Every finding on record at Mcdowell Healthcare Center

Based on record review, policy review, observation, and interview, the facility failed to provide a sanitary environment to help prevent the development and prevention of communicable disease and infection by not providing hand hygiene to multiple residents in the first floor dining room before lunch. This was a random opportunity for discovery in the long-term care survey process and had the potential to affect more than an isolated number of residents. Resident identifiers: #81, #24, #41, #82, and #12. Facility Census: 91. In a policy titled Standard Precautions given to State Agency by DON, hand hygiene is defined as cleaning hands by using handwashing, antiseptic hand wash, antiseptic hand rub, or surgical hand antisepsis. The policy stated the facility would adhere to Center for Disease Control and Prevention CDC guidelines and recommendations for hand hygiene by using soap and water before eating. During the dining observation on 02/26/26 beginning at 11:15 AM in the first floor dining room, residents were observed entering the dining room propelling their wheelchairs until lunch was served. No hand hygiene was observed during lunch service. During an interview with Nurse #18 in the dining room at 11:41 AM she confirmed that activities distributed hand hygiene before lunch. However, hand hygiene was not provided to residents who arrived after activities left. Residents #24, #81, #41, #82, and #12 arrived after activities left and were not provided hand hygiene. Nurse #18 also confirmed that these residents were not provided hand hygiene in the dining room.

Based on record review and staff interview the facility failed to implement comprehensive care plan for one (1) of 19 residents. Resident identifier: #7. Facility census: 91. Record review revealed physician orders and the resident's care plan directed staff to: Perform a fingerstick blood glucose test. If the blood glucose is less than 60 mg/dl or greater than 400 mg/dl (milligram per deciliter), notify the provider.Review of blood glucose monitoring records revealed elevated readings as follows:01/24/26 - 416 mg/dl01/29/26 - 477 mg/dl02/11/26 - 448 mg/dl02/18/26 - 440 mg/dlFurther review of the medical record revealed no evidence documenting that the provider was notified on 01/24/26, 01/29/26, 02/11/26, or 02/18/26 regarding blood glucose levels greater than 400 mg/dl (milligram per deciliter) .During interview on 02/26/26 at 12:50 PM, the Director of Nursing (DON) was informed of the above findings. The DON reviewed the record and confirmed there was no documentation indicating the provider had been notified of the elevated blood glucose readings as required by the care plan.The facility's failure to notify the provider of blood glucose readings exceeding 400 mg/dl was not in accordance with the resident's established plan of care.

Based on resident interview, observation, and staff interview, the facility failed to ensure one (1) of two (2) residents received the assistance needed with activities of daily living. Resident #88 did not receive the assistance needed to maintain personal grooming according to his preferences. Resident identifier: #88. Facility census: 91. Findings include: a) Resident #88 In an initial interview on 02/24/26 at 10:35 AM Resident #88 stated that his electric razor had broken and he had not been shaved since then. The resident said he preferred to be clean-shaven. Resident #88 had several days of beard growth noted. During an interview with Resident #88 on 02/25/26 at 1:54 PM he stated he would like to have someone shave him. The surveyor spoke to Nurse #103 and let her know the resident would like to be shaved. She said she would let the aides know. The surveyor spoke to Resident #88 on 02/26/26 at 10:40 AM, and he stated no one had asked to help him shave. Observation revealed Resident #88 was still unshaven. He stated he would like to be shaved and would allow the aides to shave him with a regular razor since his is broken. During an Interview with the Director of Nursing (DON) on 02/26/26 at 11:10 AM the surveyor asked the DON what they do if a resident's electric razor is broken. She stated that nurse aides should go in and ask the resident if he needed assistance with shaving. DON confirmed Resident #88 has not been shaved in at least three (3) days.

Based on observation and staff interview, the facility failed to ensure menus were updated when changes were being made to food items. This had the potential to affect more than an isolated number of residents. Facility census: . Findings included:a) On 02/24/26 the menu for lunch was Meatsauce with Spaghetti noodles, garlic green beans buttered dinner roll-margerine, and cinnamon brown sugar blondie for dessert. A slice of white bread was offered instead of roll. On 2/26/26 a menu review revealed the meal would consist of crispy baked chicken, brussels sprouts, macaroni and cheese and buttered dinner roll with chocolate pudding for dessert. Instead of a dinner roll, a slice of white bread was offered again. This was verified by observation in dining room on 2/24/26 at 12:15PM and 2/26/26 at 12:20 PM in dining room. The surveyor interviewed Employee#111 about this as well as the Director of Nursing on 2/26/26 on 1:03 PM. There were no further comments regaridng this matter.

This will be cited as past noncompliance because the facility identified what had happened and took immediate steps to correct the failure to ensure it does not recur. All components of the plan of correction were completed prior to this survey beginning. On 08/07/24 at 9:05 AM record review shows the facility reported incident concerning wound dressings that were not changed according to the Physicians order. Resident #45 has an order to change the dressing to the coccyx daily. On 07/21/24 when Registered Nurse (RN) #73 went to change Resident #45's wound dressing she found the old dressing to be dated 07/18/24 and the initials of Licensed Practical Nurse (LPN) #180. The documentation in Point Click Care reflected the dressing was changed on 07/20/24 when in fact it had not been changed since 07/18/24 reflecting it had not been changed for three (3) days. This allegation was reported to the appropriate offices and investigated. It was substantiated by the investigating staff. There were audits performed of all residents in house that have dressings ordered. There was a mandatory in service performed with all nursing staff attending. LPN #180 was released from their employment. The plan in place is to continue to audit all dressings weekly times ten (10) weeks and randomly thereafter. On 08/07/24 the surveyor and LPN #84 observed dressings for Resident #30, #45, #77, #35, #95 and #152. All dressings were appropriately dated for 08/06/24. The above findings were discussed and confirmed with the Administrator on 08/07/24 at 1:10 PM. d) Resident #77 This will be cited as past noncompliance because the facility identified what had happened and took immediate steps to correct the failure to ensure it does not recur. All components of the plan of correction were completed prior to this survey beginning. On 08/07/24 at 9:05 AM record review shows the facility reported incident concerning wound dressings that were not changed according to the Physicians order. Resident #77 has an order to change the dressing to the the right heel daily. On 07/21/24 when Registered Nurse (RN) #73 went to change Resident #77's wound dressing she found the old dressing to be dated 07/18/24 and the initials of Licensed Practical Nurse (LPN) #180. The documentation in Point Click Care reflected the dressing was changed on 07/20/24 when in fact it had not been changed since 07/18/24 reflecting it had not been changed for three (3) days. This allegation was reported to the appropriate offices and investigated. It was substantiated by the investigating staff. There were audits performed of all residents in house that have dressings ordered. There was a mandatory in service performed with all nursing staff attending. LPN #180 was released from their employment. The plan in place is to continue to audit all dressings weekly times ten (10) weeks and randomly thereafter. On 08/07/24 the surveyor and LPN #84 observed dressings for Resident #30, #45, #77, #35, #95 and #152. All dressings were appropriately dated for 08/06/24. The above findings were discussed and confirmed with the Administrator on 08/07/24 at 1:10 PM. e) Resident #84 On 08/05/24 at 3:44 PM an interview was conducted with Resident # 84 who reported in the early morning of Wednesday 07/31/24, she had fallen. She stated a nurse assisted her and told her they would send her for an x-ray. The resident stated that she hurt the left stump of her amputated leg and is in the process of getting a prosthetic leg. She fears if it was injured it would delay that process. Resident stated, x-ray comes in on Tuesday and Thursday, but left before seeing her this week. She stated, nursing told her they would send her out over the weekend for an x-ray but did not. An interview was conducted on 08/05/24 at 3:53 pm with Registered Nurse (RN) #107 who was the resident's assigned nurse for 08/05/24. Says she seen notes for a fall and for residents to be x-rayed. RN #106 assisted resident in reviewing the computer order and reported the facility had been having issues with the company who provides X-rays for them but was unsure as to why the resident had not yet been x-rayed. She reported she was on schedule now for 08/06/24. On 08/05/24 at 7:14 PM, a review of the resident's physician orders revealed the following: X-ray of the left stump every shift for pain post fall Diagnostic, Active dated 7/31/24 at 7:00 pm. On 08/06/24 the fall log was reviewed and revealed the resident had fallen but was caught on 07/30/24 at 12:35 AM. f) Resident #29 A medical record review on 08/07/24 at approximately 12:00 PM , found Resident #29 had an order for accu-check BID (twice a day) and to notify MD if less than 60 or greater than 350 two (2) times a day related to Type 2 (two) Diabetes Mellitus without complications. The start date for this order was identified to be 08/29/22. During a further review of the Medication Administration Record (MAR) it was identified on 07/22/24 the morning accu-check was not marked as completed. During an interview with the DON 08/07/24 at approximately 12:00 PM, the DON confirmed the accu-check had not been completed for 07/22/24 morning shift. 49650 50551

Based on medical record review and staff interview the facility failed to update the [NAME] Virginia Department of Health and Human Resources Pre-admission Screening and Resident Review (PASRR) with new qualifying diagnoses for five (5) out of 30 residents reviewed during the long term survey process. Residents identifiers: #26, #49, #14, #17, #45. Facility Census: 93. Findings include: a) Resident #17 During a medical record review on 08/06/24 at 9:30 AM, Resident #17's PASRR was reviewed. The PASRR was dated 08/19/16 with no level two required. A further review of the medical diagnosis of Resident #17 found a new diagnosis of unspecified dementia, moderate with psychotic disturbances, dated 05/13/24, unspecified dementia unspecified severity with other behavioral disturbance dated 10/01/22, unspecified psychosis not due to a substance or known physiological condition dated 09/16/24. During an interview with Director of Social Services (DSS) #78 on 08/06/24 at approximately 10:00 AM, DSS #78 stated she was aware that numerous PASSARS needed updated but she had not completed them yet. She further stated, she discussed this with the leadership team but they had not covered it in their Quality Assurance meeting. She further acknowledged, the recent diagnosis referenced had not been resubmitted on a new PASRR. b) Resident #26 During a medical record review on 08/06/24 at 9:30 AM, Resident #26's PASSAR was reviewed. The PASRR was dated 06/12/23 with no level two required. A further review of the medical diagnosis of Resident #26 found a new diagnosis of schizoaffective disorder dated 04/24/24, was not identified on the PASRR submitted on 06/12/23. During an interview with the Director of Social Services (DSS) #78 on 08/06/24 at approximately 11:45 AM, DSS #78 stated she was aware numerous PASRRs needed updated and she had completed this one on the morning of 08/06/24 and it was submitted with the new diagnosis. She further stated, she has discussed this with the leadership team but they have not covered it in their Quality Assurance meeting. c) Resident #49 Resident #49 was admitted to the facility on [DATE]. During a record review for Resident #49, it was discovered the resident was diagnosed with major depressive disorder on 01/08/20, during her stay at the facility. Upon further review, it was discovered the facility had not completed a new PASRR for Resident #49 after the diagnosis was made. At approximately 10:00 AM on 08/07/24, an interview was conducted with the Social Worker (SW) at the facility. The SW stated there was a backlog of PASRRs that needed to be resubmitted and Resident #49 was on that list. The SW stated she was submitting new PASRRs for residents in alphabetical order and would get to Resident #49, but it would take a while. d) Resident #14 On 08/05/24 at 3:05 PM, a review of the resident's medical records, found Resident #14's medical diagnoses include the following: Atherosclerotic Heart Disease, Morbid Obesity, Hereditary Idiopathic Neuropathy, Angina Pectoris, Paroxysmal Atrial Fibrillation, Vitamin B12 Deficiency Anemia, Unspecified Combined Systolic and Diastolic Congestive Heart Failure, Unspecified Psychosis Not Due to a substance or known physiological condition, Generalized Anxiety Disorder, Major Depressive Disorder Recurrent, Conversion Disorder with Seizures, Paraphilia, Hallucinations, Opioid Abuse in remission. On 08/05/24 at 3:10 PM, a review of Resident #14's current [NAME] Virginia Department of Health and Human Resources Pre-Admission Screening (WVPASRR) dated 01/28/22, revealed section III, Question 30. MI/MR Assessment, Current Diagnosis was marked a) None. Section V. Question 40. Major Mental Illness Suspected was marked none. On 08/06/24 at 4:25 PM, an interview with the social worker revealed she was aware of the WVPASRR needing updated. She said she was currently working on renewing the WVPASRRs, for the entire building. 49467 49650 50551

Based on record review and staff interview, the facility failed to ensure the correct diagnoses on the Pre-Admission Screening and Resident Review (PASRR) and, if necessary, submit a new one, at the time of admission. This was true for five (5) of thirty (30) residents reviewed for PASRRs during the survey process. Resident identifiers: #53, #33, #7, #17, #29. Facility census: 93. Findings include: A) Resident #53 At approximately 2:00 PM on 08/05/2024, a record review was conducted for Resident #53. During the review, it was determined Resident #53 was admitted to the facility on [DATE] and was diagnosed with major depressive disorder upon admission, on 08/16/22. The original PASRR was missing a diagnosis of major depressive disorder, and the facility did not submit a new PASRR upon the diagnosis of major depressive disorder. At approximately 10:00 AM on 08/07/2024, an interview was conducted with the Social Worker (SW) at the facility. The SW stated there was a backlog of PASRRs that needed resubmitted, and Resident #53 was on that list. The SW stated she was submitting new PASRRs for residents in alphabetical order and would get to Resident #53, but it would take a while. b) Resident #33 On 08/06/24 at 10:07 AM a review of Resident # 33's medical record noted a diagnosis of Bipolar Disorder, Major Depressive Disorder, Seizure Disorder and Post Traumatic Stress Disorder was present at Resident #33's time of admission to the facility. Resident # 33's Preadmission Screening and Resident Review form (PASRR) dated 01/09/19 did not reflect these diagnoses. The facility failed to complete a new PASARR that reflected the diagnoses that were present at the time of Resident # 33's admission which were Bipolar Disorder, Major Depressive Disorder, Seizure Disorder and Post Traumatic Stress Disorder. On 08/06/24 at 10:15 AM an interview with the Administrator and Social Worker (SW) was completed. At this time, the Administrator and SW acknowledged a new PASRR was not completed to reflect the diagnoses Bipolar Disorder, Major Depressive Disorder, Seizure Disorder and Post Traumatic Stress Disorder which were present at time of admission. c) Resident #7 On 08/06/24 at 11:00 AM a review of Resident #7's medical record noted a diagnosis of Major Depressive Disorder and Psychosis, and convulsions was present at Resident #7's time of admission to the facility. Resident #7's Preadmission Screening and Resident Review form (PASRR) dated 01/09/19 did not reflect these diagnoses. The facility failed to complete a new PASRR that reflected the diagnoses that were present at the time of Resident #7's admission which were Major Depressive Disorder and Psychosis and convulsions. On 08/06/24 at 10:15 AM an interview with the Administrator and Social Worker (SW) was completed. At this time, the Administrator and SW acknowledged a new PASRR was not completed to reflect the diagnoses, Major Depressive Disorder and Psychosis and convulsions, which were present at time of admission. d) Resident #17 During a medical record review on 08/06/24 at 9:30 AM, Resident #17 [NAME] Virginia Department of Health and Human Resources Pre-admission Screening (PASSAR) was identified dated 08/19/16 with no level two required. A further review of the medical diagnosis of Resident #17, identified a diagnosis of major depressive disorder dated 08/09/16. During an interview with the Director of Social Services (DSS) #78 on 08/06/24 at approximately 10:00 AM, DSS #78 stated she was aware that numerous PASRRs needed updated, but she had not completed them yet. She further stated that she had discussed this with the leadership team, but they had not covered it in their Quality Assurance meeting. She further acknowledged the diagnosis should have been submitted on the admitting PASRR and should have been resubmitted upon admission with it not included on the PASRR. e) Resident #29 During a medical record review on 08/06/24 at 9:30 AM, Resident #26 PASRR was reviewed. The PASRR was submitted on 05/22/24 with no level two required. A review of the medical diagnosis for Resident #26 identified, a diagnosis of hallucinations dated 08/01/23 and a diagnosis of psychotic disorder with delusions due to known physiological condition dated 08/01/23 which were not identified on the PASRR submitted on 05/22/24. During an interview with the Director of Social Services (DSS) #78 on 08/06/24 at approximately 10:00 AM, DSS #78 stated she was aware that numerous PASSARS needed updated, but she had not completed them yet. She further stated had discussed this with the leadership team, but they have not covered it in their Quality Assurance meeting. She acknowledged the diagnoses were missing from the PASRR when it was submitted and should have been resubmitted upon admission with it not being included on the PASRR. 49650 50552

Based on record review and staff interview, the facility failed to ensure medical records for each resident were accurately documented for two (2) of five (5) records reviewed. The facility failed to obtain correct signatures on Physician orders for scope of treatment (POST) form. Resident identifiers: #36 and #17. Facility census: 93 Findings included: a) Resident #36 On 08/05/24 at 03:06 PM a review of POST, revealed that a verbal consent was obtained and no signature was ever obtained on POST form on file dated 09/08/23. Stated signature obtained via telephone with one witness signature. On 08/07/24 at 09:45 AM a review of [NAME] Virginia POST Form Guidance for Health Care Professionals 2021 Edition which revealed that Medical Power of Attorney (MPOA) signature must obtained for POST to be valid. If MPOA is not available, verbal consent can be obtained with 2 witness signatures until the original signature can be obtained. On 08/07/24 at 10:16 AM, during an interview with the administrator and social worker, they acknowledged this resident's POST form was only singed by one witness and had not yet be signed by the Medical Power of Attorney. Social Worker stated she was currently working on correcting this. b) Resident #17 During a medical record review of Resident #17's POST form 08/07/24 at 9:25 AM it was identified that the post form did not have a signature for the Patient/Patient MPOA representative/surrogate signature. The medical record revealed a hand written note that read [typed as written] via email [West Virginia Department of Health Services (WVDOHS) name of case worker] and dated 07/19/24 with a certified mail receipt dated 08/02/24 to [WVDOHS name of case worker]. On 08/07/24 at 9:45 AM Review of WV POST, using the POST Form Guidance for Health Care Professionals 2021 Edition which reveals that MPOA signature must obtained for POST to be valid. If MPOA is not available, verbal consent can be obtained with two (2) witness signatures until the original signature can be obtained. During an interview with Director of Social Services (DSS) on 08/07/24 at approximately 9:50 AM with the Director of Social Services (DSS) #78 , she acknowledge that this resident's POST form was not signed and that an email is not an acceptable signature as identified in the Health Care Professionals 2021 Edition. The DSS #78 states she is working on getting this signed by the [WVDOHS name of case worker]. 50551

Based on facility records review and staff interview the facility failed to ensure to have all the required signatures and attendees and signatures for their Quality Assurance Performance Improvement (QAPI) meetings. This was discovered during the long term care survey process and had the ability to affect more than a limited number of residents. Identifiers: Meetings dated- 02/23/23, 06/30/23, 08/10/23, 08/02/24. Facility Census: 93. a) 02/23/23 During a record review on 08/07/24 at approximately 2:00 PM of the QAPI meeting attendance it was identified that the Director of Nursing (DON) who was also the Person In Charge (PIC) for the facility. The DON/PIC at this time did not sign in attendance for this meeting. It is further identified, the QAPI information was reviewed with the Medical Director verbally. During an interview with the Administrator on 08/07/24 at approximately 2:10 PM she stated it did not make sense that the DON/PIC did not attend this meeting. She felt the DON/PIC may have forgotten to sign. The Administrator stated the Medical Director did not attend the meeting and the DON/PIC later spoke with him. She stated that the Medical Director and his Family Nurse Practitioner later signed the form. b) 06/30/23 Record review on 08/07/24 of the QAPI meeting attendance identified the Director of Nursing (DON) who was also the Person In Charge (PIC) for the facility at this time did not sign in attendance for this meeting. It was further identified that QAPI information was reviewed with the Medical Director verbally. During an interview with the Administrator on 08/07/24 at approximately 2:10 PM she stated it did not make sense that the DON/PIC did not attend this meeting. She felt the DON/PIC may have forgotten to sign. The Administrator then confirmed the Medical Director did not attend the meeting and the DON/PIC later spoke with him. She stated the Medical Director and his Family Nurse Practitioner later signed the form. c) 08/10/23 Record review on 08/07/24 at approximately 2:00 PM of the QAPI meeting attendance identified that the Director of Nursing (DON) who was also the Person In Charge (PIC) for the facility did not sign in attendance for this meeting. It was further identified that the QAPI information was reviewed with the Medical Director verbally. During an interview with the Administrator on 08/07/24 at approximately 2:10 PM she stated it did not make sense that the DON/PIC did not attend this meeting. She felt the DON/PIC may have forgotten to sign. The Administrator further explained the note [typed as written] Spoke with and reviewed with [Medical Directors name] that was written on the signature sheet. The Administrator stated the Medical Director did not attend the meeting and the DON/PIC later spoke with him. She stated that the Medical Director and his Family Nurse Practitioner later signed the form. d) 08/02/24 During a record review on 08/07/24 at approximately 2:00 PM of the QAPI meeting attendance is was identified that the Director of Nursing (DON) did not sign in attendance for this meeting. During an interview with the Administrator on 08/07/24 at approximately 2:10 PM she stated that the DON at this time was an Interim and she felt that the DON may had already left for the week. She was not certain why the Interim DON did not attend.

.Based on record review and staff interview, the facility failed to monitor Resident #30, #29, and #82 for side effects of antidepressant, antianxiety, and antipsychotic medications as ordered. This was true for three (3) out of five (5) residents monitored for unnecessary medications during the survey process. Resident identifiers: #30, #29, #82. Facility census: 93. Findings include: A) Resident #30 On 08/06/2024 at approximately 11:30 AM during a record review for Resident #49, it was discovered side effects were not monitored for antidepressant, antianxiety, and antipsychotic medications, according to the Medication Administration Record (MAR) for the following days: -Day and night shift on 06/01/2024 -Day and night shift on 06/02/2024 -Day Shift on 06/03/2024 -Day shift on 07/20/2024 -Day shift on 07/21/2024 -Day shift on 07/24/2024 -Day shift on 07/25/2024 -Day shift on 07/30/2024 -Day and night shift on 08/01/2024 At approximately 10:05 AM on 08/07/2024, an interview was conducted with the Interim Director of Nursing (IDON). During the interview, the IDON confirmed the above dates where no side effect monitoring was documented to have occurred for antidepressant, antianxiety, and antipsychotic medications. IDON was unable to provide any additional documentation to support side effect monitoring had taken place. b) Resident #29 During a medical record review of Resident #29's behavior monitoring on 08/06/24 at approximately 12:09 PM the following monitoring orders were identified for medication behavior side effects with the noted discrepancies of the orders being completed as observed on the behavior monitoring documentation per each date identified. * Antianxiety side effect monitoring [typed as written] but not limited to : Dystonia; torticollis (stiffness of neck), anticholinergic symptom: Dry mouth, blurred vision, constipation, urinary retention, hypotension, sedation/drowsiness, increased falls/dizziness, cardiac abnormalities (tachycardia, bradycardia, irregular HR (heart rate) NMS (Neuroleptic malignant syndrome). Anxiety/agitation, blurred vision, sweating/rashes, headaches, urinary retention/hesitancy. Weakness, hangover effect. Every shift. Order and Start date 05/21/23 with no end date identified. - Missing documentation of antianxiety side effect behavior monitoring for the following; 07/01/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 07/02/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 07/03/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 07/05/24 - missing day shift (7:00 AM - 7:00 PM) 07/06/24 - missing day shift (7:00 AM - 7:00 PM) 07/07/24 - missing day shift (7:00 AM - 7:00 PM) 07/18/24 - missing day shift (7:00 AM - 7:00 PM) 07/20/24 - missing day shift (7:00 AM - 7:00 PM) 07/21/24 - missing day shift (7:00 AM - 7:00 PM) 07/24/24 - missing day shift (7:00 AM - 7:00 PM) 07/25/24 - missing day shift (7:00 AM - 7:00 PM) 07/30/24 - missing day shift (7:00 AM - 7:00 PM) 08/01/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 08/05/24 - missing night shift (7:00 PM - 7:00 AM) On 08/07/24 at 12:30 PM during an interview with the DON, the DON agreed the antianxiety side effect behavior monitoring was not completed as ordered. *Antidepressant side effect monitoring not limited to: Dystonia, torticollis (stiffness of neck), anticholinergic symptom: Dry mouth, blurred vision, constipation, urinary retention, hypotension, sedation/drowsiness, increased falls/dizziness, cardiac abnormalities (tachycardia, bradycardia, irregular HR (heart rate) NMS (Neuroleptic malignant syndrome). Anxiety/agitation, blurred vision, sweating/rashes, headaches, urinary retention/hesitancy, weakness, tremors, appetite change/weight change, insomnia, confusion, tardive dyskinesia, suicidal ideations. Every shift. Order and Start date 05/21/23 with no end date identified. - Missing documentation of Antidepressant side effect behavior monitoring for the following; 07/01/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 07/02/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 07/03/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 07/05/24 - missing day shift (7:00 AM - 7:00 PM) 07/06/24 - missing day shift (7:00 AM - 7:00 PM) 07/07/24 - missing day shift (7:00 AM - 7:00 PM) 07/18/24 - missing day shift (7:00 AM - 7:00 PM) 07/20/24 - missing day shift (7:00 AM - 7:00 PM) 07/21/24 - missing day shift (7:00 AM - 7:00 PM) 07/24/24 - missing day shift (7:00 AM - 7:00 PM) 07/25/24 - missing day shift (7:00 AM - 7:00 PM) 07/30/24 - missing day shift (7:00 AM - 7:00 PM) 08/01/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 08/05/24 - missing night shift (7:00 PM - 7:00 AM) On 08/07/24 at 12:30 PM during an interview with the DON, the DON agreed Antidepressant side effect behavior monitoring was not completed as ordered. *Antipsychotic side effect monitoring list #1: Dystonia: torticollis (stiffness of neck), anticholinergic symptom: Dry mouth, blurred vision, constipation, urinary retention, hypotension, sedation/drowsiness, increased falls/dizziness, cardiac abnormalities (tachycardia, bradycardia, irregular HR (heart rate) NMS (Neuroleptic malignant syndrome). Anxiety/agitation, blurred vision, sweating/rashes, headaches, urinary retention/hesitancy, pseudo parkinsonism: cogwheel rigidity, bradykinesia, tremors, appetite change/weight change. Every shift. Order and Start date 05/21/23 with no end date identified. - Missing documentation of Antipsychotic side effect list #1 behavior monitoring for the following: 07/01/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 07/02/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 07/03/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 07/05/24 - missing day shift (7:00 AM - 7:00 PM) 07/06/24 - missing day shift (7:00 AM - 7:00 PM) 07/07/24 - missing day shift (7:00 AM - 7:00 PM) 07/18/24 - missing day shift (7:00 AM - 7:00 PM) 07/20/24 - missing day shift (7:00 AM - 7:00 PM) 07/21/24 - missing day shift (7:00 AM - 7:00 PM) 07/24/24 - missing day shift (7:00 AM - 7:00 PM) 07/25/24 - missing day shift (7:00 AM - 7:00 PM) 07/30/24 - missing day shift (7:00 AM - 7:00 PM) 08/01/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 08/05/24 - missing night shift (7:00 PM - 7:00 AM) On 08/07/24 at 12:30 PM during an interview with the DON, the DON agreed that Antipsychotic side effect list #1 behavior monitoring was not completed as ordered. **Antipsychotic side effect monitoring list #2 not limited to: Insomnia, confusion. Akathisia: restlessness, pacing, inability to sit still, anxiety, sleep disturbances. Tardive dyskinesia: lip smacking/chewing, abnormal tongue movement, spasmodic movement of the arms/legs, rocking/swaying, blood abnormalities, sore throat, seizures, photosensitivity. Every shift. Order and Start date 06/29/23 with no end date identified. - Missing documentation of Antipsychotic side effect list #2 behavior monitoring for the following; 07/01/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 07/02/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 07/03/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 07/05/24 - missing day shift (7:00 AM - 7:00 PM) 07/06/24 - missing day shift (7:00 AM - 7:00 PM) 07/07/24 - missing day shift (7:00 AM - 7:00 PM) 07/18/24 - missing day shift (7:00 AM - 7:00 PM) 07/20/24 - missing day shift (7:00 AM - 7:00 PM) 07/21/24 - missing day shift (7:00 AM - 7:00 PM) 07/24/24 - missing day shift (7:00 AM - 7:00 PM) 07/25/24 - missing day shift (7:00 AM - 7:00 PM) 07/30/24 - missing day shift (7:00 AM - 7:00 PM) 08/01/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 08/05/24 - missing night shift (7:00 PM - 7:00 AM) On 08/07/24 at 12:30 PM during an interview with the DON, the DON agreed that the Antipsychotic side effect monitoring list #2 was completed as ordered. *Mood Stabilizer side effect monitoring: Hives, a rash, fever, or swollen glands. Signs of [NAME] Johnson's syndrome, which causes dangerous sores on the mucous membranes of the mouth, nose, genitals, and eyelids. Confusion, Slurred speech. Nausea, vomiting, and diarrhea. Trembling. Increased thirst and increased need to urinate Weight gain in the first few months of use. Drowsiness. Every shift. Order and Start date 05/21/23 with no end date identified. - Missing documentation of Mood Stabilizer side effect behavior monitoring for the following; 07/01/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 07/02/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 07/03/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 07/05/24 - missing day shift (7:00 AM - 7:00 PM) 07/06/24 - missing day shift (7:00 AM - 7:00 PM) 07/07/24 - missing day shift (7:00 AM - 7:00 PM) 07/18/24 - missing day shift (7:00 AM - 7:00 PM) 07/20/24 - missing day shift (7:00 AM - 7:00 PM) 07/21/24 - missing day shift (7:00 AM - 7:00 PM) 07/24/24 - missing day shift (7:00 AM - 7:00 PM) 07/25/24 - missing day shift (7:00 AM - 7:00 PM) 07/30/24 - missing day shift (7:00 AM - 7:00 PM) 08/01/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 08/05/24 - missing night shift (7:00 PM - 7:00 AM) On 08/07/24 at 12:30 PM during an interview with the DON, the DON agreed that the Mood Stabilizer side effect behavior monitoring was not completed as ordered. b) Resident #82 During a medical record review of Resident #82's behavior monitoring on 08/06/24 at approximately 12:11 PM the following monitoring orders were identified for medication behavior side effects with the noted discrepancies of the orders being completed as observed on the behavior monitoring documentation per each date identified. * Antianxiety side effect monitoring [typed as written] but not limited to : Dystonia; torticollis (stiffness of neck), anticholinegic symptom: Dry mouth, burred vision, constipation, urinary retention, hypotension, sedation/drowsiness, increased falls/dizziness, cardiac abnormalities (tachycardia, bradycardia, irregular HR (heart rate) NMS (Neuroleptic malignant syndrome). Anxiety/agitation, blurred vision, sweating/rashes, headaches, urinary retention/hesitancy. Weakness, hangover effect. Every shift. Order and Start date 02/15/24 with no end date identified. - Missing documentation of antianxiety side effect behavior monitoring for the following; 07/01/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 07/02/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 07/03/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 07/04/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 07/05/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 07/06/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 07/07/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 07/08/24 - missing day shift (7:00 AM - 7:00 PM) 07/20/24 - missing day shift (7:00 AM - 7:00 PM) 07/21/24 - missing day shift (7:00 AM - 7:00 PM) 07/24/24 - missing day shift (7:00 AM - 7:00 PM) 07/25/24 - missing day shift (7:00 AM - 7:00 PM) 07/30/24 - missing day shift (7:00 AM - 7:00 PM) 08/01/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) On 08/07/24 at 12:30 PM during an interview with the DON, the DON agreed the antianxiety side effect behavior monitoring was not completed as ordered. *Antidepressant side effect monitoring not limited to: Dystonia, torticollis (stiffness of neck), anticholinergic symptom: Dry mouth, blurred vision, constipation, urinary retention, hypotension, sedation/drowsiness, increased falls/dizziness, cardiac abnormalities (tachycardia, bradycardia, irregular HR (heart rate) NMS (Neuroleptic malignant syndrome). Anxiety/agitation, blurred vision, sweating/rashes, headaches, urinary retention/hesitancy, weakness, tremors, appetite change/weight change, insomnia, confusion, tardive dyskinesia, suicidal ideations. Every shift. Order and Start date 02/15/24 with no end date identified. - Missing documentation of Antidepressant side effect behavior monitoring for the following; 07/01/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 07/02/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 07/03/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 07/04/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 07/05/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 07/06/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 07/07/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 07/08/24 - missing day shift (7:00 AM - 7:00 PM) 07/20/24 - missing day shift (7:00 AM - 7:00 PM) 07/21/24 - missing day shift (7:00 AM - 7:00 PM) 07/24/24 - missing day shift (7:00 AM - 7:00 PM) 07/25/24 - missing day shift (7:00 AM - 7:00 PM) 07/30/24 - missing day shift (7:00 AM - 7:00 PM) 08/01/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) On 08/07/24 at 12:30 PM during an interview with the DON, the DON agreed Antidepressant side effect behavior monitoring was not completed as ordered. *Antipsychotic side effect monitoring list #1: Dystonia: torticollis (stiffness of neck), anticholinergic symptom: Dry mouth, blurred vision, constipation, urinary retention, hypotension, sedation/drowsiness, increased falls/dizziness, cardiac abnormalities (tachycardia, bradycardia, irregular HR (heart rate) NMS (Neuroleptic malignant syndrome). Anxiety/agitation, blurred vision, sweating/rashes, headaches, urinary retention/hesitancy, pseudo parkinsonism: cogwheel rigidity, bradykinesia, tremors, appetite change/weight change. Every shift. Order and Start date 02/15/24 with no end date identified. - Missing documentation of Antipsychotic side effect list #1 behavior monitoring for the following; 07/01/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 07/02/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 07/03/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 07/04/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 07/05/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 07/06/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 07/07/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 07/08/24 - missing day shift (7:00 AM - 7:00 PM) 07/20/24 - missing day shift (7:00 AM - 7:00 PM) 07/21/24 - missing day shift (7:00 AM - 7:00 PM) 07/24/24 - missing day shift (7:00 AM - 7:00 PM) 07/25/24 - missing day shift (7:00 AM - 7:00 PM) 07/30/24 - missing day shift (7:00 AM - 7:00 PM) 08/01/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) On 08/07/24 at 12:30 PM during an interview with the DON, the DON agreed that Antipsychotic side effect list #1 behavior monitoring was not completed as ordered. **Antipsychotic side effect monitoring list #2 not limited to: Insomnia, confusion. Akathisia: restlessness, pacing, inability to sit still, anxiety, sleep disturbances. Tardive dyskinesia: lip smacking/chewing, abnormal tongue movement, spasmodic movement of the arms/legs, rocking/swaying, blood abnormalities, sore throat, seizures, photosensitivity. Every shift. Order and Start date 02/15/24 with no end date identified. - Missing documentation of Antipsychotic side effect list #2 behavior monitoring for the following; 07/01/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 07/02/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 07/03/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 07/04/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 07/05/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 07/06/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 07/07/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 07/08/24 - missing day shift (7:00 AM - 7:00 PM) 07/20/24 - missing day shift (7:00 AM - 7:00 PM) 07/21/24 - missing day shift (7:00 AM - 7:00 PM) 07/24/24 - missing day shift (7:00 AM - 7:00 PM) 07/25/24 - missing day shift (7:00 AM - 7:00 PM) 07/30/24 - missing day shift (7:00 AM - 7:00 PM) 08/01/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) On 08/07/24 at 12:30 PM during an interview with the DON, the DON agreed that the Antipsychotic side effect monitoring list #2 was completed as ordered. 49650

Based on observation, record review, and resident and staff interview, the facility failed to ensure resident environment, over which it had control, was as free of accident hazards as possible, by failing to complete a smoking assessment, upon admission, for smokeless tobacco use for Resident #25. This was true for one (1) of eight (8) residents reviewed for accident hazards during the survey process. Resident identifier: #25. Facility census: 93. Findings included: A) Resident #25 At approximately 2:07 PM on 08/05/24, an interview was conducted with Resident #25. During the interview, the resident was observed using smokeless tobacco in his room. When asked if he had used smokeless tobacco since he had been at the facility, Resident #25 replied, yes. At approximately 3:00 PM on 08/05/24, a record review was conducted for Resident #25. During the review, it was determined there was no smoking assessment completed for Resident #25, despite being admitted to the facility on [DATE]. At approximately 10:30 AM on 08/06/24, an interview was conducted with the Interim Director of Nursing (IDON) regarding smokeless tobacco use in the facility. When asked if the facility performed smoking assessments on all smokeless tobacco users, the IDON responded, yes. IDON was asked to produce the assessment for Resident #25's tobacco usage. At approximately 4:00 PM on 08/06/24, IDON presented a smoking assessment for Resident #25's smokeless tobacco usage, with the effective date of 08/06/24. Review of the facility's smokeless tobacco use policy revealed Smokeless tobacco assessments for those residents requesting to use smokeless tobacco will be completed or re-evaluated: i. On admission ii. Quarterly iii. Significant change in condition At approximately 10:05 AM on 08/07/24, the IDON confirmed the smoking assessment was not completed on Resident #25 on admission as required, and confirmed the only smoking assessment that had been completed was the one on 08/06/24, after surveyor intervention.

Based on medical record review and staff interview, the facility failed to update the care plan for a new diagnosis. This was true for three (3) out of 30 residents reviewed during the long-term care process. Resident identifiers: #17, # 26 and #29. Facility census: 93. Findings included: a) Resident #17 During a medical record review on 08/06/24 at approximately 9:46 AM the medical record for Resident #17 identified a diagnosis of Major Depression Disorder. A further review of the care plan identified Resident #17 was being monitored for the use of an anti-depressant only and not the diagnosed condition of Major Depression Disorder. During an interview with the Clinical Manager Registered Nurse (CM RN) #51 on 08/06/24 at approximately 10:00 AM, The CM RN #51 agreed the Major Depression disorder was not care- planned. b) Resident #26 During a medical record review on 08/06/24 at approximately 9:50 AM the medical record for Resident #26 identified a diagnosis of schizoaffective disorder, bipolar type. A further review of the care plan identified Resident #26 is being monitored for the use of an anti-psychotic medication only and not the diagnosed condition of schizoaffective disorder, bipolar type. During an interview with the Clinical Manager Registered Nurse (CM RN) #51 on 08/06/24 at approximately 10:03 AM, The CM RN #51 agreed the schizoaffective disorder, bipolar type was not care - planned. c) Resident #29 During a medical record review on 08/06/24 at approximately 9:54 AM the medical record for Resident #29 identified a diagnosis of hallucinations dated 08/01/23. A further review of the care plan identified that Resident #26 was not care - planned for hallucinations. During an interview with the Clinical Manager Registered Nurse (CM RN) #51 on 08/06/24 at approximately 10:03 AM, The CM RN #51 agreed hallucinations was not care - planned.

Based on record review and staff interview the facility failed to properly investigate and make prompt efforts to resovle a grievance from Resident #19. This was true for 1 (one) of 1 (one) resident's reviewed for the Long Term Care Survey Process. Resident identifier: #19. Facility census: 93. Findings included: a) Resident #19 On 08/05/24 at 1:04 PM, an interview was conducted with Resident #19. During this interview, Resident #19 stated, Employee #86 is hateful to her when Resident #19 uses her call bell. Resident #19 further stated that when Employee #86 answers her call bell, Employee #86 states, What do you want now? This Surveyor then notified the facility Administrator of what Resident #19 stated. The Administrator stated she will have the facility Social Worker (SW) speak with Resident #19. On 08/06/24 at 1:19 PM, an interview was conducted with the facility Administrator and SW. At this time, Resident #19's complaint was discussed along with how the facility resolved it. The Administrator and SW stated a facility form entitled, Grievance/Complaint Report had been completed. When reviewing the form it was noted no statement had been obtained from Employee #86. On 08/06/24 at 3:46 PM a review of the policy and procedure entitled, Resident Grievance was conducted. This policy and procedure stated the facility shall complete a timely investigation of the resident's grievance which will include a review of facility processes, programs and policies, as well as interviews with staff, residents, others involved in resident care. On 08/07/24 at 2:05 PM, an additional interview was conducted with the facility Administrator who acknowledged an interview should have been conducted with Employee #86 as stated in the policy and procedure, Resident Grievance.

b) Observation of the kitchen Observation on 09/12/23 at 8:15 A.M., found a box of spoiled lettuce and spoiled cabbage in separate boxes in the refrigerator walk in. An interview was conducted on 09/12/23 at approximately 8:20 A.M. with Employee 12. Employee #12 stated I will take these boxes out. I did not know the lettuce and cabbage were spoiled. I will make sure we get rid of them today. I will clean this area now. Based on observation and staff interview 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 more than a limited number of residents that currently reside at the facility. Facility census 90. Findings included: a) Ice Machine in the nourishment room On 09/12/23 at 8:45 AM an observation of the ice machine found the ice machine was covered along the top and around the door with a thick buildup of a white, gray, and rusty substance. On 09/12/23 at 11:00 AM a tour with Director of Plant Maintenance (DPM) #67 said if they stop the use of the ice machine then staff would have to go upstairs to get it. DPM #67 agreed the ice machine was rusty and leaks. On 09/12/23 at 1:07 PM, the Administrator informed of the above findings and stated it will be replaced as soon as possible.

Based on staff interviews and observation the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. This was a random opportunity for discovery and has the potential to affect more than a limited number of residents who recurrently reside at the facility. Facility census 90. Findings included: a) A and B Hallways On 09/12/23 at 8:10 AM while touring the facility it was discovered the wallpaper was peeling off of the walls in hall A and B. The baseboards were pulled away from the walls bearing broken pieces of sheet rock. On the walls behind the handrails were multiple holes in the wall. On 09/12/23 at 11:00 AM, a tour with Director of Plant Maintenance (DPM) #67 found DPM #67 agreed the walls on A and B hallways were in need of repair.

Based on observation and staff interview the facility failed to ensure a dignified dining experience. This was a random opportunity for discovery and had the potential to affect a limited number of residents who currently reside in the facility. Resident identifier: #57. Facility census 90. Findings included: a) Resident #57 While monitoring staff serving lunch on 09/12/23 at 12:00 PM it was noted that the roommate of Resident #57 was eating her lunch, while Resident #57 did not have a lunch tray. The Nurse Aide (NA) #44 was asked why Resident #57 did not have a tray at the same her roommate did? NA #44 said she does have her tray. After looking in the room herself she said she must have forgotten to give Resident #57 her tray. The above was reported to the Administrator on 09/12/23 at 1:00 PM.

Based on record review, family interview, resident interview, and staff interview, the facility failed to allow a resident to return to the facility following a hospital admission. This deficient practice had the potential to affect one (1) of two (2) residents reviewed for the care area of discharge. The deficient practice caused actual psychosocial harm to the resident because the resident required a longer hospitalization while awaiting alternate placement and experienced emotional distress. The resident was also ultimately placed at a facility farther from home and family. Resident identifier: #89. Facility census: 82. Findings included: a) Resident #89 The facility's policy titled Discharge of a Resident issued 03/01/14 and revised 09/28/22 did not specifically address discharge of a resident who had been transferred to the hospital. Review of Resident #89's medical records showed the resident had been admitted for therapy following a right above knee amputation. She was receiving dialysis treatments and receiving Vancomycin for cellulitis of the left foot. She had capacity to make her own medical decisions per the physician's determination of capacity performed on 02/10/23. On 03/08/23, the resident's left foot wound worsened. The resident was transferred to the hospital that day. A discharge, return anticipated Minimum Data Set (MDS) Assessment was performed on 03/08/23. The following nursing note was written on 03/09/2023 at 6:39 AM, This nurse called [hospital's name] ER [emergency room] regarding admission status. This patient admitted to [hospital's name] for DX [diagnosis]: gangrene left great toe. This was the last note entered into the resident's medical chart. Review of reportables showed on 03/20/23, Resident #89's daughter alleged the resident had been mistreated. The allegation was unsubstantiated after investigation. The investigation concluded, It is probable and plausible that the allegation stemmed from [daughter's name]'s frustration with the denial of placement back to this facility. During an interview at 04/17/23 at 2:20 PM, the Director of Nursing (DON) stated the hospital had contacted the facility for the resident to readmitted to the facility. The facility declined to reaccept the resident. The DON confirmed there was no indication the resident's needs could not be met if she returned to the facility. The DON also confirmed there was no indication the resident was a danger to herself or to others. The DON stated the facility declined to allow the resident to return to the facility because the resident had not been happy at the facility and had asked for a transfer to another facility when previously residing at the facility. Additionally, the DON stated the resident refused treatment, particularly physical therapy. On 04/17/23 at 5:00 PM, the complainant was interviewed by telephone. The complainant said she was told by the resident's caseworker at the hospital that the resident was not permitted to return to the nursing home. The complainant said the resident had spent about a five (5) additional weeks at the hospital while awaiting alternate placement. The complainant also stated the resident had been placed at a facility farther from home and family. On 04/17/23 at 7:05 PM, Resident #89 was interviewed. She stated she had wanted to transfer back to the facility when her hospitalization was completed. She stated she heard from her daughter that she was not permitted to return to the facility. Resident #89 stated she had spent an additional four (4) to five (5) weeks at the hospital at alternate placement, and she was ultimately placed at a facility farther from her daughter's home. The resident stated she had experienced mental distress and anguish due to the refusal to allow her to return to her home because she felt stuck at the hospital. This failure cause actual psychosocial harm to Resident #89. .

Based on medical record review and staff interview, the facility failed to provide written information regarding the facility's bed hold policy. This was true for 12 of 20 residents reviewed for discharge from the facility. Resident identifiers: #93, #16, #94, #18, #70, #95, #30, #36, #12, #60, #42, and #98. Facility census: 92. Findings include: a) Residents #93, #16, #94, #18, #70, #95, #30, #36, #12, #60, #42, and #98. The facility had the following transfers to an acute care facility after 04/28/23 through current (06/20/23): -- Resident #93- on 05/09/23. --Resident #16- on 05/10/23. --Resident # 94- on 05/11/23. --Resident #18-on 05/17/23. -- Resident #70- on 05/18/23. -- Resident #95- on 05/22/23. -- Resident #30- on 05/24/23. --Resident #36 - on 05/24/23. --Resident #12-on 05/31/23. --Resident #60-on 06/02/23. -- Resident #42- on 06/03/23. -- Resident #98- on 05/04/23. Review of the above-mentioned residents' medical records found no indication a bed hold policy was provided to the resident and/or the resident's representatives. On 06/20/23 at 11:30 AM, an interview with the Nursing Home Administrator (NHA) and the Director of Nursing (DON), confirmed a written copy of the facility's bed hold policy was never provided to the residents/responsible parties.

Based on record review, family interview, resident interview, and staff interview, the facility failed to send a notice of discharge to a hospital resident who was not permitted to return to the facility. This deficient practice had the potential to affect one (1) of two (2) residents reviewed for the care area of discharge. Resident identifier: #89. Facility census: 82. Findings included: a) Resident #89 The facility's policy titled Discharge of a Resident issued 03/01/14 and revised 09/28/22 did not specifically address discharge of a resident who had been transferred to the hospital. Review of Resident #89's medical records showed the resident had been admitted for therapy following a right above knee amputation. She was receiving dialysis treatments and receiving Vancomycin for cellulitis of the left foot. She had capacity to make her own medical decisions per the physician's determination of capacity performed on 02/10/23. On 03/08/23, the resident's left foot wound worsened. The resident was transferred to the hospital that day. A discharge, return anticipated Minimum Data Set (MDS) Assessment was performed on 03/08/23. The following nursing note was written on 3/9/2023 at 6:39 AM, This nurse called [hospital's name] ER [emergency room] regarding admission status. This patient admitted to [hospital's name] for DX [diagnosis]: gangrene left great toe. This was the last note entered into the resident's medical chart. Review of reportables showed on 03/20/23, Resident #89's daughter alleged the resident had been mistreated. The allegation was unsubstantiated after investigation. The investigation concluded, It is probable and plausible that the allegation stemmed from [daughter's name]'s frustration with the denial of placement back to this facility. During an interview at 04/17/23 at 2:20 PM, the Director of Nursing (DON) stated the hospital had contacted the facility for the resident to return to the facility. The facility declined to reaccept the resident. The DON confirmed no written discharge notification had been sent to the resident. On 04/17/23 at 5:00 PM, the complainant was interviewed by telephone. The complainant said she was told by the resident's caseworker at the hospital that the resident was not permitted to return to the nursing home. The complainant said she never saw a discharge notice. On 04/17/23 at 7:05 PM, Resident #89 was interviewed. She stated she had wanted to transfer back to the facility when her hospitalization was completed. She confirmed she had not received a discharge notice. She stated she heard from her daughter that she was not permitted to return to the facility. .

Based on observation and staff interview the facility failed to ensure all residents were provided a dignified existence. The failed to provide a privacy cover on the Foley catheter collection bag. This was a random opportunity for discovery and was true for Resident #64. Resident identifiers: Resident # 64. Facility census 91. Findings included: a) Resident # 64 During a brief observation of Resident # 64 on 08/22/22 at 12:26 PM, it was discovered there was not a privacy cover on the indwelling Foley urine collection bag. Licensed Practical Nurse (LPN) #7 was present during this observation and verified there was not a privacy bag covering Resident #64's urine collection bag. LPN #7 stated she would replace the privacy cover immediately.

Based on resident interview, staff interview, observation, and record review, the facility failed to adequately assess and manage pain for one (1) of five (5) residents (Resident #47) reviewed for pain. This resulted in the resident experiencing pain which was avoidable, and failed to ensure the resident was able to participate optimally in rehabilitative therapy sessions, and therefore was actual harm. The facility also failed to monitor vital signs before administering [MEDICATION NAME] in accordance with physician's orders [REDACTED].#100) reviewed. Resident identifiers: #47 and #100. Facility census: 98. Findings include: a) Resident #47 Resident #47's medical records, reviewed on 11/17/15 at 1:00 p.m., revealed this [AGE] year-old male, admitted to the facility on [DATE], had [DIAGNOSES REDACTED]. A comminuted fracture is a fracture in which the bone involved in the fracture is broken into several pieces. At least three separate peices of the bone must be present for a fracture to be considered comminuted. Review of medical records found a Physician's Determination of Capacity completed on 11/02/15. This form indicated Resident #47 demonstrated the capacity to make decisions. Review of the most recent Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 11/06/15, revealed Resident #47 was moderately cognitively impaired, able to make himself understood and able to understand others. Resident #47 was assessed as requiring the extensive assistance of two (2) staff for bed mobility and transfers. He was incontinent of bowel functions and had an indwelling Foley catheter. His pain assessment on this MDS revealed he was on a PRN (as or when needed) pain medication regimen. The MDS indicated the resident experienced occasional pain over the last five (5) days (the assessment reference period). The pain had made it hard to sleep at night and had limited the resident's day-to-day activities due to pain. The resident indicated his worst pain as an 8 (on a zero (0) to ten (10) scale with zero being no pain and ten as the worst pain you can imagine). Interview with Resident #47 on 11/17/15 at 12:45 p.m., found the resident lying in bed. When asked about his pain, he said, I hurt a lot of the time. I broke my right hip and had to have surgery on it. The scar goes from my stomach down my leg and I broke my left shoulder/arm and my right arm is banged up from the fall. Sometimes the pain is real bad. Resident #47's physician's orders [REDACTED]. -- Review of Resident #47's comprehensive care plan, initiated on 11/08/15 revealed: -- Focus: (Resident's name) has pain related to fractures. -- Goal: Patient will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through next review date.(01/14/16) -- Interventions included: 1. Administer scheduled pain management as per orders. Provide treatments and therapies at least 30 minutes after medication administered. 2. Anticipate patient's need for pain relief and respond immediately to any complaint of pain. 3. Identify, record and treat patient's existing conditions which may increase pain and/or discomfort from fractures. 4. Monitor/document for probable cause of each pain episode. Remove/limit causes where possible. 5. Monitor/record/report to nurse loss of appetite, refusal to eat and weight loss. 6. Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain. 7. Observe and report to physician changes in usual routine, sleep patterns, decrease in functional abilities, and decrease range of motion (ROM), withdrawal or resistance to care. According to the Medication Administration Record [REDACTED] -- 10/24/15-[MEDICATION NAME]/Tylenol 10/325 mg 1 tablet was given at 9:00 a.m., for resident complaining of pain rated at 10, after the medication administered documented, E (effective). -- 10/24/15-[MEDICATION NAME]/Tylenol 10/325 mg 1 tablet was given at 7:06 p.m., for resident complaining of leg pain rated at 7, after the medication administered documented, E. -- 10/24/15-[MEDICATION NAME]/Tylenol 10/325 mg 1 tablet was given at 11:43 p.m., for resident complaining of body pain rated at 7, after the medication administered documented, E. -- 10/25/15-[MEDICATION NAME]/Tylenol 10/325 mg 1 tablet was given at 4:45 a.m., for resident complaining of pain rated at 10, after the medication administered documented, E. -- 10/25/15-[MEDICATION NAME]/Tylenol 10/325 mg 1 tablet was given at 9:32 a.m., for resident complaining of pain rated at 8, after the medication administered documented, E. -- 10/26/15-[MEDICATION NAME]/Tylenol 10/325 mg 1 tablet was given at 2:34 a.m., for resident complaining of pain rated at 10, after the medication administered documented, E. -- 10/26/15-[MEDICATION NAME]/Tylenol 10/325 mg 1 tablet was given at 8:37 a.m., for resident complaining of pain rated at 8, after the medication administered documented, E. -- 10/26/15-[MEDICATION NAME]/Tylenol 10/325 mg 1 tablet was given at 12:45 p.m., for resident complaining of pain rated at 7, after the medication administered documented, E. -- 10/27/15-[MEDICATION NAME]/Tylenol 10/325 mg 1 tablet was given at 2:00 a.m., for resident complaining of pain rated at 7, after the medication administered documented, Effective. -- 10/27/15-[MEDICATION NAME]/Tylenol 10/325 mg 1 tablet was given at 6:09 a.m., for resident complaining of pain rated at 8, after the medication administered documented, I (Ineffective). -- 10/27/15-[MEDICATION NAME]/Tylenol 10/325 mg 1 tablet was given at 10:15 a.m., for resident complaining of pain rated at 8, after the medication administered documented, E. -- 10/27/15-[MEDICATION NAME]/Tylenol 10/325 mg 1 tablet was given at 3:00 p.m., for resident complaining of pain rated at 9, after the medication administered documented, E. -- 10/27/15-[MEDICATION NAME]/Tylenol 10/325 mg 1 tablet was given at 8:28 p.m., for resident complaining of pain rated at 9, after the medication administered documented, E. -- 10/28/15-[MEDICATION NAME]/Tylenol 10/325 mg 1 tablet was given at 2:13 a.m., for resident complaining of pain rated at 8, after the medication administered documented, E. -- 10/28/15-[MEDICATION NAME]/Tylenol 10/325 mg 1 tablet was given at 6:15 a.m., for resident complaining of pain rated at 7, after the medication administered documented, I. -- 10/28/15-[MEDICATION NAME]/Tylenol 10/325 mg 1 tablet was given at 11:08 a.m., for resident complaining of pain rated at 8, after the medication administered documented, E. -- 10/29/15-[MEDICATION NAME]/Tylenol 10/325 mg 1 tablet was given at 9:09 p.m., for resident complaining of pain rated at 9, after the medication administered documented, E. -- 10/30/15-[MEDICATION NAME]/Tylenol 10/325 mg 1 tablet was given at 9:17 p.m., for resident complaining of pain rated at 6, after the medication administered documented, E. -- 10/31/15-[MEDICATION NAME]/Tylenol 10/325 mg 1 tablet was given at 2:00 a.m., for resident complaining of pain rated at 8, after the medication administered documented, E. -- 10/31/15-[MEDICATION NAME]/Tylenol 10/325 mg 1 tablet was given at 8:28 a.m., for resident complaining of pain rated at 8, after the medication administered documented, I. -- 10/31/15-[MEDICATION NAME]/Tylenol 10/325 mg 1 tablet was given at 1:15 p.m., for resident complaining of pain rated at 7, after the medication administered documented, E. -- 11/01/15-[MEDICATION NAME]/Tylenol 10/325 mg 1 tablet was given at 9:14 p.m., for resident complaining of pain rated at 8, after the medication administered documented, E. -- 11/02/15-[MEDICATION NAME]/Tylenol 10/325 mg 1 tablet was given at 6:51 a.m., for resident complaining of pain rated at 8, after the medication administered documented, U (Unable to determine-out to doctor's appointment). -- 11/02/15-[MEDICATION NAME]/Tylenol 10/325 mg 1 tablet was given at 2:22 p.m., for resident complaining of generalized pain rated at 8, after the medication administered documented, E. -- 11/03/15-[MEDICATION NAME]/Tylenol 10/325 mg 1 tablet was given at 1:11 a.m., for resident complaining of body pain rated at 8, after the medication administered documented, E. -- 11/03/15-[MEDICATION NAME]/Tylenol 10/325 mg 1 tablet was given at 5:17 a.m., for resident complaining of shoulder and back pain rated at 9, after the medication administered documented, E. -- 11/03/15-[MEDICATION NAME]/Tylenol 10/325 mg 1 tablet was given at 9:40 a.m., for resident complaining of generalized pain rated at 8, after the medication administered documented, E. -- 11/04/15-[MEDICATION NAME]/Tylenol 10/325 mg 1 tablet was given at 6:46 a.m., for resident complaining of body pain rated at 0, after the medication administered documented, E. -- 11/06/15-[MEDICATION NAME]/Tylenol 10/325 mg 1 tablet was given at 9:39 a.m., for resident complaining of generalized pain rated at 7, after the medication administered documented, E. -- 11/07/15-[MEDICATION NAME]/Tylenol 10/325 mg 1 tablet was given at 1:41 a.m., for resident complaining of body pain rated at 7, after the medication administered documented, E. -- 11/07/15-[MEDICATION NAME]/Tylenol 10/325 mg 1 tablet was given at 6:30 a.m., for resident complaining of body pain rated at 7, after the medication administered documented, E. -- 11/08/15-[MEDICATION NAME]/Tylenol 10/325 mg 1 tablet was given at 5:09 a.m., for resident complaining of pain all over body rated at 8, after the medication administered documented, E. -- 11/08/15-[MEDICATION NAME]/Tylenol 10/325 mg 1 tablet was given at 10:09 p.m., for resident complaining of pain in legs rated at 5, after the medication administered documented, E. -- 11/09/15-[MEDICATION NAME]/Tylenol 10/325 mg 1 tablet was given at 11:00 a.m., for resident complaining of generalized pain rated at 7, after the medication administered documented, E. -- 11/12/15-[MEDICATION NAME]/Tylenol 10/325 mg 1 tablet was given at 5:04 a.m., for resident complaining of body pain rated at 7, after the medication administered documented, E. -- 11/13/15-[MEDICATION NAME]/Tylenol 10/325 mg 1 tablet was given at 12:55 a.m., for resident complaining of body pain rated at 7, after the medication administered documented, E. -- 11/13/15-[MEDICATION NAME]/Tylenol 10/325 mg 1 tablet was given at 9:02 a.m., for resident complaining of generalized pain rated at 7, after the medication administered documented, E. -- 11/14/15-[MEDICATION NAME]/Tylenol 10/325 mg 1 tablet was given at 1:06 a.m., for resident complaining of pain rated at 8, after the medication administered documented, E. -- 11/15/15-[MEDICATION NAME]/Tylenol 10/325 mg 1 tablet was given at 6:43 a.m., for resident complaining of pain rated at 7, after the medication administered documented, E. -- 11/15/15-[MEDICATION NAME]/Tylenol 10/325 mg 1 tablet was given at 9:37 p.m., for resident complaining of back pain rated at 7, after the medication administered documented, E. -- 11/16/15-[MEDICATION NAME]/Tylenol 10/325 mg 1 tablet was given at 3:38 a.m., for resident complaining of pain rated at 8, after the medication administered documented, E. -- 11/16/15-[MEDICATION NAME]/Tylenol 10/325 mg 1 tablet was given at 5:18 am., for resident complaining of pain rated at 7, after the medication administered documented, E. -- 11/17/15-[MEDICATION NAME]/Tylenol 10/325 mg 1 tablet was given at 1:45 a.m., for resident complaining of back and left arm pain rated at 8, after the medication administered documented, E. There was no evidence of other pain medication administered from October 23, 2015 through November 17, 2015. Review of the Occupational Therapy (OT) Evaluation completed on 10/26/15 revealed: -- Pain at Rest: Intensity: = 6/10; Frequency = constant; Location: right side/hip and left shoulder; Description/Type: aching, sharp, shooting and stabbing. -- Pain on Movement: Intensity= 10/10; Frequency = constant; Location: right side/hip and left shoulder; Description/Type/ Passive Range of Motion (PROM): stabbing and excruciating. -- Patient verbalized the pain level and he expressed the pain limits his functional activities. -- Discussed with the interdisciplinary team (IDT) of the intensity and the limitations caused by the pain. Intervention: Patient receives pain medication on scheduled program. Further review found daily OT progress notes with concerns on the following days: -- 11/11/15: .Patient was very lethargic and reports increased tiredness . Participated at very low levels today. -- 11/12/15: . The patient will not initiate pendulum exercises to left upper extremity however will let therapist perform passive range of motion (PROM) exercises in pendulum patterns. -- 11/16/15: . Patient again refuses pendulum exercises and refused PROM in place for pendulum. He states that that the pain is too bad. Therapist advised (Physician's name) of continued refusal of pendulum exercises. -- 11/17/15: . The patient again refuses pendulum exercises to left shoulder with complaints of pain During an interview with the Director of Nursing (DON) on 11/17/15 at 2:00 p.m., it was verified the resident should be assessed for the need for pain medication prior to performing a resident's treatments and/or prior to the therapy sessions. During a telephone interview on 11/19/15 at 3:00 p.m., the physician indicated the resident had a history of [REDACTED]. He further indicated it was his understanding the resident received the medication prior to therapy sessions. He confirmed he was aware of the resident's refusal to do the pendulum exercises to left shoulder; however was not aware it was due to pain. During the interview, the physician accessed the electronic medical records of Resident #47. He further confirmed the therapy staff and nursing staff did not appear to be communicating concerning Resident #47's pain management during therapy sessions. b) Resident #100 Review of Resident #100's medical record found this [AGE] year-old female, admitted to the facility on [DATE], had [DIAGNOSES REDACTED]. Further review of the record found a physician's orders [REDACTED]. Hold for pulse < (less than) 60 bpm (beats per minute). ([MEDICATION NAME], although given for high blood pressure, can also slow the heart rate.) Review of Resident #100's Medication Administration Record [REDACTED]. The other days from 08/28/15 through present Resident #100 had been in the hospital, therefore this medication was not administered by the facility. Further review of the medical record found no indication nursing obtained Resident #100's pulse prior to administering her [MEDICATION NAME]. The failure to obtain the resident's pulse meant the nurse would not know whether the medication should be given or held could not hold the medication if her pulse was below 60 bpm as directed by the physician's orders [REDACTED].>An interview the Director of Nursing at 4:45 p.m. on 11/19/15, confirmed nursing had not been obtaining Resident #100's pulse prior to the administration of her [MEDICATION NAME] as directed by the physician's orders [REDACTED].>

Based on staff interview, resident interview, record review, and observation, the facility failed to ensure two (2) of five (5) residents reviewed for nutrition maintained, to the extent possible, acceptable parameters of nutritional status. Resident #47's weight was not accurately assessed. The resident had severe weight losses which were not identified and addressed in a timely manner. In addition, the weight loss interventions suggested by the dietitian, and/or those interventions outlined in the resident's care plan, were not implemented. For Resident #99, the facility failed to identify the resident's decreased meal intake and weight loss. While at the facility, the resident continued to lose weight with no new interventions and/or treatments implemented to prevent continued weight loss. The failure to provide necessary care and services resulted in actual harm to these residents. Resident identifiers: #47 and #99. Facility census: 98. Findings include: a) Resident #47 Resident #47's medical records, reviewed on 11/17/15 at 1:00 p.m., revealed this [AGE] year-old male, admitted to the facility on [DATE], had [DIAGNOSES REDACTED]. Review of the admission nursing assessment, completed on 10/23/15 at 6:54 p.m., revealed Resident #47 had an [MEDICAL CONDITION] scrotum and three (3) plus (+) [MEDICAL CONDITION] of bilateral feet. Further review of Resident #47's record found a Registered Dietitian Nutritional assessment dated [DATE], with an effective time of 2:34 p.m. This assessment, completed by Registered Dietitian (RD) #119, identified the resident's intake was poor with a 34% meal intake average. The RD noted the resident did have [MEDICAL CONDITION], and had no pressure ulcers. She recommended Resident #47 have Ensure one (1) can twice daily and record the percentage (%) taken, Multivitamin one (1) tablet by mouth daily, and [MEDICATION NAME] (a [MEDICATION NAME] used for bowel problems) one by mouth daily for thirty (30) days. Further review of the clinical record found a history and physical (H&P) completed by the attending physician on 11/02/15. This H&P indicated, There is no [MEDICAL CONDITION] of the lower extremities. Interview with Resident #47 on 11/17/15 at 12:45 p.m., found the resident lying in bed. When asked if he had ate lunch, he said, I don't know. He spoke in a very low voice. He further indicated he was uncomfortable. When asked about his ability to feed himself he said, I broke my left shoulder/arm and my right arm is banged up from the fall and it is difficult to eat at times, but not very hungry anyways. A review of Resident #47's weights in the electronic medical record found the following weights recorded: - 10/23/15 at 6:18 p.m. - 254.1 lb (pounds) - 10/25/15 at 11:03 a.m. - 254.2 lb - 11/01/15 at 10:50 a.m. - 250.0 lb - 11/01/15 at 10:51 a.m. - 254.0 lb - 11/08/15 at 2:18 p.m. - 221.6 lb - 11/10/15 at 1:18 p.m. - 215.9 lb - 11/10/15 at 2:18 p.m. - 216.0 lb - 11/15/15 at 1:25 p.m. - 213.6 lb From 11/01/15 to 11/08/15 the resident lost 32.4 pounds or 12.76 percent (%) of his body weight in 7 days. From 11/08/15 to 11/10/15 the resident lost 5.6 pounds or 2.5% of his body weight in 2 days. From 11/10/15 to 11/15/15 the resident lost 2.4 pounds or 1.11% of his body weight in 5 days. From 10/23/15 to 11/15/15 the resident lost 40.5 pounds or 15.94% in 23 days. (All percentages calculated using the following formula % of body weight loss = (usual weight - actual weight) / (usual weight) x 100.) Guidance to Surveyors related to suggested parameters for evaluating significance and unplanned and undesired weight loss, found in Appendix PP of the CMS State Operations Manual contained the following: -- Interval of 1 month, 5% is a significant weight loss, and greater than 5% is a severe weight loss. -- Interval of 3 months, 7.5% is a significant weight loss, and greater than 7.5% is a severe weight loss. -- Interval of 6 months, 10% is a significant weight loss, and greater than 10% is a severe weight loss. Review of Resident #47's progress notes found the following notations related to Resident #47's nutritional status: -- 10/27/15 at 12:29 p.m., Weight and Nutrition Meeting, Weight on 10/23/15 254.1 lbs. Resident is a new admission to the facility, Ideal Body Weight (IBW) 187-226 lbs. Intake in last week meals 38%, fluids 1230 cubic centimeters (cc) and snacks 83%. Resident receives a regular diet. -- 11/03/15 at 3:59 p.m., Weight and Nutrition Meeting, Weight on 11/01/15 254 lbs. No significant changes in weight. Resident had RD consult, with recommendations for Ensure twice daily, multivitamin daily and [MEDICATION NAME] daily for 30 days, approved by physician. Weekly weights. -- 11/04/15 at 8:01 a.m., Patient consumed less than 50% of meal. Will continue to encourage meal intake. -- 11/04/15 at 3:42 p.m., Multidisciplinary Care Conference, . Patient's weight are stable. He receives regular diet, no salt packet on tray; ensure twice daily (bid) and ProMod one ounce bid -- 11/09/15 at 11:21 a.m., Patient consumed less than 50% of meal. Will continue to encourage meal intake. -- 11/10/15 at 2:03 p.m., Weight and Nutrition Meeting, Weight on 11/08/15 221.6 lbs. Weight today 216.0 lbs. with wheel chair weight scale, weight today with full body lift 215.9 lbs . Meal intake 9% fluids 983 cc in last week . Resident currently receives ensure one can twice a day, with poor acceptance, talked with resident who stated does not like Ensure early in the morning, time changed to afternoon and at 8pm (8:00 p.m.) in the evening, phone RD for recommendations due to weight loss, no answer on telephone, left message for return call to facility --11/10/15 at 3:38 p.m., RD returned call to facility with recommendations for magic cup twice daily, approved by physician --11/11/15 at 10:16 a.m., Multidisciplinary Care Conference, . Patients weights are stable. He receives regular diet, ensure one can bid, magic cup bid and Promod one ounce bid --11/12/15 at 11:30 a.m., Patient consumed less than 50% of meal. Will continue to encourage meal intake. --11/14/15 at 4:35 p.m., Patient consumed less than 50% of meal. Will continue to encourage meal intake. --11/17/15 at 5:53 p.m., Current weight 213.6 lbs. Nurse practitioner (NP) notified at this time. No new orders will evaluate in the facility on 11/18/15. --11/18/15 at 5:46 p.m., Weight and Nutrition Meeting, Weight on 11/15/15 213.6 lbs. Loss of 5% change in weight compared to weight on 10/23/15. IBW- 187-226 lbs. Resident had decreased meal intake now beginning to improve from last week 9% to 19% meal consumption this week . Phoned RD for consult, recommendations for a super doughnut daily Seven (7) days after the weight loss should have been identified the multidisciplinary team noted the resident's weights were stable and he was not in need of any new interventions. They failed to identify the 38 pound weight loss and/or the resident drastic decrease in meal consumption and missed another opportunity to implement interventions to prevent further weight loss. Failed to address the RD recommendations from 11/11/15. On 11/11/15 at 5:42 p.m., RD #119, completed a review note. This note revealed, RD note due to weight loss and pressure ulcers: Current body weight (CBW) 216 (11/10/15) -14.9% since 10/23/15 admission. Body Mass Index (BMI) =27.7 (overweight). Doctor orders- Regular diet with no salt packet on tray (3%, refused x 7) average meal, ensure one (1) can (42% consumed), Promod bid, and 1193 milliliters (ml) fluids average for 11/8/15 through 11/10/15. Started magic cup 11/11/15 to supplement other interventions in place. Swift decrease in weight. However, patient noted to have [MEDICAL CONDITION] at admission so weight decrease anticipated as swelling subsides. Medication changes: [MEDICATION NAME] (11/03/15), receiving [MEDICATION NAME] due to elevated ammonia level 11/10/15. Unable to locate other lab results . At nutritional risk due to weight loss, inadequate meal intake, pressure ulcers, depleted protein stores and therapeutic diet. Currently on weekly weights . New recommendations: record % consumed of Promod, Vitamin C 500 milligrams (mg) bid for 30 days, Zinc 220mg daily for 14 days, and appetite stimulant for a trail period if an appropriate candidate. There was no evidence the facility implemented these recommendations. As well, the clinical record revealed no orders or considerations for an appetite stimulant. Review of Resident 47's comprehensive care plan, found a care plan initiated on 11/11/15: -- Focus: (Resident's name) has experienced an unplanned/unexpected weight loss related to acute illness. -- Goal: Patient will consume at least 50% two (2) of three (3) meals/day through the review date of 01/14/2016. -- Interventions: 1. Alert attending physician if intake averages less than 25% of offered foods for more than 48 hours. Consult RD as directed by physician. 2. Give supplements as ordered (Ensure one can bid). Alert Unit Charge Nurse if patient not consuming supplements on a routine basis. 3. Give supplements as ordered (Magic cup bid). Alert Unit Charge Nurse if patient not consuming supplements on a routine basis. 4. Give supplements as ordered (Promod liquid one ounce bid). Alert Unit Charge Nurse if patient not consuming supplements on a routine basis. 5. Provide and serve regular diet, no salt packet on tray with thin liquids as ordered. Monitor and document % consumed each meal. Resident preference for grilled cheese sandwich for lunch. Review of Resident #47's meal intake, as documented on the Activities of Daily Living revealed, from 10/24/15 through 10/31/15: -- Breakfast - the resident refused all except on 10/28/15 he consumed 25%. -- Lunch meal- consumed - 0% - 65%. -- Dinner meal consumption was from 0% - 65%. Review of meal consumption from 11/01/15 through 11/17/15: -- Breakfast - Refused 13 out of 17 breakfasts and consumed 20% on 11/12/15, 35% on 11/13/15, 20% on 11/15/15, and 45% on 11/16/15. -- Lunch- Refused 9 lunch meals and averaged 25-80% the other 8 days. -- Dinner- Refused 11 of 17 dinners and averaged 25-50% the other 6 days. Review of Physician order [REDACTED]. --10/30/15 - Ensure one can by mouth bid. --11/10/15 - Magic cup twice a day at lunch and dinner. --11/18/15 - Super donut daily at breakfast. --10/29/15 - Promod one ounce po bid for hypo [MEDICATION NAME]. Review of Medication Administration Record [REDACTED] --10/31/15 through 11/05/15- No documentation found for Ensure supplement. --10/29/15 through 11/17/15- No documentation on the % of Promod found. --11/10/15 through 11/17/15 -No documentation found for Magic cup consumed. --11/05/15 through 11/10/15- 9:00 a.m. dose refused --11/05/15 through 11/07/15- 9:00 p.m. dose refused --11/08/15 through 11/9/15 - 9:00 p.m. dose consumed 100% --11/11/15 - 1:00 p.m. - 75% consumed and 8:00 p.m. - 100% consumed --11/12/15 through 11/14/15- 1:00 p.m. and 8:00 p.m. doses refused --11/15/15- 1:00 p.m. - 25% consumed and 8:00 p.m. dose refused --11/16/15- 1:00 p.m. - 50% consumed and 8:00 p.m. dose 50% consumed --11/17/15- 1:00 p.m. - 100% consumed and 8:00 p.m. dose 70% consumed. An interview at 9:30 a.m. on 11/19/15 with the DON, confirmed Resident #47 had a decrease in his weight. She indicated that the admitting hospital had overloaded him with excess fluid and the weight loss was a result of the loss of fluid due to [MEDICAL CONDITION]. The DON was asked to provide information that demonstrated the resident had [MEDICAL CONDITION] upon admission and that the [MEDICAL CONDITION] was assessed and had diminished throughout the resident's stay at the facility. She was unable to provide the requested information. She stated, I don't have what you are looking for. The DON was also asked to provide information as to any interventions and or notifications of the physician/nurse practitioner and/or dietitian in regards to Resident #47's weight loss and poor meal intake. At the time of exit on 11/19/15 at 6:15 p.m., she had not provided any additional information. b) Resident #99 A review of Resident #99's medical record at 1:10 p.m. on 11/17/15, found this [AGE] year-old male was admitted to the facility on [DATE] and discharged to home on 08/25/15 at 2:37 p.m. Resident #99 was admitted from an area hospital where he was a patient from 07/31/15 through 08/05/15. The history and physical from the hospital indicated Resident #99's [DIAGNOSES REDACTED]. Review of Resident #99's record found a Registered Dietician Nutritional assessment dated [DATE] with an effective time of 2:58 p.m. This assessment, completed by Registered Dietitian (RD) #119, indicated the resident's intake was good with an 84% meal intake average. The RD noted the resident did not have any [MEDICAL CONDITION] or pressure ulcers. She made recommendations for Resident #99 to have super cereal six (6) ounces and pudding twice daily. Further review of the record found a physician's orders [REDACTED]. A review of Resident #99's meals intakes found that from 08/06/15 through 08/12/15, the resident's average meal consumption was 82.14 %. His meal consumption percentage drastically declined from 08/13/15 through 08/24/15 to an average percentage of 25.44%. Review of the Medication Administration Record [REDACTED]. A review of Resident #99's vital signs in the electronic medical record found the following weights recorded: -- 08/06/15 - 153.8 lb (pounds) -- 08/07/15 - 153.8 lb -- 08/09/15 - 154.8 lb -- 08/16/15 - 143.8 lb -- 08/17/15 - 146.2 lb -- 08/23/15 - 139 lb -- 08/25/15 - 141.1 lb and 141 lb From 08/06/15 to 08/16/15 the resident lost 10 pounds or 4.94 percent (%) of his body weight. From 08/06/15 to 08/23/15 the resident lost 14.8 pounds or 9.62% of his body weight. From 08/06/15 to 08/25/15 the resident lost 12.7 pounds or 8.3% of his body weight. (All percentages calculated using the following formula % of body weight loss = (usual weight - actual weight) / (usual weight) x 100.) Guidance to Surveyors related to suggested parameters for evaluating significance and unplanned and undesired weight loss, found in Appendix PP of the CMS (Centers for Medicare and Medicaid Services) State Operations Manual contained the following: -- Interval of 1 month, 5% is a significant weight loss, and greater than 5% is a severe weight loss. -- Interval of 3 months, 7.5% is a significant weight loss, and greater than 7.5% is a severe weight loss. -- Interval of 6 months, 10% is a significant weight loss, and greater than 10% is a severe weight loss. Review of Resident #99's progress notes found the following notations related to Resident #99's nutritional status: -- 08/12/15 at 11:31 a.m. - for a weight and nutrition meeting held on 08/11/15, read: Current status: 154.8 Weight history. status: 153.8 His IBW (ideal body weight) is 149 - 180 and BMI (body mass index) is 25 Average weekly intake of foods/fluids: He is currently receiving a NCS (no concentrated sweets) with ground meats no salt packets. His fluids intake is 1492 and meal intakes are 82%. Residents weight has been stable since admission. Will continue with the current interventions as the resident's weight is stable and he is within his ideal body weight -- 08/14/15 at 12:06 p.m. read, Consumed less than 50% of meals will enc (encourage) intake at meal time. -- 08/15/15 at 2:37 p.m. read, Consumed less than 50% of meals will enc intake at meal time. -- 08/16/15 at 12:04 p.m. read, Consumed less than 50% of meal will enc (encourage) intake at meal time. -- 08/17/15 at 11:43 a.m. read, Consumed less than 50% of meals will encourage intake at meals. -- 08/19/15 at 4:04 p.m., an Appointment/Outing Return note, this note was following his return from a Modified [MEDICATION NAME] Study, it read: . Recommendations: . Diet level Liquids Regular Dietary Supplement (if pts (patients) oral intake continues to be poor recommend he be given a dietary supplement at least once a day,) -- 08/21/15 at 9:59 a.m. a Multidisciplinary Care Conference note, . Response to treatment including dietary interventions: Patients weights are stable. He receives regular, ground meat diet, no added salt packet on tray, super cereal every day and pudding bid (twice a day) -- 08/25/15 at 2:18 p.m. read, Late entry (name of nurse practitioner (NP)) in facility yesterday 08/24/15 informed of weight loss, no new orders regarding weight status. The facility failed to identify the resident's decreased meal intake and weight loss. The resident while at the facility continued to lose weight with no new interventions and/or treatments implemented to prevent the weight loss. The staff noted on 08/14/15 through 08/17/15, the resident consumed less than 50% of his meal, but failed to notify the physician and/or nurse practitioner and failed to put into place any interventions in attempts to increase Resident #99's intakes and prevent weight loss. On 08/16/15 the facility obtained Resident #99's weight which represented a 10 pound weight loss (or a loss 4.94%) since admission and still failed to notify the physician, the nurse practitioner, or the Registered Dietitian. Five (5) days after the weight loss should have been identified, the multidisciplinary team noted the resident's weights were stable and he was not in need of any new interventions. They failed to identify the 10 pound weight loss and/or the resident's drastic decrease in meal consumption and missed another opportunity to implement interventions to prevent further weight loss. It was not until 08/24/15, the day before Resident #99 was scheduled to be discharged , that they notified the nurse practitioner who provided no new orders in regards to the resident's weight loss. By the time of discharge on 08/25/15, Resident #99 had lost 12.7 pounds or 8.3% of his body weight in 20 days. This represented a severe weight loss. An interview at 9:30 a.m. on 11/19/15 with the DON, confirmed Resident #99 had a decrease in his weight. She indicated, that the admitting hospital had overloaded him with excess fluid and the weight loss was a result of the loss of fluid. She stated, Resident #99 was receiving [MEDICATION NAME] - HCT which had a diuretic component and that in combination with the excess fluid caused the weight loss when the excess fluid resolved. The DON was asked to provide information that demonstrated the resident had [MEDICAL CONDITION] upon admission and that the [MEDICAL CONDITION] was assessed and diminished throughout the residents stay at the facility. She was unable to provide the requested information. She stated, I don't have what you are looking for. The DON was also asked to provide information as to any interventions and or notifications of the physician and/or nurse practitioner and/or dietitian in regards to Resident #99's weight loss and poor meal intake. At the time of exit on 11/19/15 at 6:15 p.m., she had not provided any additional information.

Based record review, staff interview, resident interview and observation, the facility failed, for two (2) of five (5) residents, to recognize a decline in fluid intake and implement measures to ensure adequate fluid intake and avoid dehydration. This resulted in actual harm to Resident #47, whom developed a urinary tract infection and a significant weight loss, whom required appetite stimulant after surveyor's intervention and Resident #99 whom required a hospitalization for treatment of [REDACTED].#47 and #99. Facility census: 98. Findings include: a) Resident #47 Resident #47's medical records reviewed on 11/17/15 at 1:00 p.m. revealed a [AGE] year old male was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #47's record found a Registered Dietician Nutritional assessment dated [DATE] with an effective time of 2:34 p.m. This assessment was completed by Registered Dietician (RD) #119. This assessment indicated Resident #47's estimated fluid needs were 3466 milliliters (ml) per day. The facility had the following total fluid intakes listed for Resident #47 none of which totaled his estimated fluid needs of 3466 ml: -- 11/01/15 - 1840 cubic centimeters (cc) (it should be noted a cc equals a ml) resulting in a fluid deficit of 1626 cc -- 11/02/15 - 680 cc resulting in a fluid deficit of 2786 cc -- 11/03/15 - 960 cc resulting in a fluid deficit of 2506 cc -- 11/04/15 - 1440 cc resulting in a fluid deficit of 2026 cc -- 11/05/15 - 100 cc resulting in a fluid deficit of 3366 cc -- 11/06/15 - 1330 cc resulting in a fluid deficit of 2136 cc -- 11/07/15 - 1300 cc resulting in a fluid deficit of 2166 cc -- 11/08/15 - 960 cc resulting in a fluid deficit of 2506 cc -- 11/09/15 - 1440 cc resulting in a fluid deficit of 2026 cc -- 11/10/15 - 1260 cc resulting in a fluid deficit of 2206 cc Review of Resident #47's record found a Registered Dietician Review Note dated 11/11/15 with an effective time of 5:24 p.m. This assessment was completed by Registered Dietician (RD) #119. This assessment indicated Resident #47's estimated fluid needs were 2945-3240 milliliters (ml) per day. -- 11/11/15 - 400 cc resulting in a fluid deficit of 2840 cc -- 11/12/15 - 1400 cc resulting in a fluid deficit of 1840 cc -- 11/13/15 - 1,640 cc resulting in a fluid deficit of 1600 cc -- 11/14/15 - 715 cc resulting in a fluid deficit of 2525 cc -- 11/15/15 - 1640 cc resulting in a fluid deficit of 1600 cc -- 11/16/15 - 1800 cc resulting in a fluid deficit of 1440 cc -- 11/17/15 - 940 cc resulting in a fluid deficit of 2300 cc The facility had the following total fluid outputs listed for Resident #47. *= Days the output was greater than intake -- 11/01/15- 1700 cc output 140 cc less than intake -- *11/02/15- 1100 cc output 420 cc more than intake -- *11/03/15- 1425 cc output 465 cc more than intake -- 11/04/15- 1150 cc output 290 cc less than intake -- 11/05/15- 100 cc output is same as intake -- *11/06/15- 1800 cc output is 470 cc more than intake -- 11/07/15- 950 cc output is 350 cc less than intake -- *11/08/15- 1800 cc output is 840 cc more than intake -- 11/09/15- 1400 cc output is 40 cc less than intake -- *11/10/15- 1750 cc output is 490 cc more than intake -- *11/11/15- 1350 cc output is 950 cc more than intake. -- *11/12/15- 1650 cc output is 250 cc more than intake -- *11/13/15- 1800 cc output is 160cc more than intake -- *11/14/15- 1350 cc output is 635 cc more than intake -- 11/15/15- 1500 cc output is 140 cc less than intake -- 11/16/15- 1150 cc output is 650 cc less than intake -- *11/17/15- 1220 cc output is 280 cc more than intake Resident #47's output exceeds his intake 10 out of 17 days. Dehydration is a condition that occurs when the loss of body fluids, mostly water, exceeds the amount that is taken in. With dehydration more water is moving out of our cells and bodies than what we take in through drinking. When we lose too much water, our bodies may become out of balance or dehydrated. A review of Resident #47's meals intakes found that from 10/23/15 through 10/29/15 resident's average meal consumption was 34%. His meal consumption percentage drastically declined from 10/29/15 through 11/1/15 to an average percentage of 3%. A review of the results of a comprehensive metabolic panel obtained for Resident #47 on 10/27/15 found the following pertinent lab values: -- Creatinine was below reference interval at 0.61 (Reference interval is .76 to 1.27); -- BUN (blood urea nitrogen) was within the reference interval at 10 (Reference Interval 8 - 27); -- Sodium was within the reference interval at 139 (Reference Interval 134 - 144); -- Potassium was within reference interval at 4.4 (reference interval 3.5 - 5.2); -- Chloride was within the reference interval at 100 (reference interval is 97 - 108); and --carbon [MEDICATION NAME] (CO2) was within the reference interval at 22 (reference interval is 18 - 29). No further lab results could be found in the medical records; however a blood specimen was obtained on 11/10/15 at 3:54 a.m. A review of Resident #47's weights in the electronic medical record found the following weights recorded: -- 10/23/15 at 6:18 p.m. - 254.1 lb (pounds) -- 10/25/15 at 11:03 a.m. - 254.2 lb -- 11/01/15 at 10:50 a.m. - 250.0 lb -- 11/01/15 at 10:51 a.m. - 254.0 lb -- 11/08/15 at 2:18 p.m. - 221.6 lb -- 11/10/15 at 1:18 p.m. - 215.9 lb -- 11/10/15 at 2:18 p.m. - 216.0 lb -- 11/15/15 at 1:25 p.m. - 213.6 lb An interview with the Director of Nursing (DON) and Clinical Care Supervisor (CCS) Registered Nurse (RN) # 74 at 2:30 p.m. on 11/18/15, found the facility determines residents fluid needs based on the residents ideal body weight, their current weight and any fluid restrictions they may have. When asked if the registered dietician assists with the determination of how much fluid a resident would need they indicated, the dietician will look at new admissions and will help them with those decisions. The DON and CCS #74 was then asked how the track and determine if a residents intake is sufficient or not, The DON replied, the CCS's look at the fluid intake total for the day before for all residents every morning. She stated, if a resident has consumed less than 1500 ccs of fluid they will encourage the resident to consume more fluid the following day. Resident #99's low fluid intakes, weight loss, and decreased meal intakes were reviewed with the DON and CCS #74. They were asked to provide any information pertaining to notifications of the physician and/or nurse practitioner, any interventions put into place to prevent dehydration, and any information they had pertaining to their monitoring of Resident #47 for signs and/or symptoms of dehydration. At 9:30 a.m. on 11/19/15, the DON provided the following information pertaining to Resident #47. She indicated, while at the hospital prior to admission to the facility the resident was given intravenous fluids and was plumped up on fluids prior to his admission to the facility. She indicated the resident had excessive [MEDICAL CONDITION] in abdomen and extremities. She determined these factors caused the resident to lose weight. The DON was asked to provide any information related to his excess fluid such as their monitoring of his [MEDICAL CONDITION] and/or lung sounds. She was unable to provide any evidence to support the resident was overloaded with excess fluid and/or excessive [MEDICAL CONDITION] upon his admission to the facility. In regards to his fluid deficit on a daily basis during his stay at the facility, the DON indicated the Registered Dietician's just made a recommendation that the resident receive 3466 cc per day and the resident did not require that much fluid to stay hydrated. She indicated, they encourage resident #47 to drink fluids when his intake was less than 1500 cc and the days following his decreased intake it bounced back proving they had encouraged him to drink fluids the following days. Review of the nursing progress notes showed Resident #47 was encouraged to drink more fluids on the following dates: -- Note dated 11/04/15 at 7:54 a.m. indicated Resident #47 drank on 920 cc of fluid on 11/03/15 and they would continue to encourage fluids. -- Note dated 11/07/15 at 1:47 p.m. indicated Resident #47's fluid intake was 1230 cc on 11/06/15 and they would continue to encourage fluid. -- Note dated 11/08/15 at 11:56 a.m. indicated Resident #47's fluid intake was 1300 cc on 11/07/15 and they continued to encourage fluid intake and report any changes to the nurse practitioner. -- Note dated 11/09/15 at 11:14 a.m. indicated Resident #47's fluid intake was 1140 cc on 11/08/15 will continue to encourage fluid. This note also indicates to notify nurse practitioner of any changes. -- Note dated 11/12/15 at 11:22 a.m. indicated Resident #47's fluid intake was 660 cc on 11/11/15 will continue to encourage fluid. This note also indicates to notify nurse practitioner of any changes. -- Note dated 11/13/15 at 10:33 a.m. indicated Resident #47's fluid intake was 1300 cc on 11/12/15 will continue to encourage fluid. This note also indicates to notify nurse practitioner of any changes. Resident #47's fluid intake was also below 1500 cc on 11/03/15 with 960 cc, 11/09/15 with 1440 cc, 11/10/15 with 1260 cc, 11/14/15 with 715 cc and 11/17/15 with 940 cc. These dates were not noted or acknowledged by nursing nor were fluids encouraged. The interview with the DON continued and she stated, He was capacitated we could not make him drink. She stated we give him fluids with meals and between meals and he had a water pitcher. She indicated all we can do is encourage fluids. Review of Resident #47's comprehensive care plan related to hydration: -- Focus: Urinary tract infection initiated 11/17/15. -- Goal: The urinary tract infection will resolve without complications. -- Intervention: Encourage adequate fluid intake 1500- 2000 cc/day. The DON provided a photocopied page which she stated was part of the Lippincott manual which is what they base their standards of practice from. She referenced the page and stated of the signs and symptoms of fluid and electrolyte imbalances and the only one Resident #47 demonstrated was weight loss greater than five (5) percent. The excerpt was reviewed and contained the following signs and symptoms of fluid and electrolyte imbalances in regards to fluid, Acute weight loss (>5%), drop in body temperature, dry skin and mucous membrane, postural [MEDICAL CONDITION], longitudinal wrinkles or furrows of tongue, oliguria or anuria. The DON was unable to provide any evidence the facility had assessed Resident #47 for any of the aforementioned signs or symptoms with the exception of body temperature due to the regular recording of the Resident #47's body temperature. Blood pressures obtained were not taken upon the resident rising from a seated position which is what postural [MEDICAL CONDITION] identification would require. She stated again , we only document to the exception so if it is not documented then he must not have had the any symptoms presenting. c) Resident #99 A review of Resident #99's medical record at 1:10 p.m. on 11/17/15, found this [AGE] year old male was admitted to the facility on [DATE] and discharged to home on 08/25/15 at 2:37 p.m. Resident #99 was admitted from an area hospital where he was a patient from 07/31/15 through 08/05/15. The history and physical from the hospital indicated Resident #99's [DIAGNOSES REDACTED]. Further review of the record found Resident #99 was receiving upon admission to the facility, 12.5 millgrams (mg) of [MEDICATION NAME] HCT tablet 160, one time a day for hypertension. The Nursing 2016 Drug Handbook, published by Wolters Kluwer, the drug book utilized by the facility, indicated [MEDICATION NAME] - HCT is a combination drug made up of [MEDICATION NAME] (generic name for [MEDICATION NAME]) and [MEDICATION NAME] (HCTZ). Each component of the drug was individually discussed in the drug handbook. The handbook indentified HCTZ, a component of [MEDICATION NAME] - HCT, as a diuretic. The book contained a list adverse reactions which included volume depletion and dehydration. Nursing considerations for HCTZ included monitor fluid intake and output, weight, BP (blood pressure), and electrolyte levels, and monitor elderly patients, who are especially susceptible to excessive diuresis. The drug book also indicated HCTZ may decrease potassium, and sodium levels. Resident #99's Medication Administration Record [REDACTED]. Further review of Resident #99's record found a Registered Dietitian Nutritional assessment dated [DATE], with an effective time of 2:58 p.m. This assessment, completed by Registered Dietitian (RD) #119, indicated Resident #99's estimated fluid needs were 2,111 milliliters (ml) per day. The RD's assessment also noted [MEDICATION NAME] - HCT as a medication which could have potential nutritional side effects. The facility had the following total fluid intakes listed for Resident #99 none of which totaled his estimated fluid needs of 2,111 ml: -- 08/06/15 - 1880 cubic centimeters (cc) (a cc equals a ml) resulting in a fluid deficit of 231 ccs. -- 08/07/15 - 1150 cc resulting in a fluid deficit of 961 cc -- 08/08/15 - 2060 cc resulting in a fluid deficit of 51 cc -- 08/09/15 - 1740 cc resulting in a fluid deficit of 371 cc -- 08/10/15 - 1640 cc resulting in a fluid deficit of 471 cc -- 08/11/15 - 1500 cc resulting in a fluid deficit of 611 cc -- 08/12/15 - 1860 cc resulting in a fluid deficit of 251 cc -- 08/13/15 - 1960 cc resulting in a fluid deficit of 151 cc -- 08/14/15 - 1260 cc resulting in a fluid deficit of 851 cc -- 08/15/15 - 1640 cc resulting in a fluid deficit of 471 cc -- 08/16/15 - 1390 cc resulting in a fluid deficit of 721 cc -- 08/17/15 - 900 cc resulting in a fluid deficit of 1211 cc -- 08/18/15 - 1740 cc resulting in a fluid deficit of 371 cc -- 08/19/15 - 620 cc resulting in a fluid deficit of 1491 cc -- 08/20/15 - 1560 cc resulting in a fluid deficit of 551 cc -- 08/21/15 - 780 cc resulting in a fluid deficit of 1331 cc -- 08/22/15 - 1200 cc resulting in a fluid deficit of 911 cc -- 08/23/15 - 1500 cc resulting in a fluid deficit of 600 cc -- 08/24/15 - 1260 cc resulting in a fluid deficit of 840 cc The facility was unable to track Resident #99's output due to bladder incontinence and he wore a disposable brief. In fact a review of the resident's bladder observation records completed by the nurse aides found Resident #99 only had urine output two (2) times on 08/14/15, three (3) times on 08/06/15 through 08/12/15, and 08/15/15 through 08/24/15, and four (4) times on 08/13/15. A review of Resident #99's meals intakes found that from 08/06/15 through 08/12/15, the resident's average meal consumption was 82.14%. His meal consumption percentage drastically declined from 08/13/15 through 08/24/15 to an average percentage of 25.44 %. This reduced his fluid intake further. (Food is nearly as an important source of water as food, with the exception of some processed foods, has a high water content. Metabolic water is water produced during the oxidation of food. Carbohydrates are completely metabolized to carbon [MEDICATION NAME] and water. Metabolic water is about 350 to 400 ml/day (ie 5 mls/kg). This offsets some of the obligatory water losses (sweat, breathing, bowel movements, etc.).) A review of the results of a comprehensive metabolic panel obtained for Resident #99 on 08/08/15 found the following pertinent lab values: -- Creatinine was within the reference interval at 1.22 (Reference interval 0.76 to 1.27), -- BUN (blood urea nitrogen) was 27 (Reference Interval 8 - 27), -- Sodium was 40 (Reference Interval 134 - 144), -- Potassium was 4.4 (reference interval 3.5 - 5.2), -- Chloride was 102 (reference interval 97 - 108), and -- carbon [MEDICATION NAME] (CO2) was 23 (reference interval 18 - 29). A review of Resident #99's vital signs in the electronic medical record found the following weights recorded: -- 08/06/15 - 153.8 lb (pounds) -- 08/07/15 - 153.8 lb -- 08/09/15 - 154.8 lb -- 08/16/15 - 143.8 lb -- 08/17/15 - 146.2 lb -- 08/23/15 - 139 lb -- 08/25/15 - 141.1 lb and 141 lb Additional review of the record found the following blood pressures which were considered in the [MEDICAL CONDITION] range (below 90 systolic or below 60 diastolic): -- 08/23/15 at 11:07 a.m. - 90/50 -- 08/22/15 at 12:13 p.m. - 98/56 -- 08/22/15 at 2:58 a.m. - 110/56 -- 08/21/15 at 2:12 p.m. - 88/50 -- 08/18/15 at 12:33 a.m. - 76/59 -- 08/17/15 at 12:24 a.m. - 82/58 -- 08/16/15 at 10:59 a.m. - 105/49 -- 08/14/15 at 12:18 a.m. - 89/87 A review of records from a local hospital, obtained at 12:04 p.m. on 11/18/15, found, Resident #99 was seen in the emergency room at the local hospital at 2:40 p.m. on 08/26/15, which was 24 hours after his discharge from the facility. The hospital records indicated the clinical impression of Resident #99, when seen in the emergency roiagnom on [DATE], was dehydration and [MEDICAL CONDITION]. Lab results obtained at the local hospital on [DATE] at 2:43 p.m. contained the following pertinent values: -- Creatinine was high at 2.90 (Reference range is .80 to 1.30), -- BUN (blood urea nitrogen) was high 97 (Reference Range 7 - 18), -- Sodium was low at 132 (Reference Range 135 - 145), -- Potassium was within normal range at 3.9 (Reference Range 3.5 - 5.1), -- Chloride was low at 97 (Normal Range is 98 - 107), and -- CO2 was within normal limits at 24.4 (Reference Range 21 - 32). An interview with the Director of Nursing (DON) and Clinical Care Supervisor (CCS) Registered Nurse (RN) #74, at 2:30 p.m. on 11/18/15, found the facility determined as resident's fluid needs based on the resident ' s ideal body weight, their current weight, and any fluid restrictions the resident might have. When asked if the registered dietitian assisted with the determination of how much fluid a resident would need, they said the dietitian would look at new admissions and would help them with those decisions. The DON and CCS #74 were then asked how they tracked and determined whether a resident's intake was sufficient. The DON replied, the CCS's look at the fluid intake total for the day before, for all residents every morning. She stated if a resident had consumed less than 1500 cc of fluid, they would encourage the resident to consume more fluid the following day. Resident #99's low fluid intakes, weight loss, decreased meal intakes, and [MEDICAL CONDITION] episodes were reviewed with the DON and CCS #74. They were asked to provide any information pertaining to notifications of the physician and/or nurse practitioner, any interventions put into place to prevent dehydration, and any information they had pertaining to their monitoring of Resident #99 for signs and/or symptoms of dehydration. At 9:30 a.m. on 11/19/15, the DON provided the following information pertaining to Resident #99. She said while at the hospital, prior to admission to the facility, the resident was given intravenous fluids, and was plumped up on fluids prior to his admission to the facility. She indicated this, in combination with his use of [MEDICATION NAME] - HCT caused the resident to lose weight. The DON was asked to provide any information related to his excess fluid such as their monitoring of his [MEDICAL CONDITION] and/or lung sounds. She was unable to provide any evidence to support the resident was overloaded with fluid upon his admission to the facility. In regards to his fluid deficit on a daily basis during his stay at the facility, the DON indicated the Registered Dietitian just made a recommendation that the resident receive 2111 cc per day and the resident did not require that much fluid to stay hydrated. She stated they encouraged Resident #99 to drink fluids when his intake was less than 1500 cc and the days following his decreased intake it bounced back proving they had encouraged him to drink fluids the following days. She indicated they would not call the physician and consider dehydration unless the resident consumed less than 1000 cc of fluid for three (3) consecutive days. Review of the nursing progress notes showed Resident #99 was encouraged to drink more fluids on the following dates: -- Note dated 08/08/15 at 2:17 p.m. indicated Resident #99's fluid intake was 1410 cc on 08/07/15 and they would encourage fluids. The residents intake was 1740 cc on 08/09/15 according to the facility's intake records. -- Note dated 08/22/15 at 2:32 indicated Resident #99's fluid intake was 1160 cc on 08/21/15. (It should be noted that the facility intake logs for 08/21/15 indicated the resident only consumed 780 cc on 08/21/15 not 1160 cc as noted.) Resident only consumed 1200 cc on 08/22/15 according to the facility's intake records. This amount is still below the facility's practice of 1500 cc per day. -- Note dated 08/15/15 at 12:12 a.m. indicated Resident #99's fluid intake was 860 cc on 08/14/15 will continue to encourage fluid. This note also indicates the nurse practitioner was notified. This is the only indication the physician and/or nurse practitioner was ever notified of the residents decreased fluid intake. On 08/16/15 the residents fluid intake was 1390 cc according to the facility's intake records. This amount is still below the facility's practice of 1500 cc per day. -- Note dated 08/23/15 at 10:47 a.m. indicated Resident #99's fluid intake was 1160 cc on 08/22/15 and they would continue to encourage fluid. Resident only consumed 1500 cc the following day on 08/23/15 according to the facility's intake records. -- Note dated 08/25/15 at 11:32 a.m. indicated Resident #99 drank 1380 cc of fluid on 08/24/15 and they would continue to encourage fluids. The resident was discharged on [DATE] at 2:37 p.m. Resident #99's fluid intake was also below 1500 cc on 08/16/15 with 1390 cc, 08/17/15 with 900 cc, and 08/19/15 with 620 cc. There was no evidence on these dates that nursing identified the resident's lack of fluid intake, nor was there any indication fluids were encouraged. The interview with the DON continued. She stated, He was capacitated we could not make him drink. She stated we gave him fluids with meals and between meals and he had a water pitcher. She said all we could do was encourage fluids. When asked if the facility had assessed Resident #99 for signs and symptoms of dehydration, she indicated they documented by exception and if there was nothing documented then he must not have had any sign or symptoms. The DON stated, Resident #99 did not have a care plan for risk of dehydration because they felt he was not at risk despite his use of a diuretic medication and previous [DIAGNOSES REDACTED]. The DON provided a photocopied page which she stated was part of the Lippincott manual which was what they based their standards of practice on. She referenced the page and stated of the signs and symptoms of fluid and electrolyte imbalances and the only one Resident #99 demonstrated was weight loss greater than five (5) percent. The excerpt was reviewed and contained the following signs and symptoms of fluid and electrolyte imbalances in regards to fluid, Acute weight loss (>5%), drop in body temperature, dry skin and mucous membrane, postural [MEDICAL CONDITION], longitudinal wrinkles or furrows of tongue, oligura (small amounts of urine) or anuria (no urine). The DON was unable to provide any evidence the facility had assessed Resident #99 for any of these signs or symptoms during his stay at the facility, with the exception of body temperature, due to the regular recording of the Resident #99's body temperature. Blood pressures obtained were not taken upon the resident rising from a seated position which is what postural [MEDICAL CONDITION] identification would require. She stated again, We only document to the exception, so if it is not documented, then he must not have had the any symptoms presenting. The DON stated that she had spoken with the resident's attending physician and he felt the resident was not dehydrated when he presented to theER on [DATE]. (The resident's attending physician did not examine Resident #99 at the ER.) She stated the attending physician stated the resident's lab's indicated volume depletion and that he had some kidney problems not dehydration. She stated they had not notified the physician and/or nurse practitioner about Resident #99's fluid deficits or episodes of [MEDICAL CONDITION] because, He (the physician) only wants notified if something is going on with the resident. An interview with the attending physician at 3:00 p.m. on 11/19/15, confirmed he was of the opinion the resident was suffering from volume depletion not dehydration when he presented to theER on [DATE] 24 hours after his discharge from the facility. He stated, Hospitals are too quick to give the [DIAGNOSES REDACTED]. He stated the resident's sodium level would have been higher than 132 if he was dehydrated and that is why he felt it was just a case of volume depletion (Volume depletion can be defined as a reduction in extracellular fluid volume that occurs when salt and fluid losses exceed intake on a sustained basis). He stated the resident also had some kidney issues which was also a factor. The attending physician was also asked if he wanted to be notified if the resident was suffering from [MEDICAL CONDITION]. He stated he would expect to be notified if the resident's systolic number was consistently (more than two (2) or three (3) days) below 90 or 95. He stated he would definitely want to be notified if the systolic number went below 80 just one time. The attending physician was reviewing Resident #99's medical record while participating on the telephone interview via the electronic medical record and stated, on the 18th is was below 80 so I should have been notified. The medical record contained no indication he was notified of the resident's blood pressure on 08/18/15 when Resident #99's blood pressure was 76/59.

Based on medical record review, policy review, and staff interview, the facility failed to provide necessary care and services to avoid physical harm for one (1) of five (5) sampled residents. The facility failed to appropriately monitor Resident #200's glucose levels, failed to assess and monitor a reddened area on the resident's penis, and failed to assess and monitor this resident's intake and output. Resident #200 was admitted to the hospital on [DATE], totally unresponsive, with [DIAGNOSES REDACTED]. Resident identifier: #200. Facility census: 106. Findings include: a) Resident #200 1. Record review revealed Resident #200 was an [AGE] year old white male admitted to this facility on 11/09/10 with [DIAGNOSES REDACTED]. Review of the history and physical, completed by his treating physician on 11/15/10 documented, the resident as being alert and oriented x 4. Review of the admission orders [REDACTED]. Further review found no orders for assessment of the resident's blood glucose levels. - Review of facility policy entitled "Nursing Care of the Adult Diabetes Mellitus Resident" (revised 05/01/06) found, under the section entitled "Purpose", the following language: "... 2. Prevent recurrence of [MEDICAL CONDITION]/[DIAGNOSES REDACTED]. 3. Recognize, assist and document the treatment of [REDACTED]. The section entitled "General Guidelines" contained the following language: "If you observe a diabetic resident or is a diabetic resident complains of any of the following symptoms, report it to the Unit Chare Nurse immediately. [MEDICAL CONDITION] d. malaise (appears tired)... b. lethargy (drowsiness)..." The policy did not provide instructions to the charge nurse for what interventions to provide should the above symptoms be observed or reported. - Review of a complete blood count (CBC) laboratory test from 11/12/10 that the resident's glucose was 265 mg/dl. The physician ordered an Hgb A1c test. The medical record found no evidence this ordered test was provided. A nursing note, written on 11/13/10, documented the following: "Hgb A1c No lab pick up on Saturdays." There was no subsequent documentation in the record to indicate the ordered test was obtained. (See F502 for further details.) - Review of the facility's documentation of the resident's meal intake found the resident consumed no food from the noon meal on 12/04/10 through the noon meal on 12/06/10. The medical record contained no evidence the resident's glucose level was checked at any time during this time period. - Review of the nursing notes found an entry 11/30/10 recorded at 1:18 p.m. which documented that therapy staff reported that "resident is sleeping more than usual". The medical record contained no evidence the physician was notified of this sign / symptom of [MEDICAL CONDITION], nor that the resident's blood glucose was assessed. Further review found a nursing note, written on 12/06/10 at 11:46 a.m. which documented the following (quoted verbatim): "patient is lethargic today. not following instructions... not participating well in therapy today". The medical record contained no evidence that the physician was immediately notified of these signs / symptoms of [MEDICAL CONDITION], nor did the record contain evidence that the resident's glucose was assessed. There was no evidence that nursing staff monitored the resident's condition until he was found, at approximately 5:14 p.m. on 12/06/10, with a decreased level of consciousness and an inability to respond to staff when spoken to. The resident was transported to an acute care facility at approximately 5:30 p.m. on 12/06/10. - Review of the medical records from the acute care facility found the resident was nonresponsive upon arrival at the emergency room . Subsequent laboratory testing found the resident's blood glucose level was of 886 gm/dl (normal range 74 gm/dl to 106 gm/dl), a blood urea nitrogen (BUN) of 115 mg/dl (normal range 7 mg/dl to 18 mg/dl). He was diagnosed with [REDACTED]. Review of the admission and history by the acute care physician found the following statement: "The nursing home could not find a record of his blood sugars." -- 2. Review of the medical record found a nursing note, written at 12:03 p.m. on 11/24/10, documenting: "Patient states his 'penis area' is red." The nurse informed the nurse practitioner, who ordered [MEDICATION NAME] 200 mg every day for seven (7) days. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Further review of the record found no evidence to reflect that nursing staff assessed or monitored the site following the initial resident complaint on 11/24/10. Review of nursing notes from the acute care facility, to which the resident was transferred on 12/06/10, found the following: "Patient has purulent drainage noted from penis." -- 3. Review of the medical record found Resident #200 had an indwelling urinary catheter present upon admission to the facility on [DATE]. Review of the admission MDS, with an assessment reference date of 11/16/10, found Section H was marked as "none of the above" and did not identify that Resident #200 had an indwelling catheter. Review of the care plan found no mention of the resident's catheter, nor any instructions for the care, assessment, and monitoring of the patency of the catheter or assessment of the color, consistency, and amount or urine excreted by the resident on a daily basis. An interview with a corporate nurse (Employee #118), on the afternoon of 07/08/11, revealed that, due to the failure of the assessor to accurately complete the MDS, the resident's indwelling catheter was not addressed in the resident's comprehensive care plan. (See also citations at F278 and F279.) Review of the intake / output records found the section for catheter output had been left blank by facility staff. Further review of the medical record found the resident was found nonresponsive on 12/06/10. He was transported to an acute care facility where he was diagnosed with [REDACTED]. In addition to being indicative of impaired renal function, an elevated BUN is indicative of poor hydration status. Monitoring of fluid intake and output would have afforded the opportunity for early identification of a state of fluid imbalance. .

Based on family interview, medical record review, ambulance personnel interviews, and staff interview, the facility failed to promote care for one (1) of nine (9) sampled residents in an environment that enhanced each resident's quality of life. A facility staff member forced Resident #49 to attend an appointment with a psychiatrist against her will, despite the resident's repeated and vocal statements that she did not want to go. The resident was placed on a gurney, loaded into an ambulance, and subjected to a two-hour trip to attend an appointment which she expressly did not want to attend. It was determined the resident arrived at the appointment in extreme emotional and physical distress. Resident identifier: #49. Facility census: 104. Findings include: a) Resident #49 An interview with Resident #49's daughter, on 11/15/10 at 7:42 p.m., found the daughter was present at a psychiatrist's office on 11/02/10 when her mother arrived by ambulance for a scheduled appointment. The daughter stated her mother was very upset, crying, and extremely short of breath. She relayed that her mother reported to her "they had thrown her out and made her go". She stated her mother was so upset that she was unable to interact with the psychiatrist and that she (the daughter) had to answer the questions posed to her mother by the psychiatrist due to her mother's emotional distress. She stated that both ambulance personnel told her that her mother had refused to go, but the nurse made them take her. An interview was conducted with the resident's son and medical power of attorney representative (MPOA) at 8:10 p.m. on 11/15/10. He stated that he visited the facility on 11/01/10, and was informed that his mother had an appointment with the psychiatrist the following day. He stated he informed Employee #98 (a licensed practical nurse - LPN), "If there was any way possible, I would like her to go, but she probably won't." He stated his mother had regularly refused to attend appointments outside the facility and he had always been notified by nursing staff she was refusing to go. He stated that neither he nor any staff at the facility had forced his mother to attend an appointment against her wished until this incident. He stated that, if the nurse had contacted him, he would have had them cancel the appointment. He stated his mother still refers to the incident and continues to be upset. Review of Resident #49's medical record found [DIAGNOSES REDACTED]. The resident was receiving seven (7) medications for treatment of [REDACTED]. Review of the resident's most recent minimum data set (MDS) assessment, with an assessment reference date (ARD) of 10/14/10, found the resident was assessed as having no hearing difficulty, demonstrating clear speech and understanding of others, and displaying the ability to make herself understood. Her cognitive skills were assessed as modified independence - with some difficulty in new situations only. Review of the nursing notes found the resident was afforded the right to refuse physician appointments on 05/03/10, 05/12/10, 06/04/10, 07/20/10, 07/29/10, 08/19/10, and 09/28/10. An interview with a member of the ambulance crew (AC) who took the resident to the 11/02/10 appointment (AC #1) was conducted at 12:20 p.m. on 11/17/10. He relayed that Resident #49 was alert and oriented and able to answer questions appropriately. He stated the resident repeatedly verbalized that she did not want to go. He stated she was very upset when they arrived at the appointment and accused them of throwing her on a cot and kidnapping her. He stated that neither he nor the second AC personnel wanted to take the resident after she had refused, but the nurse insisted that they take her. He stated the nurse told them that the POA wanted her to go so they had to take her. An interview with AC #2 was conducted via telephone at 3:30 p.m. on 11/18/10. He stated that, when he arrived with AC #1, the resident was using the porta potty. He stated the resident said four (4) or five (5) times that she did not want to go. He stated the resident was alert and oriented and answered questions appropriately. He stated the nurse insisted that the resident had to go, that her son was POA and wanted her to go, and that they had to take her. He stated that, when they arrived at the appointment, the resident could hardly breath and told her daughter that she had been kicked out of the nursing home. An interview with Employee #98 was conducted at 2:40 p.m. on 11/18/10. She confirmed she was the nurse who sent the resident out for the appointment on 11/02/10. She confirmed that Resident #49 had refused to go when the ambulance crew came to pick her up. She agreed she told the ambulance crew that the family wanted her to go and they had to take her. She stated that the resident had been yelling out constantly for help and calling the family in the middle of the night. She stated the son was in wanting a "psych" evaluation to get medicine to make her sleep. When inquiry was made concerning a resident's right to refuse treatment, Employee #98 stated that, if they do not have capacity and the family wants them to go to an appointment, "then I make them go unless the family calls and tells me that the resident does not have to go." She stated that, since the family did not call, she forced the resident to go. When asked if she made any attempts to call the family to inform them that the resident had refused to go to the appointment, she stated that she did not try to call them. An interview was conducted with the administrator and director of nursing at 4:45 p.m. on 11/18/10. Both stated that a resident cannot be forced to go to an appointment if they refuse. The DON stated the family should be notified and the appointment rescheduled. .