Every finding on record at Madison Park Healthcare

Based on observation and staff interviews the facility to ensure the preparation of food items in accordance with professional standards for food service safety when not obtaining a hair restraint for his beard. This was a random opportunity of discovery. Facility Census: #40. Findings Include: a) [NAME] hair restraint On 01/12/26 at 11:15 AM it was observed Dietary [NAME] #14 standing over a skillet of beef cooking for the lunch meal. He had a beard and did not have a hair restraint in placed. In according to the current standards of practice such as the Food Code of the FDA, food service staff must wear hair restraints (e.g., hairnet, hat, and/or beard restraint) to prevent hair from contacting food. When ask if he was to have a hairnet in place over his beard he responded probably. He was ask to find one and place it in order to protect the residents. Review of the facility policy for Preventing Foodborne Illness - Food Handling revealed . 3. All employees to utilize appropriate hair restraints sufficient to prevent hair from contacting food or food surfaces On 01/12/26 at 11:30 AM it was confirmed with the Dietary Services Director #31 that all cooks should have hairnets on their head as well as their beard if they have such.

Based on observation and staff interviews the facility failed to provide the resident with the right to a dignified dining experience. This was a random opportunity of discovery. Resident Identifier: #25 Facility Census: #40 Findings Include: a) Resident #25 On 01/12/26 at 12:28 PM it was observed that Resident #25 did not have a lunch tray. Staff Certified Nurse Aide (CNA) #60 was sitting with Resident #25's roommate assisting her with her lunch meal while Resident #25 watched. When the CNA was asked if Resident #25 was getting a lunch tray, she responded we are waiting for someone to free up to be able to assist her. On 01/12/26 at 1:01 PM the Director of Nursing was informed of the above, at which time she agreed they both were to be assisted with their meal at the same time.

Based on record review and staff interview the facility failed to complete the Physicians Order for Scope of Treatment (POST) accordingly. This was true for two (2) of three (3) POST forms reviewed during the long term survey process. Resident Identifiers: #13 and #47. Facility Census: #40.Findings Include: a) Resident #13 On [DATE] at 10:50 AM record review of the Physicians Order for Scope of Treatment (POST) form dated [DATE] revealed Resident #13 had a POST on file stating the Resident was a No CPR (Do not attempt Resuscitation), Comfort Care Treatments with no artificial means of nutrition desired. There was an incapacity form dated [DATE] by the Physician stating the resident has long term incapacity due to dementia. The Patient/Patient Medical Power of Attorney (MPOA) representative/surrogate signature (required) line on the form stated, Verbal consent (name of MPOA) and dated [DATE]. It was unclear as to which staff member obtained the POST form as there were no witnesses or staff member names on the POST. The POST form was signed by the house Physician and is dated [DATE]. On [DATE] during an interview with the MPOA the MPOA stated she was in the facility every week visiting her dad. On [DATE] at 2:20 PM during an interview with the Director of Nursing (DON) she could not explain why the POST form had no witnesses of the verbal consent, why the MPOA had not been requested to sign the POST in person nor why the Physician had signed and dated the POST [DATE]. On [DATE] at 12:45 PM the Administrator agreed the POST form should have been witnessed by at least one staff member and the MPOA did come in weekly allowing a physical signature to be obtained. There was no explanation for the incorrect physician's date other than an error due to the new year beginning. b) Resident #47 On [DATE] at 3:10 PM record review of the Physicians Order for Scope of Treatment (POST) form dated [DATE] revealed Resident #47 had a POST on file stating the Resident was a CPR (Attempt Resuscitation), Full Treatments with no artificial means of nutrition desired. There was an incapacity form dated [DATE] by the Physician stating the resident had short term incapacity due to confusion. As of [DATE] at the exit of the survey Resident #47 did not have capacity to make medical decisions, however Resident #47 signed the POST on file. According to the 2026 [NAME] Virginia Center for End-of-Life Care .The POST form is completed after discussion with the individual or incapacitated individual's medical power of attorney representative or surrogate decision-maker regarding treatment preferences . Therefore, the POST form in this case should have been explained, discussed and signed by Resident #47's Medical Power of Attorney which is in place. On [DATE] at 3:10 PM there was an interview with the Administrator with discussion concerning the above.

Based on observation, record review and staff interview, the facility failed to provide an appropriate infection control program for administration of medications to Resident #34 and Resident #13, cleansing of glucometer for Resident #13 and catheter care for Resident #38. There were random opportunities for discovery. Resident identifiers: #34, #13, and #38. Facility Census: 40. Findings included: a1) Resident #34 On 08/07/24 at 8:55 AM, an observation was made during medication administration by Registered Nurse (RN) #59. While preparing the medication for Resident #34, RN #59 touched two pills with bare hands. The following medication was touched by RN #59: --Flecainide 150mg --Zofran 4mg On 08/07/24 at 9:30 AM, the Director of Nursing (DON) was notified and confirmed the medication should not be touched with bare hands during medication administration. a2) Resident #13 On 08/07/24 at 9:10 AM, RN #59 touched one (1) pill during medication for Resident #13. The following medication was touched with bare hands by RN #59: --Buspar 5mg On 08/07/24 at 9:30 AM, the Director of Nursing (DON) was notified and confirmed the medication should not be touched with bare hands during medication administration. b) Resident #13 On 08/07/24 at 9:15 AM, upon completion of checking the resident's glucose level, RN #59 cleaned the glucometer with alcohol. The manufacturer's guidelines state, the following products have been approved for cleaning and disinfecting (Name of Brand of the glucometer): --Dispatch Hospital Cleaner Disinfectant Towels with Bleach --Medline Micro-Kill Disinfecting, Deodorizing, Cleaning Wipes with Alcohol --Clorox Healthcare Bleach Germicidal and Disinfectant Wipes --Medline Micro-Kill Bleach Germicidal Bleach Wipes On 08/07/24 at 9:40 AM, the DON was notified and confirmed the glucometer should have been cleaned per Manufacturer's guidelines. c) Resident #38 On 08/07/24 at 2:10 PM, catheter care for Resident #38 was observed. The catheter care was provided by Nurse Aide (NA) #42. Upon completion of the catheter care and emptying the catheter storage bag at 2:25 PM, NA #42 did not remove the soiled gloves or complete hand hygiene. NA #42 began placing the blankets on the resident, touching the side rails, bedside table and privacy curtain with soiled gloves. On 08/07/24 at 2:40 PM, the DON was notified and confirmed the soiled gloves should have been removed and hand hygiene completed.

Based on policy review, observation and staff interview the facility failed to store food in accordance with professional standards of practice. This failed practice had the potential to affect more than a limited number of residents currently residing in the facility. Facility Census: 40. Findings include: a) Reach-in refrigerator During the initial tour of the kitchen on 08/05/24 at 12:05 PM, the following items was found to be out of date or not labeled at all in the reach-in refrigerator: -- Broccoli soup with an expiration date of 08/01/24 -- Boiled eggs in a plastic container which was not labeled with a use by date. -- (2) two bowls of spiral cooked noodles which was not labeled with a use by date -- Tomato soup in a plastic container which was not labeled with a use by date. During an interview on 08/05/24 at 12:30 PM, Dietary [NAME] (DC) #17 stated, Yes, they are out. I will get them out of there. I didn't realize it. I think we just put the eggs in there this morning. A review of the facilities policy on 08/06/24 at 11:00 AM, titled {Food receiving and storage} number (8) eight reads as follows: All foods stored in the refrigerator or freezer will be covered, labeled and dated ( use by date). b) Walk-in refrigerator During the initial tour of the kitchen on 08/05/24 at 12:15 PM, the following items was found to be out of date in the walk-in refrigerator: -- Lunch meat ham with a use by date of 07/27/24 -- Lunch meat bologna with a use by date of 08/02/24 During an interview on 08/05/24 at 12:30 PM, Dietary [NAME] (DC) #17 stated, I will get the lunch meat out of there as soon as I can She confirmed it was out of date.

Based on observation, record review and staff interview, the facility failed to record temperatures for the medication refrigerator on the third floor. This was a random opportunity for discovery and has the potential to affect more than a limited number of residents currently residing in the facility. Facility Census: 40. Findings Include: a) Medication Refrigerator On 08/07/24 at 8:55 AM, a tour of the third floor medication room was completed. The tour found the medication refrigerator temperatures were not being checked twice daily. The following dates and times were blank for each month: 06/01/24 PM 06/02/24 PM 06/03/24 AM 06/03/24 PM 06/08/24 PM 06/09/24 PM 06/10/24 PM 06/11/24 PM 06/12/24 PM 06/15/24 PM 06/16/24 PM 06/17/24 AM 06/17/24 PM 06/18/24 PM 06/19/24 PM 06/21/24 PM 06/22/24 PM 06/23/24 PM 06/24/24 PM 06/25/24 PM 06/26/24 PM 06/27/24 PM 06/30/24 PM 07/01/24 PM 07/02/24 PM 07/03/24 PM 07/04/24 PM 07/06/24 AM 07/06/24 PM 07/07/24 PM 07/08/24 PM 07/09/24 PM 07/10/24 PM 07/13/24 PM 07/14/24 PM 07/15/24 PM 07/16/24 PM 07/17/24 PM 07/18/24 PM 07/20/24 PM 07/21/24 PM 07/22/24 PM 07/23/24 PM 07/24/24 PM 07/27/24 PM 07/28/24 AM 07/28/24 PM 07/29/24 AM 07/29/24 PM 07/30/24 PM 07/31/24 PM 08/04/24 PM 08/05/24 PM 08/06/24 PM On 08/07/24 at 9:00 AM, the Director of Nursing was notified and confirmed the refrigerator temperatures were not documented.

Based on record review and staff interview the facility failed to notify the Ombudsman of resident transfers to an acute care setting. This failed practice was found true for (3) three of (3) three residents reviewed for hospitalization s during the Long Term Care Survey Process. Resident identifiers #38, #30 and #4. Facility Census 40. Findings included: a) Resident #38 A record review on 08/06/24 at 3:12 PM, revealed Resident #38 was transferred to the hospital on 07/22/24. Further record review revealed no notification was sent to the ombudsman for the acute transfer on 07/22/24. During an interview on 08/06/24 at 3:46 PM, Licensed Practical Nurse Unit Manager (LPNUM) confirmed the notification was not sent to the Ombudsman. b) Resident #30 On 08/06/24 at 1:42 PM, a record review was completed for Resident #30. The review found the resident had been transferred to an acute care facility on 03/05/24 for acute encephalopathy and on 05/28/24 for a hip fracture. The review, also, found the State Ombudsman was not notified of the transfers. On 08/06/24 at 2:10 PM, Licensed Practical Nurse (LPN) #18 was notified. LPN #18 confirmed the State Ombudsman had not been notified regarding both transfers. LPN #18 stated, I'll make sure they are sent monthly. c) Resident #4 On 08/06/24 at 1:30 PM, a record review was completed for Resident #4. The review found the resident had been transferred to an acute care facility on 07/23/24 for hyponatremia (low sodium). The review, also, found the State Ombudsman was notified of the transfer. On 08/06/24 at 2:00 PM, Licensed Practical Nurse (LPN) #18 was notified. LPN #18 confirmed the State Ombudsman had not been notified regarding the transfer. LPN #18 stated, I'll make sure they are sent monthly. Surveyor: Richmond, [NAME] D. 49465

Based on record review and staff interview, the facility failed to complete transfer forms to an acute care facility for Resident #4 and #30. This was true for two (2) of three (3) residents reviewed under the care area of hospitalization s. Resident identifiers: #4 and #30. Facility Census: 40. Findings included: a) Resident #4 On 08/06/24 at 1:30 PM, a record review was completed for Resident #4. The review found the resident had been transferred to an acute care facility on 07/23/24 for hyponatremia (low sodium). The review, also, found there was no transfer form completed for the transfer. On 08/06/24 at 2:00 PM, Licensed Practical Nurse (LPN) #18 was notified. LPN #18 confirmed the transfer form was not completed. b) Resident #30 On 08/06/24 at 1:42 PM, a record review was completed for Resident #30. The review found the resident had been transferred to an acute care facility on 03/05/24 for acute encephalopathy and on 05/28/24 for a hip fracture. The review, also, found there was no transfer forms completed for the transfers. On 08/06/24 at 2:00 PM, Licensed Practical Nurse (LPN) #18 was notified. LPN #18 confirmed the transfer forms were not completed.

Based on record review and staff interview, the facility failed to complete a monthly medication review for Resident #9. This was true for one (1) of five (5) residents reviewed under the care area of unnecessary medications during the long-term care survey. Resident Identifier: #9. Facility Census: 40. Findings Include: On 08/06/24 at 3:00 PM, a record review was completed for Resident #9. The review found a pharmacy review for December 2023 was not completed and available for review. On 08/06/24 at 4:45 PM, the Director of Nursing (DON) was notified and confirmed the monthly pharmacy review was not completed. The DON stated, I don't have the pharmacy review for December 2023.

Based on observation and staff interview, the facility failed to provide access of a call bell with in reach of Resident #4. This was a random opportunity for discovery. Resident Identifier: #4. Facility Census: 40. Findings Include: a) Resident #4 On 08/05/24 at 1:00 PM, an observation of the call light being not in reach of Resident #4 was made. The call bell was located across the room on top of a refrigerator. On 08/05/24 at 1:04 PM, Nurse Aide (NA) #29 entered the resident's room. NA #29 was asked, is the resident's call bell near her? NA #29 stated, oh, it's over there .let me get it. On 08/05/24 at 1:20 PM, the DON was notified the call bell was not in reach of Resident #4. The DON stated, we will make sure the call bells are accessible to the residents.

Based on record review and staff interview, the facility failed to offer a pneumococcal vaccination to Resident #26. This was true for one (1) resident of five (5) residents reviewed under the infection control care area. Resident Identifier: #26. Facility Census: 40. Findings Include: a) Resident #26 On 08/07/24 at 11:30 AM, a record review was completed for Resident #26. The review found the resident had a Prevnar 13 (pneumococcal vaccination) on 10/24/18. After reviewing the CDC (Center for Disease and Control and Prevention) guidelines, the resident was eligible for a PCV20 in 2023. However, the documentation found under the immunization tab, stated the resident was not eligible. On 08/07/24 at 1:00 PM, Licensed Practical Nurse (LPN) #18 confirmed the vaccination should have been offered to Resident #26.

Based on record review and staff interview, the facility failed to maintain an accurate and complete record for Resident #26's Physician's Scope of Treatment (POST) form and immunization documentation. This is true for one (1) of five (5) residents reviewed under the care area of infection control. Resident Identifier: #26. Facility Census: 40. Findings Include: a1) Resident #26 On [DATE] at 3:30 PM, a record review was completed for Resident #26. The review found the POST form dated [DATE] stating, CPR (cardiopulmonary resuscitation), Full Treatments and no artificial means of nutrition desired. However, the physician's order dated [DATE] stated, CPR, Selective Treatment and No Artificial Nutrition. On [DATE] at 11:00 AM, the Director of Nursing (DON) provided an order audit report for Resident #26. The report was reviewed and the DON confirmed the physician's order was incorrect from [DATE] through [DATE]. a2) Resident 26 On [DATE] at 11:30 AM, a record review was completed for Resident #26. The review found the resident had a Prevnar 13 (pneumococcal vaccination) on [DATE]. After reviewing the CDC (Center for Disease and Control and Prevention) guidelines, the resident was eligible for a PCV20 in 2023. However, the documentation found under the immunization tab, stated the resident was not eligible. On [DATE] at 1:00 PM, Licensed Practical Nurse (LPN) #18 confirmed the vaccination should have been offered to Resident #26.

Based on record review and staff interview, the facility failed to follow physician's orders for monitoring pain four (4) times a day and documenting medication given. This was true for one (1) of five (5) residents reviewed for Unnecessary medications during the long term care survey. Resident Identifier: #31. Facility Census: 40. Findings include: A) Resident #31. A review of Resident #31's medical record on 08/06/24 found the following: Review of the Medication Administration Record (MAR) on 08/06/24 revealed for the month of April 2024, one (1) Xanax was not administered on 04/20/24 at 9:00 AM as scheduled. and one Oxycodone on 04/21/24 at 10:00 PM hours as scheduled. For the month of June 2024 one(1) Xanax was not administered on 06/04/24 at 9:00 AM as scheduled and two (2) Oxycodone on 06/10/24 and 06/19/24 at 10:00 PM hours as scheduled. Also for the month of June 2024 the Treatment Administration Record (TAR) revealed pain monitoring was not completed on the 16th, 17th at 4:00 AM, the 19th at 12:00 PM and on the 27th at 8:00 AM and 12:00 PM. On 08/07/24 at approximately 10:00 AM the Director of nursing (DON) confirmed te aboe information.

Based on record review and staff interview the facility failed to implement Resident #5's Preadmission Screening and Resident Review (PASRR) care plan. This was a random opportunity for discovery. Resident Identifier: #5. Facility Census: 40. Findings include: A review of Resident #5's record on 08/06/24 found the following care plan: Focus ~PASRR I: Resident is PASRR level 1 Goal ~ Resident will remain at current level through next review target date: 08/27/24 Interventions ~ Complete/maintain Preadmission Screening/Resident Review(PASRR). ~ Observe for symptoms that would trigger a referral to PASRR for review of current level. A further review of Reisdent #5's medical record on 08/05/24, revealed Resident #5 had a diagnosis of Psychotic disturbance and Major Depressive disorder, and psychosis. Further Record review revealed the most recent and only PASRR was done on 01/17/08 and contained the following diagnosis: ~ Bipolar disorder ~Psychosis ~Constipation ~Depression ~Nutrition Continued record review found there was no current medical diagnosis for Bipolar disorder. On 08/06/24 at 03:58 PM , the Director of Nursing (DON) confirmed the PASRR should have been updated to address Major depressive disorder, and stated not sure why there was no diagnosis for Bipolar Disorder and why it would be on the PASRR. The DON confirmed the PASRR should have been updated as directed by the residents care plan and the diagnosis Major depressive disorder should have been addressed on the care plan and was not.

Based on record review and staff interview, the facility failed to provide a bed hold policy for a transfer to an acute care setting for Resident #4. This was true for one (1) of three (3) residents reviewed under the care area of hospitalization s. Resident Identifier: #4. Facility Census: 40. Findings Include: a) Resident #4 On 08/06/24 at 1:30 PM, a record review was completed for Resident #4. The review found the resident had been transferred to an acute care facility on 07/23/24 for hyponatremia (low sodium). The review, also, found the resident and/or resident representative was not provided a bed hold policy by the facility. On 08/06/24 at 2:15 PM, Licensed Practical Nurse (LPN) #18 was notified. LPN #18 confirmed the bed hold policy had not been provided upon transfer to the acute care setting.

Based on record review and staff interview the facility failed to update a Preadmission Screening and Resident Review(PASARR). This was found true for one (1) of one (1) residents reviewed for the PASRR care area during the long term care survey process. Resident identifier: #5. Facility Census: 40. Findings include: A review of Reisdent #5's on 08/05/24, revealed Resident #5 had a diagnosis of Psychotic disturbance and Major Depressive disorder, and psychosis. Further Record review revealed the most recent and only PASRR was done on 01/17/08 and contained the following diagnosis: ~ Bipolar disorder ~Psychosis ~Constipation ~Depression ~Nutrition Continued record review found there was no current medical diagnosis for Bipolar disorder. On 08/06/24 at 03:58 PM , the Director of Nursing (DON) confirmed the PASRR should have been updated to address Major depressive disorder, and stated not sure why there was no diagnosis for Bipolar Disorder and why it would be on the PASARR.

Based on observation and staff interview, the facility failed to ensure items in the medication storage room were stored in accordance with professional standards for sanitary storage. This deficient practice had the potential to affect a limited number of residents. Facility census: 40. Findings included: a) Second-floor medication storage room On 10/04/22 at 10:32 AM, observation of the second-floor medication room was made with the accompaniment of Registered Nurse (RN) #52. The following items were located in the cabinet under the sink: a medication crusher, a suction cannister, a plastic basin, curling irons, a blood pressure kit still in the box, and a thermometer still in the box. Under the sink is not considered a clean area for equipment storage due to the potential for drips or leaks from the pipes. RN #52 acknowledged items should not be stored under the sink in the medication room.

Based on record review and staff interview, the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation. The facility did not ensure the controlled substance count was completed by two (2) nurses as required. This was a random opportunity for discovery and had the potential to affect an isolated number of residents. Facility Census: 40. a) Medication Administration On 10/04/22 at 8:00 AM, a review of the eight (8) hour verification of controlled substances count was completed. The following dates were not signed by two (2) nurses during shift change. --09/01/22 7:00 AM to 7:00 PM, the off-going nurse did not sign. --09/03/22 7:00 AM to 7:00 PM, the on-coming nurse did not sign. --09/03/22 7:00 PM to 7:00 AM, the off-going nurse did not sign. --09/10/22 7:00 AM to 7:00 PM, the on-going nurse did not sign. --09/10/22 7:00 AM to 7:00 PM, the off-going nurse did not sign. --09/15/22 7:00 PM to 7:00 AM, the on-going nurse did not sign. --09/23/22 7:00 AM to 7:00 PM, the on-going nurse did not sign. --09/23/22 7:00 PM to 7:00 AM, the off-going nurse did not sign. b) Facility Policy On 10/04/22 at 10:00 AM, a review of the facility policy entitled Medication Ordering and Receiving from Pharmacy was completed. Under the Procedures heading number two (2) the policy read asa follows: --After the supply is counted and justified, each nurse must record the date and his/her signature verifying the count is correct. On 10/04/22 at 11:30 AM, the Director of Nursing (DON) was notified and confirmed the above dates were missing the nurses's signatures.

Based on medical record review and staff interview the facility failed to ensure each resident received care and services according to physician ordered parameters. This was true for one (1) of five (5) residents reviewed for unnecessary medications. Resident identifier: #17. Facility census: 40. Findings include: a) Resident #17 Review of Resident #17's medical records found a physician order for Humalog insulin; inject six (6) units subcutaneously with meals for diabetes. Hold if blood sugar less than 150. Effective date: 08/11/22. Review of Resident #17's Medication Administration Record (MAR) for August, September and October 2022, found the following dates, and times the blood sugar was less than 150 and the insulin was administered but should have been held according to the physician-ordered parameters: 8/17/22 at 5pm blood sugar 138 8/28/22 at 5 pm blood sugar 138 9/1/22 at 5 pm blood sugar 134 9/10/22 at 8 am blood sugar 134 9/11/22 at 12 noon blood sugar 143 9/18/22 at 5 pm blood sugar 115 9/23/22 at 5 pm blood sugar 134 10/01/22 at 12 noon blood sugar 128 On 10/04/22 at 12:45 pm the MAR for Resident #17 for the above-mentioned dates was reviewed with the Assistant Director of Nursing (ADON). She confirmed on the above-mentioned dates and times the insulin was administered when blood sugar was less than 150 and it should have been held.

Based on record review and staff interview, the facility failed to ensure three (3) of twelve (12) minimum data sets (MDS) reviewed during the Long-Term Care Survey Process (LTCSP) were accurately coded. For Resident #3, the MDS inaccurately coded her siderails as a physical restraint, for Resident #17, the MDS failed to accurately reflect her pressure ulcer stage and finally for Resident #21, the MDS failed to reflect the use of a diuretic. Resident identifiers: #3, #17, and #21. Facility census: 40. Findings include: a)Resident #3 Review of Resident #3's medical records revealed Resident #3 was admitted to the facility with a diagnosis which included Cerebral Palsy and was non- ambulatory due to contractures of all extremities. The resident requires total assistance with assistantance of two (2) for bed mobility, transfers using a total lift, locomotion on and off the unit in a wheelchair, dressing and personal hygiene. Review of Resident #3's quarterly MDS with assessment reference date (ARD) of 07/09/22, found under section P -Restraints; the MDS coded the resident's use of 1/4 bilateral side rails were used daily as a restraint. Review of the Center for Medicare and Medication Services (CMS), Resident Assessment Instrument (RAI) Version 3.0 Manual CH 3: MDS Items [P] Page P-6 P0100: Physical Restraints reads: Bed rails used with residents who are immobile. If the resident is immobile and cannot voluntarily get out of bed because of a physical limitation or because proper assistive devices were not present, the bed rails do not meet the definition of a physical restraint. During an interview on 10/04/22 at 2:00 PM with the Assistant Director of Nursing (ADON) confirmed Resident #3's MDS with ARD of 07/09/22 was inaccurate related to the use of siderails as a restraint. She agreed the resident can not get out of bed on her own. b) Resident #17 A medical record review for Resident #17, revealed the resident had a facility acquired pressure ulcer on right buttocks noted on 07/22/22. Review of Resident #17's weekly pressure ulcer assessment dated [DATE], revealed the resident had a stage IV (4) pressure ulcer on the right buttocks which measured seven (7) centimeters (cm) in length, five (5) cm in width and 2 cm in depth with 75% of wound bed with a whitish/tan slough noted. Small amount of purulent drainage with no odor. Tunneling noted at 12 o'clock and 6 o'clock. Peri wound is pink in color and irregular edges. The significant change MDS with an assessment reference date (ARD) of 09/27/22, under Section M-skin conditions, indicated the resident had a facility acquired stage III (3) pressure ulcer on right buttocks. An interview with the Assistant Director of Nursing (ADON), on 10/05/22 at 11:06 am. During this interview Resident #17's medical records were reviewed, and she verified the resident had a stage IV (4) pressure ulcer on the right buttocks. She verified the MDS with ARD of 09/27/22 was inaccurate concerning the stage of right buttocks pressure ulcer. c) Resident #21 On 10/04/21 at 1:00 PM, a record review was completed under the care area of unnecessary medications. The review found a current physician's order dated 08/18/22 for Furosemide (a diuretic) tablet, also known as Lasix, 20mg (milligrams) give one (1) tablet daily for edema (swelling). A review of the Minimum Data Set (MDS) dated [DATE] of section N entitled Medications was completed. The review found no indication the resident was receiving a diuretic. On 10/04/22 at 1:47 PM, an interview was completed with the MDS nurse #25 regarding the diuretic use. The MDS nurse #25 confirmed the resident was taking a diuretic and should have been indicated on the MDS dated [DATE]. The MDS nurse #25 stated, it honestly just got missed. 45173

Based on water temperature measurements, observations, medical record reviews, staff interviews, and review of the Guidance to Surveyors found in the State Operations Manual published by the Centers for Medicare & Medicaid Services (CMS), the facility failed to ensure the resident environment, over which it had control, was as free from accident hazards as possible. Water temperature measurements taken between 10:10 a.m. and 10:26 a.m. on 02/10/16 with the maintenance department using their thermometer found the following water temperatures in the resident hands sinks in resident rooms: Room 200 the water temperature was 140 degrees Fahrenheit (F) Room 204 the water temperature was 134.6 degrees F Room 300 the water temperature was 142.9 degrees F Room 303 the water temperature was 132.8 degrees F. This discovery was determined an immediate jeopardy (IJ) situation, with the potential to affect all residents who were able to independently wash their hands and who had cognitive impairments. At 12:10 p.m. on 02/10/16, the Nursing Home Administrator (NHA), the Chief Executive Officer (CEO), the Director of Nursing (DON) and the Assistant Chief Nursing Officer (ACNO) were notified of the IJ, and that it was due to the elevated water temperature. This immediate jeopardy began at 10:10 a.m. on 02/10/16 when Employee #63, a facility consultant working with the maintenance department, obtained the water temperature of 140 degrees Fahrenheit (F) in room 200. The facility provided a plan of correction at 1:47 p.m. on 02/10/16. The immediate jeopardy was abated at 2:50 p.m. on 02/10/16. No deficient practice remained after removal of the immediate jeopardy. Eleven (11) residents were identified as being at risk for serious harm as a result of the elevated water temperatures they all suffered from cognitive impairments and were identified by facility staff as able to independently wash their hands in resident hand sinks. The eleven (11) residents identified were, Resident #36, #24, #25, #44, #18, #43, #42, #41, #13, #30, and #3. Facility Census: 40. Findings Include: a) At 10:00 a.m. on 02/10/16, during Stage 1 of the Quality Indicator Survey (QIS), the water in the hand sink in Room 200 was felt by the surveyor by placing her hand under the running water. After the water ran for approximately 30 seconds, steam began rising from the water. The water was too hot to place ones hands under comfortably. Due to this concern, the surveyor requested the maintenance department take the water temperature in Room 200. A Stage I sample resident, Resident #44, resided in Room 200. This resident was able to independently ambulate and independently wash her hands in the hand sink in her room. Resident #44 had a Brief Interview for Mental Status (BIMS) score of one (1) indicating severe cognitive impairment, and was not interviewable. The resident also had a [DIAGNOSES REDACTED]. At 10:10 a.m. on 02/10/16, Facility Consultant #63, who was working with the facility's maintenance department, obtained the water temperature using the facility's thermometer. The water temperature obtained in Room 200 was 140 degrees F. He indicated that was too hot. Due to this elevated temperature, additional water temperatures in other rooms throughout the facility were checked. Facility Consultant #63 asked Maintenance Director #60 to assist in obtaining the other water temperatures. Maintenance Director #60 confirmed Room 200 was the room closest to the water heater on the second floor. He said Room 204 was the furthest from the water heater on the second floor. The water temperature in room 204's hand sink was obtained by Maintenance Director #60 and was 134.6 degrees F. Maintenance Director #60 was asked to obtain water temperatures on the third floor in the room closest and furthest away from the water heater. He said Room 300 was the closest to the water heater and room 303 was the furthest away. The water temperature in Room 300 was 142.9 degrees F and the water temperature in Room 303 was 132.8 degrees F. All temperatures were obtained using the same theremometer by facility maintainence staff. According to Table 1 in the Guidance to Surveyors related to comfortable/safe water temperatures, found in Appendix PP of the CMS State Operations Manual, a third (3rd) degree burn can occur at 120 degrees F with an exposure time of five (5) minutes, at 124 degrees F with an exposure time of three (3) minutes, at 127 degrees F with an exposure time of one (1) minute, at 133 degrees F with an exposure time of 15 seconds, and at 140 degrees F with an exposure time of 5 seconds, noting that burns can occur even at water temperatures below that level depending on the exposed individual's condition and the length of exposure. Rooms 200, 300, 204, and 303 were chosen to demonstrate this was a facility wide problem. Water temperatures were obtained on the second and third floor because these were the only two (2) floors of the facility which housed long-term care residents. Since Rooms 200 and 300 were closest to the water heaters and Rooms 204 and 303 were furthest away from the water heaters on each of the two (2) floors, it was likely the water in the rooms between the two were also elevated, placing additional residents at risk resulting in a determination the problem was facility wide. The Director of Maintenance indicated he checked the water temperatures daily using the thermometer used for checking the temperatures on this occasion. He confirmed the water was too hot and they liked to keep the water between 110 degrees F and 112 degrees F. He stated he would have to check and see what was wrong with the water heater to determine why the water was so hot. An additional interview with Maintenance Director #60 at 10:46 a.m. on 02/10/16, found the mixing valve was stuck, likely because of the corrosion. He said he would have to take it apart and clean it. He reported that he had had the same mixing valve since 2009, and had had to replace some parts in it. He stated that he would clean the valve every couple of months due to the corrosion from the city water. He last cleaned the valve on 12/22/15. Maintenance Director #60 was asked to provide his water temperature log beginning on 11/01/15 through 02/10/16. This log was reviewed and a distinct pattern was noted. The maintenance department obtained the water temperatures daily in a resident room from the first (1st) floor (1st floor housed assisted living residents), the second (2nd) floor, and the third (3rd) floor. Every day from 11/01/15 through 02/10/16 the water temperature in the first (1st) floor room was noted to be 112 degrees F., the water temperature in the second (2nd) floor room was noted to be 111 degrees F, and the water temperature in the third (3rd) floor room was noted to be 110 degrees F. These temperatures never varied a degree in either direction for 102 consecutive days. After notification of the IJ, the CEO was asked to review the water temperature logs. After his review he stated that was unbelievable. He stated that he could not say that the temperatures were not what was recorded, but it was hard to believe that they did not vary. An additional interview with Maintenance Director #60 at 10:18 a.m. on 02/12/16, when asked the process used for obtaining water temperatures, he stated, I turn on the hot water and let it run for three minutes then fill up a Styrofoam cup, set it to the side of the sink and stick the thermometer in the cup filled with water and record the temperature. When asked to clarify if he left the cup in the sink under the running water while obtaining the temperature he stated that he did not. He stated that he filled the cup and sat it to the side of the sink, and then put the thermometer in the cup. The facility was asked to provide a list of all residents who were able to independently wash their hands at the resident hand sinks. This list contained the names of twenty-one (21) residents. Of those 21 residents, only eleven were identified as being at risk for serious harm due to their severe cognitive impairments. The medical records of all twenty-one residents were reviewed and found the following eleven (11) residents had a BIMS score less than seven (7) indicating a severe cognitive impairment. -- Resident #44 had a BIMS score of one (1). -- Resident #36 had a BIMS score of two (2). -- Resident #24 had a BIMS score of zero (0). -- Resident #25 had a BIMS score of two (2). -- Resident #18 had a BIMS score of two (2). -- Resident #43 had a BIMS score of one (1). -- Resident #42 had a BIMS score of zero (0). -- Resident #41 had a BIMS score of four (4). -- Reisdent #13 had a BIMS score of two (2). -- Resident #30 had a BIMS score of zero (0). -- Resident #3 had a BIMS score of zero (0). b) Plan of correction The facility provided a plan of correction at 1:47 p.m. on 02/10/16. The plan of correction was: 1. Reviewed and accepted through an ad hoc QA the Policies and Procedures of water temperature safety with additional times for checking water temperatures added to the policy. 2. All residents had the potential to be affected by the deficient practice. 3. Alerted and in-serviced all staff present on potential risks of burning and stopped all showers immediately Turned off all hot water at resident sinks and placed signs at the sinks and showers to alert resident, staff and/or visitors of nonuse. Maintenance to inspect & repair the mixing valve, if indicated, to hot water system which has the potential to affect the water temperature. Hand sanitizer available in resident rooms and hallways In-servicing will be conducted with all other staff prior to their next worked shift 4. The maintenance/designee will log water temperatures and report findings to the administrator/designee on a daily basis in varying rooms and areas of the facility three times daily times 2 weeks then twice daily for 2 weeks and then daily and follow up with QA monthly and as needed to ensure the deficient practice does not reoccur. The Administrator was informed of the immediate jeopardy at 12:10 p.m. on 02/10/16. The facility completed its corrective actions prior to that time with the exception of the cleaning of the mixing valve, education of the staff who were not present, and future water temperature checks. The State agency requested the facility revise its plan of correction at 2:30 p.m. on 02/10/16 to include a process, and staff education about the process, should the staff notice the water was hotter than it should be. During the time the staff were making revisions to the plan of correction, the State agency observed for implementation of the plan of correction. The facility's Policies and Procedures of water temperature safety were reviewed and noted to contain all required information including information pertaining to a process staff should follow should they notice the water temperature was too warm. The hand sinks of the facility were observed and noted to have the hot water turned off. The facility had placed signs on the sinks advising staff and residents not to use the hot water until further notice. The facility provided education sign in sheets for all staff currently working. Finally, random staff interviews were conducted and the staff were knowledgeable of the water temperature situation and knowledgeable of the policy and procedure on which they were educated. The facility provided a revised plan of correction at 2:50 p.m. on 02/10/16. The facility added the following information to the plan of correction, In the event that staff identify abnormal temperature they will report their findings to the immediate supervisor. This information and process was all ready included in the facility's policy and the staff had been in serviced on this process. The State agency accepted the facility's plan of correction at 2:50 p.m. on 02/10/16. The implementation of the plan of correction was also completed at that time by the State agency, therefore, the immediate jeopardy was abated at 2:50 p.m. on 02/10/16. No deficient practice remained after the corrective actions were implemented.

Based on staff interview and record review, the facility failed to adequately assess and manage pain for Residents #30 and #11. This resulted in the residents experiencing pain which was avoidable, and therefore, was actual harm. Also, Resident #33 had physician's orders [REDACTED]. Staff failed to assess the residents' blood pressures and heart rate (pulse) prior to each administered dose. Resident identifiers: #30, #33, and #11. Facility census: 41. Findings include: a) Resident #30 Review of the clinical record for Resident #30, on 04/04/16 at 09:30 a.m., revealed she was re-admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Resident #30 was severely cognitively impaired, unable to make herself understood, and was rarely able to understand others. Resident #30 was documented as requiring the extensive assistance of two (2) staff for bed mobility and transfers, and was incontinent of bowel functions and currently had a Foley catheter in place due to unstageable pressure ulcers on both buttocks. Observation on 04/05/16 at 11:00 a.m., found Resident #30 lying in bed. When asked about her abdomen, the resident held both hands over her abdomen and grimaced. The unit nurse was immediately notified of resident's indication of pain/discomfort. Even after the unit nurse was informed of the resident's grimacing and holding her hands over her abdomen, the resident was not assessed at that time. However, when this was brought to the attention of the director of nursing and physician, the nurse documented she had asked the resident about pain multiple times and the resident had denied pain. Review of the resident's current care plan found no interventions for pain evaluation/assessment and/or no treatments for pain management. Review of Resident #30's skilled charting notes found the following notes concerning pain (other notes were simply marked N/A - not applicable): -- 03/29/16 at 3:41 a.m.- Resident demonstrates non-verbal signs of pain. Grimaces and protective body movements. -- 03/29/16 at 10:55 a.m. - Pain section was blank. -- 04/02/16 at 5:10 a.m. - Resident demonstrates non-verbal signs of pain. Grimaces and protective body movements. -- 04/03/16 at 7:05 a.m.- Resident demonstrates non-verbal signs of pain. Grimaces and protective body movements. -- 04/04/16 at 6:57 a.m.- Resident demonstrates non-verbal signs of pain. Grimaces and protective body movements. -- 04/05/16 at 4:14 a.m.- Resident demonstrates non-verbal signs of pain. Grimaces and protective body movements. Further review of the Medication Administration Record [REDACTED]. Although the resident did not have anything ordered for pain, the nurses had standing orders that included Tylenol that could have been administered. Although the resident was identified as exhibiting nonverbal indicators of pain, which could reasonably have been expected after surgery, the resident was not given anything for pain, resulting in actual harm to the resident. On 04/05/16 at 1:31 p.m., an interview with the attending physician revealed the facility had not notified him of Resident #30's indication of pain. During an interview with the director of nursing (DON) and Registered Nurse Consultant (RN Consultant) #56, on 04/04/16 at 3:30 p.m., they were unable to find any indication the nurses had notified the physician of the resident's indications of pain. She further indicated the facility had standing orders for Tylenol; although there was no documentation this intervention was attempted. RN Consultant #56 also indicated each resident should be assessed for pain every shift. They both confirmed grimacing and guarding of the body were both nonverbal indications of pain. Review of the facility's Pain-Clinical Protocol on 04/05/16 at 4:15 p.m., found under assessment and recognition, . the nursing staff will identify any situations or interventions where an increase in the resident's pain may be anticipated; for example, wound care, ambulation and repositioning. Under monitoring, The staff will reassess the individual's pain and related consequence at regular intervals; at least each shift After surveyor intervention, a physician's orders [REDACTED]. The facility staff felt this would get the nurses to pay attention to residents having pain. b) Resident #33 On 04/04/16 at 2:00 p.m., a review of Resident # 33's medical record revealed a physician's orders [REDACTED]. Hold if heart rate (HR) less than 60. (Some medications for high blood pressure also cause the heart rate to slow.) A review of the Medication Administration Record [REDACTED]. The resident's blood pressures and heart rate were not consistently obtained prior to the administration of the medication. No heart rate (pulse) could be located prior to the administration of Carvedilol : For the 9:00 a.m. dose no heart rate was obtained on: -- 03/03/16 through 03/06/16, -- 03/09/16, -- 03/10/16, -- 03/16/16 through 03/19/16, -- 03/22/16 through 03/27/16, -- 03/29/16, -- 03/30/16, and -- 04/01/16 through 04/05/16. For the 9:00 p.m. dose no heart rate was obtained on: -- 03/01/16, -- 03/03/16 through 03/21/16, and -- 03/24/16 through 04/04/16. No blood pressure could be located prior to the administration of Carvedilol: For the 9:00 a.m. dose no blood pressure was obtained on: -- 03/23/16, and -- 04/02/16 through 04/04/16. For the 9:00 p.m. dose no blood pressure was obtained on: -- 03/01/16, -- 03/06/16 through 03/14/16, -- 03/16/16, 03/17/16, -- 03/19/16 through 03/21/16, and -- 03/24/16 through 04/04/16. An interview with the DON, on 04/04/16 at 3:08 p.m., confirmed the resident received Carvedilol twice daily. The DON confirmed Resident #33's blood pressures and heart rate should have been obtained prior to the administration of the medication and was not consistently obtained. c) Resident #11 Medical Record review on 04/04/16 at 2:45 p.m. found the following nursing notes: 02/05/16 at 1:12 p.m., (name of physician) saw resident, has open wound with hardened area to left side of scrotum, drsg. (dressing) , sero sang. (Serosanguineous-containing or relating to both blood and the liquid part of blood (serum). It usually refers to fluids collected from or leaving the body. For example, fluid leaving a wound that is serosanguineous is yellowish with small amounts of blood and purulent drainage).) Received new orders; obtained wound culture and sent to lab. Start [MEDICATION NAME] 1 gm (gram) IM (intramuscular) QD (daily) x 5 days. Cleanse area to scrotum with WC (wound cleanser), pat dry, apply [MEDICATION NAME] and cover with [MEDICATION NAME] drsg; change 3 xs (times) daily x 5 days. 02/05/16 at 11:00 p.m. .Drsg (dressing) as ordered to left side of scrotum noted more painful tonight, grimacing while drsg applied 02/06/16 at 10:29 p.m. .Remains on IM ATB (antibiotic therapy) TX (treatment) d/t (do to) scrotal abscess. Dressing change as ordered, noted large amt (amount) of purulent drainage upon touching wound. Resident noted to be grimacing during drsg. change. Will not answer when questioned regarding pain intensity. Further review of the Medication Administration Record [REDACTED]. The failure to attempt to alleviate the resident's pain resulted in actual harm to the resident. Review of the resident's most recent quarterly minimum data set (MDS) assessment, with an assessment reference date (ARD) of 01/04/16, found the resident assessed in Item C0100 as rarely to never understood and a brief interview for mental status could not be completed. Due to the resident's cognitive abilities, it would be unlikely he could rate his pain when questioned by the nurse on 02/06/16. During an interview with the Director of Nursing (DON), on 04/04/16 at 3:30 p.m., she was unable to find any evidence the facility notified the doctor of the resident's pain during the treatments and no evidence the facility provided any pain medication to the the resident. The DON was asked, What would you have expected the nurse who wrote these notes to do? The DON replied, she would have expected the nurse to give a Tylenol per the standing orders or call the physician to get something for the resident's pain if the Tylenol did not work. At 4:14 p.m. on 04/04/16, a Registered Nurse (RN) facility consultant, RN #56, verified grimacing could indicate pain. She stated she talked to the nurse who wrote the notes and the nurse said the doctor was present during the resident's treatments. The RN Consultant was asked if she looked at the time and dates of both notes. The note written on 02/05/16 was written at 11:00 p.m. on a Friday night and the 02/06/16 note was written at 10:29 p.m. on a Saturday night. She said she was not aware of the dates and times. At 1:31 p.m. on 04/05/16, the resident's physician was interviewed at the facility. The physician said he did not remember if he was at the facility at these times or dates. If I saw the resident was in pain, he could have had something. When asked if he observed the nurse complete the treatments on Resident #11, the physician said, Normally I do my thing, and the nurses do theirs, indicating he did not watch the nurses complete treatments.

Based on record review and staff interview, the facility failed to accurately assess and provide services to assist one (1) of twenty-three (23) stage II sample residents to restore, or improve, as much normal bladder functioning as possible, after the facility identified a decline in bladder continence. There was no evidence of any attempts to restore this resident's bladder continence to her prior level of functioning. As a result of the facility's failure to use the results of the resident's assessments to provide services based on the resident's needs, the resident failed to maintain or improve continence status. Resident identifier: #7. Facility Census: 41. Findings include: a) Resident #7 The admitted for this resident was 11/23/11. Her initial urinary continence evaluation indicated she was continent of bladder and had no history of urinary incontinence. The assessment also asked if the resident was continent of urine at the time of admission. The answer to this question was "yes." Her evaluation during the last seven (7) days noted she was only occasionally incontinent (this was defined as less than seven (7) episodes of incontinence in the prior seven (7) days). The summary of this evaluation stated she had functional incontinence and was UNABLE to participate in a toileting program due to [MEDICAL CONDITION]. The resident's plan stated she would be using absorbent products and receive incontinence care every two (2) hours and as needed. The initial minimum data set (MDS), dated [DATE], for urinary continence in section H0300, was coded a one (1), which indicated the resident was occasionally incontinent of urine. The care plan, established on 12/01/11, noted a problem of "Occasional Incontinence of bowel and bladder." The goal for this problem was, "Will have no s/s (signs symptoms) of UTI (urinary tract infection) reported daily and no skin breakdown daily." The approaches were to provide incontinence care PRN (as needed), assist to the BR (bathroom) when needed, absorbent products, report any s/s (signs or symptoms) of UTI (urinary tract infection) to nurse, UA (urinalysis) with c & s (culture and sensitivity) if indicated." A quarterly MDS, dated [DATE], assessed this resident's urinary continence, in section H0300, as a two (2), meaning the resident was frequently incontinent of urine. This was a decline in bladder continence since the initial admission MDS dated [DATE]. The care plan was reviewed, on 02/23/12, by the interdisciplinary team. The previous problem, written on 12/01/11, when the resident was occasionally incontinent of bladder was reviewed and continued. There was no evidence the care plan was revised to reflect the resident's decline in bladder continence. By 02/23/12, the resident was frequently incontinent of bladder. The care plan contained no interventions to assist the resident in regaining continence, and no plans to further assess the decline in continence. Interview with the director of nursing, at 2:30 p.m. on 03/20/12, confirmed the resident's decline in bladder continence had not been addressed. It was also confirmed no measures were in place in an attempt to restore this resident to her previous level of functioning. .

Based on observations, resident interview, record review and staff interview, the facility failed to assess, monitor, and intervene to improve the nutritional status for three (3) of twenty-three (23) stage II sample residents who had experienced unplanned weight losses. Resident #7 experienced a weight decline of twenty-five (25) pounds in four (4) months. She had not been assessed by the dietitian and no interventions were implemented to address the weight loss. Resident #21 experienced weight loss, with no evidence the facility attempted to find the underlying cause and/or implement measures to address the weight loss. Resident #3 experienced a thirteen (13) pound weight loss in one (1) month which was not assessed or addressed to prevent further weight loss. Resident identifiers: #7, #21, and #3. Facility Census: 41. Findings include: a) Resident # 7 This resident was admitted on [DATE]. Her admission weight was one 125 pounds. The dietary progress notes, dated 12/01/12, indicated this resident was admitted with an open area. A multivitamin and protein supplement were recommended. At that time, nothing was in the resident's care plan related to nutrition. The initial minimum data set (MDS), with an assessment reference date (ARD) of 12/01/11, was reviewed. Section "V," indicated care area #12, related to nutritional status, had triggered. However, it was not addressed in the care plan. Review of the resident's weights, on 03/21/12, found the following weights had been recorded: - 11/23/11, 125 pounds (#) (admission weight) - 12/08/11, 113# - 01/08/12, 118# - 02/08/12, 102# - 03/08/12, 102# (Weekly weights were ordered due to the weight loss.) - 03/15/12, 100# The record was reviewed for meal intakes from 11/23/11 - 11/30/11. During the first week of admission, the resident refused nine (9) of of twenty-one (21) meals. The intake for seven (7) of the remaining meals was noted as "poor" at 25%, and there five (5) additional meals when the resident consumed only 50%. Meal intakes were reviewed for the month of February 2012. Her intake records indicated she refused meals nineteen (19) times during that month. This resident was observed, on 03/19/12 at the noon meal, alone in her room. She was sitting at a table with her tray in front of her, but she was not eating. No one was present to assist her or encourage her to eat. When asked whether her food was good, she stated she was not hungry. The resident was observed later that day, at 3:00 p.m. She was at the nurses' station asking for something to eat. A nursing assistant assisted her to get a snack. Further review of this resident's medical record indicated she was started on new medications since her admission to the facility. She was started on [MEDICATION NAME] 0.5 mg by mouth as needed. On 12/29/11, the [MEDICATION NAME] was increased to three (3) times a day scheduled around the clock. The resident was also started on [MEDICATION NAME] 0.5 mg by mouth twice a day, due to dementia and behaviors. ([MEDICATION NAME] is an antianxiety medication. [MEDICATION NAME] is an atypical antipsychotic.) There was no evidence this resident's weight loss was identified or assessed to determine possible causal factors. Additionally, she did not receive supplements to assist with her nutritional status, even though her intake was poor. On 03/20/12, when a nurse, Employee #2, was asked whether the resident received supplements, the nurse stated she thought the resident was receiving supplements. Employee #2 later verified this resident had not been receiving supplements. After the interview with Employee #2, at 10:00 a.m. on 03/21/12, the dietitian (Employee #30) reviewed the resident's weights. She identified the resident was started on [MEDICATION NAME] three (3) times a day and was sleeping more. The dietitian stated the family requested not to awaken the resident if she was sleeping. She stated she would consult nursing to ask for a decrease in the [MEDICATION NAME]. There was no plan to ensure the resident's nutritional needs were met if she was allowed to sleep, and was not awakened for meals. On 03/21/12, after the weight loss was discussed with facility personnel, a new order was received from the physician to decrease the [MEDICATION NAME] to twice daily and add [MEDICATION NAME] 30 mg (due to weight loss) at bedtime. A supplement was also ordered for the resident on 03/21/12, and the weight loss and nutritional problem were added to the care plan. During an interview with the dietitian, on 03/21/12 at 2:00 p.m., a discussion was held regarding the facility's weight committee. She stated she was the "weight person." The dietitian confirmed the resident's weight loss was a significant weight loss which had not been brought to her attention. She also stated the facility will change the way they record weights to ensure they are reviewed promptly. . . b) Resident #21 The facility failed to assess this resident to determine why there was weight loss so appropriate interventions could be implemented. The resident was on a regular low concentrated sweets diet. She had the following weights documented in the weight book: - 01/15/12, 214 pounds (#) - 02/06/12, 199 # - 03/05/12, 201# Discussion with the director of nursing, Employee #1, on 3/22/12 at 9:30 a.m., revealed the resident had further weight loss, as she weighed 195 # on 03/19/12 and 198# on 03/22/12. The consultant dietitian, Employee #39, on 3/22/12 at mid morning, stated the resident refused to eat some of the foods served because she had diabetes and believed she could not eat some of the items. The dietitian documented, on 02/28/12, she had done patient education to ensure the resident these foods were allowed on her diet. In an interview with the resident, at 9:30 a.m. on 03/22/12, she stated she had not been eating well, as her stomach was upset. The resident stated she kept snacks in a refrigerator in her room so she could have something between meals if she wanted. A progress note by the physician, on 02/12/12, stated the resident had a good appetite, even though she had lost from 214# to 198#. The note stated the resident ate 75% to 100% at all meals. According to Employee #1, the intake records indicated the resident had good intake at meals, but a weight loss was occurring. A medical record entry, by nursing on 02/18/12, stated the doctor was in the facility and assessed the resident. At that time, the doctor requested weekly weights for four (4) weeks 4 weeks "d/t (due to) weight gain (13 pounds)." This was incorrect, as the weight change had actually been a weight loss, not a weight gain. On 03/03/12, there was a physician's orders [REDACTED]. Although the resident ate well, according to meal intake records, she was losing weight. The resident was not assessed for causal factors for the weight loss. No interventions had been implemented to address the weight loss. . . c) Resident #3 Review of the medical record revealed this resident's weight was recorded as 191.8 pounds on 02/09/12. On 03/01/12, the resident was weighed and had lost ten (10.2) pounds, down to 181.6 pounds. In an interview with Employee #39, the registered dietitian, on 03/21/12 at 10:30 a.m., the dietitian revealed she had not addressed the resident's weight loss of 10.2 pounds. She stated she normally addressed weight losses at the end of the month. Employee #39 further added, "I feel the weight loss was beneficial due to her respiratory problems." However, the dietitian was unable to provide evidence of a planned weight loss program for this resident. Further review of the medical record, on 03/22/12, after the interview with the dietitian, found the resident was weighed again on 03/21/12. The weight on this date was 178.8 pounds, a total weight loss of 13 pounds within one (1) month. .