Every finding on record at Majestic Care of Manchin

Based on observation and staff interview, the facility failed to ensure meals were served in a sanitary manner. This was a random opportunity observed during the Long-Term Care Survey Process. This failed practice had the potential to affect more than a limited number of residents. Facility census: 36.Findings include: a) Review of the Facility Policy for Safe Food Handling -Purpose read in part: To provide Care Team Members the best practices for safe handling of food. -Policy read in part: To significantly reduce the risk for foodborne illness and strengthen the safety of the food provided to Residents/Patients, we follow the U.S. Food and Drug Administration's Food Code and relevant state laws, regulations, and codes for food safety -Care Team Members wear clean outer clothing to prevent contamination of food, equipment, utensils, linens, and single-use articles -Care Team Members will sanitize and clean multi-use equipment and utensils before they are reused. Sanitizer buckets/solutions will be available to sanitize food contact and other surfaces. b) Review of Policy for Meal Service (tray line) -Purpose read in part: To ensure that all meals are served safely, accurately, and attractively to residents/patients in accordance with physician-ordered diets, infection control guidelines and food safety regulations. -Foods on tray line are served using the identified portion control and serving utensils. -Cross contamination is avoided by using a separate serving utensil for every food item, avoiding bare hand contact and maintaining a clean area. c) Observations During Tray Line Assembly On 08/04/26 at around 11:50 AM, during tray line observation, the cook used gloved hand to obtain the hamburger buns package, open them with the same gloved hands, place the bun onto the plate, add the BBQ pork, then the cook used same gloved hand to obtain onion rings and french fries. This was observed for approximately six (6) trays. The State Agency Surveyor questioned the dietary manager regarding glove use with tray line. The dietary manager verified the cook should be using tongs to obtain the bun from the package and separate tongs for onion rings and the French fries. The dietary manager educated the cook on the spot, the cook then removed gloves, washed hands, placed new gloves on then returned to using just gloved hands to obtain the hamburger buns, onion rings and French fries. Dietician observed this behavior and stopped tray line again to educate the cook. The cook then obtained tongs for each item needed. On 08/04/26 at around 12:05 PM, the surveyor observed four (4) cleaning rags laying in the sink and one (1) on preparation table, with no sanitation bucket in view. [NAME] #60 reported, They should be in the bucket, he then moved the cleaning rags to a bucket on the three compartment sink at back of kitchen. Sanitizer Parts Per Million (PPM) checked per [NAME] #60, it did not register. [NAME] was asked how often the sanitizer buckets got checked and changed. [NAME] #60 reported, It should be changed every two (2) hours and as needed, I just got here so I am not sure how long ago it was changed. He then changed the sanitation solution in the bucket checked PPM read 150. This surveyor then questioned the dietary manager of how often the sanitation buckets get changed and PPM gets checked. She reported, We don't use the sanitation solution for our buckets we use bleach water. Questioned [NAME] on duty for morning shift when he changed the sanitation bucket and what solution was used, he reported, I think over two (2) hours ago and the bleach solution.

The facility failed to obtain informed consent for psychotropic medications. This was true for four (4) of five (5) residents reviewed for Unnecessary Medications and Medication Regimen Review throughout the Long-Term Care Survey Process. Resident identifiers: #2, #18, #3 ,#4. Census: 48. Findings included:a) Resident #2 Psychoactive Medication Consent and Management Agreement stated in Section 1. Name of Medication. 6. Consent to the use of the above medication. There was no date of initiation, review, or revised. On 08/04/2026 at 2:04 PM in reviewing the psychoactive medications ordered for Resident #2 found the risk and benefits Psychoactive Medication Consent and Management Agreement had three (3) medications listed on one (1) agreement. The three (3) medications were Namenda, Zyprexa and Zoloft. This was signed on 11/01/25. Namenda is used for residents with Alzheimer's/Dementia and is not an antipsychotic medication. Zyprexa is an antipsychotic medication. Common side effects include weight gain and increased appetite. Drowsiness or sleepiness, dizziness, constipation and dry mouth. Important warnings, can cause high blood sugar, diabetes or high cholesterol. Zoloft is a selective serotonin reuptake inhibitor (SSRI) class. It is used to treat major depression. Common side effects include nausea, indigestion, and diarrhea. Trouble sleeping or daytime sleepiness. Headache and dry mouth. Increased sweating or tremors. Serious risks and red flags include Serotonin syndrome (high fever, rigid muscles, fast heartbeat, confusion). Unusual bleeding or easy bruising. Low sodium levels in the blood (weakness, confusion). Worsening depression or new thoughts of self-harm. Depakote is used to teat manic or mixed episodes in bipolar disorder. Side effects included: nausea, vomiting, stomach pain or diarrhea. Drowsiness, dizziness or weakness. Weight changes and appetite shifts. Tremors (shaking of the hands). The Director of Nursing (DON) confirmed there were three (3) medications listed on the Psychoactive Medication Consent and Management Agreement. The DON also stated that they did not have a consent for Depakote and just obtained that today on 08/04/26 at 2:04 PM. b) Resident #3 On 08/04/26 at 1:30 PM, a record review was completed for Resident #3. The review found one (1) Psychoactive medication Consent Management Agreement was obtained for Buspar, Effexor and Seroquel 12/dated 18/25. However, the agreement did not differentiate between drug class, diagnoses, side effects and adverse reactions. On 08/04/26 at 3:32 PM, the Director of Nursing (DON) confirmed the consent included all three (3) medications. The DON stated, we need to get separate ones for each medication. c) Resident #4 On 08/04/26 at 2:30 PM, a record review was completed for Resident #4. The review found one (1) Psychoactive medication Consent Management Agreement was obtained for Risperdal and Effexor dated 12/18/25. However, the agreement did not differentiate between drug class, diagnoses, side effects and adverse reactions. On 08/04/26 at 3:32 PM, the DON confirmed the consent included two (2) medications. The DON stated, we need to get separate ones for each medication.

Based on observations, record review, and staff interview. The facility failed to prepare and serve food in a form to meet individual needs of residents. The facility failed to follow the International Dysphagia Diet Standardization Initiative (IDDSI) diet guidelines with preparation, cooking and presentation when necessary. This failed practice had the potential to harm more than a limited number of residents that required a mechanically altered diet. This was found during the annual survey process. Resident Identifiers: #11, #3, #12, #2, #21, #23, #4, #1, and #15. Facility census: 36. Findings include: a) Policy review for Culinary Team Staffing. Purpose read in part: The culinary department will employ a sufficient number of qualified, competent, and properly trained Culinary Trained Team Members to safely prepare, serve, and distribute meals. All culinary personnel are expected to perform their duties in a professional manner that supports Residents/Patients safety, nutritional needs, satisfaction, and quality of life. Policy read in part: All culinary care team members are expected to perform their duties in a safe, sanitary, respectful, and professional manner while adhering to federal, state, and local regulations, facility policies, and department procedures. All culinary care team members shall receive orientation and ongoing training appropriate to their job duties, including but not limited to food safety, sanitation, infection control, allergen awareness, modified diets, textures and liquids. b) Review of the International Dysphagia Diet Standardization Initiative (IDDSI) for Level 4 Pureed, Level 5 Minced and Moist, and Level 7 Soft and Bite Sized. Level 4 Pureed description read in part: usually eaten with a spoon. Do not require chewing. Have a smooth texture with no lumps. Holds shape on spoon. Level 4 Pureed may be used if the person is not able to bite or chew food or if tongue control is reduced. Level 5 Minced and Moist description reads in part: soft and moist, but with no liquid leaking/dripping from the food.Biting is not required.Minimal chewing is required.Lumps of 4mm in size.Food can be easily mashed with just a little pressure from a fork.Level 6 Soft and Bite Sized description read in part: soft, tender and moist, but with no thin liquid leaking/dripping from the food. Ability to bite off a piece of food is not required. Ability to chew bite sized pieces so that they are safe to swallow. Pieces should be no bigger than a 1.5cm x1.5cm bite size. No pieces larger than a fork. c) Review of recipes for PU4 cake funnel, chopped corn dogs mini, ground corn dogs mini., and MM5 potato salad mustard. Recipe for PU4 cake funnel read in part. Pour liquid in blender or food processor. Add prepared product. Blend until desired consistency is reached. PU4 usually eaten with a spoon. Cannot be drunk from a cup because it does not flow easily. Does not require chewing if presented in this form. No lumps. Recipe for chopped mini corn dogs reads in part. Chop prepared product to desired consistency. Pieces should be no larger than a fork. Gravy needs to be added to product. Recipe for ground mini corn dogs reads in part. Finely mince or grind prepared product to desired consistency. Lumps of 4mm in size and easily mashed with just a little pressure from a fork. Recipe for MM5 potato salad mustard reads in part. Finely mince or grind prepared product to desired consistency. Can be eaten with a fork or spoon. Soft and moist with no separate thin liquid. Lumps are easy to squash with tongue. d) Record reviews of physician orders, and care plans. Physician order for Resident 11 read in part: Regular diet. Soft and bite sized texture, all food in bowls; must use contrast mat for all meals. Limit one bowl at a time. Care plan reads ,under interventions, in part, provide and serve diet as ordered-soft bite sized texture, all food in bowls; must use contrast mat for all meals; limit one bowl at a time. Physician order for Resident #23 read in part: Regular diet, minced and moist texture. Care plan, under interventions, reads in part. Provide and serve diet as ordered-Regular diet minced and moist texture. Physician order for Resident #1 reads in part: Regular diet minced and moist texture, no bread. Care plan ,under interventions, reads in part. Provide and serve diet as ordered-Regular diet, minced and moist texture, no bread. Physician order for Resident #3 read in part: Regular diet soft and bite sized texture, extra gravy for meats; no bread. Care plan, under interventions, reads in part. Provide and serve diet as ordered-Regular diet soft and bite sized texture, extra gravy for meats; no bread. Physician order for Resident #21 read in part: Regular diet soft and bite sized texture. Care plan, under interventions, reads in part, Provide and serve diet as ordered-Regular diet soft and bite sized texture. Physician order for Resident #2 reads in part: Regular diet soft and bite sized texture for diet individual bowls. Care plan, under interventions, reads in part, provide and serve diet as ordered. Regular diet soft and bite sized texture, for diet individual bowls. -Physician order for Resident #12 read in part: Regular diet puree texture, nectar/mildly thick liquids. Care plan, under interventions, reads in part. Provide and serve diet as ordered-puree texture, nectar/mildly thick consistency -Physician order for Resident #4 read in part: Regular diet, puree texture, nectar/mildly thick liquids. Care plan, under interventions, reads in part. Provide and serve diet as ordered. Regular diet, puree texture, nectar/mildly thick consistency. e) Review of directions for use of thickening agent, simply thick easy mix. The directions read in part, achieve desired beverage consistency by following the colors on the chart. IDDSI Level 2 mildly thick one (1) stroke per 4oz. f) Observations during meal service on 08/03/2026 and 08/04/2026. Observations in the dining room on 08/03/2026 at around 12:50 PM: -Resident #11 was not served gravy per ticket, when the meal was placed in front of the resident, the staff member placed all of the bowls in front of the resident. Physician order read serve one bowl at a time, use contrasting mat, no mat was observed. The dietary manager verified no gravy was prepared, the staff did not serve resident one bowl at a time, and failed to use a contrasting mat. -Resident #23 was served hand chopped mini corn dogs larger that width of fork, the ticket read ground, served regular potato salad, ticket read MM5 potato salad, served watermelon, ticket read mandarin oranges, served regular funnel cake, ticket read PU4 funnel cake, dietary manager verified these items were served incorrectly. -Resident #26 served hand chopped mini corndog larger than fork, ticket read to give soft and bite sized mini corn dog. Dietary manager reviewed meal and verified the chopped pieces of the mini corn dog were too large. -Resident #33 was served hand chopped mini corndog larger than the fork, the ticket read soft and bite sized mini corn dog. Dietary manager reviewed meal and verified the chopped pieces of the mini corn dog were too large. -Resident #4 was served an eight (8) ounce glass of green liquid with lid, thin in nature. The ticket read nectar thick, dietary manager verified it was not thick enough replaced the drink with correct consistency of liquid. The health shake supplement was sitting on table frozen. The dietary manager verified should be served thawed. The plate was placed in front of Resident #4 at around 12:20PM. The surveyor questioned when she was to be assisted at around 12:40PM, the plate was cold to touch. The temperature was checked per dietary manager with administrator present. The meat read-84 degrees Fahrenheit. The plate was sent to kitchen for new warmer one. -Resident #15 received a hand chopped mini corndog larger than the fork, the ticket read soft and bite size texture. The dessert given was a regular funnel cake, the ticket read to give puree (PU4) funnel cake. Dietary Manager reviewed meal and verified the mini corn dog was not chopped into small enough pieces and the dessert needed to be puree. Corrections were made upon discoveries. Observations in dining room on 08/04/2026 at around 12:45PM observation in dining room: -Resident #1 received ground barbeque on a bun, the ticket read Minced and Moist (MM5) BBQ pork on Pureed (PU4) white bread, coin sized carrots, the ticket read MM5 soft marinated carrots. The dietician verified this was not correct, reporting MM5 should be fork prong size and bun should have been pureed. Resident #23 received puree BBQ pork, the ticket read to give MM5 BBQ pork on PU4 white bread. The dietician verified this was not correct and reported, The BBQ pork should have been ground fine and placed on puree bread.

The facility failed to maintain an infection control program for laundry services, dining services, and Enhanced Barrier Precautions. These were random opportunities for discovery. Resident Identifiers: #11 and #4. Census: 48.a) Laundry Observation in the Laundry, on 08/05/26 at 11:55 AM, found the airflow was from the soiled side to the clean side. Confirmed by Laundry Aide #48 that the tissue moved from the soiled laundry side to the clean laundry side when the tissue was laid in the floor. At 12:02 PM, the surveyor informed the Nursing Home Administrator (NHA) of finding and she requested the Maintenance Director go with surveyor to observe/confirm finding. The Maintenance Director appeared at the NHA office and went with surveyor to the laundry room. At 12:10 PM, three (3) pieces of toilet paper when placed in the floor at the bottom of the door between the soiled and clean laundry was immediately blown across the floor with air coming from the soiled side to the clean side. The Maintenance Director and Housekeeping Supervisor confirmed the air flow was in the wrong direction. In addition, the door to the clean laundry door was propped open. The Maintenance Director stated the door should not have been propped open. b) Resident #11 On 08/04/26 at 12:20 PM, an observation was made during the noon meal. Activities Assistant (AA) #49 delivered the lunch tray to Resident #11. Upon delivery, AA #49 unwrapped the resident's BBQ sandwich and picked the sandwich up with bare hands. Upon Surveyor intervention, AA #49 was notified and stated, Did I? At this time, AA #49 disposed of the sandwich and got the resident another sandwich. The Administrator was notified and stated, Did she use hand sanitizer? The Administrator then confirmed the sandwich should not have been picked up with bare hands. c) Observations during tray line assembly On 08/04/26 at around 11:50 AM, during tray line, the cook used gloved hand to obtain the hamburger buns package, open them with the same gloved hands, place the bun onto the plate, add the BBQ pork, and then used the same gloved hand to obtain onion rings and french fries. this was observed for approximately six (6) trays. The State Agency Surveyor questioned the dietary manager regarding glove use with tray line. The dietary manager verified the cook should be using tongs to obtain the bun from the package and separate tongs for onion rings and the French fries. The dietary manager educated the cook on the spot. the cook then removed gloves, washed hands, placed new gloves on, and then returned to using just gloved hands to obtain the hamburger buns, onion rings and French fries. The Dietician observed this behavior and stopped tray line again to educate the cook. The cook then obtained tongs for each item needed. d) Resident #4 A record review revealed Resident #4 had an active order, dated 04/30/26, that read, Enhanced Barrier Precautions when engaging in high contact resident care activities for (chronic MDRO [multi-drug resistant organism], indwelling medical device, wound) every shift. At 1:40 PM on 08/05/26, State Surveyor observed that the PPE had been removed from Resident #4's door which was confirmed by Nurse Aide #63. Observed Nurse Aide #63 and Nurse Aide #18 transferring Resident #4 from her bed to her wheelchair with no personal protective equipment (PPE) on 08/05/26 at 1:45 PM. Observed Nurse Aide #63 transferring Resident #4 in the shower after bathing resident with no PPE on at 1:58 PM on 08/05/26.

Based on observation, record review and staff interview, the facility failed to follow physician's orders regarding diet orders for Resident #11 and Resident #7; and, treatment orders for Resident #21. This was true for two (2) of 15 residents reviewed under the care area of dining and one (1) of two (2) reviewed for wound care. Resident Identifiers: #11, #7 and #21. Facility Census: 36. Findings Included:a) Resident #11On 08/04/2026 at 12:20 PM, the noon meal was observed in the dining room. The resident was served the lunch meal with all food in bowls. However, all the food bowls were served at one time. They were sitting in front of the resident in a line. A review of the physician's order for Resident #11 states: Regular diet, Soft and Bite Sized texture, Thin consistency. All food in bowls; Must use contrast mat for all meals; Limit one bowl at a time. Super donut and fortified juice with breakfast; Fortified mashed potatoes with gravy with lunch M (Monday) W (Wednesday) F (Friday); Magic Cups with lunch and dinner tray. (Typed as written.)On 08/04/26 at 12:25 PM, the Registered Dietary Manager was notified and confirmed the resident should have been served one (1) bowl at a time.b) Resident #7On 08/04/2026 at 12:20 PM, the noon meal was observed in the dining room. The resident was served the lunch meal with all food in bowls. However, all the food bowls were served at one time. They were sitting in front of the resident in a semicircle. A review of the physician's order for Resident #7 states, Regular diet, Easy to Chew texture, Thin consistency. Super donut at all meals, individual bowls, presented one (1) at at time. On 08/04/26 at 12:25 PM, the Registered Dietary Manager was notified and confirmed the resident should have been served one (1) bowl at a time.c) Resident #21On 08/05/26 at 3:20 PM, a review of the 06/2026, 07/2026, and 08/2026 treatment administration record (TAR) was completed. The review found blanks for the following:--06/24/26 day shift-Cetaphil Cream (Emollient) Apply to arms topically every day shift for dry skin apply to both arms daily.--06/16/26 day shift-Cleanse wound to left lateral heel with normal saline, pat dry. Apply sure prep peri wound, Apply medihoney, alginate, and dry dressing every day shift every other day for wound treatment.--06/08/26 day shift-Cleanse wound to left lateral heel with wound cleanser, pat dry. Apply medihoney, alginate, and dry dressing. Change daily and PM (evening).--06/16/26 day shift-Groin/abscess clean wound with normal saline, pat dry. Apply sure prep peri wound, apply collagen sheet cover with calcium alginate every day shift every other day for wound treatment.--06/24/26 day shift-Groin/abscess clean wound with normal saline, pat dry. Apply sure prep peri wound, apply collagen sheet cover with calcium alginate every day shift every other day for wound treatment.--06/08/26 day shift-Right foot underside (right plantar foot area), cleanse with IHWC (in-house wound cleanser), pat dry. Apply medihoney, alginate and dry dressing. change daily and prn (as needed).--06/16/26 day shift-Right foot underside (right plantar foot area), cleanse with IHWC (in-house wound cleanser), pat dry. Apply medihoney, alginate and dry dressing. change daily and prn (as needed).--06/24/26 day shift-Skin tear to left lower leg, clense with IHWC, and place hydrocolloid dressing. Change q (every) 7 days or as needed. every day shift every 7 days.--06/03/36 day shift-Empty catheter drainage bag at least once every shift or when it becomes 1/2 to 2/3 full every shift.--06/05/26 day shift-Empty catheter drainage bag at least once every shift or when it becomes 1/2 to 2/3 full every shift.--06/10/26 day shift-Empty catheter drainage bag at least once every shift or when it becomes 1/2 to 2/3 full every shift.--06/16/26 day shift-Empty catheter drainage bag at least once every shift or when it becomes 1/2 to 2/3 full every shift.--06/10/26 day shift-Foley catheter care every shift check for privacy bag covering in place.--07/02/26 night shift-Empty catheter drainage bag at least once every shift or when it becomes 1/2 to 2/3 full every shift.--07/09/26 night-shift-Empty catheter drainage bag at least once every shift or when it becomes 1/2 to 2/3 full every shift.--07/18/26 day shift-Empty catheter drainage bag at least once every shift or when it becomes 1/2 to 2/3 full every shift.--07/19/26 day shift-Empty catheter drainage bag at least once every shift or when it becomes 1/2 to 2/3 full every shift---07/18/26 day shift-Tubi Grip Sleeves bilaterally as tolerated every shift for skin tear prevention.--08/01/26 night shift-Empty catheter drainage bag at least once every shift or when it becomes 1/2 to 2/3 full every shift.t--08/03/26 night shift-Flush catheter with 60ml (milliliters) of sterile saline solution every shift for catheter care/occlusion prevention.On 08/05/26 at 3:30 PM, the Director of Nursing (DON) confirmed the blanks on each month's TARs. The DON stated, I just terminated the nurse who was supposed to complete those things .she has been gone about three (3) weeks.

Based on record review and staff interview, the facility failed to provide an accurate and complete medical record for Resident #12. This was true for one (1) of five (5) residents reviewed under the care area of unnecessary medications. Resident Identifier: #12. Facility Census: 36.Findings Include: a) Resident #12 On 08/04/26 at 1:25 PM, a record review was completed for Resident #12. The review found an inaccurate diagnosis. The inaccurate diagnosis was benign prostatic hyperplasia (BPH) without urinary tract symptoms. Resident #12 is a female. On 08/04/26 at approximately 3:00 PM, the Director of Nursing (DON) confirmed the diagnosis was incorrect.

Based on resident interview, record review, and staff interview, the facility failed to ensure the Minimum Data Set (MDS) was coded correctly for Resident #34 and Resident #4's cognition. This was a random opportunity for discovery during the Long-Term Care Survey Process. Resident identifiers: #34, #4. Facility Census: 36.Findings included:a) Resident #34 During an initial interview on 08/03/26 at approximately 1:00 PM, Resident #34 was able to answer interview questions appropriately with no difficulty being understood by the State Surveyor. A review of the Quarterly MDS dated [DATE] Section C read: Should brief interview for mental status (BIMS) be conducted? The answer recorded was no (resident is rarely/never understood). A review of the Quarterly MDS dated [DATE] Section B read: Ability to express ideas and wants and the answer was recorded as usually understood. In an interview with Licensed Practical Nurse #41 at 1:20 PM on 08/04/26, she stated Resident #34 has a heavy accent but is able to be understood and make her needs known. In an interview with Nurse Aide #63, on 08/04/26 at 1:25PM, she stated she never has trouble understanding Resident #34. In an interview with MDS Coordinator #32, at 2:45 PM on 08/04/26, she stated she does not complete section B or section C of the MDS. She stated it is completed by the Social Worker and signed off by her. In an interview with Social Services Director #11, at 3:30 PM on 08/05/26, she stated she did not understand that she needed to do the BIMS on Resident #34 because Resident #34 did not always understand what was being asked. b) Resident #4 During an initial interview with Resident #4 on 08/03/26 at 3:30 PM, she was able to answer interview questions appropriately and be understood by state surveyor. A review of the Quarterly MDS dated [DATE] section C read, Should Brief Interview for Mental Status be conducted?' The answer was coded as no (resident is rarely/never understood). A review of the Quarterly MDS dated [DATE] section B read, Ability to express ideas and wants and was coded as understood. In an interview with Licensed Practical Nurse #41, at 1:20 PM on 08/04/26, she stated Resident #4 makes her wants known perfectly fine and she has no difficulty understanding Resident #4. In an interview with Nurse Aide #63, on 08/04/26 at 1:25 PM, she stated she never has trouble understanding Resident #4. In an interview with MDS Coordinator #32 at 2:45 PM on 08/04/26, she stated she does not complete Section B or Section C of the MDS. She stated it is completed by the Social Worker and signed off by her. In an interview with Social Services Director #11, at 3:30 PM on 08/05/26, she stated she did not understand that she needed to do the BIMS on Resident #4 because Resident #4 did not always understand what was being asked.

Based on observation, record review, and staff interview, the facility failed to ensure Resident #4 was free from accidents during transfers and failed to ensure the med cart on the hall was locked. Resident #4 was one (1) of three (3) residents sampled for accident hazards and the med cart was a random opportunity for discovery during the Long-Term Care Survey Process. Resident Identifier: #4. Census: 36 Findings included:a) Resident #4 During an interview with Nurse Aide #63, on 08/04/26 at approximately 3:00 PM, the nurse aide stated Resident #4 is a dependent transfer that required two (2) people, but they did not use a hoyer lift. She stated Resident #4 did not help with transfers but could communicate with them. In an interview with Physical Therapy Assistant #40, at 8:40 AM on 08/05/26, the physical therapist stated she would expect a person coded as dependent x two (2) to be transferred via a hoyer lift. Review of Resident #4's physician orders showed two (2) person assist for transfers. Review of the Quarterly Minimum Data Set (MDS), with an assessment reference date of 05/18/26, Section GG showed transfers as dependent. A Review of the care plan, with a revision date of 04/03/26, showed bed to chair transfers as dependent. A review of the chair/bed-to-chair transfer task in the last 14 days showed Resident #4 was dependent with 20 transfers. In an interview with Director of Nursing (DON) on 08/05/26 at 9:50 AM, she stated if a resident was coded as dependent she would expect them to transfer using a full body lift. In an interview with Nurse Aide #63 on 08/05/26 at 10:00 AM, she demonstrated on State Surveyor how the nurse aides transfer Resident #4 by each putting an arm under her shoulders and grabbing her pants from the back and pivoting Resident #4 into the wheelchair. State Surveyor asked Nurse Aide #63 if Resident #4 would be safer using a lift. Nurse Aide #63 stated she would probably do well with a split lift. In an interview with Physical Therapy Assistant #40 at 10:15 AM on 08/05/26, she stated it is never appropriate to transfer a resident under the arms and using the pants because you take the risk of falls if the pants rip or damage to the residents' shoulders. The State Agency Surveyor observed Nurse Aide #63 and Nurse Aide #18, at 1:42 PM on 08/05/26, transferring Resident #4 from bed to wheelchair with each one lifting under Resident #4's arm and using a gait belt. State Surveyor asked both nurse aides if they had ever used a gait belt before and they both stated before today they had never seen one on the unit. The State Agency Surveyor observed Nurse Aide #63, at 1:58 PM on 08/05/26, with Resident #4 in the shower room standing at the bar with no gait belt with Nurse Aide #63 holding on to her pants and turning to pull the wheelchair behind her. In an interview with Administrator, at 4:00 PM on 08/05/26, she confirmed there has been no training provided to new nurse aides for transfers. Interviewed Nurse Aide #18 who signed off on the competencies for Nurse Aide #63 and Nurse Aide #26. She stated, on 08/05/26 at 4:15 PM, that the only competency observed for transfers is using a mechanical lift. b) Medication Cart On 08/05/2026 at 8:28 AM, an observation was made of the medication cart being unlocked. The top drawer and the third drawer were ajar. After approximately four (4) minutes, Registered Nurse (RN) #27 came into the hallway from a resident's room. RN #27 confirmed the medication cart was unlocked. RN #27 stated, I'm sorry. On 08/05/26 at 8:35 AM, the Director of Nursing (DON) was notified and confirmed the medication cart should be locked at all times when staff is away from the medication cart.

Based on observation, record review and staff interview, the facility failed to administer oxygen to Resident #29 and Resident #4 at the correct rate. This was true for two (2) of two (2) residents sampled for oxygen during the Long-Term Care Survey process. Resident Identifiers: #29, #4. Facility Census: 36.Findings included: a) Resident #29 Resident #29 was observed, at 1:07 PM on 08/03/26, with her oxygen set to four (4) liters per minute. At 1:10 PM, the Director of Nursing (DON) stated that Resident #29's oxygen was set to four (4) liters per minute and it is not supposed to be. The physician order for Resident #29 stated, Oxygen at two (2) liters per minute via nasal cannula continuously. b) Resident #4 Resident #4 was observed, at 2:55 PM on 08/03/26, with her oxygen on and set to four (4) liters per minute. Licensed Practical Nurse #53 confirmed the oxygen was set on four (4) liters per minute. The physician order for Resident #4 stated, Check oxygen saturation if resident is below 90% initiate oxygen at 2L [two liters] via Nasal Cannula. A review of the oxygen saturations show on 07/15/26 at 4:27 PM Resident #4's oxygen saturation was 95% at three (3) liters per minute (oxygen via nasal cannula). Observed Resident #4 throughout the day on 08/04/26 with no oxygen applied. Observed Resident #4 at 10:00 AM on 08/05/26 with no oxygen applied.

Based on observation and staff interview, the facility failed to ensure meals were served at a safe and appetizing temperature. This was a random opportunity for discovery found during the annual facility survey process. This failed practice had the potential to affect more than a limited number of residents. Facility census: 36.Findings included:a) Observations During Tray Line ServiceOn 08/04/26 at around 11:30 AM, this surveyor entered the kitchen area and noticed meal trays lined along the window ledge and on a table with tray tickets, dessert, cold food item for lunch, and cartons of supplements already on the trays. This surveyor questioned tray aide #51 what her process for preparing for the tray line was, she reported I get this set up by 11:30 AM each day so the line moves faster. The dietary manager was present and verified this practice. Questioned both tray aide #51 and dietary manager if the cold foods stayed cold for palatability, both confirmed We have not had any complaintsOn 08/04/26 at around 11:55 AM, tray line began. The meal delivery cart was delivered to floor two (2) for meal service. The surveyor then requested for the dietary manager to obtain temperatures of all meal items on the chosen test tray at around 12:40 PM. The dietary manager began checking temperatures of the meal items on the test tray. Results of test tray were:-Puree BBQ pork temperature 115 degrees Fahrenheit (F).-Puree carrot salad 69 degrees (F).-Puree peach cobbler (meant to be chilled) 75 degrees (F).-8oz glass of iced tea 63 degrees (F).The Dietary Manager verified hot foods should have been 120 degrees F or above and cold foods should have been 40 degrees F or below. The Dietary Manger then stated, I will work on this.

Based on observation and staff interviews, the facility failed to Store, prepare, distribute and serve food in accordance with professional standards for food service safety. This was a random opportunity for discovery and had the potential to affect multiple residents of the facility. Facility census 25. Findings included: Upon initial visit to the kitchen on [DATE] at 12:38 PM the following was observed in the refrigerators: -Staff food items consisting of bowls of butter and a bottle of flavored coffee creamer were found stored with facility refrigerated food supply. -Cooked hamburger labeled and dated to expire [DATE] still in fridge on [DATE]. -boiled eggs expiration date of [DATE] still in the fridge [DATE] -Grape jelly labeled with a label of open date of [DATE] with no expiration date -Large bottle of Salsa dated and labeled as Iced tea -Large bowl of coleslaw not completely covered was exposed open to air -Stacked trays of fruit bowls were unlabeled Freezer: -Hash browns opened, rewrapped and out of box unlabeled Pantries: -Opened bread loaves unlabeled -Opened clear bag of Vanilla Wafer cookies on shelf left opened to air unlabeled -Clear bag of Salsa Chips out of box unlabeled In an interview with a kitchen employee on [DATE], at approximately 2:00 PM, she acknowledged the list of items incorrectly stored in the refrigerators, freezers, and pantries. She stated that staff should not have stored personal items in the facility refridgerators and the expired foods should have been removed and disposed of. She also stated the unlabled fruit bowls were recently prepared but should have been labeled with dates before being placed into the refrigerators. In an interview with the Administrator on [DATE] at approximately 3:00PM, she acknowledged the incorrectly stored items in the kitchen pantries, refrigerators and freezers and stated the staff was working to correct the issues. On [DATE] at 11:00 AM an observation in the kitchen revealed the cook was wearing a ball cap and beard cover but not wearing a hairnet. On [DATE] at 11:00 AM the following was observed in the kitchen freezer area: -Frozen mixed vegetables left on the shelf out of box unlabeled -Whipped topping in piping decorating bag left in plastic bag on freezer shelf unlabeled On [DATE] at 11:00 AM the following was observed in the kitchen refrigerator area: -An onion wrapped in clear wrap had an expired date of [DATE] On [DATE] at 11:20 AM grilled cheeses made and ready to serve temp tested at 125 degrees and a second tested at 130 degrees. In an interview with the cook and the dietary manager approximately 11:30 AM on [DATE] they both acknowledged the temp was too low and discarded the remaining sandwiches and began making more. On [DATE] at approximately 9:20 AM, it was observed in the kitchen, the cook was wearing a ball cap exposing locks of uncovered hair without a hairnet. In an interview with both the cook and the Dietary Manager on [DATE] at 10:45 AM, they both stated they did not know a hair net was required if a hat (ball cap) was being worn. a) On [DATE] at approximately 11: 40 AM, during lunch preparations, a leftover breakfast tray with a plate of scrambled eggs was still sitting in the kitchen beside the food prep table, on a stack of trays close to the floor. During an interview at 11:40 AM on [DATE], the Dietary Manager acknowledged the breakfast tray was still in the kitchen and stated it should have been thrown away during breakfast clean up.

Based on observation and staff interviews, the facility failed to provide a safe, clean, comfortable, and homelike environment for resident Room identifiers: #218, #212, and #205. This was a random opportunity for discovery. Census: 25. Findings include: a) Upon survey entrance on 04/21/25 at 1:05PM, the following issues were observed in room [ROOM NUMBER]-bathroom areas: -black scuff marks on backside of bathroom door, - Rips and tears in the bathroom dry in the paint on right side wall under the paper towel dispenser. b) Upon survey entrance on 04/21/25 at 1:05PM, the following issues were observed in room [ROOM NUMBER]-bathroom areas: -Tissue holder right side was missing, - Cracks in caulking around the sink, -Black scuffmarks on the back side of bathroom door. c) Upon survey entrance on 04/21/25 01:05 PM the following issues were observed in room [ROOM NUMBER]-bathroom areas: -Drywall in the bathroom to the left of the sink above soap dispenser tear approx. 2 inches wide, -Tissue holder right side was loosely hanging off the wall, -Black scuffs on the backside of the bathroom door. During a walk through and interview with the Administrator on 04/22/25 at 12:55 PM, she acknowledged the bathroom areas were not in good repair for room [ROOM NUMBER], #212, and #205, and stated she would report to maintenance.

Based on Electronic Medical Record review and staff interview, the facility failed to develop a care plan for non-pharmacological interventions and implement a toileting care plan for two (2) residents. This had the potential to affect more than a limited number of residents who were reviewed for care plans. Resident identifiers: #14, #4, #20. Facility census: 25. Findings included: a) Resident #14 Resident #14 was admitted on [DATE] with medical diagnoses of anxiety, memory impairment and bewilderment secondary to Bipolar I Disorder, substance induced mood disorder and Major Neurocognitive disorder. Brief Interview for Mental Status (BIMS) could not be assessed. A review of medications on 04/22/25 at 1:17 PM found the following: Divaproex (Depakote) for bipolar affective disorder; Sertraline for depression and Zyprexa for Bipolar disorder order. These medications were monitored through a psychiatric consultation and approved by the attending physician. The behaviors of refusing care and cussing at staff were monitored. On 04/23/25 at 9:22 AM during an interview with the Nursing Home Administrator (NHA) it was confirmed there were no non-pharmacological interventions in the care plan. b) Resident #4 On 04/22/25 at 9:20 AM, a toileting sheet was observed hanging on Resident #4's bathroom door. The toileting sheet was scheduled for every two (2) hours. The toileting sheet was noted for 04/19/25 through 04/25/25. No documentation was found from 8:00 AM through 10:00 PM. A physician's order dated 01/16/25 stated, Will ask resident if they need to void q2h (every two hours) while awake to help with toileting needs. (Typed as written.) The care plan does indicate a toileting schedule for the resident. However, the care plan was not implemented. On 04/22/25 at 9:30 AM, during an interview with Registered Nurse (RN) #22, RN #22 stated, The resident is on a toileting program. On 04/22/25 at 11:26 AM, the Administrator confirmed the care plan was not implemented regarding the toileting program schedule. c) Resident #20 On 04/22/25 at 9:23 AM, a toileting sheet was observed hanging on Resident 20's-bathroom door. The toileting sheet was scheduled for every two (2) hours. The toileting sheet was noted for 04/19/25 through 04/25/25. No documentation was found for 04/20/25 from 12:00 AM through 6:00 PM. A physician's order dated 04/03/25 stated, Toileting program every two (2) hours while awake and as needed. (Typed as written.) The care plan does indicate a toileting schedule for the resident. However, the care plan was not implemented. On 04/22/25 at 9:30 AM, an interview was held with Registered Nurse (RN) #22. RN #22 stated, The resident is on a toileting program. On 04/22/25 at 11:26 AM, the Administrator confirmed the care plan was not implemented regarding the toileting program schedule. 45173

Based on record review, observation, and staff interviews, the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. Resident #22 was found to have a razor in his bathroom. For residents #25 and #27, Facility Reported Incidents (FRIs) revealed the facility failed to to ensure each resident received adequate supervision to prevent accidents and elopements. For Resident #27 the facility staff failed to respond to a wander guard alarm. During Resident #5's medication administration, the medication cart was left unlocked. These were random opportunities for discovery. Resident identifiers: #22, #25, #27, and #5. Facility Census: 25. Findings include: a) Resident #22 04/21/25 01:29 PM During facility entrance observation of Resident #22's room revealed a blue razor was found in the bathroom on top of the paper towel dispenser. On 04/21/25 at 1:30 PM, after an interview with Nurse Aide (NA) #25, the NA removed the razor and stated it was not supposed to be in the resident's room. In an interview with the Administrator on 04/22/25 at 12:55 PM, she acknowledged the razor was found in Resident #22's bathroom on top of the paper towel dispenser and stated that it should not have been there. b) Resident #25 On 09/06/24, at 8:00 PM Resident #25 attempted to elope through the fire exit door. Record review on 04/23/25 revealed staff, responding to alarms, found Resident #25 was led by the hand with Resident #27 in the stairwell and was at the top of the stairs. She was redirected and brought back into the unit 12 seconds later, with no injury. Resident #25 had dementia and impaired judgement. Record review also revealed that after the elopement Resident #25 was observed as normal as continued to wander but did not exit seek. She had no bodily injuries and no mood or behavior changes. c) Resident #27 On 09/09/2024, Resident #27 eloped with resident #25 through the fire door by pushing the fire door exit and went to the stairwell until redirected by the nurse. She was out for 12 seconds and returned with no serious bodily injury occurring and no changes to her mood or behavior. Record review revealed Resident # 27 had dementia and impaired judgement and a history of exit seeking and appeared to be anxious previous to this incident. In an interview with the facility administrator on 04/23/25 at approximately 10:30AM, She stated resident #27 had a history of elopement and exiting ideas. She would pack her bags and state she was going home daily. She has since stopped packing her bags but still many times daily gets to the exit doors and tries to exit by way of the exit doors and the elevator. The facility provided a timeline of updates and changes in medications, activities, and staff interventions to keep her busy and to deter her from attempting to exit. Resident has not had a successful elopement since 12/08/24. On 12/8/24, Resident #27 was exit seekiing multiple times. At 2:37 PM, she eloped by exiting the fire exit door and made it down the stairs to the elevator. Based on video watched by the Administrator regarding the elopement on 12/8/24 at 2:37 PM. Resident was redirected away from the exit door by staff three times: 2:32 PM, and 2:35 PM, before exiting the fire exit door and walking down the stairs at 2:37 PM. The facility put in place the following correction actions: Staff will not use the fire exit door located by the solarium. Also, interventions were emplemented including: placing an anti-slip floor STOP sign, and duct tape outlining the black floor tile in the front of the two fire exits doors. Also, a warning sign alerting the security alarm sounds if the door is open was placed on wall near the 2 exit doors. In an interview with the facility administrator on 04/23/25 at approximately 10:30 AM, she stated Resident #27 had a history of elopement and exiting ideas. She said the resident would pack her bags and say she was going home daily. The administrator said the resident has since stopped packing her bags but still many times each day she tried to elope by way of the exit doors and the elevator. The administrator stated the facilty developed a timeline of facility updates, evaluations and physician order medication changes, and staff interaction and redirection to deter her from attempting to exit after each elopment. She stated Resident #27 has not had a successful elopement since 12/08/24. On 04/23/25 approximately 2:25 PM, in an interview with the Administrator, she acknowledged that Resident #27's elopement attempts had been redirected by staff twice 2:32 PM and again at 2:35 PM Despite these efforts the resident eloped through the fire exit door and made it down to the elevator on the third attempt at 2:37 PM. On 04/23/25 2:31 PM, Resident #27 was observed at the elevators on the unit. The wander guard alarm was ringing. The elevator doors remained open. The wander guard alarm rang for approximately four (4) minutes before Maintanence staff #53 responded to the alarm. The resident moved down the hall away from the elevators prior to the response to the alarm. On 04/23/25 at 2:35 PM, Registered Nurse (RN) #22 was interviewed. The Charge Nurse stated, the staff should respond immediately. But the elevator will not move from the second floor while the wander guard alarm is sounding; and, a code must be used to get the elevator to move. RN #22 was advised no other nursing staff responded to the wander guard alarm. RN #22 stated, the other staff members must have been in rooms taking care of other residents. Resident #27 was noted with a history of elopement at the facility on 08/14/24, 09/06/24, 09/23/24 and 12/08/24. Interventions were put into place immediately. Referrals were made to other facilities which had locked memory units were declined due to the resident's diagnosis and psychiatric medication. On 04/23/25 at 3:04 PM, RN #22 demonstrated how the wander guard alarm works and the elevator will not move when the alarm is sounding. The wander guard alarm must have a code input before the elevator will move. On 04/23/25 at 3:15 PM, the Administrator, Director of Nursing (DON) were informed of the incident. Both the Administrator and the DON agreed the staff should have responded immediately. e) Resident #5 On 04/24/25 at 7:23 AM, an observation was made during medication administration completed by Registered Nurse (RN) #22. Upon entering Resident #5's room, RN #22 left the medication cart unlocked. On 04/24/25 at 7:27 AM, RN #22 acknowledged the medication cart was unlocked. On 04/24/25 at 7:40 AM, the Administrator was notified and confirmed the medication cart should have been locked.

Based on observation and staff interviews the facility failed to maintain kitchen equipment in safe operating condition. This was a random opportunity for discovery. Facility census: 25. Findings Include: a) On 04/22/25 11:20 AM, during the kitchen food temperature testing, observation revealed the burner knobs were not on the stove. The kitchen staff was preparing lunch causing the grilled cheeses to burn. The cook stated the grill was set too high and was unable to adjust the grill temperatures until he replaced the missing knobs with control knobs from the other burners to adjust the grill temperatures. This left the other burners without control knobs. On 04/22/25 at 11:25 AM, In an interview with the facility cook he stated the knobs fell off and were probably under the stove somewhere. During an interview with the dietary manager on 04/22/25 at 11:30AM, she acknowledged the missing knobs and stated they had probably fallen off and guessed they were underneath the stove.

Based on observation, record review and staff interview, the facility failed to ensure the Minimum Data Set (MDS) assessment indicated the use of restraints. This was true for one (1) of two (2) residents reviewed under the care area of falls. Resident identifier: #4. Facility Census: 25. Findings Include: a) Resident #4 On 04/22/25 at 2:45 PM, a record review was completed for Resident #4 regarding multiple falls. The review found the resident had a physician's order dated 06/21/24 for a self-releasing seat belt for improve safety/cues to resident upon standing attempts to help with fall prevention. However, the physician's order did not contain the information to release the restraint every two (2) hours. Upon further review, the care plan under the focus area of at risk for falls related to history of falls, did list the self-releasing seat belt as an intervention. On 04/23/25 at 2:37 PM, Resident #4 was sitting in a wheelchair in the unit lobby with the self-releasing seat belt in place. Registered Nurse (RN) #22 was asked to assist with a demonstration of the resident releasing the seat belt. RN #22 asked the resident 4 multiple times to remove the seat belt. The resident was unable to remove the seat belt after multiple requests. The resident is noted with a score of zero (0) on the Brief Interview for Mental Status (BIMS), which indicates severe cognitive impairment. During the observation, the resident was noted with nonsensical speech. RN #22 stated, she cannot remove the seat belt upon request. On 04/23/25 at 3:15 PM, an interview was held with the Administrator. The Administrator was advised, after the observation of the resident, the seat belt could not be removed by the resident. The resident showed severe cognitive impairment. The Administrator stated, It will release when she stands up .it is for safety . The Administrator was asked, is there documentation the seat belt is removed every two (2) hours. The Administrator stated, the staff toilets the resident every two (2) hours. On 04/24/25 at approximately 10:00 AM, the Administrator presented a copy of a care plan team meeting summary dated 04/15/25. The Administrator stated, the seat belt was discussed the Medical Power of Attorney (MPOA) and the MPOA requests the seat belt because the resident has had so many falls. The Administrator presented a copy of a progress note dated 04/09/25 at 3:25 PM. The progress note indicated the monthly physical therapy (PT) assessment was completed. The interview with the Administrator continued with the discussion of what the definition of physical restraints and removes easily per the Centers of Medicare and Medicaid Services regulation. The definition of physical restraint is defined as any manual method, physical or mechanical device, equipment, or material that meets the following criteria: -is attached or adjacent to the resident's body -cannot be removed easily by the resident, and -restricts the resident's freedom of movement or normal access to his/her body The definition of removes easily is: -the restraint can be easily removed by the resident in the same manner as it was applied by the staff. On 04/24/25 at 11:00 AM, the Administrator confirmed the self-removing seat belt did meet the criteria for physical restraint. The Administrator stated, we will contact the MPOA and explain the seat belt is considered a restraint. On 04/24/25 at 11:15 AM, the MDS assessment dated [DATE] section P did not indicate the use of a restraint. At this time, the Administrator did confirm the MDS did indicate the use of restraint. b) Facility Policy On 04/24/25 at 11:20 AM, the Administrator provided a copy of the facility's policy entitled, Use of Restraints. The policy statement includes the following: --Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. --Restraints shall not be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls. --When the use of restraints is indicated, the least restrictive alternative will be used for the least amount of time necessary, and the ongoing re-evaluation for the need for restraints will be documented.

Based on observation and staff interview, the facility failed to ensure privacy and confidentially for Resident #5 during medication administration. Resident identifier: #5. Facility Census: 25. Findings include: a) Resident #5 On 04/24/25 at 7:23 AM, an observation was made during medication administration completed by Registered Nurse (RN) #22. Upon entering Resident #5's room, RN #22 left the computer screen unlocked with access to Resident #5's medical record. On 04/24/25 at 7:27 AM, RN #22 acknowledged the computer screen was unlocked. On 04/24/25 at 7:40 AM, the Administrator was notified and confirmed the computer screen should have been locked.

Based on observation, record review, and staff interview, the facility failed to ensure Resident #4 was free from restraints. This was true for one (1) of the two (2) residents reviewed under the care area of falls. Resident Identifier: #4. Facility Census: 25. Findings Include: a) Resident #4 On 04/22/25 at 2:45 PM, a record review was completed for Resident #4 regarding multiple falls. The review found the resident had a physician's order dated 06/21/24 for a self releasing seat belt for improve safety/cues to resident upon standing attempts to help with fall prevention. However, the physician's order did not contain the information to release the restraint every two (2) hours. Upon further review, the care plan under the focus area of at risk for falls related to past history of falls, did list the self releasing seat belt as an intervention. On 04/23/25 at 2:37 PM, Resident #4 was sitting in a wheelchair in the unit lobby with the self releasing seat belt in place. Registered Nurse (RN) #22 was asked to assist with a demonstration of the resident releasing the seat belt. RN #22 asked Resident #4 multiple times to remove the seat belt. The resident was unable to remove the seat belt after multiple requests. The resident is noted to have a score of three (3) on the Brief Interview Interview for Mental Status (BIMS), which indicates severe cognitive impairment. During the observation, the resident was noted to have nonsensical speech. RN #22 stated, she cannot remove the seat belt upon request. On 04/23/25 at 3:15 PM, an interview was held with the Administrator. The Administrator was advised, after the observation of the resident, the seat belt could not be removed by the resident. The resident showed severe cognitive impairment. The Administrator stated, it will release when she stands up .it is for safety . The Administrator was asked, is there documentation the seat belt is removed every two (2) hours. The Administrator stated, the staff toilets the resident every two (2) hours. On 04/24/25 at approximately 10:00 AM, the Administrator presented a copy of a care plan team meeting summary dated 04/15/25. The Administrator stated, the seat belt was discussed with the Medical Power of Attorney (MPOA) and the MPOA requests the seat belt because the resident has had so many falls. The Administrator presented a copy of a progress note dated 04/09/25 at 3:25 PM. The progress note indicated the monthly physical therapy (PT) assessment was completed. The interview with the Administrator continued with the discussion of what the definition of 'physical restraints' and the definition of 'removes easily' per the Centers of Medicare and Medicaid Services regulation. The definition of physical restraint is as follows: --is defined as any manual method, physical or mechanical device, equipment, or material that meets the following criteria: -is attached or adjacent to the resident's body -cannot be removed easily by the resident, and -restricts the resident's freedom of movement or normal access to his/her body The definition of removes easily is: -the restraint can be easily removed by the resident in the same manner as it was applied by the staff. On 04/24/25 at 11:00 AM, the Administrator confirmed the self removing seat belt did meet the criteria for a physical restraint. The Administrator stated, we will contact the MPOA and explain the seat belt is considered a restraint. b) Facility Policy On 04/24/25 at 11:20 AM, the Administrator provided a copy of the facility's policy entitled, Use of Restraints. The policy statement includes the following: --Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. --Restraints shall not be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls. --When the use of restraints is indicated, the least restrictive alternative will be used for the least amount of time necessary, and the ongoing re-evaluation for the need for restraints will be documented.

Based on record review and staff interview, the facility failed to revise the care plan regarding restraint use for Resident #4 and actual skin breakdown for Resident #12. This was true for two (2) of 15 residents reviewed during the survey process. Resident Identifiers: #4 and #12. Facility Census: 25. Findings Include: a) Resident #4 On 04/22/25 at 2:45 PM, a record review was completed for Resident #4 regarding multiple falls. The review found the resident had a physician's order dated 06/21/24 for a self releasing seat belt for improve safety/cues to resident upon standing attempts to help with fall prevention. The care plan does indicate an intervention of the self releasing seat belt under the focus area of risk for falls due to a history of falls; however, the care plan was not revised to indicate the self releasing seat belt is a restraint. An interview was held with the Administrator on 04/23/25 at 4:15 PM. The Administrator did confirm the self releasing seat belt was not identified as a restraint on the care plan. b) Resident #12 On 04/21/25 at 4:13 PM, a record review was completed for Resident #12. The review found the resident has an unstagable pressure ulcer on the right great toe. A physician's order dated 04/15/25 stating cleanse right great toe with mild soap and water. Pat dry. Apply a thin layer of silvadene to wound bed necrotic area. Apply nitropaste around wound. Cover with gauze, kling and secure with tape to be completed daily and prn (as needed) for loose and soiled dressing. (Typed as written.) Upon further review of the care plan, a focus area was listed as risk for skin break down due to skin fragility and age. (Typed as written.) However, the care plan was not revised to indicate the resident had an actual unstagable pressure ulcer on the right great toe. An interview was held with the Administrator on 04/22/25 at approximately 11:00 AM. The Administrator did confirm the care plan had not been revised to indicate the resident had an actual pressure ulcer.

Based on record review and staff interview, the facility failed to follow physician's orders for toileting schedules for Resident #4 and Resident #20. This was true for two (2) of 15 residents reviewed during the survey process. Resident Identifiers: Resident #4 and #20. Facility Census: 25. Findings Include: a) Resident #4 On 04/22/25 at 9:20 AM, a toileting sheet was observed hanging on Resident #4's bathroom door. The toileting sheet was scheduled for every two (2) hours. The toileting sheet was noted for 04/19/25 through 04/25/25. No documentation was found from 8:00 AM through 10:00 PM. A physician's order dated 01/16/25 stated, Will ask resident if they need to void q2h (every two hours) while awake to help with toileting needs. (Typed as written.) On 04/22/25 at 9:30 AM, an interview with held with Registered Nurse (RN) #22. RN #22 stated, the resident is on a toileting program. On 04/22/25 at 11:26 AM, the Administrator confirmed the physician's order was not followed regarding the toileting schedule b) Resident #20 On 04/22/25 at 9:23 AM, a toileting sheet was observed hanging on Resident 20's bathroom door. The toileting sheet was scheduled for every two (2) hours. The toileting sheet was noted for 04/19/25 through 04/25/25. No documentation was found for 04/20/25 from 12:00 AM through 6:00 PM. A physician's order dated 04/03/25 stated, Toileting program every two (2) hours while awake and as needed. (Typed as written.) The care plan does indicate a toileting schedule for the resident. On 04/22/25 at 9:30 AM, an interview was held with Registered Nurse (RN) #22. RN #22 stated, the resident is on a toileting program. On 04/22/25 at 11:26 AM, the Administrator confirmed the physician's order regarding the toileting program schedule was not followed.

Based on record review, staff interview and observation, the facility failed to ensure Resident #35 had a physician's order when given a narcotic. Resident #35 received [MEDICATION NAME] (a [MEDICATION NAME] oral concentrate) without a physician's order. After receiving the medication, the resident became unresponsive and lethargic and was sent to the hospital. This failed practice resulted in actual harm to Resident #35 which resulted in an immediate jeopardy situation. The facility did not have a physician order to administer [MEDICATION NAME]. As a result the resident's oxygen saturation levels feel to the 82-84% range, and she became lethargic. Resident #35 was noted as unresponsive to both verbal and tactile stimulus. The facility failed to recognize their medication administration error, and the need for this resident to be transferred to the emergency department of the hospital. The resident's daughter requested an ambulance be called and her mother be transferred to the hospital. As a result, the ambulance personnel assessed the resident and administered [MEDICATION NAME] due to the symptoms of opioid overdose. After the Centers for Medicare and Medicaid Services, Regional Office review of the deficient practice, it was determined to support the deficient practice at an immediate jeopardy level. Facility administrator notified of the immediate jeopardy on 11/06/19 at 11:01 AM. Facility abatement plan of correction accepted on 11/06/19 at 2:52 PM. Immediate Jeopardy Abatement Plan of Correction: 1. All residents have the potential to be affected by this deficient practice. The DON and Unit Manager will review all the Medication Administration Records and physician's orders of all Residents receiving a narcotic to ensure all narcotics have a current physician order. The DON or Designee will review the previous 6 months of Controlled Substance sign out sheet to determine if there are any discrepancies between what was administered and what was noted on the logs. This will be completed by 11/8/2019. 2. The DON or Designee will review the following policies with all license Nursing staff by 11/8/2019: Medication Administration policy Controlled Substance policy The Licensed Nurse will re-assess the effectiveness of the medication within 60 minutes and document in the resident's medical record. The Licensed Nurse will notify the physician of any change in condition or adverse reaction and provide treatment as ordered. 3. The DON or Designee will review all Resident's MARs daily x 30 days, then weekly x 60 days, then monthly x 2 months to ensure any new narcotic administered has a valid physician order. 4. All Results will be submitted to the QAPI meeting no less than quarterly. Upon verification of the implementation of the abatement plan of correction the deficiency was reduced to a D. Abatement plan verification was completed on 11/07/19 at 10:48 AM. In addition, the facility failed to ensure a [MEDICAL CONDITION] machine was used in accordance with standards of care. This was a random opportunity for discovery. These failed practices had the potential to affect a limited number of residents. Resident identifier: #35. Facility census: 35. Findings included: a) Resident #35 1. Narcotic use Record review found the resident was admitted to the facility on [DATE], under the care of Hospice Services. [DIAGNOSES REDACTED]. Review of the nurses notes revealed the following, dated 09/21/19 at 13:35 (1:35 PM): --Resident has been lethargic today and has had labored breathing as noted by myself and Hospice RN (Registered Nurse) she has been administered Roxinol (medication misspelled by the nurse) 0.25 ml at 849 to ease her breathing and improve her 02 sat of 87% her sat has improved to 97-100% by late afternoon. Resident has been fed toast for breakfast but her appetite has been poor for lunch as her daughter has come to visit and brought in a small dog. She has been a febrile temp 98.0, she remains on Keflex as ordered, she has been drinking small amount of spring water today. This note was typed and spelled as written. Further review of the physician's orders found no evidence the physician ordered [MEDICATION NAME] (an opioid) for this resident on 09/21/19. Warning label for [MEDICATION NAME]: --Opioid medicine can slow or stop your breathing, and death may occur. --Serious side effects may be more likely in older adults and those who are malnourished or debilitated --Side effects include: The major hazards of [MEDICATION NAME], as of other narcotic [MEDICATION NAME], are Respiratory Depression and, to a lesser degree, Circulatory Depression, Respiratory Arrest, Shock and [MEDICAL CONDITION] have occurred. A second nurses note, dated 09/21/19 at 17:53 (5:53 PM) --Resident lethargic on this shift. Daughter requested resident be sent out. (Name of physician) notified, DON (director of nursing) notified. EMS (emergency medical squad) contacted at 5:30 PM arrived at 541 pm and resident transported out. Resident O2 was 82-84% and resident unable to respond to verbal or tactile stimuli. Hospice came and seen resident, talked to (Name of daughter). Review of the hospital emergency room visit from 09/21/19 revealed the following: .Daughter states the patient was given [MEDICATION NAME] last night and then given 5 milligrams [MEDICATION NAME] this morning .(name of ambulance service) arrived and gave the patient 2 milligrams of [MEDICATION NAME] . The hospital emergency room visit noted treatments prior to arrival were oxygen and [MEDICATION NAME]. [MEDICATION NAME] is a drug that can temporarily stop the effects of opioid drugs. [MEDICATION NAME] can help restore breathing during an opioid overdose. Review of the Medication Administration Record [REDACTED]. No evidence could be found to substantiate [MEDICATION NAME] was ever ordered or given at the facility, since the resident's admission. The controlled substance record noted the resident received [MEDICATION NAME] at 8:48 AM on 09/20/19. The dosage given was marked out 2 times before noting 0.25 ML was given. The nurse who wrote the nursing note on 09/21/19 was the same nurse who noted she gave the [MEDICATION NAME] on 09/20/19 on the controlled substance sheet. The nursing note says the resident received the [MEDICATION NAME] on 09/21/19; however, this date is not the same as the date on the controlled substance record. On 10/09/19 at 9:36 AM, during a staff interview, Registered Nurse, unit manager, RN #35 confirmed the facility did not have a physician's order to give [MEDICATION NAME]. An interview with the Director of Nursing (DON) on 10/09/19 01:04 PM, confirmed the facility had no physician's order to give [MEDICATION NAME]. The DON said the Hospice nurse told her nurse to give the medication. When asked if a nurse can give orders to another nurse, the DON replied, No. The DON verified Resident #35 did receive [MEDICATION NAME] (narcotic-like pain medication) at 4:08 PM and 10:00 PM on 09/20/19. This failed practice resulted in actual harm an immediate jeopardy to Resident #35. The facility did not have a physician order to administer [MEDICATION NAME]. As a result the resident's oxygen saturation levels feel to the 82-84% range, and she became lethargic. Resident #35 was noted as unresponsive to both verbal and tactile stimulus. The facility failed to recognize their medication administration error, and the need for this resident to be transferred to the emergency department of the hospital. The resident's daughter requested an ambulance be called and her mother be transferred to the hospital. As a result, the ambulance personnel assessed the resident and administered [MEDICATION NAME] due to the symptoms of opioid overdose. 2. [MEDICAL CONDITION] Observation on 10/10/07/19 at 11:10 AM, found the resident's [MEDICAL CONDITION] (stands for Bi-level Positive Airway Pressure) mask laying on her night stand with a pair of tennis shoes positioned on top of the mask. The tubing was touching the floor. Registered Nurse (RN) #16 confirmed the mask and tubing should be in a bag. She removed the shoes, did not clean the mask, and left the room. Further record review found the resident had a physician's order for: Auto [MEDICAL CONDITION]. Patient to use as directed for shortness of breath and/or bedtime. Patient to continue same daily continuous oxygen via Nasal Cannula of 3 liter/minute. If O2 sat (saturation) decreases on [MEDICAL CONDITION], increase O2 level to 4 liters/ minute. Do not increase above 4 liter/minute. Review of the policy entitled, Standard of Care, [MEDICAL CONDITION] and [MEDICAL CONDITION] support revealed: Attach pulse oximeter to the resident during us of [MEDICAL CONDITION]. Record review provided no evidence of physician's orders for oxygen checks. 10/08/19 02:10 PM, an interview with the DON confirmed staff have no orders to obtain residents oxygen levels and no orders to attach a pulse oximeter to the resident during use of the [MEDICAL CONDITION] machine. A review of facility policy found resident to wear pulse ox at all times when using [MEDICAL CONDITION]. The DON confirmed this needed to be in the physician's orders.

Based on record review, staff interview and policy review the facility failed to provide prompt pain management to Resident #32 when he was experiencing pain in his legs and back. From 12:00 a.m. until 5:30 a.m.on 10/13/16 the facility failed to effectively treat Resident #32's pain when a treatment option was available to them. This failure caused Resident #32 to suffer undo pain for a prolonged period of time resulting in actual harm. In addition the facility on multiple occasions failed to assess the effectiveness of Resident #32's as needed pain medication in a prompt manner. Also for Resident #32 the facility failed to administer his physicians prescribed atvian as directed by the physicians order. This was true for one (1) of four (4) residents reviewed for the care area of pain management during Stage 2 of the Quality Indicator Survey (QIS). Resident identifiers: #32. Facility Census: 29 Findings Include: a) Resident #32 1. Pain Management - Failure to provide prompt pain management. A review of Resident #32's medical record found the following physicians orders: -- [MEDICATION NAME] 5/ [MEDICATION NAME] 325 milligrams (mg) (Brand name [MEDICATION NAME]) every eight (8) hours as needed for pain. This order had a start date of 06/08/16 and was a current order at the time of this review. -- [MEDICATION NAME] 500 mg (Brand Name Tylenol) every four hours as needed for pain. This order had a start date of 07/08/16 and was a current order at the time of this review. Further review of the record found a nursing progress note dated 10/13/16 which read as follows (typed as written), Resident woke up around 12 am (12:00 a.m.) to use the bathroom and c/o (complained of) leg and back pain and Tylenol was given with very little effectiveness (he woke up several more times this shift c/o of leg pain). At appox (approximately) 530am (5:30 a.m.), resident was given [MEDICATION NAME] and OOB (out of bed), toileted and given a snack and a cup of coffee. At, 645 (6:45 a.m.), he was sitting in geri chair in pleasant mood and answered, Oh yes indeedy, they feel better, when asked how his legs and back felt. No further problems noted this shift. This note was written by Licensed Practical Nurse (LPN) #77. A review of Resident #32's Medication Administration Record [REDACTED]. The LPN noted Resident #32 continued to suffer with pain until 5:36 a.m. when she finally administered the resident his as needed [MEDICATION NAME]. During an interviews with the Director of Nursing (DON) at 2:32 p.m. on 11/02/16 and at 10:10 a.m. on 11/03/16, the DON agreed that LPN # 77 should have administered Resident #32's [MEDICATION NAME] prior to 5:36 a.m. She indicated, the effectiveness of an as needed pain medication should be assessed between 30 minutes to an hour after its administration and if the Tylenol was not effective he should have been administered the [MEDICATION NAME]. The DON indicated she did not know why the LPN would have not administered the [MEDICATION NAME] if Resident #32 had continued to complain of pain in his back and legs. An additional interview with the DON at 8:35 a.m. on 11/04/16, found she had spoken with the Health Service Workers (HSW) that were working the night of 10/13/16 and they reported to her that the resident rested well from 12:00 a.m. until 5:36 a.m. when they got him out of bed. She indicated she did not know why LPN #77 would write such a note. She agreed the note did not reflect the information which was obtained from the HSWs. She agreed the note entered into the chart by the LPN responsible for his care indicated the resident went from 12:00 a.m. to 5:36 a.m. without relief from his pain when he had an as needed [MEDICATION NAME] order which could have been administered after the Tylenol was found to be ineffective. b) Prompt assessment of effectiveness after the administration of an as needed pain medication. A review of Resident #32's medical record found the following physicians orders: -- [MEDICATION NAME] 5/ [MEDICATION NAME] 325 milligrams (mg) (Brand name [MEDICATION NAME]) every eight (8) hours as needed for pain. This order had a start date of 06/08/16 and was a current order at the time of this review. -- [MEDICATION NAME] 500 mg (Brand Name Tylenol) every four hours as needed for pain. This order had a start date of 07/08/16 and was a current order at the time of this review. Review of the MAR from 06/08/16 through present found the following occasions when Resident #32 was administered Tylenol and/or [MEDICATION NAME] and prompt assessments of the medications effectiveness was not completed: For the administration of [MEDICATION NAME]: -- 06/16/16 administered at 8:08 a.m. the effectiveness was not assessed until 06/17/16 at 7:54 a.m. (23 hours and 46 minutes after administration). -- 06/17/16 administered at 8:24 a.m. the effectiveness was not assessed until 06/17/16 at 12:57 p.m. (4 hours and 33 minutes after administration). -- 06/20/16 administered at 8:20 p.m. the effectiveness was not assessed until 06/23/16 at 7:34 p.m. (2 days 23 hours and 14 minutes after administration). -- 06/21/16 administered at 4:10 p.m. the effectiveness was not assessed until 06/21/16 at 8:05 p.m. (3 hours and 55 minutes after administration). -- 06/22/16 administered at 8:47 p.m. the effectiveness was not assessed until 06/23/16 at 5:16 a.m. (8 hours and 29 minutes after administration). -- 06/24/16 administered at 5:31 p.m. the effectiveness was not assessed until 06/25/16 at 5:40 a.m. (12 hours and 9 minutes after administration). -- 06/26/16 administered at 12:32 a.m. the effectiveness was not assessed until 06/26/16 at 5:22 a.m. (4 hours and 50 minutes after administration). -- 08/03/16 administered at 2:32 p.m. the effectiveness was not assessed until 08/08/16 at 1:56 p.m. (4 days 23 hours and 24 minutes after administration). -- 08/10/16 administered at 11:31 a.m. the effectiveness was not assessed until 08/10/16 at 2:39 p.m. (3 hours and 08 minutes after administration). -- 08/23/16 administered at 7:04 p.m. the effectiveness was not assessed until 08/26/16 at 3:00 p.m. (2 days 19 hours and 56 minutes after administration). -- 08/24/16 administered at 9:02 p.m. the effectiveness was not assessed until 08/25/16 at 12:06 p.m. (15 hours and 4 minutes after administration). -- 09/14/16 administered at 5:45 a.m. the effectiveness was not assessed until 09/15/16 at 5:16 a.m. (23 hours and 31 minutes after administration). -- 09/25/16 administered at 5:36 a.m. the effectiveness was not assessed until 09/25/16 at 8:32 a.m. (2 hours and 56 minutes after administration). -- 10/11/16 administered at 2:15 a.m. the effectiveness was not assessed until 10/11/16 at 5:19 a.m. (3 hours and 7 minutes after administration). -- 10/13/16 administered at 5:36 a.m. the effectiveness was not assessed until 10/13/16 at 1:27 p.m. (7 hours and 51 minutes after administration). -- 10/20/16 administered at 8:28 a.m. the effectiveness was not assessed until 10/20/16 at 2:45 p.m. (6 hours and 17 minutes after administration). For the administration of Tylenol: -- 07/20/16 administered at 9:12 a.m. the effectiveness was not assessed until 07/20/16 at 1:23 p.m. (4 hours and 11 minutes after administration). -- 07/21/16 administered at 7:41 p.m. the effectiveness was not assessed until 07/26/16 at 5:46 a.m. (4 days 10 hours and 5 minutes after administration). -- 10/15/16 administered at 7:55 p.m. the effectiveness was not assessed until 10/16/16 at 6:27 a.m. (10 hours and 32 minutes after administration). During an interview with Registered Nurse (RN) #24 at 11:04 a.m. on 11/03/16, she indicated one of the supervising nurses run a report at the end of every shift and if there is missing pain documentation then a note is sent to the nurse who administered the medication that she needs to go into the computer and supply the missing documentation. When asked why on some occasions the documentation was entered days later she stated, The nurse who gave the medication may be off for a few days and not be back to supply the needed documentation. She indicated that perhaps they needed to run the report a little more often and have the nurses supply the documentation before they leave for the day. Review of the facility's Assessment and Documentation of Pain policy found the following in regards to monitoring the effectiveness of a medication used to treat pain (typed as written): Monitor effectiveness of medication 30 minutes post administering the medication consider all the relevant factors: 1. Is there a change of behavior which leads you to believe the medication is working? 2. What level of relieve id the resident obtaining at this point in time? 3. Do you have reason to believe the medication is relieving the pain and will do so without other intervention? 4. If complete relief is not obtained return to check in an hour? 5. How long does the effectiveness of the medication last? Is there reason to believe the medication would be more effective at a higher dosage or increased frequency? 6. On some occasions does the medication need to be decreased? 7. Should medication be given q4h prn (every four (4) hours as needed schedule every four hours for 24 hours? To see if changing it to a schedule would make the resident pain free. 8. Is there some reason to believe the medications needs changed? 9. To report to a doctor the medication is not relieving the pain, you must know how much relief was obtained and how long did the relief last. YOU MUST DOCUMENT During an interview with the DON at 2:32 p.m. on 11/02/16 she indicated the nurse should go back 30 minutes to one hour after giving a pain medication to evaluate for its effectiveness she was asked to review the MAR for Resident #32 and she agreed these assessments were not completed timely. During an additional interview with the DON at 8:35 a.m. on 11/04/2016, she confirmed the facility did not follow their policy in monitoring for the relief of pain within 30 minutes to one (1) hour after the administration of a pain medication. She indicated, she felt the nurses did monitor for effectiveness but their documentation is very poor and there is no way to know for sure when they monitored for the effectiveness or if it was effective or not. 2. Failure to administer medications per physician orders. A review of Resident #32's medical record found a physicians order for [MEDICATION NAME] .5 milligrams (MG) twice daily beginning on 06/30/16. This order was in effect until 07/13/16 when it was discontinued. There were no parameters to hold the medication if the resident was sedated. On 07/13/16 the physician changed Resident #32's [MEDICATION NAME] order to .25 mg twice daily and gave the parameter to hold if sedated. A review of the Medication Administration Record [REDACTED] -- 07/03/16 - 8:00 p.m. dose and the reason for holding the medication noted as Lethargy -- 07/04/16 - 8:00 a.m. and 8:00 p.m. doses and the reason for holding the medication on both occasions was Lethargy -- 07/05/16 - 8:00 a.m. dose and the reason for holding the medication Lethargy -- 07/05/16 - 8:00 p.m. dose and reason for holding the medication was listed as Doctors order -- 07/06/15 - 8:00 a.m. dose and the reason for holding the medication was again Lethargy -- 07/06/16 - 8:00 p.m. dose and the reason for holding the medication was listed as Doctors order -- 07/07/16 - 8:00 a.m. and 8:00 p.m. doses and the reason for holding the medication on both occasions was Lethargy -- 07/08/15 - 8:00 a.m. dose and the reason for holding the medication was Lethargy -- 07/09/15 - 8:00 a.m. dose and the reason for holding the medication was Lethargy Further review of Resident #32's medical record found no evidence the physician was notified when this medication was held. The record contained no order to hold Resident #32's [MEDICATION NAME] until 07/13/16 when the doctor was in the facility and saw the resident and decreased his dose of [MEDICATION NAME] and added the parameter to hold the medication if Resident #32 was sedated. An interview with the DON at 4:36 p.m. on 11/03/16 confirmed his medication was held on the above mentioned dates. She indicated she was certain that the physician knew they were holding the medicine, but agreed it was not documented in his record until 07/13/16. She stated, (Name of Attending Physician) was out of town and (Name of another physician) was covering for him in his absence and he came up to the floor frequently and she knows they had to have told him they were holding the medication. She indicated that once he was started on that medication he just went to sleep for days and that is why they were not giving it to him.

Based on medical record review and staff interview, the facility failed to ensure three (3) of three (3) residents maintained acceptable parameters of nutritional status. The residents had severe and/or significant weight losses which were not identified and addressed. Resident #31 lost 6.43 % (percent) of her body weight, from 01/13/14 to 02/07/14, which represented a severe weight loss in one (1) month. There was no evidence the facility identified or addressed the weight loss. Between 01/13/14 and 06/17/14, the resident's total weight loss was 10.94%, representing a severe weight loss in five (5) months. There was no evidence this weight loss was identified and addressed. As no interventions were implemented, the weight loss could not be be determined to be unavoidable. This represented actual harm to Resident #31. Resident #26 lost 12.23 % of her body weight, from 04/14/14 to 05/14/14, a severe weight loss in one (1) month. The resident had another severe weight loss of 5.37 % from 05/14/14 to 06/17/14. There was no evidence the facility identified or addressed either of these weight losses. As no interventions were implemented, the weight loss could not be be determined to be unavoidable. This represented actual harm to Resident #26. Resident #20 had a severe weight loss which was not identified by the facility. The facility asserted the weight was inaccurate; however, they were unable to provide evidence of this inaccuracy. As the facility did not identify the resident's weight was inaccurate, they were unable to adequately monitor this resident's parameters of nutritional status. Resident identifiers: #31, #20, #26. Facility Census: 36. Findings Include: a) Resident #31 A record review on 07/09/14 at 10:49 a.m., revealed the following weights: -- 01/13/14 - 124.3 pounds -- 02/07/14 - 116.3 pounds -- 03/01/14 - 112.0 pounds -- 04/01/14 - 113.4 pounds -- 06/17/14 - 110.7 pounds There was no weight recorded for Resident #31 for the month of May 2014. There was no other information which indicated what Resident #31 weighed in May 2014. The resident's percentage of weight loss from 01/13/14 to 02/07/14 and from 01/13/14 to 06/17/14 were calculated using the following formula % of body weight loss = (usual weight - actual weight) / (usual weight) X 100. -- From 01/13/14 to 02/07/14, the resident lost 6.43 % of her body weight, a severe weight loss in one (1) month. -- From 01/13/14 to 06/17/14, the resident's weight loss in five (5) months was 10.94 %, representing a severe weight loss in that time period. Further review of the medical record revealed a quarterly minimum data set (MDS) with an assessment reference date (ARD) of 04/27/14, which indicated Resident #31 had a weight loss in the previous 30 days and/or 6 (six) months. The MDS also indicated the resident was not on a physician prescribed weight loss program. From 01/13/14 to 06/17/14 the Registered Dietitian (RD) completed two (2) dietary progress notes: -- The first note written by the RD was dated 02/10/14. It revealed a care conference meeting was held in regards to Resident #31 on 02/05/14. The note indicated Resident #31 weighed 124.3 pounds, and her ideal body weight (IBW) was between 115-138 pounds. The note indicated the resident was within her IBW. The RD indicated they would continue to monitor Resident #31 for any significant change in her weight. -- The second note written by the RD, dated 04/30/14, revealed Resident #31's care needs and plan of care were reviewed with the interdisciplinary team. This note identified the resident's current weight was 113.4 pounds, which was an 11 pound weight loss in 90 days. The RD identified the resident was now below her ideal body weight. The note indicated Resident #31 received a supplemental feeding of Ensure three (3) times a day to prevent weight loss. The final sentence of the note stated, "Goal not met - continue plan of care." Resident #31's physician orders [REDACTED].#31 had been receiving Ensure since November 2013, three (3) months prior to her first severe weight loss. There was no evidence to indicate any additional interventions to prevent weight loss were put in place for Resident #31, since the addition of the Ensure in November 2013. Resident #31's consumption record for her supplement of Ensure three (3) times a day was reviewed for the previous six (6) months. Resident #31 drank less than 50 percent or refused her supplement 34 percent of the time it was offered to her. Resident #31's meal percentage documentation was reviewed for the months of January 2014, February 2014, March 2014, April 2014, and June 2014. The month of May 2014 was not reviewed due to the fact the facility was unable to locate this documentation. The resident refused or ate less than 50 % of her meal an average of 87% of the time. In an interview with the RD, on 07/09/14 at 1:18 p.m., she stated she attended every care plan conference and she was not aware Resident #31 had lost weight. She stated, "I don't really have a clue unless they tell me when a resident has lost weight." She indicated anytime there was a significant weight change, she wrote a note and put additional interventions in place to prevent further weight loss. When asked what interventions were put in place for Resident #31 following her severe weight losses, she stated, "She receives the supplements." When asked if she reviewed how much of the supplement the resident consumed, she stated, "No, I just monitor how much they eat of their meals." She explained she did not know where to look in the electronic medical record to review how much of the supplements the resident was consuming. The RD confirmed they had not changed interventions for Resident #31 since November of 2013, when she was started on the supplement three (3) times a day. When asked if the supplement was effective, she was unable to answer because she did not know whether or not the resident consumed the supplement. She stated she could only address a weight loss if nursing notified her. The RD was asked why the weight loss was not addressed in April 2014 when she wrote the note indicating the resident had lost 11 pounds and was below her ideal body weight. The RD remained silent and did not answer. The director of nursing (DON), in an interview on 07/09/14 at 3:05 p.m., stated Resident #31 would occasionally take the supplements, but usually did not drink them. She stated they had not changed the supplements since November 2013. The DON stated they often offered the resident other supplements to see if she would take them; however, the physicians order was not changed. She stated the resident was not offered other supplements every time she refused the ordered supplement. The DON indicated they offered meal substitutes at times, but the resident's appetite was very poor. When asked if the physician had addressed Resident #31's weight loss, the DON stated the physician may not have been notified of the weight loss, so he probably did not address it. She stated she could not refute the fact the facility did not intervene when Resident #31 experienced severe weight losses. The DON agreed the resident continued to lose weight. . . b) Resident #26 A review of Resident #26's medical record, on 07/08/14 at 12:50 p.m., revealed the following recorded weights from 01/13/14 to 06/17/14: 1. 01/13/14 = 114.8 2. 02/14/14 = 128.2 (increase of 11.6%) 3. 03/03/14 = 128.4 (increase of .02%) 4. 04/14/14 = 146.3 (increase of 13.9%) 5. 05/14/14 = 128.4 (loss of 12.23%) 6. 06/17/14 = 121.4 (loss of 5.37%) These weights revealed a severe weight loss from the month of 04/14/14 to 05/14/14, and a significant weight loss from 05/14/14 to 06/17/14. The MDS, with an assessment reference date (ARD) of 05/04/14, was reviewed on 07/08/14 at 12:52 p.m. Section K0200 indicated the resident's height was 60 inches and her weight was 146 pounds. Section K0310 was coded that the resident was receiving a prescribed weight gain regimen. On 07/08/14 at 1:00 p.m., a review of the resident's medical record revealed [REDACTED]. It indicated the resident's appetite was poor, resulting in weight loss. The last updated intervention was on 05/09/13. This intervention stated staff would continue to offer food items with a spoon at each meal. It also noted the medical power of attorney gave staff permission to mix pureed food with milk or to provide a supplement for the resident to drink as desired. Review of the physician's orders [REDACTED].#26 had received a pureed diet since 03/22/11. It also indicated she is received [MEDICATION NAME] 200 milligram (mg) / 5 milliliter (ML) daily, a medication for poor appetite. This was prescribed on 10/08/13. The Resident was placed on a supplement (Ensure) three (3) times a day with meals on 02/20/13. According to the medical record, the resident's intake percentage of the supplement was 100%; however, the supplement was discontinued on 04/16/14. Review of the dietary progress note, dated 02/10/14, revealed RD #81 documented the resident was within her IBW. The note indicated, "Will continue to monitor for any significant change." Further review of the medical record found no evidence of any further progress notes written by the RD. In an Interview with the RD, on 07/09/14 at 1:30 p.m., she stated she was informed by nursing, during stand up meetings, which residents were losing weight. She stated no one informed her Resident #26 was losing weight. She said the nursing department was responsible for weighing the resident and reporting weight losses to her. She said the food service supervisor (FSS) #59 had been short handed, and had had to work in the kitchen. For this reason she had not been able to evaluate which residents were losing weight. The RD also stated the FSS did not know how to determine how much weight a resident lost. She said she could only tell whether a resident's intake was good, fair, poor or if the resident refused meals. Review of the nursing and physician progress notes [REDACTED].#26 had a weight loss. The FSS had no documentation in the resident's record. Interview with the DON, on 0709/14 at 2:00 p.m., revealed the facility had no written policy regarding how staff obtained residents' weights. She said the guideline she used was for nursing assistants to weigh the residents between the first and third day of each month. The staff gave the weights to office assistant (OA) #57. The OA reported any five (5) pound (lb) or more weight loss to the DON. The DON stated she had the resident re-weighed. If the weight was still a five (5) lb weight loss, then she notified the RD in care plan conferences. The RD would evaluate and address the resident's weight loss to prevent further weight loss. The DON said she did not know the resident had lost that much weight. She also did not know the resident's supplement was discontinued in April 2014. When asked what interventions were put in place for the weight gain regimen, as coded on the MDS with the ARD of 05/04/14, she stated, "I do not know anything about the weight gain regimen the resident was placed on." . . c) Resident #20 A review of the resident's electronic weight record on 07/08/14 found the resident's last recorded weight was 147 pounds on 06/17/14. The previous weight, obtained on 04/14/14, was 161 pounds. This reflected a 14 pound (9.5%) weight loss. Further review of the medical record found no evidence the resident had a terminal condition or physician orders [REDACTED]. There was no evidence of any interventions to address the weight loss. In addition, there was nothing in nursing or dietary notes which addressed the weight loss. The RD's last note was dated December 2012. At 4:41 p.m. on 07/08/14, the DON said she believed the weight was wrong. She said, "You can look at her and tell she has not lost any weight." The DON was unable to provide evidence the resident's weight was incorrect or evidence the resident was re-weighed to determine if the weight was correct. On 07/09/14 at 1:18 p.m., the RD said she reviewed weight losses when facility staff informed her a resident had lost weight. She said she was unaware of Resident #20's weight loss. When asked if she had seen the resident since her last note recorded in December 2012, she said she probably had notes but they were in her car and she had a car wreck. When asked if the dietary manager reviewed weight losses, she said, "The dietary manager has to cook, they are short handed and she can't go to the care conferences." A second interview with the DON, on 07/09/14 at 3:12 p.m., found she was unable to provide evidence the resident's weight was incorrect. She stated the resident had not been sick or had any changes, so she knew the resident had not lost any weight. .

Based on minimum data set (MDS) assessment review, medical record review, resident interview, and staff interview, the facility failed to ensure a resident did not develop an avoidable pressure ulcer. A resident developed an avoidable pressure ulcer to the coccyx when a new electric wheelchair was purchase and a pressure relieving cushion was not applied to the wheelchair seat. This affected one (1) of six (6) sample residents. Resident identifier: Resident #25. Facility census: 39. Findings include: a) Resident #25 On 05/29/13 at 1:00 p.m., a review of Resident #25's MDS, with an assessment reference date (ARD) of 11/04/12, revealed the resident was assessed as having no pressure ulcers. The MDS, with an ARD of 02/03/13, revealed an in-house acquired Stage III pressure ulcer was coded for item M0300C. In item M0610, the measurements were recorded as having a length of 1.5 cm, width of 1.0 cm and depth of 0.5 cm, and slough present. A review of the MDS, with an ARD of 04/21/13, revealed a Stage IV pressure ulcer was coded in M0300D. In item M0610m, the measurements were recorded as length 1.5 cm, width .7 cm and depth of 1.8 cm with granulation tissue present. In Section S, item S5005 was coded to indicate "none" to answer the question "In what setting did the pressure ulcers in S5000 develop?" This MDS was completed as a readmission from an acute care facility. This resident also returned with a wound vac in place and treatment was being provided by a local wound care clinic. On 05/30/13 at 10:15 a.m., an interviewed was conducted with Resident #25 in private in the resident's room. Resident #25 stated, "I am supposed to be turned every two (2) hours and that does not happen all the time." The resident was asked if she was not turned on one (1) shift or all shifts. Resident #25 stated, "All shifts. I have a sore above my tailbone and need to be turned." On 05/29/13 at 9:00 a.m., an interview was conducted with the director of nursing (DON) regarding the development of Resident #25's pressure ulcer. The DON replied, "I will never forgive myself for this happening." She explained the family had purchased a new electric wheelchair for this resident. Because of family conflicts with the facility, the facility had agreed to allow the family to manage the wheelchair. Therefore, no assessment was conducted of the wheelchair seat as to its pressure relieving/reducing capabilities, nor was a pressure relieving device placed in the seat of the new electric wheelchair. The DON agreed the pressure ulcer could have been avoided if the new wheelchair had been properly assessed and a pressure relieving device had been placed in the chair as it had been done with the old electric wheelchair. Additionally, the DON stated by the time the pressure ulcer was discovered, "it was too late." When the DON was asked if any of this information had been placed in the care plan about a new electric wheelchair and/or the family managing the new electric wheelchair, she stated, "No." .