Every finding on record at Main Street Care

Based on record review and staff interview, the facility failed to employee a Registered Nurse for eight (8) hours per day, seven (7) days a week as required. Facility:Faciity. Facility Census: 28Findings include: a) Registered Nurse Staffing On 01/07/26 at 11:00 AM observation of the Daily Staffing Report for the time period of 12/23/25 through 01/05/26 (14 days) finds there was not a Registered Nurse (RN) on duty for eight (8) consecutive hours daily as required. The facility employees four (4) Registered Nurses. They are the Director of Nursing (DON) (#28), The Assistance Director of Nursing (ADON) (#35) and two (2) part time Registered Nurses, #18 and #19. According to a review of the Employee Period Total Report, RN #19 did not work at all during the above time period. RN #18 worked 7.3 hours over the fourteen (14) days in the time period. According to the Administrator on 01/07/26 at 12:10 PM the DON and ADON usually work Monday through Friday but she can not provide documentation or state for sure the DON and ADON performed resident care. Review of the time frame of 12/23/25 through 01/05/26 show one (1) RN on eight (8) of the fourteen (14) days of which, according to the Administrator, may have been the DON or ADON. The above was confirmed on 01/07/26 at 12:30 PM with the Administrator at which time she agreed they needed to hire additional RN's.

Based on record review and staff interview the facility failed to ensure a new, current Registered Nurse waiver was completed. Resident Identifier: Facility:Facility. Facility Census: #28 Findings include: a) Registered Nurse Waiver On 01/07/26 at 11:00 AM observation of the Daily Staffing Report for the time period of 12/23/25 through 01/05/26 (14 days) finds there was not a Registered Nurse (RN) on duty for eight (8) consecutive hours daily as required. The facility employees four (4) Registered Nurses. They are the Director of Nursing (DON) (#28), The Assistance Director of Nursing (ADON) (#35) and two (2) part time Registered Nurses, #18 and #19. According to a review of the Employee Period Total Report, RN #19 did not work at all during the above time period. RN #18 worked 7.3 hours over the fourteen (14) days in the time period. According to the Administrator on 01/07/26 at 12:10 PM the DON and ADON usually work Monday through Friday but she can not provide documentation or state for sure the DON and ADON performed resident care. The facility may apply for and request a waiver for exemption of such if they have attempted to employee additional RN's and are unable to do so based on location in a rural area and the supply of RN's may not be sufficient to hire. The facility failed to re-apply for such a waiver. The above was confirmed on 01/07/26 at 12:30 PM with the Administrator at which time she agreed they needed to hire additional RN's or apply and renew the waiver.

Based on record review and staff interview the facility failed to ensure the continuing competence of nurse aides to include no less than 12 hours per year which include dementia management training and resident abuse/neglect prevention training. Facility Census: 28.Findings include: a) Certified Nurse Aide Training On 01/07/26 at 1:10 PM review of Certified Nurse Aide (CNA) training documentation for the following staff members were missing required training documentation on Abuse/Neglect. Staff Members:Nure Aide: #4, #9, #11, #15, #33 On 01/07/26 at 1:32 PM during an interview with the Administrator and Director of Nursing they stated there is no training for abuse/neglect. They felt this was covered under the Ethics in Healthcare in Medline University. A review of the description for Ethics in Healthcare revealed the following:Ethics in healthcare are the backbone of patient centered care, guiding decisions that respect autinomy, justice and human deginity. A strong ethical foundation is privotal in navigating the moral complexities of clinical practice, ensuring every patient is treated with fairness and respect. On 01/07/26 at 1:40 PM the above was confirmed with the Administrator at which time she agreed the abuse/neglect training was not completed as required by staff members.

Based on record review and staff interview, the facility failed to ensure a new Preadmission Screening and Resident Review (PASRR) was completed when residents received a diagnosis of a newly evident psychiatric disorder. This deficient practice had the potential to affect three (3) of three (3) residents reviewed for the care area of PASRR. Resident identifiers: #24, #3, and #5. Facility census: 28. Findings included:a) Resident #24 Review of Resident #24's medical record showed a Preadmission Screening and Resident Review (PASRR) was completed on 03/22/22. No diagnoses of mental illnesses were documented on the PASRR. On 10/01/24, while a resident at the facility, Resident #24 received a diagnosis of major depressive disorder, recurrent, moderate. On 01/07/2026 at 11:20 AM, the Director of Nursing (DON) confirmed a new PASRR had not been completed when Resident #24 received the new diagnosis of major depressive disorder. No further information was provided through the completion of the survey process. Findings include: b) Resident #3 On 01/06/26 at 12:58 PM record review of the Preadmission Screening and Resident Review (PASSR) dated 05/12/21 for Resident #3 found a new diagnosis of psychosis of which they receive Seroquel that is absent on the PASSR. On 01/06/26 at 2:10 PM during an interview with the Social Services Director #6 he stated he did not resubmit the PASSR because he was not aware he had to do such. The above was confirmed with Director of Nursing and the Administrator on 01/07/2026 10:43 AM at which time they agreed the PASSR should have been resubmitted. c) Resident #5 On 01/06/2026 1:30 PM record review of the Preadmission Screening and Resident Review (PASSR) dated 10/17/23 for Resident #5 found a new diagnosis of depression of which they receive Remeron for that is absent on the PASSR. On 01/06/26 at 2:10 PM during an interview with the Social Services Director #6 he stated he did not resubmit the PASSR because he was not aware he had to do such. The above was confirmed with Director of Nursing and the Administrator on 01/07/2026 10:43 AM at which time they agreed the PASSR should have been resubmitted.

Based on observation and staff interviews the facility failed to ensure resident hand hygiene was performed before meals in order to maintain an effective infection control program to prevent spread of disease and infections. Facility Census: #28 Findings Include: a) hand hygiene in rooms On 01/05/26 at 12:05 PM observation of the lunch meal tray pass found thygiene was not provided to residents on the [NAME] Hall specifically room [ROOM NUMBER] and #338. On 01/05/26 at 12:10 PM an interview with Certified Nurse Aide (CNA) #4 when asked if the residents were provided hand hygiene prior to the meal she stated, I usually give them a wipe or I give them a wet washcloth. When the surveyor stated they did not see them provide hand hygiene care, she stated, I didn't do it. On 01/05/26 at 12:25 PM observation In the dining room found hand hygiene was not performed. Residents had their meal and was eating their lunch at this time. Licensed Practical Nurse (LPN) #42 was ask if they provided hand hygiene to residents prior to all meals, she stated We usually do but haven't today. The above observations were confirmed with the Administrator #29 on 01/05/26 at 1:01 PM at which time she agreed they should have been provided hand hygiene.

Based on record review and staff interview, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) was completed and accurate when residents were admitted with a diagnosis of an evident psychiatric disorder. This deficient practice had the potential to affect one (1) of three (3) residents reviewed for the care area of PASRR. Resident identifier: #5. Facility census: 28. Findings include: a) Resident #5 On 01/07/26 at 11:55 AM during a review of the PASSR for Resident #5 it was found this resident has a diagnosis of anxiety and visual hallucinations on the PASSR dated 10/17/23 which the Social Services Director #6 confirmed was the latest PASSR. Review of the current medical diagnosis for Resident #5 also reflected a diagnosis of Delusional disorders which was present on admission and receives Depakote and Seroquel for the diagnoses. The PASSR did not have this diagnosis listed. On 01/07/26 at 1:30 PM the above was confirmed with Director of Nursing and Administrator when they agreed the PASSR was incorrect.

Based on observation, record review, and staff interview, the facility failed to maintain medication in accordance with accepted standards of practice. Multi-dose insulins had been in use longer than was recommended by the manufacturer. This was a random opportunity for discovery. Resident Identifiers: #6 and #3. Facility census: 28. Findings included: a) Medication Preparation Room - Insulins On 01/06/26 at 9:15 AM, the facility medication preparation room was inspected. A multiple-dose vial of Lantus insulin for Resident #6 was noted to have an opening date of 12/05/25. A multiple-dose prefilled pen of Lantus insulin for Resident #3 was noted to have an opening date of 12/05/25. Both opening dates were written on the medications in pen by the nurse who had first accessed the medication. The multiple-dose vial of Lantus insulin had a package insert which stated the following: - A multiple-dose vial of Lantus insulin can be used for 28 days refrigerated or at room temperature.- A multiple-dose prefilled pen of Lantus insulin can be used for 28 days at room temperature.Licensed Practical Nurse (LPN) #39 confirmed the Lantus insulins for Residents #6 and #3 had been in use for longer than recommended by the manufacturer. No further information was provided through the completion of the survey process.

Based on observation, and staff interview, the facility failed to maintain an appropriate infection control program for storage of personal hygiene products in a shared bathroom. This was a random opportunity for discovery. Facility Census: 30. Findings Included: a) Personal hygiene products On 01/14/25 at 11:05 AM, an observation was made of personal hygiene items sitting on the safety bar and on the floor of the shower. The personal items were two (2) cans of shaving cream, one (1) bottle of shampoo/conditioner/body wash, one (1) container of eczema soothing lotion, and one (1) stick. The personal hygiene items were not labeled. On 01/14/25 at 11:07 AM, Resident #12 was asked, Are these your personal items? Resident #12 stated, I think they are (Name of Resident #18). On 01/14/25 at 11:10 AM, Nurse Aide (NA) #10 was asked, do you know which resident these belong to? NA #10 said, I'm not sure .I will throw them away. On 01/14/25 at 1:00 PM, the Director of Nursing (DON) confirmed the items should be labeled.

Based on record review and staff interview, the facility failed to have a Registered Nurse (RN) in the facility for at least eight (8) hours on weekends. This failed practice had the potential to affect all residents residing in the facility. Facility census: 31. a) RN weekend staffing During a record review on 08/21/24 it was revealed that the facility did not have an RN working on weekends in the facility. A review of the schedule revealed there was no RN working on 07/06/24, 07/07/24, 07/13/24, 07/14/24, 07/20/24, 07/21/24, 07/27/24, 07/28/24. In addition, there was no RN coverage on 08/03/24, 08/04/24 and 08/11/24. On 08/21/24 at 1:36 PM the Director of Nursing (DON) stated she and the Assistant Director of Nursing (ADON) were on call and can be at the facility with in seven (7) to fifteen minutes, however they did not work in the facility on weekends. At approximately 2:00 PM on 08/21/24 the facility's Administrator stated they have an agreement with the hospital and if the on-call is not available then the emergency room RN will come up to the unit.

Based on record review and staff interview, the facility failed to provide side effect monitoring for Psychotropic medications. This failed practice was found true for (5) five of (5) five residents reviewed for unnecessary medications during the Long-Term Care Survey Process. Resident identifiers #8, #10, #29, #6, and #30. Facility Census: 31. Findings Included: a) Resident #8 A record review on 08/20/24 at 10:01 AM, revealed that Resident #8 is prescribed the following Psychotropic medications: Alprazolam oral tablet 0.5 Milligrams (MG) Give (1) one tablet by mouth two times a day related to anxiety disorder. Depakote oral tablet delayed release 250 MG Give (1) one tablet by mouth one time a day related to anxiety disorder. Effexor XR oral capsule extended release 24 hour 75 MG Give (1) one capsule by mouth one time a day related to anxiety disorder. Seroquel oral tablet 50 MG Give (1) one tablet by mouth (3) three times a day related to delirium due to known physiological conditions. Further record review of Resident #10's Medication Administration Record (MAR), and Treatment Administration Record (TAR) for the months of 06/24, 07/24, and 08/24 shows no side effect monitoring for psychotropic medications. During an interview on 08/20/24 at 11:17 AM, the Director of Nursing (DON) stated, We do monitor for behaviors, we look at them every day but we do not document that we monitor for side effects. b) Resident #10 A record review on 08/20/24 at 10:01 AM, revealed that Resident #10 is prescribed the following Psychotropic medications: Xanax Tablet 0.25 Milligrams (MG) Give (1) one tablet by mouth two times a day related to generalized anxiety disorder. Zoloft Tablet 100 MG Give (1) one tablet by mouth at bedtime related to other specified depressive disorder. Risperdal tablet 0.5 MG Give (1) one tablet by mouth two times a day related to vascular dementia with behavioral disturbance. Further record review of Resident #10's MAR, and TAR for the months of 06/24, 07/24, and 08/24 shows no side effect monitoring for psychotropic medications. During an interview on 08/20/24 at 11:17 AM, the DON stated, We do monitor for behaviors, we look at them every day but we do not document that we monitor for side effects. c) Resident #6 A record review on 08/20/24 at 11:00 AM, revealed that Resident #6 is prescribed the following Psychotropic medications: Seroquel oral tablet 50 MG Give (1) one tablet by mouth (3) three times a day related to delirium due to known physiological conditions. Further record review of Resident #6's MAR, and TAR for the months of 06/24, 07/24, and 08/24 shows no side effect monitoring for psychotropic medications. During an interview on 08/20/24 at 11:17 AM, the DON stated, We do monitor for behaviors, we look at them every day but we do not document that we monitor for side effects. d) On 08/21/24 at 11:21 AM a record review for unnecessary medications was completed for Resident #29. The review found the resident was prescribed Donepezil hydrochloride, DULoxetine HCl, Mirtazapine, and Mirtazapine. The review found there was no monitoring of side-effects for these psychotropic medications. On 08/20/2024 at 11:17 AM the Assistant Director of Nursing (ADON) was notified. The ADON stated, we monitor for behaviors and we look at them every day, but we do not document that we monitor side-effects. e) Resident #30 On 08/20/24 at 10:00 AM, a record review for unnecessary medications was completed for Resident #30. The review found the resident was prescribed Risperdal, an antipsychotic; Trazodone and Paxil, antidepressants. The review found there was no monitoring of side effects for these psychotropic medications. On 08/20/24 at 11:17 AM, the ADON was notified. The ADON stated, we monitor for behaviors and we look at them every day; but we do not document that we monitor for side effects. 49466 49751

Based on observation and staff interview, the facility failed to maintain an appropriate infection control program for storage of clean linen. This was a random opportunity for discovery. Facility Census: 32. Findings Included: a) Linen Cart On 08/20/24 at 10:42 AM, a tour of the unit was completed. During the tour, a linen cart with clean linen was observed uncovered on the top and sides. On 08/20/24 at 10:46 AM, the Assistant Director of Nursing (ADON) was notified and observed the clean linen cart which was uncovered. The ADON stated, I'll take care of this.

Based on observation and staff interview, the facility failed to maintain cleanliness of the air conditioning vents blowing into the kitchen. This failed practice had the potential to affect more than a limited number of residents. Facility Census: 31. Findings Included: a) Kitchen The initial tour of the facility kitchen on 08/19/24 at 12:16 PM, revealed (7) seven vents in the window blowing over the (3) three compartment sink and into the open area of the kitchen where food is prepared and served that were covered in dust and a black substance. During an interview on 08/19/24 at 12:21 PM, the Food and Nutrition Contact (FNC) #14 stated, The maintenance department takes them down for us and we clean them. Yes, I agree. It is time to get that done The FNC confirmed that the vents were dirty and covered in a black substance.

Based on record review and staff interview, the facility failed to provide side effect monitoring for Psychotropic medications. This failed practice was found true for (5) five of (5) five residents reviewed for unnecessary medications during the Long-Term Care Survey Process. Resident identifiers #8, #10, #29, #6, and #30. Facility Census: 31. Findings Included: a) Resident #8 A record review on 08/20/24 at 10:01 AM, revealed that Resident #8 is prescribed the following Psychotropic medications: Alprazolam oral tablet 0.5 Milligrams (MG) Give (1) one tablet by mouth two times a day related to anxiety disorder. Depakote oral tablet delayed release 250 MG Give (1) one tablet by mouth one time a day related to anxiety disorder. Effexor XR oral capsule extended release 24 hour 75 MG Give (1) one capsule by mouth one time a day related to anxiety disorder. Seroquel oral tablet 50 MG Give (1) one tablet by mouth (3) three times a day related to delirium due to known physiological conditions. Further record review of Resident #10's Medication Administration Record (MAR), and Treatment Administration Record (TAR) for the months of 06/24, 07/24, and 08/24 shows no side effect monitoring for psychotropic medications. During an interview on 08/20/24 at 11:17 AM, the Director of Nursing (DON) stated, We do monitor for behaviors, we look at them every day but we do not document that we monitor for side effects. b) Resident #10 A record review on 08/20/24 at 10:01 AM, revealed that Resident #10 is prescribed the following Psychotropic medications: Xanax Tablet 0.25 Milligrams (MG) Give (1) one tablet by mouth two times a day related to generalized anxiety disorder. Zoloft Tablet 100 MG Give (1) one tablet by mouth at bedtime related to other specified depressive disorder. Risperdal tablet 0.5 MG Give (1) one tablet by mouth two times a day related to vascular dementia with behavioral disturbance. Further record review of Resident #10's MAR, and TAR for the months of 06/24, 07/24, and 08/24 shows no side effect monitoring for psychotropic medications. During an interview on 08/20/24 at 11:17 AM, the DON stated, We do monitor for behaviors, we look at them every day but we do not document that we monitor for side effects. c) Resident #6 A record review on 08/20/24 at 11:00 AM, revealed that Resident #6 is prescribed the following Psychotropic medications: Seroquel oral tablet 50 MG Give (1) one tablet by mouth (3) three times a day related to delirium due to known physiological conditions. Further record review of Resident #6's MAR, and TAR for the months of 06/24, 07/24, and 08/24 shows no side effect monitoring for psychotropic medications. During an interview on 08/20/24 at 11:17 AM, the DON stated, We do monitor for behaviors, we look at them every day but we do not document that we monitor for side effects. d) On 08/21/24 at 11:21 AM a record review for unnecessary medications was completed for Resident #29. The review found the resident was prescribed Donepezil hydrochloride, DULoxetine HCl, Mirtazapine, and Mirtazapine. The review found there was no monitoring of side-effects for these psychotropic medications. On 08/20/2024 at 11:17 AM the Assistant Director of Nursing (ADON) was notified. The ADON stated, we monitor for behaviors and we look at them every day, but we do not document that we monitor side-effects. e) Resident #30 On 08/20/24 at 10:00 AM, a record review for unnecessary medications was completed for Resident #30. The review found the resident was prescribed Risperdal, an antipsychotic; Trazodone and Paxil, antidepressants. The review found there was no monitoring of side effects for these psychotropic medications. On 08/20/24 at 11:17 AM, the ADON was notified. The ADON stated, we monitor for behaviors and we look at them every day; but we do not document that we monitor for side effects.

Based on observations and staff interview, the facility failed to protect residents from possible hazards, by leaving five (5) medicine cups of Triamcinolone acetonide cream 0.1% at the bedside. This was a random opportunity for discovery and had the potential to affect a limited number of residents residing in the facility. Resident identifier: #13. Facility census: 31. Findings included: a) Resident #13 On 08/19/24 at 3:43 PM during an interview with Resident #13, this surveyor observed five (5) small medication cups on Resident #13's bedside table with white creamy substance in it. On 08/19/24 at 12:59 PM the Assistant Director of Nursing (ADON) stated, It is Triamcinolone acetonide Cream 0.1% for Resident #13's face. During an interview on 08/20/24 at 10:06 AM the Director of Nursing (DON) stated that they do not have an order for Resident #13 to self administer the medication or have it by the bedside.

Based on record review and staff interview, the facility failed to provide a bed hold notice for Resident #30 after a fall. This was true for one (1) of three (3) residents reviewed under the care area of hospitalization s. Resident Identifier: #30. Facility Census: 32. Findings Included: a) Resident #30 On 08/20/24 at 9:55 AM, a record review was completed for Resident #30. The review found the resident was transferred to an acute care hospital on 06/25/24 for an unwitnessed fall. The resident was noted with a large knot and bruising to the back of the resident's head. The following progress note dated 06/25/24 at 2:03 PM states, Resident found lying in the floor beside of her bed. Resident stated she fell on her head. Full body assessment completed. Hematoma with bruise observed to back of resident's head. Neuro (Neurological) checks initiated. (Name of facility physician) and POA notified via phone. Resident transferred to the emergency room for evaluation. The review, also, found a bed hold notice had not been provided to the resident. The bed hold notice provided by the facility was dated for 07/23/23. On 08/20/24 at 2:30 PM, the Assistant Director of Nursing (ADON) was notified that a bed hold notice was not completed for this transfer to an acute care facility. On 08/20/24 at 2:35 PM, the ADON stated, we use the bed hold notice which is signed upon admission to the facility.

Based on record review and staff interview, the facility failed to complete an accurate Minimum Data Set (MDS) regarding a fall for Resident #30. This was true for one (1) of two (2) residents reviewed under the care area of falls. Resident Identifiers: #30. Facility Census: 32. Findings Included: a) Resident #30 On 08/20/24 at 9:55 AM, a record review was completed for Resident #30. The review found the resident was transferred to an acute care hospital on 06/25/24 for an unwitnessed fall. The resident was noted with a large knot and bruising to the back of the head. The following progress note dated 06/25/24 at 2:03 PM states, Resident found lying in the floor beside of her bed. Resident stated she fell on her head. Full body assessment completed. Hematoma with bruise observed to back of resident's head. Neuro (Neurological) checks initiated. (Name of facility physician) and POA notified via phone. Resident transferred to the emergency room for evaluation. The review, also, found an inaccurate MDS dated [DATE]. Section J noted the resident had no falls. Although, the resident was noted to have a fall on 06/25/24. On 08/20/24 at 2:30 PM, the Assistant Director of Nursing (ADON) was notified of the inaccurate MDS. The ADON stated, I will get that corrected right away. No further information was obtained during the survey process.

Based on record review and staff interview, the facility failed to provide a transfer form and notify the State Ombudsman of a transfer to an acute care facility for Resident #30. This was true for one (1) of three (3) residents reviewed under the care area of hospitalization s. Resident identifier: #30. Facility Census: 32. Findings Included: a) Resident #30 On 08/20/24 at 9:55 AM, a record review was completed for Resident #30. The review found the resident was transferred to an acute care hospital on 06/25/24 for an unwitnessed fall. The resident was noted with a large knot and bruising to the back of the head. The following progress note dated 06/25/24 at 2:03 PM stated, Resident found lying in the floor beside of her bed. Resident stated she, fell on her head. Full body assessment completed. Hematoma with bruise observed to back of resident's head. Neuro (Neurological) checks initiated. (Name of facility physician) and POA notified via phone. Resident transferred to the emergency room for evaluation. The review, also, found no transfer form in the medical record and the State Ombudsman was not notified of the transfer. On 08/20/24 at 2:30 PM, the Assistant Director of Nursing (ADON) was notified of the transfer form not being found as well as the State Ombudsman notification. On 08/20/24 at 2:35 PM, the ADON stated, we send note summaries to the acute care facility and the State Ombudsman is not notified unless the resident is admitted . No further information was obtained during the survey process.

Based on record review and staff interview, the facility failed to ensure Resident #16's Minimum Data Set (MDS) reviewed during the Long-Term Care Survey Process (LTCSP) were accurately coded in the area of pressure ulcers. Resident identifier: #16. Facility census: 28. Findings included: a) Resident #16 A medical record review for Resident #16, revealed the resident had a facility acquired pressure ulcer on left posterior thigh noted on 07/15/22. A review of Resident #16's initial pressure ulcer assessment dated [DATE], revealed the resident had a stage IV (4) pressure ulcer on the left posterior thigh. The annual MDS with an Assessment Reference Date (ARD) of 09/16/22, under Section M-skin conditions, indicated the resident had a stage IV (4) pressure ulcer on the left posterior thigh which was present on admission. (Re-admitted was 04/26/22). An interview was conducted with the Director of Nursing (DON) on 11/08/22 at 11:06 AM. During the interview Resident #16's medical records were reviewed, and she verified the resident had a facility acquired Stage IV (4) pressure ulcer on the left posterior thigh. She verified the MDS with ARD of 09/16/22 was inaccurate concerning the pressure ulcer on left thigh present on admission. The resident was readmitted on [DATE] and the pressure ulcer developed on 07/15/22.

Based on medical record review and staff interview, the facility failed to follow physician's orders. Resident #8 had Accuchecks twice daily without an order and Resident #16 the facility failed to follow the physician's order for monthly weights. Resident identifiers: #8 and #16. Facility census: 28. Findings included: a) Resident #8 A review of Resident #8's physician orders found and order for Lantus insulin- inject 12 units subcutaneously (sq) in the morning and 10 units sq at bedtime for diabetes mellitus. (Effective date 09/29/22). Resident #8's Medication Administration Record (MAR) reviewed for October and November 2022 found the licensed nurses had obtained Accuchecks twice daily prior to the administration of the Lantus insulin. The Director of Nursing (DON) reviewed the physician orders and MAR during our interview on 11/08/22 at 2:00 PM, she verified there was no order for Accuchecks prior to the administration of the Lantus insulin. b) Resident #16 Review of Resident #16's physician orders found an order for Monthly weights. Effective 11/09/22. Review of Resident #16's electronic weights found no weights for September and October 2022. An interview with the DON on 11/08/22 at 2:20 PM, she verified Resident #16's had no weights for September and October 2022.

Based on observation, staff interview, and record review, the facility failed to develop a care plan that specified Resident #12's medication administration needs. This failed practice was true for one (1) of 13 sample residents reviewed. Resident identifier: #12. Facility census: 28. Findings included: An observation of medication pass on 11/03/10 at 8:40 AM for Resident #12 showed Licensed Practical Nurse (LPN) #34 to crush Eliquis 2.5 mg tablet, Metoprolol Succinate 25 mg tablet, Multivitamin tablet, Plavix 75 mg tablet, Senocot 8.6-50 mg 2 tablets, and Trimethoprim 100 mg tablet and then dump all the crushed medications into apple juice. LPN #34 then opened the hydrochlorothiazide 12.5 mg capsule and sprinkled it in the juice mixture, along with 15 ml of liquid potassium (20 meq dose). LPN #34 stated, I hope it is ok to crush and mix all these together, that's the only way I can get her [Resident #12] to take them is in liquid. She [Resident #12] drinks them better through a straw than she takes them in food. A record review of Resident #12's care plan did not indicate the Resident's need to take medications crushed mixed in liquid. No specific focus for medication administration was indicated on the care plan. During an interview on 11/08/22 at 2:14 PM LPN #34 stated I have been dissolving them in juice for a while now, you have to give them [medications] to her through a straw. She won't take them on a spoon. Her daughter was giving them [medications] to her with a syringe in the hospital but we can't do that that here. Even before her last hospitalization in September 2022 she wasn't able to take her meds from a spoon mixed with food. During an interview on 11/08/22 at 2:19 PM the Director of Nursing (DON) stated, I know she was having trouble taking her mediations from a spoon, they [hospital staff] were doing it like that [putting medications in liquids] at the hospital as well. During an interview on 11/08/22 at 2:21 PM the Assistant Director of Nursing (who is responsible for care plans) stated they did not put anything specific on the care plan for Resident #12's medications being given in fluids because she thought the diet order would cover it. The diet order indicated a Regular diet, Pureed texture, Regular/Thin consistency, with no mention of the need for mediations to be given in liquids.

Based on medical record review and staff interview, the facility failed to identify and address a severe weight loss experienced by Resident #14. Resident #14 lost six (6) pounds, or 4.5% (percent) of her body weight, from 05/24/13 to 06/24/13. She lost an additional twelve (12) pounds, or 9.5% of her body weight from 06/24/13 to 07/24/13, which represented a severe weight loss. There was no evidence the facility identified these weight losses and assessed causes and/or provided interventions to prevent additional weight loss until 08/26/13. As no interventions had been implemented, the weight loss could not be determined to have been unavoidable. One (1) of three (3) residents reviewed for nutrition during Stage 2 of the survey was affected. Resident Identifier: #14. Facility Census: 25. Findings Include: a) Resident #14 Resident #14's medical record was reviewed on 10/16/13 at 3:30 p.m.. The following weights were recorded in the electronic medical record for Resident #14: -- 05/24/13 - 132 pounds, -- 06/24/13 - 126 pounds, -- 08/24/13 - 113.60 pounds, and -- 09/25/13 - 115.60 pounds. There were no weights recorded in the resident's electronic medical record for the month of July 2013. The Director of Nursing (DON) provided a copy of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. She said the weight was obtained, but was not put into the computer. A weight of 114 pounds was record on the July MAR indicated [REDACTED] The resident's percentage of weight loss from 05/24/13 to 06/24/13 and from 06/24/13 to 07/24/13 were calculated using the following formula: % of body weight loss = (usual weight - actual weight) / (usual weight) x 100. -- From 05/24/13 to 06/24/13 the resident loss 4.5% of her body weight. -- From 06/24/13 to 07/24/13, the resident lost an additional 9.5% of her body weight which was a severe loss for a 30 day time period. The medical record contained the following pertinent [DIAGNOSES REDACTED]. Further review of the resident's medical record found two (2) dietary progress notes written by Employee #32, Registered Dietitian. On 07/30/13, the dietitian noted (typed as typed in progress note), "Resident is currently on a regular diet and has poor intake, averaging 33% for past 7 days recorded. It is reported that resident falls asleep during meal times frequently and attempts to feed are many. Residents weight has been stable since admission up until May and June. Between May and June resident say (had) a 6 lb (pound) (5%) weight loss. No weights recorded yet for the month of July. It is noted resident does have [MEDICAL CONDITIONS] and is on [MEDICATION NAME]. Some weight loss/gain could be contributed to these fluid gains/losses." Employee #32 recommended on this date the resident's Boost, her nutritional supplement be increased to twice a day from once a day. The physician's orders [REDACTED].#32. On 10/18/13, the DON also reviewed the resident's physician orders [REDACTED]. She confirmed there was no evidence to indicate the dietitian's recommendation of 07/30/13 was reviewed with the physician. The second progress note by the dietitian, Employee #32, was completed on 10/01/13. The dietitian noted, (typed as typed in progress note), ". . . average intake for past seven days was 49% but still remains inadequate. Fluid intake has also been extremely inadequate per Blue Strata (facility's electronic medical record software), only averaging 120 ml for 24 hour period." "Resident has continued to lose weight over the course of 5 months but saw a small weight increase of 2 lbs between August and September. Resident is underweight with a BMI of 18.9 for geriatric population. Weight gain is desired at this time. It is noted resident is on [MEDICATION NAME] and may contribute to some weight gains and losses. However, feel that suboptimal intake is more likely the cause at this time. " The DON was interviewed on 10/17/13 at 9:30 a.m. The DON confirmed the resident's nutritional supplement was not increased until 08/26/13. She stated the physician's assistant had given this order on 08/26/13 when she was contacted about the resident's weight loss which was identified on 08/24/13 when they obtained her monthly weight for August 2013. The DON confirmed she could not find any additional documentation to indicate the physician or nursing staff had identified this weight loss prior to 08/26/13. When the DON provided the July 2013 MAR indicated [REDACTED]. She stated she would have to review the medical record prior to answering this question. An additional, interview with the DON, at 10:32 a.m. on 10/17/13, revealed she could not find any additional information in the medical record where the facility had identified Resident #14's weight loss prior to 08/26/13. The DON, on 10/18/13 at approximately 11:00 a.m., stated she wanted to provide additional information from a conversation she had with the resident's physician. She stated they feel the resident's weight loss was a result of an increase in [MEDICATION NAME] which took place on 05/03/13. She provided the following physician order [REDACTED]. At the time the [MEDICATION NAME] was increased to 40 mg every other day, the physician had documented she had [MEDICAL CONDITION] in her lower extremities. The DON also provided a nurse's progress note dated 10/18/13 at 10:29 a.m.. The note stated, "Spoke with Dr. (Last Name) regarding weight loss between the month of June and July. Noted Increase in [MEDICATION NAME] in May. Weight has remained stable since July with weight varying between 1-2 pounds. (Resident #14's Name) has been placed on weekly weights at this time. Dr. (Last Name) stated that most of the weight was fluid weight and she is a very sick lady. He feels that she probably has [MEDICAL CONDITION] but resident and POA has chosen not to have any further testing. He feels that her weight is good for her condition and he does not want to be very aggressive. He also stated, 'that she has definitely not been neglected with meals or receiving assistance.'" This conversation between the nurse and the physician was subsequent to the surveyor identifying the severe weight loss and the DON's confirmation they had not identified this weight loss prior to 08/26/13. The resident was started on an increased dose of [MEDICATION NAME] every other day on 05/03/13. Her weight, on 05/24/13, three (3) weeks after the increase in the dose of [MEDICATION NAME], was recorded as 132 pounds. The resident's weight continued to decline significantly. While fluid loss may have contributed to her weight loss, she was also noted by the dietitian to not be eating well. There was no evidence of further assessment of the reason for the resident's significant weight loss until 08/26/13 - by which time she had lost 18.4 pounds since 05/24/13. There was no evidence the dietitian's 07/30/13 recommendation to increase the resident's diet supplement was communicated to the resident's physician. It was noted that after the supplement (Boost) was increased to twice a day, the resident's weight did increase by two (2) pounds in the next month. .