 at 10:10 AM, during a tour of the dry storage room with the Assistant Dietary Manager (ADM) there was a plastic square container 1/2 [half] full of elbow pasta dated 12/16/22. The Surveyor asked the ADM if he could locate the open date on the container. The ADM stated, I'm not going to be able to do that. The Surveyor asked if the pasta should have been dated when it was removed from the original container. The ADM stated, Yes, it should. 2. On 01/17/23 at 10:18 AM, there was unopened carton of strawberry shake on the top shelf with no date. The Surveyor asked the ADM to find a date on the carton. The ADM stated, no, I cannot find one. A plastic container 1/2 full of pickles had a received date of 1/11/23. The Surveyor asked the ADM to find a date on the container. The ADM stated, it should be yesterday and he dated the container. 3. On 01/17/23 at 10:24 AM, the Surveyor asked the ADM to wipe the inside of the ice machine in the kitchen with a white napkin or white paper towel. When the ADM wiped the inside of the ice machine, there was a residue on the paper towel. The ADM stated, oh, that's not good. It was just cleaned on the 3rd [third]. It was obviously not done well. The ADM wiped the inside of the ice machine a second time and there was more residue. The ADM stated, that's really bad. the Surveyor asked the ADM to describe the residue. The ADM stated, brown and black stuff. I will get that corrected today. 4. On 01/17/23 at 10:31 AM, there was a stainless-steel rack near the fryer that contained 3/4 of a loaf of sliced wheat bread in a plastic bag with no date and 4 hamburger buns in a plastic bag with no date. The Surveyor asked the ADM to locate a date on the bags. The ADM stated, I will get it. the ADM left the kitchen and the Surveyor followed. The ADM was in the dry storage room writing dates on the bags. The Surveyor asked how he determined the dates. The ADM stated, from this box right here. (Pointing to a carboard box of loaves of bread). The Surveyor asked if the loaf and buns should have been dated when they were removed from the box. The ADM stated, yes, ma'am, they should have. It sure shows when you have a new group. 5. On 01/17/23 at 10:38 AM, the Surveyor asked the ADM to open a container of vanilla ice cream in the freezer that had a tear in the lid. The ADM opened the container and the Surveyor asked him to describe the brown and grey colored substance on top of the vanilla ice cream. The ADM stated, I have no idea what it is. The ADM discarded the vanilla ice cream in the trash. 6. On 01/17/23 at 10:52 AM, the following items were in the resident refrigerator by Nurse's Station #3: a. 1 container of peach cottage cheese with an expiration date of 1/16/23 and no name on it. b. A plastic tray with 5 pieces of various types of pie and cheesecake, covered by a torn piece of aluminum foil and no name or date on it. c. A plastic container full of pineapple chunks dated 11/24/22 and R #26's name on it. d. A bottle of [named] sauce dated 10/2/22 and R #51's name on it. e. A bottle of [named soft drink] 1/2 full with no name on it. f. A rectangular plastic storage container with a red lid dated 11/26/22 with R #61's name on it. g. An oval plastic storage container with a red lid dated 12/2/22 with R #5's name on it. h. Two 4 oz [ounce] plastic bottles of orange juice with foil tops with no name or date on them. i. Two brown and black spotted bananas that were soft to the touch. j. A brown bag of fast food [named] with no name or date on it. k. One 4 oz plastic container of cranberry juice with a foil top with no name or date on it. The ADM discarded all the above listed items in the trash. 7. On 01/17/23 at 11:47 AM, the Administrator provided a policy for Use and Storage of Foods Brought to Residents by Family/Others which documented, .4. Any outside food must be stored in covered containers and labeled with the resident's name and date the food was brought into the facility. 5. Any item in its original packaging that is past its expiration date will be discarded. 6. Foods brought into the facility outside of its original container or packaging will be discarded three days after the date identified on the label . 8. On 01/19/23 at 10:36 AM, the Dietary Manager (DM) removed two pans of biscuits from the oven and placed one pan on top of the other. The bottom of the top pan was laying against some of the biscuits and touched the top surface of the bottom pan that contained biscuits. At 10:40 AM, the DM did not wash the two pans and placed new raw biscuits onto the pans. The Surveyor asked if the bottom of the pans were considered clean. The DM stated, no, oh dang, I forgot to wash the pans. The Surveyor asked if the pans should be cleaned before being used again. The DM stated, oh yeah. I'm trying to do too many things at one time. 9. On 01/19/23 at 3:06 PM, the Administrator provided a policy for Dry Food Storage which documented, .9. Opened food items will be labeled with contents and opened dates as well as stored in clean, dry, and sealed containers .11. The guideline Storage Periods: Use-by Guidelines (Policy #5.6) will be used to ensure food quality . and a policy for Safe Food Handling Practices which documented .To minimize contamination and bacteria while providing nutritious meals .all work surfaces and equipment are clean and sanitized after each use .

Based on interview and record review, the facility failed to employ a qualified Social Worker with a minimum of a bachelor's degree in Social Work or a Human Services field to meet the needs of the residents. This failed practice had the potential to affect all 73 residents who resided in the facility per Resident Daily Census provided by the Administrator on 1/17/23. The findings are: a. On 01/19/23 at 08:44 AM, the Surveyor requested a copy of the Social Service Director's (SSD) Social Worker License or bachelor's degree. The HR Employee stated, SSD [named] is not licensed because of our census. The Surveyor stated the facility was licensed for 122 beds. The HR stated, I have been here since 2013, I know she does not have one. The certificate she does hold is a CNA (Certified Nursing Assistant) certificate, but that is all she has. The HR Employee produced a CNA certificate for SSD [named] with an expiration date of 1/31/25. The Surveyor asked her hire date. HR stated, SSD [named] was hired July 16, 1996. HR provided a copy of the CNA certificate. b. On 01/19/23 at 09:15 AM, the Surveyor asked the SSD if she had a social worker license or a bachelor's degree in in Social Work (SW), Human Services Sociology, Gerontology, Special Education, Rehabilitation Counseling, or Psychology. The SSD stated, no ma'am. Just a certificate in CNA and a social work class certificate. c. On 01/19/23 at 09:20 AM, the SSD provided the Surveyor a copy of her Social Service Director Training certificate dated 2/28/2020. d. On 01/19/23 at 09:28 AM, the Surveyor asked the Administrator and Director of Nursing (DON), how many beds is your facility licensed for? The Administrator stated, we are licensed for 122. The Surveyor asked if the facility's SSD had a SW license or a bachelor's degree in Social Work, Human Services Sociology, Gerontology, Special Education, Rehabilitation Counseling, or Psychology. The Administrator stated, no ma'am. The Surveyor asked if the Administrator realized that was a regulation for the SSD. The Administrator stated, when I first started working here, I was told it was by census. We are actually looking for a Licensed Social Worker and we were just told it is based on actual beds and not our census. The Surveyor asked when the Administrator was made aware of this regulation. The Administrator stated, it was November or December or January that I was notified. The Surveyor asked who she was notified by. The Administrator stated, CANC, my nursing consultant, just notified me. She's [SSD named] been doing this for [AGE] years. We discussed it at a stand up. The DON stated, I did put it out on 3 different social media sites lately. The Administrator stated, we put ads out today. We have a potential applicant who is a friend of mine that works for DHS (Department of Human Services) and we were going to reach out to the Ombudsman because she told us she wanted to retire. The Surveyor requested documentation of meetings for the SSD position, job postings for the SSD position, and any other documentation related to attempts at filling that position prior to the survey. e. On 01/19/23 at 11:27 AM, the DON provided a copy of a [named social] media post from the DON regarding the Social Worker position. The post was dated 01/19/23 11:00 AM and documented it was posted Just now. f. On 01/19/23 at 04:27 PM, the Surveyor requested a copy of the signed job description for the SSD from the HR Employee. The HR Employee provided a copy which documented .Qualifications .The following for more than 120 beds: A degree in Social Work or related field .

Based on interview and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASRR) evaluation process was completed in accordance with the State PASRR process for 1 (Resident #17) of 7 (Resident #1, R #14, R #17, R #36, R #55, R #57, and R #62) sample selected residents who had a diagnosis of a Serious Mental Disorder documented on the Mental Health Diagnosis list provided by the Administrator on 1/20/23, to ensure the resident received appropriate care and services. The findings are: 1. Resident #17 had diagnoses of Schizophrenia and Hallucinations. The Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 10/23/22 showed the Resident scored a 15 (13-15 signified cognitively intact) on a Brief Interview for Mental Status (BIMS). a. On 01/17/23 at 01:34 PM, during R #17's Electronic Record Review, a [State Designated Professional Associates] letter dated 7/23/19 showed, You MUST contact [State Designated Professional Associates] with the Resident's admitted to receive a completed PASRR packet. b. On 01/19/23 at 02:35 PM, the Surveyor requested the PASRR II for R #17 from the Administrator. c. On 01/19/23 at 02:51 PM, the Administrator provided the Surveyor a copy of the [State designated Professional Associates] letter from 7/23/19 which documented, You MUST contact [State designated Professional Associates] with the resident's admitted to receive a completed PASRR packet The Surveyor pointed to the grey box on the middle of the letter and informed the Administrator the Surveyor was requesting the completed PASRR packet that was mentioned in the grey box. d. On 01/19/23 at 03:56 PM, the Director of Nursing (DON) and Assistant Director of Nursing (ADON) stated they had run a Department of Human Services (DHS) report which showed R #17 was admitted on [DATE]. The Surveyor asked if they had documentation that [State designated Professional Associates] was contacted with R #17's admitted and received his completed PASRR evaluation from [State designated Professional Associates]. The ADON stated, We are still looking in the paper records for R #17's [named] PASRR. e. On 01/20/23 at 09:25 AM, the Surveyor asked the Administrator if the PASRR process should be fully completed for any resident with a serious mental health issue. The Administrator stated, Yes ma'am. The Surveyor asked who was ultimately responsible for ensuring the process was completed. The Administrator stated, it's between the Business Office and the Medical Records office. The Surveyor asked what information does the PASRR I and II give the facility. The Administrator stated, if they are a PASRR II, they [PASRR] tell us about the care for the mental health issues they need. The Surveyor asked what a possible negative outcome could be if the PASRR process was not completed. The Administrator stated, we do not know what type of services we need to provide. f. On 01/20/23 at 09:29 AM, the Administrator informed the Surveyor the facility did not have a PASRR policy.

Based on observations, interviews, and record review, the facility failed to ensure Resident #1 and Resident #4 were free from verbal/mental abuse, as evidenced by the facility's failure to ensure staff reported allegations of verbal/mental abuse in a timely manner, which resulted in failure to ensure an investigation was promptly initiated and protective measures were immediately implemented to prevent further potential abuse for 2 (Resident #1 and Resident #4) of 4 (Residents #1, #2, #3, and #4) sampled residents. This failed practice resulted in noncompliance at the level of immediate jeopardy, which caused or could have caused serious psychological harm for R#1 and R#4, who experienced verbal/mental abuse from facility staff, and had the potential to cause more than minimal harm to 75 residents who resided in the facility according to the Roster Matrix provided by the Administrator on 9/27/2022 at 3:37 pm. The Administrator was informed of the Immediate Jeopardy condition on 9/28/2022 at 4:13 pm. The Immediate Jeopardy was removed on 9/28/2022 at 8:35 pm. The findings are: 1. Resident #1 had a diagnosis of kidney failure and atrial fibrillation. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/14/2022, documented the resident scored 15 (13-15 cognitively intact) on the Brief Interview for Mental Status (BIMS), had no behaviors symptoms, did not reject care, and had no hallucinations or delusions or displayed any wandering behaviors. R #1 required supervision for eating and toilet use and used a walker to assist with ambulation. a. A progress note dated 9/8/2022 at 20:42 by Licensed Practical Nurse (LPN) #1 documented, .Behavior notes: This nurse returned to the floor from her 15 min break and seen resident in the hallway visibly upset. As soon as resident seen me, she started accusing my Certified Nursing Assistant (CNA) of being hateful and rude and talking bad to her. She Stated all she did was inform the CNA she smelled smoke and wanted her to check on another resident. She stated the CNA started talking bad to her. This nurse asked the Resident what the CNA said to her, she could not remember. The Resident stated she thought the CNA was coming at her like a bull and trying to use her size to scare her .Describe Interventions: redirected resident that I would talk to the CNA and try to figure out what was said. Reassured her that the CNA would not be coming back into her room tonight and if she needed anything I would personally take care of it .Intervention Effective: Yes, resident laid down in bed and relaxed while I was in the room . b. On 9/14/2022 at 4:05 pm, a complaint intake #29490 from the Office of Long-Term Care (OLTC) documented .Resident/Patient/Client Abuse .OLTC notified the facility of the allegation at 3pm . When (date, time, shift) did the problem occur? a few weeks ago 1. What happened? A worker a weeks ago, answered the light yelling at her. resident was highly upset with the situation and reported it, but nothing was done. 2. How did it happen? unknown 3. Is the problem ongoing? no 4. Who was involved? staff 5. Are there any witnesses? complainant 6. Did you speak to someone at the facility? yes, resident said she did, but compliant hasn't talked to them. 7. Has facility tried to address the situation? no 8. Do you know if this has happened before to the same individual, or to others? entire building c. On 9/27/2022 at 3:07 pm, an entrance conference was held with the Administrator, the Director of Nursing, and The Assistant Director of Nursing. 2. Resident #4 had a diagnoses of kidney failure, and pleural effusion. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/25/2022 documented the resident scored 15 (13-15 cognitively intact) on the Brief Interview for Mental Status (BIMS), had no hallucinations, delusions, no behaviors, and no rejection of care, required extensive assist of two staff for bed mobility, dressing toilet use, personal care, was totally dependent on two staff for transfers, and required extensive assist of one staff for eating, and had an indwelling foley catheter and was always incontinent of bowel. a. On 9/27/2022 at 3:22 pm, R #4 was lying in bed in room. Surveyor introduced self and asked R #4 if it was ok to enter the room in which R #4 stated, yes. The Surveyor asked R #4, has any staff member ever answered your light and yelled/screamed at you? R #4 replied, yes, one time, but the other nurse told her not to talk to me like that and she kept coming in and apologizing. The Surveyor asked, did you report it? R #4 replied, yes, to the head nurse. The Surveyor asked, when did this happen? R #4 replied, on night shift a few days ago. The Surveyor asked R #4, do you know the name of the staff member? R #4 replied, no, she was African American. b. On 9/27/2022 between 4:00 pm and 4:30 pm, the Administrator was notified of R #4 allegation of verbal abuse by a staff member. c. On 9/28/2022 at 8:55 am, the Administrator stated, I talked to R #4's daughter, she was here ten minutes after you left, and we think the resident may have been thinking about the last place she was at, she wasn't treated very well over there. The Surveyor asked the Administrator, did you interview R #4? The Administrator replied, no, just the daughter. d. On 9/28/2022 at 9:47 am, the last three facility reportables were reviewed. There was no reportable documented for R #1's allegation of verbal/mental abuse reported to OLTC. There was no reportable documented for R #4's allegation of verbal abuse reported to the OLTC. e. On 9/28/2022 at 10:47 am, The Surveyor asked the Administrator, are you working on any other reportable? The Administrator replied, no. The Surveyor asked, is this all your reportable? The Administrator replied, yes. f. On 9/28/2022 at 11:02 am, the Administrator was again notified of the abuse allegation regarding R #1. g. On 9/28/2022 at 11:08 am, the Administrator stated, they (OLTC) talked to me and asked if I knew anything about a Certified Nursing Assistant (CNA) who was loud with R #1. I went to the chart, the nurse had charted for 9/8/2022, the CNA went into her room and asked her what she wanted. The resident told the CNA someone was smoking cigarettes in her bathroom. We had the nurse and the CNA's fill out witness statement. h. On 9/28/2022 at 11:14 am, The Surveyor asked the Administrator, did you do a reportable after the office notified you of the allegation of abuse? The Administrator replied, no, we investigated it. The Surveyor asked, so these three witness statements are your investigation? The Administrator replied, yes, and we didn't find anything, I didn't think it was reportable. i. On 9/28/2022 at 2:24 pm, The Surveyor asked Licensed Practical Nurse (LPN) #1, why did you fill out the witness statement on 9/8/2022 for R #1? LPN #1 replied, I did a behavior note and we were told to fill that out because of what was said. The Surveyor asked LPN #1, who told you to fill it out? LPN #1 replied, the Administrator, later. The Surveyor asked LPN #1, what do you mean later? LPN #1 replied, they (CNA's), they told they had filled out the witness statements that night. The Surveyor asked, when were you asked to fill out the witness statement? LPN #1 replied, it wasn't that day or even a couple of days later, maybe a week, I didn't inform anyone of this situation, I handled it, I thought. I asked the CNA's, I asked the resident, and I told the CNA's I would handle any problems or answer the call light, for the CNAs to stay out of the room for the rest of the night. The resident was intimidated by the CNA size. I took this as behavior. The Surveyor asked LPN #1, have you been in-serviced and trained on abuse? LPN #1 replied, yes. LPN #1 stated, she has a history of accuses staff, residents steal from her, nonstop accusations. The Surveyor asked LPN #1, if they (residents) have a history of accusations, and they say they are scared, intimidated, or rude and talking bed to her and coming at her like a bull trying to use her size to scare her, would you consider that abuse? LPN #1 replied, yes, if it were done. The Surveyor asked LPN #1, how did you determine this was not abuse? LPN #1 replied, she (R#1) couldn't tell me what was said or what happened, and I talked to both CNA's. The Surveyor asked, what are you supposed to do if a resident claims verbal or physical abuse, or any abuse? LPN #1 replied, separate the resident and the accuser and call my Administrator. The Surveyor asked, did you separate the resident and the CNA's that night? LPN #1 replied, yes, I told the CNA's and the resident, and the resident relaxed after I told them I would handle that resident and room that night. was The Surveyor asked, did you call the Administrator? LPN #1 replied, no, not that night. The Surveyor asked, when was the Administrator notified? LPN #1 replied, I think state notified her. The Surveyor asked, was there a full investigation done that night? LPN #1 replied, no, just me doing the investigation on the floor. The Surveyor asked, how did you protect the rest of the residents after this allegation of abuse? LPN #1 replied, I didn't feel the residents were in jeopardy. The Surveyor asked LPN #1, when are you supposed to do a reportable? LPN #1 replied, within twenty-four hours of an incident. The Surveyor asked, do you know if there was a reportable done? LPN #1 replied, I do not, I assume not because I didn't inform the Administrator. The Surveyor asked, after the facility has been informed of an allegation of abuse, should the facility do a reportable? LPN #1 replied, yes, they should. I didn't realize I put any resident's life at risk, I thought it was just something that was blown up. The Surveyor asked, what did you mean by or when you said, the resident relaxed after you told her you'd be taking care of her? LPN #1 replied, she was in the hallway upset, I took her to her room, and we sat on the side of the bed, and then she laid down and went to sleep. j. On 9/28/2022 at 3:58 pm, The Surveyor asked CNA #1, have you been in-serviced and trained on abuse and neglect? CNA #1 replied, yes. The Surveyor asked, when do you report allegations of abuse and neglect? CNA #1 replied, when you see it or hear it. The Surveyor asked CNA #1, who do you report allegations of abuse and neglect to? CNA #1 replied, supervisor, charge nurse, go up the chain of command. The Surveyor asked, how are the resident/residents protected during an investigation of allegation of abuse or neglect? CNA #1 replied, 'separate them. The Surveyor asked, why should allegations of abuse and neglect be reported? CNA #1 replied, to protect the residents. k. On 9/28/2022 at 4:26 pm, The Surveyor asked LPN #2, have you been in-serviced and trained on abuse and neglect? LPN #2 replied, yes. The Surveyor asked, when do you report allegations of abuse and neglect? LPN #2 replied, immediately. The Surveyor asked, who do you report allegations of abuse and neglect to? LPN #2 replied, CNA, Charge Nurse, DON, and the Administrator. The Surveyor asked, how are the resident/residents protected during an investigation of allegation of abuse or neglect? LPN #2 replied, depends on what it is, employee is removed, talk to residents, if physical, everybody gets a body audit, police report, and reportable. The Surveyor asked, why should allegations of abuse and neglect be reported? LPN #2 replied, because this is their home, and we have to protect them. l. On 9/28/2022 at 4:31 pm, The Surveyor asked CNA #2, have you been in-serviced and trained on abuse and neglect? CNA #2 replied, yes. The Surveyor asked, when do you report allegations of abuse and neglect? CNA #2 replied, as soon as it happens. The Surveyor asked, who do you report allegations of abuse and neglect to? CNA #2 replied, the nurse. The Surveyor asked, how are the resident/residents protected during an investigation of allegation of abuse or neglect? CNA #2 replied, separate them, keep them safe. The Surveyor asked, why should allegations of abuse and neglect be reported? CNA #2 replied, it's their rights, they need to be taken care of. m. On 9/28/2022 at 4:35 pm, The Surveyor asked LPN #3, have you been in-serviced and trained on abuse and neglect? LPN #3 replied, yes. The Surveyor asked, when do you report allegations of abuse and neglect? LPN #3 replied, the first site of either. The Surveyor asked LPN #3, who do you report allegations of abuse and neglect to? LPN #3 replied, the DON, and the ADON. The Surveyor asked LPN #3, how are the resident/residents protected during an investigation of allegation of abuse or neglect? LPN #3 replied, tend to their needs and cares. The Surveyor asked LPN #3, why should allegations of abuse and neglect be reported? LPN #3 replied, because some don't have a voice and we need to be their advocate. n. On 9/28/2022 at 5:28 pm, the Administrator entered the Conference room with a witness statement and stated, I have people coming to help me with this, but I want you to fill out this witness statement on R#4 so I can get that reported. o. On 9/28/2022 at 7:48 pm, the Administrator provided a copy of the second Plan of Removal. The Surveyor asked the Administrator, what hall is LPN #1 working? The Administrator replied, station 1 and R #1 is on station #2. The Surveyor asked, should an LPN that didn't report alleged verbal abuse, be working on the floor with the residents? The Administrator replied, I see the LPN thought she took care of the situation. p. On 9/28/2022 at 7:52 pm, the Administrator stated, we have educated the LPN on timely reporting. q. The Administrator provided a copy of the September 2022 nursing schedule on 9/28/2022 at 8:13 pm. LPN #1 worked on 9/8, 9/9, 9/10, 9/11, 9/14, 9/15, 9/16, 9/17, 9/18, nine days, including two and half hours on 9/28/2022, LPN #1 was allowed to work with residents after the abuse allegation. LPN #1 did work the floor on 9/28/2022 until 8:30 pm per the Immediate Jeopardy Plan of Removal. r. The Administrator provided a copy of the September 2022 CNA schedule on 9/28/2022 at 8:13 pm. CNA #3 worked on 9/8, 9/11, 9/12, 9/13, 9/14, 9/15, 9/16, 9/18, 9/19, 9/20, 9/21, 9/22, 9/25, 9/26, 9/27, fifteen days, including the day of incident, CNA #3 was allowed to work with residents after the abuse allegation, and was scheduled to work on 9/28/2022. CNA #3 was notified by the facility on 9/28/2022 at 6:30 pm, they would be off work until investigation was complete per the Immediate Jeopardy Plan of Removal. s. The Administrator provided a copy of the September 2022 CNA schedule on 9/28/2022 at 8:13 pm. CNA #4 worked on 9/8, 9/12, 9/13, 9/14, 9/18, 9/19, 9/20, 9/21, 9/24, 9/25, and 9/26/200, eleven days, including the day of incident, CNA #4 was allowed to work with residents after the abuse allegation. t. On 9/29/2022 at 12:00 pm, The Surveyor asked the Director of Nursing (DON), have you been in-serviced and trained on abuse and neglect? The DON replied, yes. The Surveyor asked, when should an allegation of abuse or neglect be reported? The DON replied, immediately. The Surveyor asked, who do you report allegations of abuse/neglect to? The DON replied, I would report to my Administrator. The Surveyor asked, what is the facilities policy and procedure for reporting, investigating, and protecting the residents for/during an allegation of abuse or neglect? The DON replied, report immediately, being an internal investigation, report to appropriate OLTC, report to several people, investigate, keep alleged employee away from resident, I would make sure they (the resident) felt safe. The Surveyor asked, if a resident states a staff was mean, rude, or came at me like a bull to scare me, what type of abuse would this be considered? The DON replied, verbal abuse, emotional abuse, intimidating, that would be emotional. The The Surveyor asked, should that be reported and to whom? The DON replied, yes, to the Administrator. The Surveyor asked the DON, what guidelines does the facility follow regarding reporting, investigating, and protecting residents after an allegation of abuse or neglect? The DON replied, our abuse and neglect policy, policy and procedure. The Surveyor asked, what are your expectations from your staff regarding reporting, investigating, and protecting the residents after an allegation of abuse or neglect, and following facility policy and procedures and the Centers for Medicare and Medicaid Services (CMS) Federal Regulations? The DON replied, I expect them to treat residents with respect and dignity like their own family member and if anyone witnesses anything different, to report it and it be investigated. u. On 9/29/2022 at 1:02 pm, The Surveyor asked the Administrator, have you been in-serviced and trained on abuse and neglect? The Administrator replied, yes. The Administrator was asked, when should an allegation of abuse or neglect be reported? The Administrator replied, immediately upon suspension. The Surveyor asked, who do you report allegations of abuse/neglect to? The Administrator replied, I'm the one they report to, and I investigate, and if it's founded, I report to OLTC. This happened on 9/8/2022 and I found out on 9/14/2022, someone reported that a CNA was loud and hateful to a resident, I don't know if that's the right date, but it coincides with the two weeks. The Surveyor asked, what is the facilities policy and procedure for reporting, investigating, and protecting the residents for/during an allegation of abuse or neglect? The Administrator replied, if the allegation has been looked at and unfounded, I put it in a special file, if it's founded or any other negative findings, I do a reportable. The Surveyor asked the Administrator, is this the way you were taught to report abuse? The Administrator replied, she's had so many behaviors and allegations, that's the way I looked at it. The Surveyor asked, if a resident sates a staff was mean, rude, or came at me like a bull to scare me, what type of abuse would this be considered? The Administrator replied, I would say verbal abuse. The Surveyor asked, should that be reported and to whom? The Administrator replied, well I so, I should have reported it to OLTC. The Surveyor asked, what guidelines does the facility follow regarding reporting, investigating, and protecting residents after an allegation of abuse or neglect? The Administrator replied, we have our policy and procedure book, send the person home, interview staff and residents, depending on type of abuse, we do body audits, we do mood assessments. The Surveyor asked, what are your expectations from your staff regarding reporting, investigating, and protecting the residents after an allegation of abuse or neglect, and following facility policy and procedures and the CMS Federal Guidelines? The Administrator replied, I expect them to follow it, I expect them to report it, they are in-serviced on hire, yearly, then they have their yearly competencies. v. A policy provided by the Administrator on 9/27/2022 at 3:57 pm documented .abuse, neglect, misappropriation and exploitation .investigation and reporting policy .the facility will endeavor to protect residents from maltreatment, which means adult abuse, sexual abuse, neglect, misappropriation of resident property, and exploitation of residents .It recognizes resident rights to be free from physical, verbal, or mental abuse, corporal punishment, involuntary seclusion, and any chemical and physical restraints as defined by federal guidelines .all alleged, witnessed, or suspected resident maltreatment, including abuse, sexual abuse, neglect, misappropriation of resident property and exploitation of residents, shall be immediately reported to Administrator or immediate supervisor and investigated by Facility management .all alleged, witnessed or suspected incidents must be reported according to state and federal law, according to the time restrictions required by law. All alleged violations will be reported immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. The following persons or entities will be notified, as required by state law, by Facility personnel (Administrator or Administrator Designee): a. Administrator b. State Survey Agency c. Local law enforcement d. Physician e. Resident's Responsible Party or Emergency Contact f. Coroner if death has occurred g. State Registry Time for completing Incident & Accident (I & A) Intake Forms .an incident & accident intake form (form DMS-7734) will be completed by the Administrator or Administrator Designee and submitted to the State Survey Agency no later than 11:00 am on the next business day following discovery by the facility of any incident of alleged, witnessed or suspected resident maltreatment, including abuse, sexual abuse, verbal abuse, neglect, misappropriation of resident property and exploitation of residents .The Administrator or Administrator's Designee will complete the flow up Investigation Report (Form DMS-762) and summit a copy to the State Survey Agency within five (5) days of the incident's discovery, or as otherwise mandated by law or regulation .Protecting Residents from incidents and preventing further occurrences during investigation .In an effort to protect a resident who has allegedly been abused, neglected, exploited, or has had property misappropriated, the suspected employee (s) may be either reassigned to another shift, shadowed by another facility employee, reassigned to non-resident care duties, or suspended immediately from employment until an investigation has determined that the employee is no longer a suspect .abuse .willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish .verbal abuse .any intentional act that a reasonable person would believe subjects an endangered person or an impaired person, regardless of age, ability to comprehend, or disability, to ridicule or psychological injury in a manner likely to provoke fear or alarm, excluding necessary care and treatment provided in accordance with generally recognized professional standards of care, including any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within hearing distance .metal abuse .any intentional threat that a reasonable person would find credible and nonfrivolous to inflict pain on or cause injury to an endangered person or an impaired person except in the course of medical treatment or for justifiable cause .includes humiliation, intimidation, fear, shame, agitation, harassment, threats of punishment or deprivation that are likely to provide fear or alarm .an inability of a resident to express outward signs of mental anguish does not mean mental abuse did not occur . The Plan of Removal for Resident # 1 and #4 was provided by the Administrator on 09/28/22 at 7:58 PM reads as follow: 1. After notification of immediate Jeopardy on 09/28/22 at 4:13pm; Reportable for abuse allegation began by Administrator and DON. 7734 was completed and submitted to OLTC on 09/28/22 at 7:31pm. 2. On 09/28/22 at 5:30pm; DON, ADON, and Treatment assessed Resident # 1 and #4 with no negative findings. Interview was conducted regarding abuse allegations. 3. On 09/28/22 at 4:50pm; All alert and oriented residents were interviewed for potential abuse allegations related to staff behavior. Mood interviews was conducted for all residents. No negative findings from interviews with residents. 4. On 09/28/22 at 5pm; Staff interviews began in regard to if they have witnessed any abuse/neglect in facility. All staff will be interviewed prior to next shift by Administrative Staff. interviews resumed no negative findin8s at this time and will continue to educate staff. 5. On 09/28/22 at 5:00pm all staff in-services begun regarding Abuse/Neglect policy. This includes what constitutes abuse and timely reporting. All staff will be educated by administrative staff prior to working next shift. 6. On 09/28/22 at 6:00pm, The Nursing Consultant reviewed policy and procedure for Abuse/Neglect for requirements and notifications with administrative team. 7. On 09/28/22, CNA notified at 6:30pm and LPN notified at 8:30 pm that both employees will be off work until investigation is complete. 8. Protecting the residents by CNA being taken off work until investigation is completed. Interview questions about abuse and neglect on resident counsel to be done monthly. Staff to be in serviced monthly on abuse and neglect. interviewing all alert & oriented residents once a week and body audits on all residents weekly. Staff interviews on all shifts to be done weekly regarding abuse and neglect policy and reporting.

Based on observations, interviews, and record review, the facility failed to ensure Resident #1 and Resident #4 were free from verbal/mental abuse, as evidenced by the facility's failure to ensure staff reported allegations of verbal/mental abuse in a timely manner, which resulted in failure to ensure an investigation was promptly initiated and protective measures were immediately implemented to prevent further potential abuse for 2 (Resident #1 and Resident #4) of 4 (Residents #1, #2, #3, and #4) sampled residents. This failed practice resulted in noncompliance at the level of immediate jeopardy, which caused or could have caused serious psychological harm for R#1 and R#4, who experienced verbal/mental abuse from facility staff, and had the potential to cause more than minimal harm to 75 residents who resided in the facility according to the Roster Matrix provided by the Administrator on 9/27/2022 at 3:37 pm. The Administrator was informed of the Immediate Jeopardy condition on 9/28/2022 at 4:13 pm. The Immediate Jeopardy was removed on 9/28/2022 at 8:35 pm. The findings are: 1. Resident #1 had a diagnosis of kidney failure and atrial fibrillation. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/14/2022, documented the resident scored 15 (13-15 cognitively intact) on the Brief Interview for Mental Status (BIMS), had no behaviors symptoms, did not reject care, and had no hallucinations or delusions or displayed any wandering behaviors. R #1 required supervision for eating and toilet use and used a walker to assist with ambulation. a. A progress note dated 9/8/2022 at 20:42 by Licensed Practical Nurse (LPN) #1 documented, .Behavior notes: This nurse returned to the floor from her 15 min break and seen resident in the hallway visibly upset. As soon as resident seen me, she started accusing my Certified Nursing Assistant (CNA) of being hateful and rude and talking bad to her. She Stated all she did was inform the CNA she smelled smoke and wanted her to check on another resident. She stated the CNA started talking bad to her. This nurse asked the Resident what the CNA said to her, she could not remember. The Resident stated she thought the CNA was coming at her like a bull and trying to use her size to scare her .Describe Interventions: redirected resident that I would talk to the CNA and try to figure out what was said. Reassured her that the CNA would not be coming back into her room tonight and if she needed anything I would personally take care of it .Intervention Effective: Yes, resident laid down in bed and relaxed while I was in the room . b. On 9/14/2022 at 4:05 pm, a complaint intake #29490 from the Office of Long-Term Care (OLTC) documented .Resident/Patient/Client Abuse .OLTC notified the facility of the allegation at 3pm . When (date, time, shift) did the problem occur? a few weeks ago 1. What happened? A worker a weeks ago, answered the light yelling at her. resident was highly upset with the situation and reported it, but nothing was done. 2. How did it happen? unknown 3. Is the problem ongoing? no 4. Who was involved? staff 5. Are there any witnesses? complainant 6. Did you speak to someone at the facility? yes, resident said she did, but compliant hasn't talked to them. 7. Has facility tried to address the situation? no 8. Do you know if this has happened before to the same individual, or to others? entire building c. On 9/27/2022 at 3:07 pm, an entrance conference was held with the Administrator, the Director of Nursing, and The Assistant Director of Nursing. 2. Resident #4 had a diagnoses of kidney failure, and pleural effusion. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/25/2022 documented the resident scored 15 (13-15 cognitively intact) on the Brief Interview for Mental Status (BIMS), had no hallucinations, delusions, no behaviors, and no rejection of care, required extensive assist of two staff for bed mobility, dressing toilet use, personal care, was totally dependent on two staff for transfers, and required extensive assist of one staff for eating, and had an indwelling foley catheter and was always incontinent of bowel. a. On 9/27/2022 at 3:22 pm, R #4 was lying in bed in room. Surveyor introduced self and asked R #4 if it was ok to enter the room in which R #4 stated, yes. The Surveyor asked R #4, has any staff member ever answered your light and yelled/screamed at you? R #4 replied, yes, one time, but the other nurse told her not to talk to me like that and she kept coming in and apologizing. The Surveyor asked, did you report it? R #4 replied, yes, to the head nurse. The Surveyor asked, when did this happen? R #4 replied, on night shift a few days ago. The Surveyor asked R #4 do you know the name of the staff member? R #4 replied, no, she was African American. b. On 9/27/2022 between 4:00 pm and 4:30 pm, the Administrator was notified of R #4 allegation of verbal abuse by a staff member. c. On 9/28/2022 at 8:55 am, the Administrator stated, I talked to R #4's daughter, she was here ten minutes after you left, and we think the resident may have been thinking about the last place she was at, she wasn't treated very well over there. The Surveyor asked the Administrator, did you interview R #4? The Administrator replied, no, just the daughter. d. On 9/28/2022 at 9:47 am, the last three facility reportables were reviewed. There was no reportable documented for R #1's allegation of verbal/mental abuse reported to OLTC. There was no reportable documented for R #4's allegation of verbal abuse reported to the OLTC. e. On 9/28/2022 at 10:47 am, The Surveyor asked the Administrator, are you working on any other reportable? The Administrator replied, no. The Surveyor asked, is this all your reportable? The Administrator replied, yes. f. On 9/28/2022 at 11:02 am, the Administrator was again notified of the abuse allegation regarding R #1. g. On 9/28/2022 at 11:08 am, the Administrator stated, they (OLTC) talked to me and asked if I knew anything about a Certified Nursing Assistant (CNA) who was loud with R #1. I went to the chart, the nurse had charted for 9/8/2022, the CNA went into her room and asked her what she wanted. The resident told the CNA someone was smoking cigarettes in her bathroom. We had the nurse and the CNA's fill out witness statement. h. On 9/28/2022 at 11:14 am, The Surveyor asked the Administrator, did you do a reportable after the office notified you of the allegation of abuse? The Administrator replied, no, we investigated it. The Surveyor asked, so these three witness statements are your investigation? The Administrator replied, yes, and we didn't find anything, I didn't think it was reportable. i. On 9/28/2022 at 2:24 pm, The Surveyor asked Licensed Practical Nurse (LPN) #1, why did you fill out the witness statement on 9/8/2022 for R #1? LPN #1 replied, I did a behavior note and we were told to fill that out because of what was said. The Surveyor asked LPN #1, who told you to fill it out? LPN #1 replied, the Administrator, later. The Surveyor asked LPN #1, , what do you mean later? LPN #1 replied, they (CNA's), they told they had filled out the witness statements that night. The Surveyor asked, when were you asked to fill out the witness statement? LPN #1 replied, it wasn't that day or even a couple of days later, maybe a week, I didn't inform anyone of this situation, I handled it, I thought. I asked the CNA's, I asked the resident, and I told the CNA's I would handle any problems or answer the call light, for the CNAs to stay out of the room for the rest of the night. The resident was intimidated by the CNA size. I took this as behavior. The Surveyor asked LPN #1, have you been in-serviced and trained on abuse? LPN #1 replied, yes. LPN #1 stated, she has a history of accuses staff, residents steal from her, nonstop accusations. The Surveyor asked LPN #1, if they (residents) have a history of accusations, and they say they are scared, intimidated, or rude and talking bed to her and coming at her like a bull trying to use her size to scare her, would you consider that abuse? LPN #1 replied, yes, if it were done. The Surveyor asked LPN #1, how did you determine this was not abuse? LPN #1 replied, she (R#1) couldn't tell me what was said or what happened, and I talked to both CNA's. The Surveyor asked, what are you supposed to do if a resident claims verbal or physical abuse, or any abuse? LPN #1 replied, separate the resident and the accuser and call my Administrator. The Surveyor asked, did you separate the resident and the CNA's that night? LPN #1 replied, yes, I told the CNA's and the resident, and the resident relaxed after I told them I would handle that resident and room that night. The Surveyor asked, did you call the Administrator? LPN #1 replied, no, not that night. The Surveyor asked, when was the Administrator notified? LPN #1 replied, I think state notified her. The Surveyor asked, was there a full investigation done that night? LPN #1 replied, no, just me doing the investigation on the floor. The Surveyor asked, how did you protect the rest of the residents after this allegation of abuse? LPN #1 replied, I didn't feel the residents were in jeopardy. The Surveyor asked LPN #1, when are you supposed to do a reportable? LPN #1 replied, within twenty-four hours of an incident. The Surveyor asked, do you know if there was a reportable done? LPN #1 replied, I do not, I assume not because I didn't inform the Administrator. The Surveyor asked, after the facility has been informed of an allegation of abuse, should the facility do a reportable? LPN #1 replied, yes, they should. I didn't realize I put any resident's life at risk, I thought it was just something that was blown up. The Surveyor asked, what did you mean by or when you said, the resident relaxed after you told her you'd be taking care of her? LPN #1 replied, she was in the hallway upset, I took her to her room, and we sat on the side of the bed, and then she laid down and went to sleep. j. On 9/28/2022 at 3:58 pm, The Surveyor asked CNA #1, have you been in-serviced and trained on abuse and neglect? CNA #1 replied, yes. The Surveyor asked, when do you report allegations of abuse and neglect? CNA #1 replied, when you see it or hear it. The Surveyor asked CNA #1, who do you report allegations of abuse and neglect to? CNA #1 replied, supervisor, charge nurse, go up the chain of command. The Surveyor asked, how are the resident/residents protected during an investigation of allegation of abuse or neglect? CNA #1 replied, 'separate them. The Surveyor asked, why should allegations of abuse and neglect be reported? CNA #1 replied, to protect the residents. k. On 9/28/2022 at 4:26 pm, The Surveyor asked LPN #2, have you been in-serviced and trained on abuse and neglect? LPN #2 replied, yes. The Surveyor asked, when do you report allegations of abuse and neglect? LPN #2 replied, immediately. The Surveyor asked, who do you report allegations of abuse and neglect to? LPN #2 replied, CNA, Charge Nurse, DON, and the Administrator. The Surveyor asked, how are the resident/residents protected during an investigation of allegation of abuse or neglect? LPN #2 replied, depends on what it is, employee is removed, talk to residents, if physical, everybody gets a body audit, police report, and reportable. The Surveyor asked, why should allegations of abuse and neglect be reported? LPN #2 replied, because this is their home, and we have to protect them. l. On 9/28/2022 at 4:31 pm, The Surveyor asked CNA #2, have you been in-serviced and trained on abuse and neglect? CNA #2 replied, yes. The Surveyor asked, when do you report allegations of abuse and neglect? CNA #2 replied, as soon as it happens. The Surveyor asked, who do you report allegations of abuse and neglect to? CNA #2 replied, the nurse. The Surveyor asked, how are the resident/residents protected during an investigation of allegation of abuse or neglect? CNA #2 replied, separate them, keep them safe. The Surveyor asked, why should allegations of abuse and neglect be reported? CNA #2 replied, it's their rights, they need to be taken care of. m. On 9/28/2022 at 4:35 pm, The Surveyor asked LPN #3, have you been in-serviced and trained on abuse and neglect? LPN #3 replied, yes. The Surveyor asked, when do you report allegations of abuse and neglect? LPN #3 replied, the first site of either. The Surveyor asked LPN #3, who do you report allegations of abuse and neglect to? LPN #3 replied, the DON, and the ADON. The Surveyor asked LPN #3, how are the resident/residents protected during an investigation of allegation of abuse or neglect? LPN #3 replied, tend to their needs and cares. The Surveyor asked LPN #3, why should allegations of abuse and neglect be reported? LPN #3 replied, because some don't have a voice and we need to be their advocate. n. On 9/28/2022 at 5:28 pm, the Administrator entered the Conference room with a witness statement and stated, I have people coming to help me with this, but I want you to fill out this witness statement on R#4 so I can get that reported. o. On 9/28/2022 at 7:48 pm, the Administrator provided a copy of the second Plan of Removal. The Surveyor asked the Administrator, what hall is LPN #1 working? The Administrator replied, station 1 and R #1 is on station #2. The Surveyor asked, should an LPN that didn't report alleged verbal abuse, be working on the floor with the residents? The Administrator replied, I see the LPN thought she took care of the situation. p. On 9/28/2022 at 7:52 pm, the Administrator stated, we have educated the LPN on timely reporting. q. The Administrator provided a copy of the September 2022 nursing schedule on 9/28/2022 at 8:13 pm. LPN #1 worked on 9/8, 9/9, 9/10, 9/11, 9/14, 9/15, 9/16, 9/17, 9/18, nine days, including two and half hours on 9/28/2022, LPN #1 was allowed to work with residents after the abuse allegation. LPN #1 did work the floor on 9/28/2022 until 8:30 pm per the Immediate Jeopardy Plan of Removal. r. The Administrator provided a copy of the September 2022 CNA schedule on 9/28/2022 at 8:13 pm. CNA #3 worked on 9/8, 9/11, 9/12, 9/13, 9/14, 9/15, 9/16, 9/18, 9/19, 9/20, 9/21, 9/22, 9/25, 9/26, 9/27, fifteen days, including the day of incident, CNA #3 was allowed to work with residents after the abuse allegation, and was scheduled to work on 9/28/2022. CNA #3 was notified by the facility on 9/28/2022 at 6:30 pm, they would be off work until investigation was complete per the Immediate Jeopardy Plan of Removal. s. The Administrator provided a copy of the September 2022 CNA schedule on 9/28/2022 at 8:13 pm. CNA #4 worked on 9/8, 9/12, 9/13, 9/14, 9/18, 9/19, 9/20, 9/21, 9/24, 9/25, and 9/26/200, eleven days, including the day of incident, CNA #4 was allowed to work with residents after the abuse allegation. t. On 9/29/2022 at 12:00 pm, The Surveyor asked the Director of Nursing (DON), have you been in-serviced and trained on abuse and neglect? The DON replied, yes. The Surveyor asked, when should an allegation of abuse or neglect be reported? The DON replied, immediately. The Surveyor asked, who do you report allegations of abuse/neglect to? The DON replied, I would report to my Administrator. The Surveyor asked, what is the facilities policy and procedure for reporting, investigating, and protecting the residents for/during an allegation of abuse or neglect? The DON replied, report immediately, being an internal investigation, report to appropriate OLTC, report to several people, investigate, keep alleged employee away from resident, I would make sure they (the resident) felt safe. The Surveyor asked, if a resident states a staff was mean, rude, or came at me like a bull to scare me, what type of abuse would this be considered? The DON replied, verbal abuse, emotional abuse, intimidating, that would be emotional. The The Surveyor asked, should that be reported and to whom? The DON replied, yes, to the Administrator. The Surveyor asked the DON, what guidelines does the facility follow regarding reporting, investigating, and protecting residents after an allegation of abuse or neglect? The DON replied, our abuse and neglect policy, policy and procedure. The Surveyor asked, what are your expectations from your staff regarding reporting, investigating, and protecting the residents after an allegation of abuse or neglect, and following facility policy and procedures and the Centers for Medicare and Medicaid Services (CMS) Federal Regulations? The DON replied, I expect them to treat residents with respect and dignity like their own family member and if anyone witnesses anything different, to report it and it be investigated. u. On 9/29/2022 at 1:02 pm, The Surveyor asked the Administrator, have you been in-serviced and trained on abuse and neglect? The Administrator replied, yes. The Administrator was asked, when should an allegation of abuse or neglect be reported? The Administrator replied, immediately upon suspension. The Surveyor asked, who do you report allegations of abuse/neglect to? The Administrator replied, I'm the one they report to, and I investigate, and if it's founded, I report to OLTC. This happened on 9/8/2022 and I found out on 9/14/2022, someone reported that a CNA was loud and hateful to a resident, I don't know if that's the right date, but it coincides with the two weeks. The Surveyor asked, what is the facilities policy and procedure for reporting, investigating, and protecting the residents for/during an allegation of abuse or neglect? The Administrator replied, if the allegation has been looked at and unfounded, I put it in a special file, if it's founded or any other negative findings, I do a reportable. The Surveyor asked the Administrator, is this the way you were taught to report abuse? The Administrator replied, she's had so many behaviors and allegations, that's the way I looked at it. The Surveyor asked, if a resident sates a staff was mean, rude, or came at me like a bull to scare me, what type of abuse would this be considered? The Administrator replied, I would say verbal abuse. The Surveyor asked, should that be reported and to whom? The Administrator replied, well I so, I should have reported it to OLTC. The Surveyor asked, what guidelines does the facility follow regarding reporting, investigating, and protecting residents after an allegation of abuse or neglect? The Administrator replied, we have our policy and procedure book, send the person home, interview staff and residents, depending on type of abuse, we do body audits, we do mood assessments. The Surveyor asked, what are your expectations from your staff regarding reporting, investigating, and protecting the residents after an allegation of abuse or neglect, and following facility policy and procedures and the CMS Federal Guidelines? The Administrator replied, I expect them to follow it, I expect them to report it, they are in-serviced on hire, yearly, then they have their yearly competencies. v. A policy provided by the Administrator on 9/27/2022 at 3:57 pm documented .abuse, neglect, misappropriation and exploitation .investigation and reporting policy .the facility will endeavor to protect residents from maltreatment, which means adult abuse, sexual abuse, neglect, misappropriation of resident property, and exploitation of residents .It recognizes resident rights to be free from physical, verbal, or mental abuse, corporal punishment, involuntary seclusion, and any chemical and physical restraints as defined by federal guidelines .all alleged, witnessed, or suspected resident maltreatment, including abuse, sexual abuse, neglect, misappropriation of resident property and exploitation of residents, shall be immediately reported to Administrator or immediate supervisor and investigated by Facility management .all alleged, witnessed or suspected incidents must be reported according to state and federal law, according to the time restrictions required by law. All alleged violations will be reported immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. The following persons or entities will be notified, as required by state law, by Facility personnel (Administrator or Administrator Designee): a. Administrator b. State Survey Agency c. Local law enforcement d. Physician e. Resident's Responsible Party or Emergency Contact f. Coroner if death has occurred g. State Registry Time for completing Incident & Accident (I & A) Intake Forms .an incident & accident intake form (form DMS-7734) will be completed by the Administrator or Administrator Designee and submitted to the State Survey Agency no later than 11:00 am on the next business day following discovery by the facility of any incident of alleged, witnessed or suspected resident maltreatment, including abuse, sexual abuse, verbal abuse, neglect, misappropriation of resident property and exploitation of residents .The Administrator or Administrator's Designee will complete the flow up Investigation Report (Form DMS-762) and summit a copy to the State Survey Agency within five (5) days of the incident's discovery, or as otherwise mandated by law or regulation .Protecting Residents from incidents and preventing further occurrences during investigation .In an effort to protect a resident who has allegedly been abused, neglected, exploited, or has had property misappropriated, the suspected employee (s) may be either reassigned to another shift, shadowed by another facility employee, reassigned to non-resident care duties, or suspended immediately from employment until an investigation has determined that the employee is no longer a suspect .abuse .willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish .verbal abuse .any intentional act that a reasonable person would believe subjects an endangered person or an impaired person, regardless of age, ability to comprehend, or disability, to ridicule or psychological injury in a manner likely to provoke fear or alarm, excluding necessary care and treatment provided in accordance with generally recognized professional standards of care, including any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within hearing distance .metal abuse .any intentional threat that a reasonable person would find credible and nonfrivolous to inflict pain on or cause injury to an endangered person or an impaired person except in the course of medical treatment or for justifiable cause .includes humiliation, intimidation, fear, shame, agitation, harassment, threats of punishment or deprivation that are likely to provide fear or alarm .an inability of a resident to express outward signs of mental anguish does not mean mental abuse did not occur . The Plan of Removal for Resident # 1 and #4 was provided by the Administrator on 09/28/22 at 7:58 PM reads as follow: 1. After notification of immediate Jeopardy on 09/28/22 at 4:13pm; Reportable for abuse allegation began by Administrator and DON. 7734 was completed and submitted to OLTC on 09/28/22 at 7:31pm. 2. On 09/28/22 at 5:30pm; DON, ADON, and Treatment assessed Resident # 1 and #4 with no negative findings. Interview was conducted regarding abuse allegations. 3. On 09/28/22 at 4:50pm; All alert and oriented residents were interviewed for potential abuse allegations related to staff behavior. Mood interviews was conducted for all residents. No negative findings from interviews with residents. 4. On 09/28/22 at 5pm; Staff interviews began in regard to if they have witnessed any abuse/neglect in facility. All staff will be interviewed prior to next shift by Administrative Staff. interviews resumed no negative findin8s at this time and will continue to educate staff. 5. On 09/28/22 at 5:00pm all staff in-services begun regarding Abuse/Neglect policy. This includes what constitutes abuse and timely reporting. All staff will be educated by administrative staff prior to working next shift. 6. On 09/28/22 at 6:00pm, The Nursing Consultant reviewed policy and procedure for Abuse/Neglect for requirements and notifications with administrative team. 7. On 09/28/22, CNA notified at 6:30pm and LPN notified at 8:30 pm that both employees will be off work until investigation is complete. 8. Protecting the residents by CNA being taken off work until investigation is completed. Interview questions about abuse and neglect on resident counsel to be done monthly. Staff to be in serviced monthly on abuse and neglect. interviewing all alert & oriented residents once a week and body audits on all residents weekly. Staff interviews on all shifts to be done weekly regarding abuse and neglect policy and reporting.

Based on record review and interview, the facility failed to ensure medical exemption forms for the COVID-19 vaccine, contained the components for which COVID-19 vaccines were clinically contraindicated for 2 of 2 facility staff who requested medical exemptions from the COVID-19 vaccines. The findings are: 1. A policy titled .COVID-19 Vaccine Policy and Procedures .provided by the Assistant Director of Nursing (ADON) on 3/3/22 at 9:39 am; documented, .Purpose .To establish the process to comply with the Federal mandate that all staff are vaccinated against COVID-19 unless they have a medical or religious exemption to help reduce the risk residents and staff have of contracting and spreading COVID-19 . Staff that request a medical exemption or delay must provide the following . the letter must include the following components . All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications . 2. The CMS- (Centers For Medicare and Medicaid Services) form dated 1/20/22 documented, .for staff who have requested and/or are granted medical exemption, verify facility records are traced, secure, and include the following . Which COVID-19 vaccine is clinically contraindicated . 3. The COVID-19 Staff vaccination Status for Providers, received from the Administrator on 3/3/22 at 10:09 am, documented 2 facility staff members were granted medical exemptions. 4. A copy of Request for Accommodation: Medical Exemption from Vaccination, for Staff #1 documented, The person named above should not receive the COVID-19 vaccine due to: Sensitivity to Poly-Ethylene [MEDICATION(S)] and was signed and approved on 1/25/2021 by a Medical Physician. The Medical Exemption form did not document which COVID-19 vaccines Staff #1 was exempted from and did not document any specific accommodations. 5. A copy of Request for Accommodation: Medical Exemption from Vaccination, for Staff #2 received from the Administrator on 3/4/22 at 10:04 am, documented, The person named above should not receive the COVID-19 vaccine due to: Documented episode of [CONDITION(S)] 4/15/19 and was signed and approved on 1/21/2021 by an Advance Practice Registered Nurse. The Medical Exemption form did not document which COVID-19 vaccines Staff #2 was exempted from and did not document any specific accommodations. 6. A second copy of Request for Accommodation: Medical Exemption from Vaccination, for Staff #2 received from the Administrator on 3/4/22 at 10:04 am, documented, The person named above should not receive the COVID-19 vaccine due to: [CONDITION(S)] r/t vaccination. This exemption should be . permanent . was signed by the APRN (Advanced Practical Registered Nurse) on 1/10/22. The document had no signature of approval and did not specify accommodation details. 7. On 3/4/22 at 10:51 am, the Assistant Director of Nursing (ADON) was asked, What components/information is supposed to be documented on a medical exemption form for the COVID-19 vaccine? The ADON stated, They go to the doctor, they have the doctor fill out the form with the contraindications. The ADON was asked, On the form, is the individual COVID-19 vaccines listed? The ADON stated, No. The ADON was asked, What guidelines does the facility follow for the COVID-19 vaccine medical exemptions? The ADON stated, Centers for Disease Control (CDC). 8. On 3/4/22 at 11:37 am, the Director of Nursing (DON) was asked, What components/information is supposed to be documented on a medical exemption form for the COVID-19 vaccine? The DON stated, Contraindicated verses precautionary COVID-19 vaccines. The DON was asked, On the form, is the individual COVID-19 vaccines listed? The DON stated, No. The DON was asked, What guidelines does the facility follow for the COVID-19 vaccine medical exemptions? The DON stated, CMS and CDC's guidelines. 9. On 3/4/22 at 12:37 pm, the Administrator was asked, What components/information is supposed to be documented on a medical exemption form for the COVID-19 vaccine? The Administrator did not answer the question. The Administrator was asked, On the form, is the individual COVID-19 vaccines listed? The Administrator stated, No. The Administrator was asked, What guidelines does the facility follow for the COVID-19 vaccine medical exemptions? The Administrator stated, CDC.

Based on observation, record review, and interview, the facility failed to ensure hand rolls or gauze rolls were applied as ordered by the physician to prevent further decline in range of motion (ROM) for 2 (Resident #06, #46) of 5 (Residents #6, #11, #26, #28, #46) sampled residents who had contractures. The findings are: 1. Resident #46 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Refence Date (ARD) of 09/23/2021 documented the resident was severely impaired in cognitive skills for daily decision-making per a Staff Assessment for Mental Status (SAMS) and had functional limitation in range of motion to the upper extremities on both sides. a. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . b. The Care Plan dated as revised on 10/21/2021 documented, .The resident has an ADL [activities of daily living] self-care performance deficit r/t [related to] [CONDITION(S)], MR [Mental [CONDITION(S)]], NONVERBAL BUT ABLE TO MAKE NEEDS KNOWN . HAND ROLL RIGHT HAND . The resident has limited physical mobility r/t [CONDITION(S)], contractures . Clean right hand with Theraworx then apply gauze roll or palm pillow 3x/wk [3 times per week] for preventative care of contractures . c. On Monday 11/15/21 at 12:41 PM, the resident was lying in bed on her back. Her right hand and wrist were contracted, and no hand roll was in place. d. On 11/16/21 at 2:40 PM, the Director of Nursing (DON) was asked, Should the resident have a hand roll in place in her right hand? She stated, Yes. She was asked why and stated, Contractures. e. On 11/16/21 at 2:48 PM, Licensed Practical Nurse (LPN) #2 was asked, Should the resident have a hand roll in place in her right hand? She stated, Yes. She was asked why and stated, Helps with contractures. 2. Resident #6 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/15/21 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status, required extensive two-person physical assistance for bed mobility and transfers, and had functional limitation in range of motion of the upper extremities on both sides. a. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . check placement of gauze hand rolls q [every] shift . b. The Care Plan dated as revised 3/29/21 documented, The resident has an ADL self-care performance deficit r/t [related to] Alzheimer's . no hand rolls, use only gauze . c. On 11/15/21 at 12:03 PM, the resident was reclined in a geri-chair in Station One's Lounge / Dining Room. Both hands were contracted, and no gauze rolls were in place. d. On 11/16/21 at 8:32 AM, the resident was reclined in a geri-chair in Station One's Lounge / Dining Room. Both hands were contracted into closed fists with the fingers pressed against her palms, and no gauze rolls were in place. e. On 11/16/21 at 8:49 AM, LPN #1 accompanied the surveyor to Station One's Lounge / Dining Room and was asked, According to the resident's Care Plan, should she have hand rolls for her contracted hands? She stated, Yes, ma'am. She was asked how the staff knew to apply the hand rolls and stated, The Treatment Nurse applies the hand rolls to her hands. She was asked, What are the potential complications of not applying the hand rolls? She stated, Contractures could worsen. f. On 11/18/21 at 8:01 AM, the Treatment Nurse was asked, Do you apply the hand rolls to [Resident #6]? She replied, Yes, she is ordered to have gauze; she has treatments on Monday, Wednesday and Fridays. The Treatment Nurse was asked, Do the CNAs [Certified Nursing Assistants] apply the gauze? She replied, No. She was asked, Do you check her hands daily to ensure the gauze is in place? She replied, Yes, and if the CNAs give her a shower or if the gauze is missing, the CNAs are to notify me. She was asked, Do you have documentation that you check her hands for placement of the gauze? She replied, No.

Based on observation, record review and interview, the facility failed to ensure humidification bottles were refilled promptly for 1 (Resident #26); respiratory supplies were changed weekly to prevent possible respiratory infections for 2 (Residents #26 and #19); and respiratory supplies were properly stored to prevent potential contamination for 1 (Resident #69) of 6 (Residents #7, #8, #11, #19, #26, #69) sampled residents who received respiratory services. The findings are: 1. Resident #26 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/10/2021 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and did not receive oxygen therapy while a resident. a. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . b. The Care Plan dated 11/11/2021 documented, .The resident has oxygen therapy r/t [related to] ineffective gas exchange . Change O2 tubing, clean filter and O2 cabinet, date all tubing every Tuesday night on 11-7 shift . c. On Monday 11/15/21 at 12:01 PM, the resident was lying in bed on her back with her eyes closed and receiving oxygen via nasal cannula. The flow meter on the oxygen concentrator was set to deliver O2 at 2.5 liters per minute. A humidification bottle dated 11/9 (11/9/2021) was connected to the concentrator but was empty. The storage bag for the tubing was dated 11/02. d. On 11/16/21 at 2:21 PM, the Director of Nursing (DON) was asked, Should humidification bottles be replaced once empty? She stated, Yes. She was asked why and stated, It helps with the airway, so they won't dry out, and it is more comfortable. She was asked, Should the plastic storage bags be replaced weekly? She stated, Yes. She was asked why and stated, Infection control. e. On 11/16/21 at 2:48 PM, Licensed Practical Nurse (LPN) #2 was asked, Should the humidification bottle be replaced once it is empty? She stated, Yes. She was asked why and stated, It keeps the nasal passages moist instead of drying out. She was asked, Should the plastic storage bags be replaced weekly? She stated, Yes. She was asked why and stated, Infection control. 2. Resident #19 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Significant Change MDS with an ARD of 11/01/2021 documented the resident scored 7 (0-7 indicates severe impairment) on a BIMS, received oxygen therapy while not a resident, and did not receive oxygen therapy while a resident. a. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . May remove for ADLs every shift related to SHORTNESS OF BREATH . b. The Care Plan dated as revised 10/29/2021 documented, .The resident has altered respiratory status / difficulty breathing r/t [related to] O2, Sleep Apnea, has [CONDITION(S)] [continuous positive airway pressure] but often refuses it . OXYGEN 2-4 LITERS per NC AS TOLERATED PRN . EQUIPMENT CHANGE EVERY TUES PER TAR [Treatment Administration Record] . c. On 11/15/21 at 1:14 PM, the resident was lying in bed on her back. The flow meter on the resident's oxygen concentrator was set to deliver O2 at 2 liters per minute. The storage bag for the oxygen tubing was dated 10/25. 3. Resident #69 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/28/2021 documented the resident scored 11 (8 -12 indicates moderately impaired) on a BIMS; required extensive assistance of two-plus persons with bed mobility and, transfers; had shortness of breath with exertion and when lying flat; and received oxygen therapy while a resident. a. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)]-[MEDICATION(S)] Solution 0.5-2.5 (3) MG/3ML [milligrams per 3 milliliters] 1 application inhale orally every 8 hours as needed for Shortness of breath . b. The Initial Care Plan dated 11/11/21 documented, The resident has oxygen therapy r/t [related to] ineffective gas exchange . The resident will have no s/sx [signs/symptoms] of poor oxygen absorption through the review date . c. On 11/15/21 at 12:52 PM, the resident was sitting in her recliner, with oxygen in use via nasal cannula. The updraft mask was on the bedside table next to the nebulizer and was not in a bag or closed container. d. On 11/15/21 at 1:21 PM, LPN #1 accompanied the surveyor to the resident's room and was asked, What is the proper way to store the resident's updraft mask when it's not in use? She replied, They are to be placed in the black bags. The resident's mask still on the bedside table. The surveyor asked, Is that the proper way to store it? She replied, No, it should not be laying on the table. e. On 11/18/21 at 1:33 PM, the Director of Nursing (DON) was asked, What is the proper way to store an updraft when it is not in use? She stated, In the bag; after you do the updraft, you rinse it, clean it, make sure it is dry and store it in an appropriately dated storage bag. She was asked why and stated, Infection control; make sure you clean it and keep it clean.

Based on observation, record review, and interview, the facility failed to ensure Minimum Data Set (MDS) assessments were accurate and complete to facilitate the ability to plan and provide necessary care and services for 1 (Resident #8) of 2 (Residents #8 and #49) sampled residents who had an indwelling catheter. The findings are: Resident #8 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . a. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This was documented as a current, active order on the Order Summary Report dated 11/16/21. b. The Care Plan dated 4/19/21 documented, The resident has Indwelling Catheter: OBSTRUCTIVE AND REFLUX [CONDITION(S)] . c. The Quarterly Minimum Data Set with an Assessment Reference Date of 8/18/21 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status; required extensive assistance of one person for toilet use; was occasionally incontinent of bladder; and did not have a urinary catheter. d. On 11/15/21 at 1:03 PM, the resident was sitting on the side of her bed. Her urinary catheter drainage bag was on the floor. The resident stated she took the catheter bag out of the privacy bag when she repositioned herself and forgot to put it back in the privacy bag. e. On 11/18/21 at 10:47 AM, the MDS Coordinator was asked who was responsible for completing Section H (Bladder and Bowel section) of the MDS? She replied, Me. The surveyor asked, How long has the resident had an indwelling catheter? She replied, Since admission, The MDS Coordinator was asked if the responses of occasionally incontinent and no urinary catheter were correct on the MDS with an assessment reference date of 8/18/21. She replied, No, it is not; I will correct that.

Based on observation and interview, the facility failed to ensure meals were prepared and served according to the planned, written menu to meet the nutritional needs of all 58 residents who resided in the facility, according to the Resident Census and Conditions of Residents form provided by the Assistant Director of Nursing (ADON) on 9/22/20. The findings are: a. On 9/21/2020 at 11:30 a.m., the menu provided by the Administrator documented the residents were to receive Chicken Enchilada Casserole, Refried beans, tortilla chips, salsa, peach cobbler, and coffee or tea for the lunch meal. b. On 9/21/2020 at 11:45 a.m., Dietary Employee #1 rolled a cart holding covered deserts from the refrigerator towards the steam line. Dietary Employee #1 was asked, What is on the cart? She stated, Its lemon pie and chocolate pie for dessert. c. On 9/21/2020 at 11:59 a.m., the Dietary Manager (DM) was asked why she wasn't serving peach cobbler like the menu indicated. She stated, We didn't have time to do the cobbler. I had a call-in this morning. The Dietary Manager was asked, How is the Dietitian made aware of changes? She stated, She already knows that we don't have enough people to do real elaborate meals anymore, so she told me to put the changes I make on a sheet and staple it to the menu for her to sign later in the week. The Dietary Manager was asked if the residents were aware of the menu change today. She stated, No.

Based on observation and interview, the facility failed to ensure food was stored properly in the refrigerator and freezer; and Dietary Staff washed their hands between dirty and clean tasks, and before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 56 residents who received meals from the kitchen (Total Census: 58), as documented on a list provided by the Dietary Manager on 9/24/2020 at 10:40 a.m. The findings are: 1. On 9/21/2020 at 11:08 a.m., one zip lock bag containing ham was stored on a shelf in the refrigerator. The bag was torn approximately 2 to 3 inches right below the zipper seal line. a. On 9/21/2020 at 11:09 a.m., a metal pan containing oatmeal and a pan containing brown gravy covered with a metal top were stored on a shelf in the refrigerator. The metal pan of oatmeal and brown gravy were not dated. The Dietary Manager stated, That's the oatmeal from this morning. I guess he forgot to put a date on it. Both pans were removed from refrigerator by the Dietary Manager. b. On 9/21/2020 at 11:11 a.m., Dietary Employee #1 had a pair of gloves on while pureeing tortillas. She placed the tortillas in the blender, placed the lid on the top of the blender, and began to puree the mixture. She picked up a can of chicken broth and set it down. She picked up more tortillas with the same contaminated gloved hand that picked up the can and placed the tortillas into the blender. c. On 9/21/2020 at 12:05 p.m., Dietary Employee #2 was preparing trays for the residents' lunch meal. He set the serving ladle down, and with the same hand, picked a small serving cup up placing his thumb on the inside of cup. d. On 9/21/2020 at 12:11 p.m., one single bag of tortillas was stored on a shelf in the refrigerator. The bag of tortillas was open, and the bag was not dated. e. On 9/21/2020 at 12:13 p.m., a box containing cubed beef steak fritters was stored on a shelf in the freezer. The box was open the bag containing the beef steak fritters was not tied / closed or sealed. f. On 9/21/2020 at 12:14 p.m., 2 small serving cups with a frozen water-like substance in them were uncovered and were stored on the top shelf of the freezer. The Dietary Manager was asked, What was in the small cups in the freezer? She stated, It's not anybody's. I was experimenting with thickened water. g. On 9/22/20 at 9:42 a.m., Dietary Employee #2 washed his hands and began to puree some greens. Once finished, he placed the blender in the dishwashing station and picked up clean plates, grabbing approximately 5 plates with his fingers touching the interior side of the plates. He grabbed tray covers with his thumbs on the insides of the covers. He did not perform any hand hygiene between pureeing the greens and handling the clean dishes. h. On 9/22/2020 at 11:09 a.m., Dietary Employee #4 had gloves on and removed 4 slices of bread from the loaf of bread. She set the slices of bread on top of foil that was lying on the countertop. She picked up a knife and began to place peanut butter on each slice of bread. Dietary Employee #4 picked up a plastic container that contained individual packets of jelly and opened them. She picked up a small paring knife and poured the contents of the packets of jelly on the slices of bread. She picked up each slice of bread and began to spread the jelly on it. She went back to the loaf of bread with the same gloves on and removed four more slices of bread. She placed the slices of bread on top of the slices of bread with the peanut butter and jelly spread, making sandwiches. Dietary Employee #4 went to a box containing zip lock bags and removed 5 zip lock bags. She placed each sandwich into its own individual bag, sealed it, removed her gloves, and dated each bag. Dietary Employee #4 did not perform hand hygiene between handling food and contaminated items.

Based on observation, the facility failed to ensure trash was properly contained within 2 of 2 dumpsters, to minimize the presence of foul odors and decrease the potential for pest infestation. This failed practice had the potential to affect all 58 residents who resided in the facility, as documented on the Resident Census and Conditions of Residents form dated 9/22/2020. The findings are: 1. On 9/22/2020 at 9:14 a.m., two dumpsters were located in the dumpster area which was located out the back door from the kitchen. The first dumpster had no barrier around it. The first dumpster had the lid closed but had a clear bag that contained a blue glove, a brief, and white paper hanging on the outside of the right corner of the dumpster. On the right corner on the ground was a white piece of paper, a blue glove, and white straw cover. 2. On 9/22/2020 at 9:15 a.m., the second dumpster was located behind a barrier. The lid to the dumpster was closed. On the ground located on the right side of the dumpster was a KN-95 mask, a blue surgical mask, 5 pieces of white paper, and a straw. There were three blue gloves on the ground behind the dumpster. One blue glove and two white pieces of paper were on the ground in front of the dumpster.

Based on observation, record review and interview, the facility failed to ensure the physician was notified of a significant weight loss and dietary recommendations from the Registered Dietician to maintain acceptable parameters of nutrition and prevent further weight loss for 1 (Resident #3) and failed to ensure power potatoes were served to prevent further weight loss for 1 (Resident #7) of 4 (Residents #2, #3, 7, and #10) case mix residents who had a significant weight loss. This failed practice resulted in actual harm to Resident #3 who had a significant weight loss over a 6 month time frame and had the potential to affect 4 residents who were at risk for weight loss per a listing provided by Medical Records Supervisor on 4/4/14 at 12:25 p.m. The findings are: 1. Resident #3 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/10/14 documented the resident scored 3 (0-7 indicates severely impaired) on the Brief Interview for Mental Status (BIMS), required extensive assistance with eating, and weight loss of 5% or more in the last month or loss of 10% or more in last 6 months and not physician prescribed. a. The care plan dated 1/10/14 documented, "...Alteration in nutrition; below IBW (Ideal Body Weight) w (with)/Sig (significant) weight loss, poor appetite, assisted w/meals as she will allow... Ensure B (breakfast)/L (Lunch)/ S (Supper)..." b. The monthly weight audit sheet provided by Dietary Manager (DM) #1 on 4/1/14 at 8:40 a.m. documented the resident's weight was 136.8 pounds in September 2013, 133.20 pounds in October 2013, 136.20 pounds in November 2013, 124.0 pounds in December 2013, 116.60 pounds in January 2014, 110.20 for February 2014, and 108.4 pounds in March 2014 which represented a significant weight loss (20.7% weight loss in 6 months and a 12.6% weight loss in 3 months). On 4/3/14 at 11:00 a.m., Certified Nursing Assistant (CNA) #3 and CNA #4 weighed the resident and stated the resident weighed 104.4 pounds. This was a 3.6% weight loss from the March 2014 weight. c. A dietary progress note from the Registered Dietician (RD) dated 3/18/14 documented, "...dietary interventions include: chocolate ensure pudding BID (twice daily), magic cup BID, Ensure TID (three times daily), super cereal @ (at) breakfast... Recommend adding 2 oz (ounce) house supplement TID (with) med pass..." d. Nurse's notes dated 12/15/13-4/2/15, did not document that the physician was notified of the significant weight loss or the Registered Dietician's (RD) recommendations. As of 4/3/14, there was no documentation in the clinical record by the physician concerning the resident's significant weight loss. e. On 4/1/14 at 12:32 p.m., the resident was served the lunch meal that consisted of pureed Polish sausage, American fried potatoes, Sauerkraut, cornbread, and fruit salad. The resident ate 40% of the meal. The resident was also served Magic Cup and she ate 25% of it. At 5:45 p.m., the resident was served the supper meal that consisted of pureed Goulash, yams, pudding parfait, and breadsticks. The resident consumed 60% of the meal. The resident was also served a Magic Cup and ate 25% of it. The resident was not served Ensure pudding or Ensure drink during the lunch and supper meals. f. On 4/2/14 at 10:10 a.m., a copy of the meal card provided by DM #1 documented for lunch and supper under the heading Likes, "Ensure, Choc (chocolate) Ensure pudding." On 4/2/14 at 2:50 p.m., Dietary Manager #1 was asked how the RD recommendations were handled and DM #1 stated, "We transfer them to the meal card under 'likes'." On 4/3/14 at 9:06 a.m., DM #1 was asked when does Resident #3 received Ensure and DM #1 stated, "With all meals." When asked when Resident #3 received Ensure pudding, DM #1 stated, "At lunch and supper." g. On 4/2/14 at 3:50 p.m., the Director of Nursing (DON) was asked how RD recommendations were communicated to the physician and the DON stated, "If it is a supplement, usually a physician order [REDACTED]." 1) As of 4/1/14, the Med (Medication) Sheet dated 3/18/14-3/31/14 did not document a house supplement per the RD's recommendation. 2) As of 4/2/14 the closet care plan did not document supplements per the RD's recommendations. 3) As of 4/3/14, there was no documentation in the clinical record of physician orders [REDACTED]. h. On 4/3/14 at 9:15 a.m., the DON was asked what the facility's procedure was for recommended dietary supplements. The DON stated, "The dietician will meet with me and give me a report, then we call the physician and obtain orders for those recommendations." i. On 4/3/14 at 9:35 a.m., the DON provided a copy of the "Dietary Quality Assurance Report" dated 3/18/14, which documented, "...(Resident #3)...Problem: wt. (weight) loss... Recommendations: Recommend adding 2 oz. house supplement TID (with) med pass..." 2. Resident #7 had [DIAGNOSES REDACTED]. The Annual MDS with an ARD of 3/28/14 documented the resident scored 3 (0-7 indicates severe impairment) on the Brief Interview for Mental Status (BIMS), required extensive assistance with eating, and had a weight loss of 5% or more in the last month or loss of 10 % or more in the last 6 months and not on a physician prescribed weight-loss regimen. a. The Weight Audit record documented the resident weighed 87 pounds in September 2013, 91.6 pounds in October 2013, 86.4 pounds in November 2013, 89 pounds in December 2013, 98.1 pounds in January 2014, 98.8 pounds in February 2014, and 90.2 pounds in March 2014. b. The Overall Care Plan, undated, documented, ."..Has a significant wt loss - 5% or more in 30 days, assisted with meals as she will allow, ... power potatoes @ l (lunch)..." c. Dietary notes dated 3/18/14 by the DM, "...Added power potatoes @ lunch..." d. On 4/1/14, the resident's meal card for lunch documented, "...likes power pots (potatoes)..." e. On 4/1/14 at 1:00 p.m., the resident was the lunch meal that consisted of Polish Sausage, American Fried Potatoes, Sauerkraut, Cornbread, and Fruit Salad. The resident ate 70% of the meal. There were no power potatoes with the lunch meal. At 5:55 p.m., the resident was served the supper meal that consisted of Goulash, squash, sweet potatoes, and pudding parfait. The resident ate 60% of the meal. There were no power potatoes served with the supper meal. f. On 4/2/14 at 2:38 p.m., the DM was asked, "How does the kitchen staff know what residents receive power potatoes with meals or any other weight loss intervention?" DM stated, "I add it to the diet card and then I put it in the chart. I tell my employees to pay attention to the likes and dislikes on the diet card."

Based on observation, record review and interview, the facility failed to ensure nursing administration had a system in place for notifying the physician of a significant weight loss and dietary recommendations from the Registered Dietician to maintain acceptable parameters of nutrition and prevent further weight loss for 1 (Resident #3) of 3 (Residents #2, #3, and #10) case mix residents who had a significant weight loss. This failed practice resulted in actual harm to Resident #3 who had a significant weight loss over a 6 month time frame and had the potential to affect 4 residents who were at risk for weight loss per a listing provided by Medical Records Supervisor on 4/4/14 at 12:25 p.m. The findings are: 1. Resident #3 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/10/14 documented the resident scored 3 (0-7 indicates severely impaired) on the Brief Interview for Mental Status (BIMS), required extensive assistance with eating, and weight loss of 5% or more in the last month or loss of 10% or more in last 6 months and not physician prescribed. a. The care plan dated 1/10/14 documented, "...Alteration in nutrition; below IBW (Ideal Body Weight) w (with)/Sig (significant) weight loss, poor appetite, assisted w/meals as she will allow... Ensure B (breakfast)/L (Lunch)/ S (Supper)..." b. The monthly weight audit sheet provided by the Dietary Manager #1 on 4/1/14 at 8:40 a.m. documented the resident's weight was 136.8 pounds in September 2013, 133.20 pounds in October 2013, 136.20 pounds in November 2013, 124.0 pounds in December 2013, 116.60 pounds in January 2014, 110.20 for February 2014, and 108.4 pounds in March 2014 which represented a 20.7% weight loss in 6 months, a 12.6% weight loss in 3 months, and a 1.63% weight loss in 30 days. On 4/3/14 at 11:00 a.m., Certified Nursing Assistant (CNA) #3 and CNA #4 weighed the resident and stated the resident weighed 104.4 pounds. This was a 3.6% weight loss from the March 2014 weight. c. Nurse's notes dated 12/15/13-4/2/15, did not document that the physician was notified of the significant weight loss or the Registered Dietician's (RD) recommendations. d. As of 4/3/14, there was no documentation in the clinical record by the physician concerning the resident's significant weight loss. e. A dietary progress note from the Registered Dietician (RD) dated 3/18/14 documented, "...dietary interventions include: chocolate ensure pudding BID (twice daily), magic cup BID, Ensure TID (three times daily), super cereal @ (at) breakfast... Recommend adding 2 oz (ounce) house supplement TID (with) med pass..." f. On 4/1/14 at 12:32 p.m., the resident was served the lunch meal that consisted of pureed Polish sausage, American fried potatoes, Sauerkraut, cornbread, and fruit salad. The resident ate 40% of the meal. The resident was also served Magic Cup and she ate 25% of it. At 5:45 p.m., the resident was served the supper meal that consisted of pureed Goulash, yams, pudding parfait, and breadsticks. The resident consumed 60% of the meal. The resident was also served a Magic Cup and ate 25% of it. The resident was not served Ensure pudding or Ensure drink during the lunch and supper meals. g. On 4/2/14 at 10:10 a.m., a copy of the meal card provided by DM #1 documented for lunch and supper under the heading Likes, "Ensure, Choc (chocolate) Ensure pudding." On 4/2/14 at 2:50 p.m., Dietary Manager #1 was asked how the RD recommendations were handled and DM #1 stated, "We transfer them to the meal card under 'likes'." On 4/3/14 at 9:06 a.m., DM #1 was asked when does Resident #3 received Ensure and DM #1 stated, "With all meals." When asked when Resident #3 received Ensure pudding, DM #1 stated, "At lunch and supper." h. On 4/2/14 at 3:50 p.m., the Director of Nursing (DON) was asked how RD recommendations were communicated to the physician and the DON stated, "If it is a supplement, usually a physician order [REDACTED]." 1) As of 4/1/14, the Med (Medication) Sheet dated 3/18/14-3/31/14 did not document a house supplement per the RD's recommendation. 2) As of 4/2/14 the closet care plan did not document supplements per the RD's recommendations. 3) As of 4/3/14, there was no documentation in the clinical record of physician orders [REDACTED]. i. On 4/3/14 at 9:15 a.m., the DON was asked what the facility's procedure was for recommended dietary supplements. The DON stated, "The dietician will meet with me and give me a report, then we call the physician and obtain orders for those recommendations." j. On 4/3/14 at 9:35 a.m., the DON provided a copy of the "Dietary Quality Assurance Report" dated 3/18/14, which documented, "...(Resident #3)...Problem: wt. (weight) loss... Recommendations: Recommend adding 2 oz. house supplement TID (with) med pass..."