Every finding on record at Meeker Nursing Center

Based on record review and interview, the facility failed to ensure residents were offered and/or administered the pneumonia vaccination for 4 (#3, 4, 13, and #24) of 5 sampled residents reviewed for immunizations.The DON identified 47 residents resided in the facility. Findings:A policy titled Pneumoccocal Vaccine, revised October 2019, read in part, Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series with thirty (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated.Pneumococcal vaccines will be administered to residents (unless medically contraindicated, already given, or refused) per our facility's physician-approved pneumococcal vaccination protocol.For residents who receive the vaccines, the date of the vaccination, lot number, expiration date, person administering, and the site of the vaccination will be documented in the resident's medical record.1. An undated diagnoses report showed Res #4 had diagnoses which included pneumonia and chronic obstructive pulmonary disease.A document titled Consent for Vaccination, dated 04/28/23, showed Res #4 gave permission to receive the pneumonia vaccine.There was no documentation in Res #4's medical record the pneumococcal vaccine had been offered and/or administered.2. An undated diagnoses report showed Res #3 had diagnoses which included dementia and cerebral infarction.A document titled, Permission to Administer Vaccines, dated 04/03/24, showed Res #3 gave permission to receive the pneumonia vaccine.There was no documentation in Res #3's medical record the pneumococcal vaccine had been offered and/or administered.3. An undated diagnosis report showed Res #13 had diagnoses which included dementia and Alzheimer's disease.A document titled Consent for Vaccination, dated 10/04/24, showed Res #13 gave permission to receive the pneumonia vaccine.There was no documentation in Res #13's medical record the pneumococcal vaccine had been offered and/or administered.4. An undated diagnoses report showed Res #24 had diagnoses which included dementia and hypertension.A document titled Consent for Vaccination, dated 04/02/25, showed Res #24's representative gave permission for Res #24 to receive the pneumonia vaccine.There was no documentation in Res #24's medical record the pneumococcal vaccine had been offered and/or administered.On 09/10/2025 12:02 p.m., the IP was asked if residents were offered and/or administered pneumonia vaccines upon admission if they were eligible. The IP stated they were new to the IP position and were not knowledgeable of the policy. They stated they were not sure if the pneumonia vaccine had been offered and/or administered to Res #3, 4, 13, and #24.On 09/10/2025 12:45 p.m., the IP stated they could not locate any documentation of Res #3, 4, 13, and #24 ever having been offered or received the pneumonia vaccine. They stated they were not aware the policy showed residents should have been assessed, offered, and administered the vaccine within 30 days of admission until now.

Based on observation, record review, and interview, the facility failed to provide pureed food with accurate serving size and nutritive value.The DON identified three residents on pureed diets.Findings: On 09/08/2025 at 11:32 a.m., cook #1 was observed to perform the puree process. a. Using a gloved hand, cook #1 placed 3 staff handfuls of cooked turkey in the blender, added hot water for consistency, and placed on 3 plates with a spatula.b. Placed 3 4-ounce scoops of dressing in the blender, added hot water for consistency, and placed on 2 plates with a spatula,c. Placed 2 4-ounce scoops of sweet potatoes in the blender, added hot water for consistency, and placed on 2 plates with spatula, andd. Placed gravy on top of the ground turkey. An undated policy Guidelines: Directions of pureeing food, read in part: Add liquid gradually to reach the desired consistency. Suitable liquids include broth, gravy, milk, cream or fruit juice. On 09/08/25 at 11:45 a.m., cook #1 was asked about liquid used for the pureed process. [NAME] #1 stated they used hot water for all hot items that need thinned. [NAME] #1 was asked about measurements of food for servings. [NAME] #1 stated they place amount from menu in the blender for each resident, except meats like turkey and they eyeball those. [NAME] #1 stated after the pureed process was completed, they used the spatula to place on plates and just make sure it looks like equal amounts. [NAME] #1 was asked about amount of food left in the blender. [NAME] #1 stated they just made sure the servings looked right on the plates. On 09/08/25 at 1:20 p.m., the dietary manager was asked about the puree process. The dietary manager stated they used hot water for consistency of food. The dietary manager was asked about measurements of pureed foods. The dietary manager stated they should be using the appropriate scoop for servings that was on menu.

Based on record review and interview, the facility failed to ensure RN coverage for 8 consecutive hours per day for 5 (April 2025 through July 2025) of 5 months of staff schedules reviewed for RN coverage.The administrator identified 47 residents resided in the facility.Findings: A PBJ Staffing Data Report, dated 04/01/25 through 06/30/25, showed during quarter three, the facility did not have RN coverage for 04/05/25, 04/06/25, 04/11/25, 04/12/25, 04/13/25, 04/19/25, 04/20/25, 05/16/25, 05/17/25, 05/30/25, 05/31/25, 06/01/25, 06/07/25, 06/08/25, 06/14/25, 06/15/25, 06/21/25, 06/22/25, 06/28/25, or 06/29/25. Payroll detail reports reviewed for registered nurse coverage for the months of 04/2025 through 08/2025, showed the facility did not have eight consecutive hours per day for 04/01/25, 04/08/25. 04/09/25, 04/10/25, 04/13/25, 04/19/25, 04/20/25, 04/27/25, 04/28/25, 05/03/25, 05/05/25, 05/11/25, 05/12/25, 05/14/25, 05/16/25, 05/17/25, 05/18/25, 05/29/25, 05/30/25, 05/31/25 06/01/25, 06/07/25, 06/08/25, 06/14/2025, 06/15/2025, 06/21/2025, 06/22/2025, 06/25/25, 06/26/25, 06/28/25, 06/29/25, 07/05/25, 07/06/25, 07/12/25, 07/13/25, 07/19/25, 07/20/25, 07/26/25, 07/27/25, 08/02/25, 08/03/25, 08/09/25, 08/10/25, 08/14/25, 08/16/25, 08/17/25, 08/18/25, 08/20/25, 08/23/25, 08/24/25, and 08/30/25.On 09/10/25 at 2:40 p.m., administrator was asked about RN staffing. The administrator stated they were aware of not having an RN on the weekends and had not had one for some time. The administrator stated they had not had any luck finding a weekend RN that would be a good fit for the facility.

Based on observation, record review, and interview, the facility failed to ensure EBP were utilized during urinary catheter care for 1 (#13) of 3 sampled residents reviewed for infection control practices.The DON identified five residents on EBP in the facility and two residents with an indwelling urinary catheter.Findings:On 09/10/25 at 9:48 a.m., LPN #1 was observed performing indwelling urinary catheter care on Res #13. LPN #1 was observed to have worn gloves while performing indwelling catheter care. LPN #1 was not observed to have worn a personal protective gown during the procedure. No PPE was observed inside or near Resident #13's room.An Infection Control/Enhanced Barrier Precautions policy, dated 03/20/24, read in part, EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. EBP are indicated for residents with any of the following: Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO.Indwelling device examples include central lines, urinary catheters, feeding tubes, and tracheostomies.A diagnoses report, dated 09/30/24, showed Res #13 had diagnoses which included malignant neoplasm of prostrate and benign prostatic hyperplasia.A physician order, dated 10/05/24, showed urinary catheter care every shift.A quarterly assessment, dated 07/14/25, showed Res #13 was severely cognitively impaired with a BIMS score of 00. The assessment showed Res #13 had an indwelling urinary catheter.On 9/10/2025 at 10:00 a.m., LPN #1 was asked if any additional PPE should have been worn during the urinary catheter care for Res #13. LPN #1 stated they should have put on a gown because the resident was on EBP. They stated all residents with catheters, peg tubes, and chronic wounds should be on enhanced barrier precautions. LPN #1 stated staff should always wear a gown and gloves during catheter care, changing the catheter, and emptying the catheter.On 09/10/2025 10:15 a.m., the IP stated EBP should have been utilized during care of Res #13's indwelling urinary catheter. The IP stated staff should have worn gloves and a gown while providing care.

Based on observation, record review, and interview, the facility failed to ensure food items were properly sealed, dated, and labeled in the dry storage area, freezers, and refrigerators in the kitchen.The DON reported 47 residents received services from the kitchen.Findings:On 09/08/25 at 10:04 a.m., the following items were observed in the dry storage area:a. 1 opened, undated paper package of pancake mix, not secured in airtight package, b. 1 opened undated package of rice,c. bulk container of cereal, not labelled or dated, andd. bulk container of rice, not labelled or dated.On 09/08/25 at 10:08 a.m., a opened, undated package of frozen biscuits in a plastic bag that was not labelled was observed in the upright freezer: On 09/08/25 at 10:10 a.m., the following items were observed in the upright refrigerator on the far right of the back wall in the kitchen:a. two trays of drinking glasses, filled with liquid, not covered or labelled, b. an undated, unlabeled metal bowl with foil covering. The staff stated it was Jello that was made over the weekend,c. a container of Jello, dated 9/03, without a use by date indicated. A policy Food Receiving and Storage, revised October 2017, read in part, Dry foods that are stored in bins will be removed from original packaging, labeled and dated . all foods stored in refrigerator or freezer will be covered, labeled and dated On 09/08/25 at 1:20 p.m., the dietary manager was asked about food storage, labelling and dating. The dietary manager stated items should be labeled and dated. The dietary manager stated they had not thought about covering open glasses since they were prepared for the next meal, but understood things could fall into them from shelves above or when setting them out. The dietary manager was asked about labelling of dry storage containers and items that were opened such as the pancake mix, being in sealed containers. The dietary manger stated they did not realize the open mix was not in an airtight container and would fix that. The dietary manager stated dry storage should all be labeled with content and date opened.

Based on observation, record review, and interviews, the facility failed to ensure supervision and evaluation during transfers for 1 (#17) of 3 sampled residents reviewed for the use of mechanical lifts and accident hazards. The DON identified nine residents that use mechanical lifts.Findings:On 09/10/25 at 11:15 a.m., CNA #2 and CNA #3 were observed to perform a transfer for Resident #17 using the sit to stand lift. The transfer was completed safely. A lift assessment for Resident #17, dated 02/18/25, showed the resident did not need a lift to transfer. No lift assessment was located in the clinical record since 02/18/25. An in-service, dated 03/24/25, covered the following education:a. demonstrated how to safely use mechanical lifts, andb. review of policy, revised 07/2017, titled Safe Lifting and Movement of Residents which read in part Only staff with documented training on the safe use and care of the machines and equipment used in this facility will be allowed to lift or move residents .at least two nursing assistants are needed to safely move a resident with a mechanical lift.A Certified Nursing Assistant Competency Assessment for CNA#4, with a completion date of 06/05/25, showed a date of hire as 05/07/25. The assessment read in part, Has duty and responsibility of assist with lifting, turning, moving, positioning and transporting resident into and out of beds, chairs, bathtubs, wheelchairs, lifts, etc. There was a Y for competency demonstration. No other documentation of training for mechanical lifts was noted in new hire education. A policy titled Lift Policy, dated 06/06/25, read in part, This facility is to use the mechanical lifts with two staff members for all transfers of newly admitted resident unless they are deemed independent by the nurse.A care plan for Resident #17, initiated 06/23/25, showed the resident required a sit to stand lift at all times with two staff assist with transfers. An Incident report for Resident #32, dated 07/25/25, showed a witnessed fall with no injuries occurred when a CNA was assisting the resident with the sit to stand by themself for a brief change. The report read in part, Educated staff to get help before utilizing equipment and always have a minimum of two person assist.On 09/10/25 at 11:15 a.m., CNA #2 was asked about the use of a mechanical lift. CNA #2 stated they always made sure they had two staff members with any use of the mechanical lift. CNA #2 stated they had in-services for lift use, but it had been a few months ago.On 09/10/25 at 11:20 a.m., CNA #3 was asked about the use of the mechanical lift. CNA #3 stated to always two persons for use, communication between staff on who they use the lifts on, and they have had training. The new CNAs hired were trained by the current CNAs regarding job duties. On 09/11/25 at 12:01 p.m., CNA #4 was asked about sit to stand use. CNA #4 stated they knew now they were to always have two persons, and the resident had to be weight bearing to use the sit to stand. CNA #4 stated they were a new CNA starting in April and they were not taught about sit to stand use in school. CNA #4 stated they were shown by another CNA at the facility, and they did not instruct or educate them correctly on number of staff to use the lift. CNA #4 stated they were told they only needed one staff to change a resident, only two staff if transferring. CNA #4 stated the CNA that did their education at the facility no longer works there and was not a good person to learn from. CNA #4 stated after the incident, the charge nurse did education immediately with them. CNA #4 was asked if there was any education on lifts when hired. CNA #4 stated there may have been, but they did not remember, education was usually CNA to CNA. On 09/11/25 at 12:30 p.m., the DON was asked about evaluation of residents for mechanical lift use. The DON stated if they had therapy, the therapist would tell them, if the resident was non-weight bearing or bedbound they would use them. The DON stated they were not sure if it showed up on the Kardex for the CNA or not, but they usually communicated amongst themself regarding who required a lift and who did not. The DON was asked about education and requirements for staff regarding the use of mechanical lifts. The DON stated they usually knew how to use them when they were hired since they have a certification. The DON stated they did an initial competency check-off for skills they thought had mechanical lifts included. The DON stated a nurse reviewed the check list with them. The DON was asked about care plan updates and lift assessments. The DON stated they were working on getting them all caught up.

Based on record review and interview, the facility failed to ensure a resident was assessed after an accident which resulted in a fracture for 1(#2) of 3 residents sampled for falls. The administrator identified 46 residents resided in the facility. Findings: A facility policy titled Fall and Fall Risk, Managing, dated March 2018, read in part, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try and minimize complications from falling. A quarterly assessment for Resident #2, dated 12/19/24, showed the resident had severe cognitive impairment with a brief interview for mental status score of 00. A Health Status Note for Resident #2, dated 12/28/24 at 2:44 p.m., read in part, resident holding [left] hip and crying out in pain. [Provider name withheld] notified. New order to obtain x-ray due to [left] hip pain. DON [director of nursing] and family notified. A Health Status Note for Resident #2, dated 12/28/24 at 3:38 p.m., read in part, x-ray tech [technician] in facility at this time to obtain x-ray of [left] hip. A Health Status Note for Resident #2, dated 12/28/24 at 7:44 p.m., read in part x-ray results received at this time and reported to [provider name withheld]. New order to send resident out of facility. A Health Status Note for Resident #2, dated 12/28/24 at 9:49 p.m., read in part [hospital name withheld] called to notify that resident has been admitted for surgery. An OSDH Initial Incident Report Form, dated 12/29/24, read in part, Resident was in bed, holding [left] hip and complaining of pain with movement. No previous fall or event noted. X-ray ordered. Results of x-ray indicate possible [left] hip fx [fracture]. Resident sent to ER [emergency room]for [evaluation] .Resident was admitted for treatment of fracture to [left] hip. Investigation in progress. An in-service record, dated 12/30/24 at 1:30 p.m., showed staff were in-service on incident reporting. A Health Status Note for Resident #2, date created 12/30/24 at 11:12 p.m. and note effective 12/27/24 at 5:30 p.m., read in part, [Resident #2] slid self out of recliner in front lobby area. Assisted back to recliner no signs or symptoms of pain or discomfort at time 5:00 p.m. Assisted to wheelchair 30 minutes later taken to dining room for supper, then resident started rubbing both thighs. Unable to state what side is hurting. PRN [as needed] Tylenol [pain medication] given for discomfort. Fed supper by staff, appetite good. A OSDH Initial Incident Report Form, dated 01/02/25, read in part, Investigation completed. [Resident #2] was admitted to [name withheld] hospital for surgical repair of [left] femur fracture and returned to facility. [Resident #2] has history of frequent falls, sliding herself out of recliner or wheelchair. [Resident #2] appears per nursing interview to have slid from recliner to floor on evening of 12/27/24 and assisted by nurses and CMA [certified medication aide] back to chair. According to report [Resident #2] was rubbing both thighs and given Tylenol which appeared to be effective. [Resident #2] did not complain during the night but next day complained of pain and indicated left hip. That is when xrays ordered and fracture noted. [Resident #2] was sent out at that time. Nurses have been inserviced on completing incident report timely, notification of MD [medical doctor] for any fall or injury and obtaining follow up orders or evaluations. Care staff have been inserviced on notification of changes in condition, changes in status, incidents, or injury to charge nurse. Will continue to monitor and address any issues with resident as they may arise. A quality assessment and performance improvement plan, dated 01/30/25, showed the facility identified the root cause, held in-services, and put measures in place to monitor future incidents. On 04/15/25 at 11:20 p.m., the administrator stated upon investigation the nurse failed to complete an incident report or write a note. On 04/15/25 at 12:04 p.m., the administrator stated there was no assessment at the time of the fall. On 04/16/25 at 3:18 p.m., the administrator stated they checked incident reports to ensure all were completed. On 04/16/25 at 3:19 p.m., administrative support staff stated the facility continued to educate on incidents. On 04/16/25 at 3:20 p.m., the administrator stated it was a definite failure and no other residents had an incident like that since.

Based on observation, record review, and interview, the facility: a. Failed to ensure the removal of expired medication/supplies were removed from the medication storage room. b. Failed to ensure a change of direction sticker was placed on a medication card. The Administrator reported 44 residents resided in the facility. Findings: Res #36 admitted to the facility with diagnosis of hyperlipidemia. A physician order, dated 06/09/24, documented Rosuvastin Calcium 10mg Give one tablet by mouth one time a day for Lipid control May give 2-10mg tab to equal 20mg till gone. On 06/27/24 at 7:54 a.m., CMA #1 was observed during medication pass preparing medications for Res #36. The directions on Res #36's card of Rosuvastatin documented to administer the Rosuvastatin 10mg daily. On 06/27/24 at 9:40 a.m., CMA #1 was made aware of resident #36's Rosuvastatin discrepancy order and what the card read. CMA #1 stated they would put a change of direction sticker on the card. On 06/27/24 at 1:59 p.m., a tour of the medication storage room was conducted with CMA #2 The following medications and supplies were observed to be expired: 2 boxes of Covid-19 test kits with an expiration date of 06/30/23, 5 flu swab kits with an expiration date of 02/29/24, 2 culture swabs with an expiration date of 05/31/23, 3 culture swabs with an expiration date of 05/03/24, 1 culture swab with an expiration date of 02/29/24, 7 culture swab kits with an expiration date of 12/31/23, 1- 18ml bottle of instant hand sanitizer with an expiration date of 03/2022, 1- 18ml bottle of instant hand sanitizer with an expiration date of 06/2022, 11 safety blood collection sets + luer adapter with an expiration date of 08/05/22, 7 house stock bottles of Vitamin C 500mg with a pharmacy label expiration date of 06/19/24, 2 house stock bottles of Acetaminophen 500mg with an expiration date of 05/29/24, 1 open house stock bottle of antacid tablets 500mg with an expiration date of 06/05/24, On 06/27/24 at 2:24 p.m., CMA #2 reported the expired medications should have already been removed from the medication/supply storage room. 06/27/24 at 2:25 p.m., LPN #1 reported the expired supplies should have already been removed from the medication/supply storage room.

Based on interview and record review, the facility failed to ensure a resident with a diagnosis of Alzheimer's disease was not given Seroquel (anti-psychotic medication) routinely at bedtime for insomnia for 1 (resident #38) of 5 residents whose records were reviewed for unnecessary medications. Findings: The Administrator identified 44 residents at the facility. Resident #38 admitted to the facility 04/17/24. The MDS, dated [DATE], read in part, .Alzheimer's disease . The Physician Orders, dated 04/17/24, read in part, .Seroquel Oral Tablet 50 MG (Quetiapine Fumarate) Give 1 tablet by mouth at bedtime for insomnia . The April MAR, documented the resident received Seroquel 14 times at bedtime for insomnia. The May MAR, documented the resident received Seroquel 31 times at bedtime for insomnia. The June MAR, documented the resident received Seroquel 25 times at bedtime for insomnia. On 07/01/24, at 10:30 a.m., the DON stated the resident had received Seroquel for insomnia since his admission 04/17/24.

Based on observation, record review and interview the facility failed to administer medications as ordered by the physician for one (#36) of two resident's sampled for medication administration. The Administrator reported 44 residents resided in the facility. Findings: Res # 36 admitted to the facility with diagnoses of hyperlipidemia, atherosclerosis of aorta, and hypertension. A physician's order, dated 06/09/24, documented Rosuvastatin Calcium oral tablet 10mg, give 1 tablet by mouth one time a day for Lipid control May give 2-10mg tab to equal 20mg till gone. On 06/27/24 at 7:54 a.m., CMA #1 was observed during medication pass preparing medications for Res #36. CMA #1 was observed dispensing one tablet of Rosuvastatin 10mg. On 06/27/24 at 9:40 a.m., CMA #1 was made aware of resident #36's physcian's order for Rosuvastatin 10mg 2-10mg tab to equal 20mg till gone. CMA #1 reported he should have administered two tablets.

Based on record review and interview, the facility failed to develop/implement the care plan related to nutrition/significant weight loss. The Administrator reported 44 residents resided in the facility. Findings: Res #20 was admitted to the facility with diagnoses of dementia. Hypothyroidism, anxiety, and depression. A review of the resident's record documented the resident had a significant weight loss of 13.05% in the last six months. A care plan, revised on 04/11/24, contained no documentation of weight loss. On 06/28/24 at 8:50 a.m., the IP/MDS coordinator reported nutrition should have been care planned.

Based on record review and interview, the facility failed to ensure a discharged resident's clinical record contained a discharge summary for one (#44) of three sampled residents reviewed for discharge. The Administrator reported 44 residents resided in the facility. Findings: Res #44 admitted to facility with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side and chronic kidney disease stage 3. The electronic health record documented the resident expired in the facility on [DATE]. The resident's record did not contain a discharge summary. On [DATE] at 10:45 a.m., the DON reported a discharge summary had not been completed

Based on record review and interview, the facility failed to maintain documentation of Covid-19 vaccination status for staff. The Administrator reported 44 residents resided in the facility. Findings: On 07/01/24 at 8:48 a.m., the DON was asked for the staff Covid-19 vaccine documentation. They reported they do not keep documentation of them. On 07/01/24 T 8:48 a.m., the DON reported that the staff are not offered vaccines at the facility, they go to the health department to receive them. The DON was asked if they keep documentation for refusals and she reported no because that is their personal stuff.

Based on record review and interview, the facility failed to implement dietary recommendations to promote wound healing for one (#5) of three sampled residents reviewed for wounds. The administrator identified 39 residents resided in the facility. Findings: Resident #5 had diagnoses that included pressure ulcers (stage 3) and diabetes (type 2). A Dietitian's Recommendation for Primary Care Provider for Resident #5, dated 10/19/23, read in parts, Stage 3 PU to left glute, right glute and right heel .add protein shake, vit C, zinc to assist with wound healing . A Dietitian's Recommendation for Primary Care Provider for Resident #5, dated 11/27/23, read in part, .Remove magic cup and mighty shake from diet order. Remove one of the two diets ordered . The dietitian recommendations for Resident #5 dated 10/19/23 and 11/27/23 were not signed as reviewed by the DON nor signed as addressed by their physician. On 12/07/23 at 10:42 a.m., Corp. Nurse Consult. #1 was asked how recommendations from the dietitian were communicated to the physician. Corp. Nurse Consult. #1 stated dietary recommendations were forwarded to the DON or charge nurse to review and then put in the book for the physician to address. Corp. Nurse Consult. #1 was asked if the above dietary recommendations for Resident #5 to promote wound healing had been implemented. After a review of Resident #5's clinical record they acknowledged the above dietary recommendations had not been reviewed by the DON nor addressed by the physician.

Based on record review and interview, the facility failed to ensure blood pressures were not obtained from a resident's arm, where a dialysis fistula was located, for one (#14) of two residents sampled for dialysis services. The Resident Census and Conditions of Residents report, dated 06/19/23, documented three residents received dialysis services. Findings: A Care of AVF's and AVG's policy, read in part, .Do not use the access arm to take blood pressure . Resident #14 had diagnoses which included acute respiratory failure, type 2 Diabetes Mellitus, and chronic kidney disease stage 4. Blood pressure logs for resident #14 were reviewed for 03/06/23 through 06/20/23, and documented the blood pressure was recorded 25 times in the right arm by licensed and unlicensed staff. Resident #14's Physician's orders, dated 5/20/23, read in part, resident received/returned from .hemodialysis treatment this shift (if yes enter progress note and document VS on dialysis assessment tool) every shift for fistula . A care plan for resident #14, dated 06/07/23 through 08/22/23, read in part, Renal Function .Monitor dialysis site as ordered .Skin Integrity .Fistula to right upper arm dressing C/D/I, No S/SX of infection or active bleeding noted every shift . On 06/22/23 at 11:15 a.m., resident #14 remained in the hospital. There was no posting observed in the resident's room regarding obtaining blood pressures, or reminders not to use the resident's right arm for blood pressures. LPN #1 was asked what arm they would use for obtaining resident #14's blood pressure. The LPN reported they used the left arm. On 06/22/23 at 11:20 a.m., the DON was asked if resident #14's care plan documented the location of the resident's fistula. The DON reported it was documented to be in the right upper arm and this information was located in the plan of care, under the care area of skin. The DON was asked to review the blood pressure readings and asked if there were instructions for staff not to use the right arm when obtaining the resident's blood pressure. The DON stated there were not instructions to use a specific arm.

Based on observation, record review, and interview, the facility failed to monitor the dish washing machine to ensure proper sanitation was being conducted. The DON identified 37 residents who received food service from the kitchen. Findings: On 10/19/21 at 9:00 a.m., during the initial tour, dietary aide #1 was asked how it was determined the dish machine was working properly. Dietary aide #1 stated she did not know but was aware the cook was to test the dish machine with testing strips. The cook was not available during the initial tour. The monthly Temperature/Sanitizer Log, dated 10/2021, did not contain documentation the dish machine had been tested for the morning meals on 10/15/21 or 10/16/21; and any meals from the morning of 10/17/21 thru the morning of 10/19/21. At 10:15 a.m., cook #1 was asked to demonstrate how the dish machine was tested to ensure it was in working order. Cook #1 stated the chemicals in the dish machine were not tested at the breakfast meal and should have. Cook #1 stated the dish machine had two cycles and required two types of test strips. The water was to get to 130 degrees during the cycle. Cook #1 initiated the dish machine to begin a cycle. Chemical tests strips from two containers were obtained. One was labeled chlorine test strips, and the second labeled for QAC-QR test strips. During the cycle, cook #1 moistened each test strip in the outer basin of the dish machine. Cook #1 stated the chlorine test strip read 25 and the QAC-QR strip did not change colors/react. Cook #1 was asked if the dish machine was working properly. Cook #1 stated, I think so. Cook #1 was asked what level/color the chlorine test strip should have been, and if the second strip did not change colors, were the dishes sanitized. He stated, I really don't know. On 10/26/21 at 9:00 a.m., dietary aide #1 stated the test strips were outdated and had to be replaced.

Based on record review and interview, the facility failed to ensure the physician was notified of abnormal/elevated laboratory results for one (#8) of three sampled residents whose laboratory results were reviewed. The Resident Census and Conditions Report identified 38 residents resided in the facility. Findings: Resident #8 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A significant change assessment, dated 05/04/21, documented the resident's cognition was moderately impaired, required assistance with ADLs, and was incontinent of bladder. A care plan, updated 08/02/21, read in parts, .(name withheld) is incontinent of bladder r/t [CONDITION(S)] .Monitor need for/schedule appropriate diagnostic procedures as ordered .Report significant changes in bladder status to physician . On 08/02/21, the resident had lab drawn for a Free and Total PSA (prostate specific antigen). On 08/03/21 the lab reported results, an elevated PSA total of 23.5 ng/ml. Normal reference range < or = 4.0 ng/ml. August 2021 nursing progress notes were reviewed. There was no documentation in the progress notes to ensure the physician had been notified of the elevated lab results. On 10/25/21 at 2:45 p.m., LPN #1 was asked if the physician had been notified of the abnormal lab results. She stated she could not find any documentation he had been notified.

Based on record review and interview, the facility failed to provide complete, informed advance notice of discharge from Medicare Part A skilled services for three (#10, 26, and #236) of three sampled residents who were reviewed for beneficiary protection notification. The business office manager identified 10 residents who had been discharged from Medicare Part A skilled services, with benefit days remaining, in the last six months. Findings: 1. Resident (Res) #10 was discharged from Medicare part A skilled services on 05/06/21, but remained in the facility. Res #10 had been provided Form CMS- , Notice of None [sic] Covered Medicare. The resident signed the notice on 05/04/21. The Notice of None [sic] Covered Medicare Form CMS- , provided to the resident, read in parts, .Your Medicare health plan and/or provider have determined that Medicare probably will not pay for your current {insert type} services .Form CMS -NOMNC (Exp. 10/31/2013) . The Notice of Medicare Non Coverage Form the resident had been provided did not inform the resident of the services that would not be covered as the prompt, on the form, to {insert type} of services had not been completed by the facility. In addition, the facility did not provide Res #10 a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN), informing the resident of potential liability for payment of non-covered services. 2. Res #26 was discharged from Medicare part A skilled services on 04/28/21, but remained in the facility. Res #26 had been provided Form CMS- , Notice of None [sic] Covered Medicare. The resident signed the notice on 04/26/21. The Notice of None [sic] Covered Medicare Form CMS- , provided to the resident, read in parts, .Your Medicare health plan and/or provider have determined that Medicare probably will not pay for your current {insert type} services .Form CMS -NOMNC (Exp. 10/31/2013) . The Notice of Medicare Non Coverage Form the resident had been provided did not inform the resident of the services that would not be covered as the prompt, on the form, to {insert type} of services had not been completed by the facility. In addition, the facility did not provide Res #26 a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN), informing the resident of potential liability for payment of non-covered services. 3. Res #236 was discharged from Medicare part A skilled services on 06/10/21. Res #236 had been provided Form CMS- , Notice of None [sic] Covered Medicare. The resident signed the notice on 06/08/21. The Notice of None [sic] Covered Medicare Form CMS- , provided to the resident, read in part, .Your Medicare health plan and/or provider have determined that Medicare probably will not pay for your current {insert type} services .Form CMS -NOMNC (Exp. 10/31/2013) . The Notice of Medicare Non Coverage Form the resident had been provided did not inform the resident of the services that would not be covered as the prompt, on the form, to {insert type} of services had not been completed by the facility. On 10/21/21 at 2:58 p.m., the business office manager was asked what form was used to inform a resident their Medicare Part A, skilled services were ending. The business office manager stated Form CMS- was the only form they used regardless of whether the resident planned to remain in the facility to receive long term care services or planned to go home. The business office manager was asked when CMS Form , Skilled Nursing Facility Advanced Beneficiary Notice, would be provided to the resident. The business office manager stated they had never used that form. The business office manager was asked how the resident knew what services were not being covered since the type of services prompt on the form had not been completed. The business office manager stated the resident would be informed verbally.

Based on record review and interview, the facility failed to ensure residents were free from physical restraints for one (#138) of two sampled residents who were reviewed for physical restraints. The Resident Census and Conditions Report identified 38 residents resided in the facility. Findings: The Use of Restraints, policy, dated April 2017, read in parts, .Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls .Examples of devices that are/may be considered physical restraints include leg restraints, arm restraints, hand mitts, soft ties or vest, wheelchair safety bars, geri-chairs, and lap cushions and trays that the resident cannot remove . Resident (Res) #138 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An Incident Report, dated 09/04/20, documented on 09/24/20, it was reported via the compliance hotline that on 09/04/20, Res #138 was secured into the wheelchair with a safety velcro sign by CNA #4. CNA #4's statement, dated 09/28/20, documented a velcro stop sign was used while Res #138 was in the wheelchair. The statement documented the velcro sign was left loose, hoping Res #138 would not attempt to get up out of the chair and walk since the resident had fallen that morning. The DON's statement, dated 09/25/20, documented on 09/11/20, CNA #4 had wrapped a stop sign that goes on doorways around Res #138 to try to keep the resident from getting up and falling again. Staff in-services from 06/15/20 through 09/09/20 were reviewed and revealed in-services were conducted on the following dates: 06/15/20; 07/10/20; 08/24/20; and 09/01/20. However, the review did not reveal staff had been in-serviced on the use of restraints. A discharge assessment, dated 03/27/21, documented the resident was severely impaired in cognition for daily decision making, required extensive assistance for bed mobility, transfers, toileting, and personal hygiene, always incontinent of bowel and bladder, and had multiple falls. On 10/27/21 at 11:24 a.m., the administrator was asked why the incident, dated 09/04/20, was not investigated until 09/24/20. The administrator stated they started the investigation when the administrator became aware of the incident. The administrator was asked if all staff had received an in-service on restraints following the incident on 09/04/20. The administrator stated staff should have been in-serviced. The administrator was asked if newly hired employees were in-serviced on the use of restraints. The administrator stated it was not on the new hire checklist. On 10/27/21 at 11:50 a.m., RN #1 was asked if they had been aware of the incident involving Res #138. RN #1 stated yes. RN #1 stated on 09/11/20, Res #138 had fallen that morning and the CNA thought the resident should be tied down in the chair. RN #1 was asked if she had reported the incident. RN #1 stated yes, it had been reported to the administrator that day. RN #1 was asked if an incident report had been completed. RN #1 stated they could not remember. RN #1 was asked if the incident had been documented in the progress notes. RN #1 stated they did not think so. On 10/27/21 at 12:05 p.m., the administrator was asked if the incident dated 09/04/20 could have been 09/11/20 which was reported by RN #1. The administrator stated they were not sure. The administrator was asked if the incident had been reported to her on 09/11/20. The administrator stated they did not remember.

Based on observation, record review, and interview, the facility failed to ensure resident's rights to allow/receive visitors of the resident's choice for two (#7 and #33) of two sampled residents reviewed for visitation. The Resident Census and Conditions Report identified 38 residents resided in the facility. Findings: The Oklahoma State Department of Health (OSDH) guidance on nursing home visitation, dated 08/02/21, read in parts, .Outbreak .Indoor visits suspended .If first round of outbreak testing reveals no additional COVID-19 cases in other areas (e.g., units) of the facility, visitation can resume for residents in areas/units with no COVID-19 cases . An untitled policy, dated 09/14/21, read in parts, .Indoor visitation for unvaccinated residents should be limited solely to compassionate care situations if the COVID-19 county positivity rate is >10% and <70% of residents in the facility are fully vaccinated .If the facility is in outbreak status visitation will cease until first round of facility testing has been completed and no additional positive cases have been identified . LPN #1 identified 30 out of 38 residents (78.9%) had received the COVID-19 vaccination. 1. Resident (Res) #7 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An annual assessment, dated 08/02/21, documented Res #7 had mild cognitive impairment for daily decision making, and the resident reported family or close friend involvement was very important. The care plan, last updated 07/26/21, read in parts .Focus .potential for psychological distress for psychosocial well-being .limitation in place from the pandemic .goal .will demonstrate effective coping skills .interventions .Encourage family-friends to remain involved with resident .Focus .impaired thought processes r/t developmentally delayed .interventions .keep res routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion . A progress note, dated 10/05/21 at 11:05 a.m., read in parts, .Residents and Families were notified that we tested stuff [sic] on 10/01/2021, all of our stuff [sic] were nagative [sic] except one employee. the facility is on quarantine for 14 days we will continue face time and window visit, no body is allowed to come in the facility for visit until further notice . A progress note, dated 10/07/21 at 11:30 p.m., read in parts, .Residents and Families were notified that we tested stuff [sic] on 10/05/2021 and Residents on 10/07/2021 all of our stuff [sic] and Residents were nagative [sic] the facility is still on quarantine for 14 days we will continue face time and window visit, no body is allowed to come in the facility for visit until further notice . A progress note, dated 10/11/21 at 5:32 p.m., read in parts, .Residents and Families were notified that we tested stuff [sic] on 10/08/2021 and all results came back nagative [sic], facility is still on quarantine for 14 days we will continue face time and window visit, no body is allowed to come in the facility for visit until further notice . A progress note, dated 10/14/21 at 4:54 p.m., read in parts, .Residents and Families were notified that we tested stuff [sic] on 10/12/2021 and all results came back nagative [sic], facility is still on quarantine for 14 days we will continue face time and window visit, no body is allowed to come in the facility for visit until further notice. A progress note, dated 10/18/21 at 9:07 p.m., read in parts, .Residents and Families were notified that we tested staff on 10/15/2021 and all results came back nagative [sic]. The facility is only allowing porch visitation by appointment . On 10/19/21 at 8:55 a.m., Res #7 asked the surveyor if the facility was still on lock-down and not letting any one inside. Res #7 asked if the surveyor was going to help get the visitations changed. Res #7 was asked if visitors were allowed to visit. Res #7 stated, Not for a very long time. A progress note, dated 10/19/21 at 11:40 p.m., read in part, .Residents and families were notified that,there is covid19 possibility in our facility and we will be on locked [sic] down until further notice,they were also told that we will have window visitation and face time for right now.all staff and Residents were tested and everybody today was nagative [sic] . On 10/20/21 at 10:02 a.m., LPN #1 was asked if the facility was currently allowing visitation. LPN #1 stated, No. Res #7 was observed in the hall stating the facility was on Lockdown. The LPN was asked what Res #7 meant by the home was in Lockdown. LPN #1 stated the facility was in outbreak testing. LPN #1 stated they were confused because they had received a memo stating they could allow visitation after the first round of outbreak testing. 2. Res #33 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] An admission assessment, dated 10/08/21, documented the resident was severely impaired in cognition, family or significant other participated in completion of the assessment, and reported having family or close friend involved in discussion about care was very important. A progress note, dated 10/05/21, read in part, .Residents and Families were notified that we tested stuff [sic] on 10/01/2021, all of our stuff [sic] were nagative[sic] except one employee. the [sic] facility is on quarantine for 14 days we will continue face time and window visit, no body is allowed to come in the facility for visit until further notice . A progress note, dated 10/07/21, read in part, .Residents and Families were notified that we tested stuff [sic] on 10/05/2021 and Residents on 10/07/2021 all of our stuff [sic] and Residents were nagative [sic] the facility is still on quarantine for 14 days we will continue face time and window visit, no body is allowed to come in the facility for visit until further notice . A progress note, dated 10/11/21, read in part, .Residents and Families were notified that we tested stuff [sic] on 10/08/2021 and all results came back nagative [sic], facility is still on quarantine for 14 days we will continue face time and window visit, no body is allowed to come in the facility for visit until further notice . A progress note, dated 10/14/21, read in part, .Residents and Families were notified that we tested stuff [sic] on 10/12/2021 and all results came back nagative [sic], facility is still on quarantine for 14 days we will continue face time and window visit, no body is allowed to come in the facility for visit until further notice . A progress note, dated 10/18/21, read in part, .Residents and Families were notified that we tested staff on 10/15/2021 and all results came back nagative [sic]. The facility is only allowing porch visitation by appointment. Temperatures will be taken daily when visitors come to see their loved ones. Masks are required as well as hands sanitizing . On 10/19/21, Res #33 became teary stating their family doesn't visit. The resident was asked how long it had been since family had visited. Res #33 stated it had been a long time but stated They know where I am. A progress note, dated 10/19/21, read in part, .Residents and families were notified that, [sic] there is covid19 possibility in our facility and we will be on locked [sic] down until further notice, [sic] they were also told that we will have window visitation and face time for right now. [sic] all [sic] staff and Residents were tested and everybody today was nagative [sic] . On 10/19/21, during entrance conference, the administrator was asked about the facility's current visitation procedures. The administrator stated on 10/18/21 the facility had started allowing outdoor visitation again, by appointment. On 10/27/21 at 11:24 a.m., the administrator was asked why the facility had not been allowing indoor visitation. The administrator stated they had been more strict than CDC but had been allowing compassionate care visitation.

On [DATE] at 12:50 p.m., a past noncompliance Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to provide continuous cardiopulmonary resuscitation (CPR) for resident #3, who had a full code status. On [DATE] at 6:20 a.m., CPR was initiated by licensed practical nurse (LPN) #2 to an unresponsive resident #3. Prior to the arrival of first responders, LPN #1 pronounced the resident as deceased and ordered LPN #2 to stop CPR. The resident's clinical record documented the resident was deceased upon the arrival of first responders. On [DATE] at 12:55 p.m., the Oklahoma State Department of Health (OSDH) verified the existence of the past noncompliance IJ related to the facility's failure to provide continuous CPR, until the arrival of first responders, on an unresponsive resident who had a full code status. At 1:45 p.m., the administrator and the director of nurses (DON) were informed of the past noncompliant IJ related to the facility's failure to provide continuous CPR until the arrival of first responders. On [DATE], the facility initiated an investigation of the incident. Interviews and written statements were obtained from LPN #1, LPN #2, additional staff members, a local police officer (who was a witness to the incident) and the paramedics from the local fire department (who were the first responders). Based on the results of the investigation the facility initiated the following actions; LPN #1 and #2 were reported to the board of nursing, LPN #1 was terminated, LPN #2 was re-educated on continuing CPR until paramedics take over and the protocols for advanced cardiac life support (ACLS). The LPN will be required to complete a basic life saving course along with education provided by the facility. He was advised he can not stop CPR on the command of another nurse. All licensed staff were re-educated on ACLS protocol related to continuing CPR until paramedics take over. The local police department and fire department were advised of the facility policy to continue with CPR until the arrival of paramedics. A new facility policy was developed, dated [DATE], which documented: It is the policy of Meeker Nursing Center to initiate cardiopulmonary resuscitation (CPR) on all residents without a legally signed Do Not Resuscitate form. CPR shall be initiated immediately upon those observed to be without a pulse and/or respiration. CPR shall continue until paramedics with REACT Emergency medical Service, or other accredited emergency medical service, complete advanced cardiac life support and/or the resident is taken to the hospital for further intervention. At no time shall the Nurse (sic) or any other employee(s) of Meeker Nursing Center call time of death or give direction to stop emergency intervention. The facility provided documentation the nursing staff had been individually inserviced, related to the new facility policy, between the dates of [DATE] and [DATE]. The facility also provided documentation a new packet was created for any newly hired staff members. The packet contained a copy of the facility policy related to the provision of CPR. The newly hired employees were required to read and sign a copy of the policy. [DATE] at 10:00 a.m., inservices and information contained in the facility investigation packet were reviewed for subject matter, dates of the inservices and signatures. At 10:50 a.m., interviews were conducted with the two registered nurses and two LPNs (who were on duty at the time) related to their knowledge of the facility policy for providing CPR. They verbalized appropriate responses; they understood the protocol for CPR. Based on record review and interview, it was determined the facility failed to provide CPR until the arrival of first responders for one (#3) of one sampled resident who had a full code status. This resulted in an IJ situation. The facility provided documentation that 17 residents, who resided in the facility, had a full code status. Findings: Resident #3 was admitted to the facility on skilled services on [DATE]. She had [DIAGNOSES REDACTED]. The admission assessment, dated [DATE], documented the resident's cognition was intact, required limited assistance with transfers and ambulation and self-propelled in a wheelchair for ambulation. The care plan, dated [DATE], documented the resident had an activities of daily living self-care performance related to a [MEDICAL CONDITION] of the left leg. A nurse's note, dated [DATE] at 8:03 a.m., documented the nurse was summoned to the resident's room at 6:20 a.m. The resident was lying flat in bed with emesis and food in and around her mouth. The resident was unresponsive without detectible pulses or respirations. The resident was placed on the floor and her mouth was cleared of food Staff was told to call 911 and alert first responders. Chest compressions were initiated and continued until first responders arrived. The resident still had no respirations and pulses. The residents time of death was verbalized at 6:35 a.m. by a first responder. The clinical record documented the man identified as a first responder by LPN #2 was not a first responder: instead, it was a police officer from a local police department. The record also documented the police officer had not called the time of death but had been informed by LPN #1 that she was calling the resident's death at 6:35 a.m. An incident report, dated [DATE], documented: LPN #2 was called to the resident's room. The resident was observed to be in bed, unresponsive with emesis around her mouth and neck. The resident was apneic and without a pulse. LPN #2 placed the resident on the floor and instructed staff to phone 911. The resident's mouth was cleared of food and compressions were started and continued until the first responder arrived. The resident still had no pulse or respirations. The incident report documented an internal investigation was being conducted. The incident report also documented a copy of a police report was obtained on [DATE] at 2:45 p.m. The report documented the 911 call was received at 6:33 a.m., and a police officer arrived on scene at 6:36 a.m. The report documented LPN #1 told the police officer that the resident's time of death was 6:35 a.m. At that time the police officer advised paramedics and the local fire department, everyone can slow down the nurses have called it. The fire department arrived on scene at 6:43 a.m. and no further interventions were rendered. The police officers statement, dated [DATE], documented when he arrived he observed a nurse (later identified as LPN) #2 providing CPR to the resident. A female nurse (later identified as LPN #1) had stated the female had been found cold and unresponsive. The report also documented LPN #1 had advised the male nurse she was calling the time of death at 6:35 a.m. The report documented the police officer contacted dispatch to advise other medical units to slow down because the nurse called the time of death. The dispatch report from the local paramedics, dated [DATE], documented they had been dispatched to the facility at 6:34 a.m.: however, they had been advised at 6:39 a.m., to slow down because the nurses had called it. On [DATE] at 11:28 a.m., the director of nurses (DON) was interviewed. She stated the facility staff should not have stopped CPR before first responders arrived and took over the resuscitation. She added nurses do not have the authority to pronounce a resident's death. At 11:30 a.m., the administrator stated the staff had failed the resident but she felt the police department, fire department, and paramedics should have been aware that a nurse can not pronounce a resident's death and terminate a CPR in progress. She added that was why she had notified everyone of the facility policy related to continuing CPR until the arrival of first responders.

Based on interview and record review, it was determined the facility failed to provide care and services to heal and prevent the development of a new pressure ulcer for one (#1) of three sampled residents. The facility's roster sample matrix, dated 03/14/18, documented four residents were high risk for pressure ulcers. This had the potential to affect the 49 residents who resided in the facility. Findings: Resident #1 was admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. The resident's admit/readmit screener form, dated 11/03/17, documented the resident had a pressure wound on her coccyx. The form described the area, Scabbed over area with bulk leather like escar (sic) 9x5.2 with openings on either end post edge to the left 3x1 cm (centimeter), opened are closest inside buttocks 2.2x1.5. The resident's care plan, last updated 12/06/17, documented the resident's pressure ulcers and interventions the facility had put in place. A wound care specialist's evaluation, dated 12/06/17, documented an unstageable deep tissue injury (DTI) on the left lateral calf a recommendation to add foam every three days. The 12/2017 treatment administration record (TAR) documented the treatment was to apply foam dressing to the deep tissue injury of the left lateral calf every three days, off load wound and reposition often. The treatment was to be completed three times a day. There was a blank undocumented space dated 12/08/17. The treatment was completed for the first time on 12/09/17. A wound care specialist evaluation form, dated 12/13/17, documented a recommendation for the sacrum pressure ulcer was to, Cleanse with hypochlorous acid on gauze 15 minutes then dress. A physician's orders [REDACTED]. The resident's 12/2017 TAR documented the first time the Dakin's treatment was completed for the resident was on 12/18/17. There was an undocumented space for Friday 12/15/17. A health status note, dated 12/30/17, documented, nursing repositioned resident. Found wound to right knee. resident knee has been resting against wall. Area is black with redened (sic) edges. The note documented the director of nursing (DON) was notified. The note documented the DON told the nurse to apply a foam dressing. A wound care specialist evaluation, dated 01/03/18, documented an unstageable pressure ulcer (due to necrosis) of the right knee. The evaluation documented the area was debrided. The evaluation documented to discontinue the foam dressing three times a week and to add calcium alginate, a dry protective dressing, and leptosepermum honey every three days. A health status note, dated 01/03/18 at 1:52 p.m., documented the dressing to the right knee was dry and intact. A health status note, dated 01/04/18 at 9:15 a.m., documented a new order to the right knee, to apply medi honey and calcium alginate with dry protective dressing every three days. The resident's 01/2018 TAR documented a physician's orders [REDACTED]. The first treatment was documented as completed on 01/05/18. The resident was admitted to the hospital on [DATE]. The hospital's emergency room physical exam, dated 01/06/18 at 2:21 p.m., did not document about the resident's knee. The hospital's history and physical (H&P), dated 01/06/18 at 4:56 p.m., documented a 3 centimeter annular ulcer of the right knee. The H&P documented a plan to have physical therapy consult on the resident's stage IV decubitus (on the sacrum), however did not say anything about the knee. On 03/27/18 at 2:25 p.m., the director of nursing (DON) was shown the 12/13/17 physician's orders [REDACTED]. The DON was asked why the resident's treatment with the Dakin's solution was not done on the 15th. She reviewed the resident's electronic record and stated the documentation did not say why the treatment had not been done on 12/15/17. On 03/27/18 in the afternoon, the DON was asked how the resident had gotten an unstageable pressure ulcer on her right knee. She stated the resident had been positioned with her knee against the wall. She was asked if she had investigated how long the resident had been in that position. She stated she had not. On 03/29/18 at 1:00 p.m., the DON was called and asked what the facility had done once the resident developed the right knee pressure ulcer. She stated they had moved the resident's bed, used pillows for positioning, and added pillows to protect all areas.

Based on observation, record review and interview, it was determined the facility failed to implement interventions to prevent the development of avoidable pressure ulcers for one (#44) of three sampled residents with pressure ulcers. Within 23 days of admission, the resident, who was admitted to the facility with no pressure ulcers, had developed one stage 2 and two unstageable pressure ulcers. The facility identified two residents with pressure ulcers and 15 residents receiving preventative skin care. Findings: An undated facility policy titled Managing and Preventing Pressure Sores documented: .Goal To reduce the frequency and severity of pressure sores; to reduce problems and complications when such ulcers do develop . Policy .Attending physicians and nursing staff should both monitor skin integrity, and implement appropriate preventive and treatment measures . Procedure .The nursing staff will notify the attending physician in a timely fashion of early pressure sores which occur between physician visits, so that appropriate treatment measures may be implemented promptly .The attending physician should be aware of the resident's nutritional status and order appropriate changes or supplements, when needed. As indicated, the attending physician may also order a high protein diet; order a multivitamin with zinc; check hematocrit and protein levels; and debride, or order debridement of, a wound site . Prevention of Pressure Ulcers .The C.N.A. (certified nursing assistant) will do a head to toe skin assessment at each shower/bath with every resident in facility at least weekly .if any skin issues are found they will be documented on the skin sheet .The skin sheet will be handed in to the Charge Nurse for further assessment .The Charge nurse will check the residents skin issue, and call the physician to get any treatment orders needed .The C.N.A.'s will turn and reposition each resident every 2 hours or more frequently if directed to do so in the plan of care . Resident #44 was admitted to the facility, on 03/06/17, with [DIAGNOSES REDACTED]. admission orders [REDACTED]. The clinical record documented the resident's weight was 110.0 pounds on 03/06/17. A weekly skin integrity review, dated 03/06/17, documented the resident's skin was intact, had a fractured right humerus, and had swollen bruises to the left upper extremity, right upper extremity, left hip, spine and abdomen. A risk assessment (Braden scale) for predicting pressure ulcers, dated 03/06/17, documented a score 16.0, which indicated the resident was at risk for developing pressure ulcers. The Medication Administration Record, [REDACTED]. The record documented the resident began receiving the Boost on 03/07/17, however, did not document how much of the supplement the resident consumed. The clinical record documented the resident's weight was 109.0 pounds on 03/13/17. An admission assessment, dated 03/13/17, documented the resident was able to make herself understood, sometimes understood others and was severely impaired in cognitive function. The assessment documented the resident required extensive assistance of one or two staff for all ADL's (activities of daily living) except for eating, for which she required supervision and setup assistance. The assessment documented the resident had impairment of functional range of motion of one upper extremity and required the use of a wheelchair for mobility. The resident was at risk for pressure ulcers, had no current pressure ulcers, no venous/arterial ulcers, no other skin conditions and was not receiving any skin treatments. The CAAs (care area assessment summary) for the assessment documented nutrition and pressure ulcers were to be care planned. The resident's care plan, initiated 03/17/17, documented the resident had a problem with pressure ulcers, however, did not contain any interventions to prevent or treat pressure ulcers. The care plan did not address nutrition. A weekly skin integrity review, dated 03/23/17, documented the resident's skin was intact, dry and had bilateral heel blisters to which skin prep was applied. The treatment administration record, dated March 2017, documented a treatment order, dated 03/23/17, for skin prep to be applied to bilateral heels and coccyx area bid (twice daily) for skin integrity. The record documented the treatments were performed bid, from 03/23/17 through 03/29/17, and were dc'd (discontinued) on 03/30/17. A physician's orders [REDACTED]. The treatment administration record, dated March 2017, documented, .Mighty shakes TID c (with) meals FYI (for your information) . The record did not document the supplement was given or how much of the supplement the resident consumed. A nurse's note, dated 03/29/17 at 6:20 p.m., documented, .opened areas on both heels and right upper post buttocks. Measurements are as follows .R (right) outer heel 6 cm (centimeters) wide x (times) 4 cm long with dark maroon center posterily (posteriorly) .L (left) posterior heel 3 cm long x 5 cm wide black, unable to deremine (determine) depth on both d/t (due to) escar (eschar) .R upper buttocks, open area 2.5 cm wide x 2 cm long x 0.1cm deep .Dr (Name deleted) notified and will be here to see res (resident) in afternoon. Dtr (daughter Name deleted) notified of skin issues, tx, and Dr .visit. A nurse's note, dated 03/30/17 at 8:13 p.m., documented, Seen by Dr (Name deleted) this day for skilled services, n/o (new orders) 1. cleanse bilateral heels with ns (normal saline), pat dry with 4x4 (gauze), apply skin prep to outter (outer) edge of wound, cover with [MEDICATION NAME], secure with [MEDICATION NAME] (adhesive/tape) once daily and prn (as needed), 2. Wound consult with Dr (Name deleted wound physician) 3. Pre [MEDICATION NAME] next lab (laboratory) day 4. protein shakes tim (tid) in between meals .9. air mattress d/t wounds 10. dc (discontinue) prev (previous) skin prep order 11. clean rt (right) buttocks open area with normal saline, pat dry with 4x4, apply [MEDICATION NAME] and secure with tape. change daily and prn. A wound care specialist initial evaluation, dated 04/04/17, documented two unstageable pressure ulcers of greater than five days duration to bilateral heels. The ulcer to the right heel measured 4.2 cm L (length) x 2.0 cm W (width) x D (depth) not measurable, with 100% thick adherent black necrotic tissue (eschar) and no exudate. The ulcer to the left heel measured 3.7 cm L x 3.2 cm W x D not measurable, with 100% thick adherent black necrosis and no exudate. Both ulcers were debrided. Orders for wound care were dry protective dressing once daily and Santyl once daily. Recommendations made were to float heels in bed, off load wounds, reposition per facility protocol, obtain a [MEDICATION NAME] and if the resident did not have a dietician following her, he recommended dietary consultation for abnormal BMI (body mass index). A lab (laboratory) result documented a pre-[MEDICATION NAME] was drawn on 04/04/17. The result was 9.4 L (low) with a reference range of 17.0 - 40.0. The [MEDICATION NAME] was 3.0 L with a reference range of 3.5 - 5.7 and total protein was 5.5 L with a reference range of 6.4 - 8.9. The clinical record documented the resident's weight was 101.0 pounds on 04/07/17, which was an eight pound or 7.3 % severe weight loss. A weight change note made by the DON (director of nursing), dated 04/07/17 at 1:11 p.m., documented, res (resident) had 9 pounds weight loss in 30 days .will continue with current plan of care. The treatment administration record, dated April 2017, documented the staff began floating the resident's heels while in bed on 04/10/17 and continued through the end of the month. A nutrition/dietary note made by the consultant registered dietician, dated 04/24/17 at 4:38 p.m., documented, .CBW (current body weight) .4/10/17 103.2# (pounds), 4/7/17 101# (pounds) .Diet order is Regular. Res feeds self with supervision. PO (oral) intake is poor to fair per TASK (activities of daily living) documentation. Wounds remain and continue to be treated. Recent lab values 4/10/17 .[MEDICATION NAME] 3.0(L), Protein 5.5 (L) REC (recommendations) .Decubivite to aid wound healing .Resource 2.0 90 ml (milliliters) TID = 540 cal (calories), 22 gm (grams) Pro (protein). Cont (continue) to monitor wt (weight) status and PO intake . The recommendations were not implemented until the physician signed them on 05/17/17. A lab result, dated 04/27/17, documented the resident's [MEDICATION NAME] was 2.7 L with a reference range of 3.5 - 5.7 and total protein was 5.2 L with a reference range of 6.4 - 8.9. The resident's care plan, updated on 05/01/17, documented a problem of multiple pressure ulcers. The following interventions were initiated on 05/01/17: .The resident requires the bed as flat as possible to reduce shear . Administer medications as ordered . Administer treatments as ordered . Assess/record/monitor wound healing. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD (medical doctor) . Educate the resident/family/caregivers as to causes of skin breakdown; including: transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning . Follow facility policies/protocols for the prevention/treatment of [REDACTED]. Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated . Treat pain as per orders prior to treatment/turning etc. to ensure The resident's comfort . Weekly treatment documentation to include measurement of each area of skin breakdown's width, depth, type of tissue and exudate . A weight change note made by the DON (director of nursing), dated 05/10/17 at 2:58 a.m., documented, .current weight 101.2 lbs (pounds) . - (minus) 2 lb loss x 30 days .Supplements given if intake less than 50% .requires cues to finish eating, and is in dining room for all meals. Weight is monitored weekly. Continue Current POC (plan of care). A nutrition/dietary note made by the DON, dated 05/17/17 at 4:48 a.m., documented, dietician recommendations faxed to Dr (Name deleted) office. Also left for his scheduled rounds this afternoon. A wound care specialist evaluation, dated 05/31/17, documented the pressure ulcer to the left ischium was resolved. A nutrition/dietary note made by the consultant registered dietician, dated 06/23/17, documented, June wt. 104.3# Sig (significant) wt loss 7.9% 3 mos. Diet order continues as Regular texture. Res feeds self with supervision. PO intake 50-75% most meals. Noted pressure ulcers to bilateral heels. REC .Decubivite to aid wound healing .Resource 90 cc TID = 540 cal, 22 gm Pro. Con (cont) to monitor wt status and PO intake. A verbal order, dated 06/29/17, documented the resident was to receive a Decubivite capsule (multiple vitamins with minerals) daily for wound healing and Resource 2.0 liquid (nutritional supplement) 90 ml (milliliters) tid (three times daily) for wound healing. A nutrition/dietary note made by the DON, dated 06/29/17 at 4:25 p.m., documented, New order per dietician recommendations to begin Decubivite to aid in wound healing and resource 2.0 90 cc tid. The recommendations were not implemented until the physician signed them on 07/05/17. A verbal order, dated 07/12/17, documented to change the Resource 2.0 liquid (nutritional supplement) to 2 cal 90 ml tid after meals for wound healing. On 07/17/17 at 9:55 a.m., wound care was observed for the resident. The resident was observed to have healing unstageable pressure ulcers to bilateral heels. At 11:13 a.m., the DON (director of nursing) was asked about the resident's skin on admission. She stated the resident had no problems with her skin when she was admitted . She stated the resident developed a stage two pressure ulcer to her coccyx and unstageable pressure ulcers to both heels. On 07/19/17 at 8:35 a.m., the DON was asked what interventions had been put into place to prevent the development of the pressure ulcers. While looking at the clinical record, she stated they should have been turning and repositioning her frequently. After looking at the resident's clinical record and care plan, she stated there had been no interventions put into place until after the development of the three pressure ulcers.

Based on observation, interview and record review, it was determined the facility failed to ensure residents were not neglected and left alone sitting in water, in a locked whirlpool room for more than 120 minutes for one (#53) of four sampled residents who utilized the whirlpool (WP) tub. The resident was placed in the WP room in a tub filled with water and left unattended, unsupervised, without access to the call light, the ability to exit the tub and open the door to the WP room, if she could reach the door. The facility failed to implement it's policy to provide supervision during care and not neglect the resident. The failure to provide supervision caused the resident to feel abandoned, helpless and fearful while being neglected as well as fearing physical harm and mental anguish. This caused mental harm to the resident due to the fact she is no longer able to enjoy the one thing she liked the most at the facility without fear of abandonment. The facility immediately suspended the staff member responsible for the action, and an immediate investigation was begun. The facility immediately provided an in-service for all staff members present during the incident, provided written witness accounts of the incident from all staff involved. The facility provided an in-service for all staff members the night of the incident and again the day following the incident. Facility staff was interviewed regarding the in-services and verified the information had been provided by facility administration. The facility identified 57 residents residing in the facility. Findings: A facility policy documented, Abuse and Neglect It is a policy of this facility that the residents of this facility will be free of abuse, neglect, mistreatment and misappropriation of property. The facility will implement a seven step program for abuse prevention and investigation. Resident #53 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. An annual assessment, dated 03/14/16, documented the resident was cognitively intact, hard of hearing, exhibited clear speech, was able to make herself understood and able to understand others. The assessment further documented the resident considered the choice of choosing between a tub bath and/or a shower to be very important and required supervision during bathing. A care plan, last updated 03/19/16, documented the resident had a self care deficit related to an unsteady gait, history of falls, dementia and the potential to have a decline in function. The care plan goals documented the resident would maintain her current level of function. On 04/26/16 at 10:00 a.m., a review of the facilities 'Reportable Incidents' was reviewed from 01/01/16 through 04/26/16. An incident report, dated 04/22/16 at 6:05 p.m., documented, Res (resident) found by CNA (certified nurse aide) in tub. Res stated she had been left in tub since around 1600 (4:00 p.m.) hrs, (hours) & (and) that another CNA had left her in the tub alone. The report documented the physician and family were notified of the incident. A nurse note, dated 04/22/16 at (illegible time), documented, Res was assisted into whirlpool bath via hydraulic lift chair @ (at) about 1600 hrs. CNA who initiated bath had to leave shift, but passed off care to another CNA, giving her report on Res in WP bath & asking her (new CNA) to stay w/(with) Res while she bathed. At some point p/(after) CNA who had assumed care left Res in WP & went to start getting Res up for evening meal. Toward end of dinner CNA, (#2) came to charge nurse in DR (dining room) & stated that Res had been left in WP, alone since just p/ 1600 hrs. The time was 1800 hrs (6:00 p.m.) CNA's assisted Res out of WP & to get dressed. When I questioned CNA who left Res in WP, she stated that she had given Res emergency call light before leaving her alone in WP room. Nurse told CNA, (#1) that this was unacceptable, that policy for Res safety states that NO RES are to be left unattended in showers or WP bath d/t (due to) Safety, & that policy is posted on walls . A nurse note, dated 04/24/16 at 10:00 p.m., documented, When this nurse went to give the res her night time meds(medications) she noticed that the res had been crying. She talked to the res, and the res said she had been crying all day. She was upset over the incident that happened Friday. She said, 'I was so mad at the time' I couldn't cry, and now I can't stop crying. On 04/26/16 at 10:30 a.m., the director of nurses (DON) was asked to show the surveyor the WP room. The door to the room had a five button key pad for which a 3 digit code would unlock the door. The room was observed to be approximately 8 x 10 feet, with a small whirlpool tub in the middle near the rear wall. A call light/cord hung on the wall to the left side of the tub. One small chair sat in the corner near the door to the room. A laminated sign observed attached to a bulletin board above the tub documented, Do Not Leave Residents Unattended in the Whirlpool Room. The DON was asked how many residents were allowed to use the WP room unsupervised. She stated none were. The DON left the room, but immediately re-keyed the door and re-entered. As she stuck her head inside the door, she stated, If you don't know how to open this door, you cant get out of here. She stated the dead bolt on the door had to be disengaged before the door lock would release. For clarification, she was asked to demonstrate for the surveyor. The DON held the doorknob and then grabbed and twisted the deadbolt lock above the door handle and pulled the door open. She was then asked if a resident left unattended in the WP room would be able to access the door to get out. She stated, Not unless they know how to open it. She was asked if she thought that was safe. She stated, No. She further stated. I don't know why it hasn't been fixed. On 04/26/16 at 11:30 a.m., CNA #2 was interviewed and asked about the above incident. She stated the resident had been placed in the WP room by her and another staff member who had elected to stay over and assist the evening shift CNAs. She was asked if the evening shift had been short staffed that day. She stated no, however, One CNA (#1) was late. She was asked what she remembered about the incident. She stated she noticed the resident was not at her usual place in the dining room for dinner. She stated she reported it to her charge nurse, licensed practical nurse (LPN) #1 and went to look for the resident. She stated she went up and down the halls looking for her as she continued to assist other residents to the dining room for dinner. Once all of the residents were in the dining room, she continued to look for the missing resident. While walking near the nurse's desk she stated she heard a faint cry for help, as she passed the whirlpool room. She stated she opened the door to find resident #53, crying and shivering, sitting in the empty whirlpool tub. She stated she alerted the charge nurse, and the resident was assisted out of the tub. The resident was then dried off and provided blankets for warmth. She was then assisted back to her room and dressed. The CNA was then asked if she thought the resident could have opened the door, had she managed to get out of the tub. The CNA was quiet for a moment and then said, No. She probably couldn't have opened it. She was asked what the resident's demeanor was after she was found in the empty whirlpool tub. She stated the resident was .very upset. She was cold, mad and hungry. The CNA stated the DON was immediately notified of the incident by the charge nurse and then said, (CNA #1) knows we are never to leave a resident in the WP room. I don't know what was wrong with her. On 04/26/16 at 11:45 a.m., the DON was interviewed regarding the incident. She was asked what knowledge she had of the incident. The DON stated, (CNA #1) left (Resident #53) unattended in the tub. She was asked what the facility's response was to ensure an incident like this would not happen again. She stated our policy has always been to not leave residents unattended in the whirlpool room. In addition to the policy, the staff member involved was immediately suspended and an investigation was started. At the conclusion of the investigation, the CNA was terminated. All staff were immediately in-serviced the same night regarding leaving residents unattended. She further stated the CNA involved was reported to the state nurse aide registry for abuse and neglect, compliance rounds were being conducted daily to ensure no residents were left unattended in the WP room. The DON was then asked what was being implemented for independent residents who didn't want or require supervision with bathing, but choose to use the WP. She stated, Nope, can't do it, showers are one thing and whirlpools are totally different. They could drown. At 12:10 p.m., an interview was conducted with the administrator (ADM). She was asked what the facility's response to the incident was. She stated the staff was in-serviced that same night and the incident would be presented during the next QA (quality assurance) meeting to discuss how to keep this from happening again. We are also planning a re-in-service on our next pay day to cover this again. The ADM further stated, In the meantime, staff is not allowed to leave anyone unattended in the WP room. On 04/26/16, from 11:00 a.m. to 11:55 a.m., interviews were conducted with four alert and oriented residents who utilized the whirlpool room on a regular basis. When asked if they had ever been left unattended in the whirlpool room, two of the four stated they had been left unattended. When asked if they had been left unattended in the whirlpool room this week (since the incident), they stated they had not. From 10:30 a.m. to 12:15 p.m., interviews were conducted with the staff regarding leaving residents unattended in the WP room. CNA # 3 was interviewed and asked which of her residents utilized the WP room on a regular basis. She stated resident #57, #53 and one other who only uses the WP room. She was asked what the facility policy was regarding use of the WP room. She stated. Residents are not to be left alone in the tub room under any circumstances. She further stated the facility had just presented an in-service regarding abuse and leaving residents unattended in the WP room. The CNA was asked who she reported any allegations of abuse, neglect or misappropriation of property to. She stated any allegations or observation of abuse or neglect is reported to her charge nurse, immediately. CNA #4 was asked if she had any knowledge of residents being left unattended in the WP room before or since the incident. She stated, Residents are never to be left alone in the WP room. Prior to the in-service she stated, On occasion, I would leave for 2 to 3 minutes to grab supplies, but made sure they had the call light. CNA #5 was asked if she had any knowledge of residents being left unattended in the WP room before or since the incident. She stated she did not. She stated she made sure residents were able to reach the call light. She further stated she received an in-service regarding leaving residents unattended in the WP room. When asked if she could identify signs of abuse and/or neglect. She stated she could and any allegation would be reported to her charge nurse immediately. The staff member also stated she received an in-service about not leaving residents unattended in the WP room. CNA #2 was interviewed again and asked if she had received any in-services recently. She stated she did and they were not to leave any resident alone in the WP room. She was asked how she handled residents who didn't want her in the WP room with them. She identified one resident who didn't want staff in the room with him during bathing and that she allowed him privacy by standing outside the door, until he had covered himself with a towel. CNA #6 was interviewed and asked the same questions. She stated she received an in-service in which it was reported residents are never to be left unattended in the WP room. She further stated she was told if she needed something while in the WP room she was to use the call light or yell out the door. She was asked about allegations of abuse and neglect. She stated she would report any observed allegations of abuse/neglect to her charge nurse immediately. On 04/26/16 at 1:00 p.m., an interview was conducted with resident #53. The resident was alert and oriented to person, place and time. She was observed to be dressed appropriately and was well groomed. The resident was asked to tell the surveyor of her encounter in the WP room on 04/22/16. The resident stated, I thought I was gonna have to jump out of it (WP tub). It made me so mad that girl left me in there like that. She stated she was taken into the whirlpool room by CNA #2 and certified medication aide (CMA) #1. She was asked if she remembered the time she was taken into the tub room. She stated she was placed in the whirlpool tub around 4:00 p.m. by two staff members. CMA #1 left the room and returned with CNA #1. The resident stated CNA #1 sat on the chair near the door for a little while and then said, It's too hot in here. I'll be right back. CNA #1 then left the room. The resident was asked if the CNA gave her the call light before she left the tub room. She stated she did not. The resident stated as she waited for the CNA to return, the water inside the tub turned cold, and she begin to get chilled and started to feel like she had been abandoned. She stated she began to look around for the call light, but the call light cord was hanging on the wall, well out of her reach. She then stated she began to look for something to throw at the door, but could only find a plastic cup. She stated she threw the plastic cup at the door, but the noise it made was not loud enough for anyone to hear. The resident stated she began to get scared and kept trying to think of things to do to get attention from anyone outside. She also stated she feared no one would remember she was there. She stated the water became really cold and she managed to maneuver the drain on the tub to allow the water out. She was asked how long she was in the tub without any water. She stated she wasn't sure and just remembered being afraid, cold and unable to get out. She stated she felt very afraid and helpless and had not felt that way since she had been there. She stated she thought they were going to leave her there all night. She stated her only course of action was to continue to call out for help and finally (CNA #2) heard her cries for help and opened the door. The resident was asked how long she thought she had been in the WP room. She stated, They took me in around 4:00 p.m., and when I got back to my room, it was after 6:30 p.m. She was asked if she had received any more whirlpool tub baths since the incident. She stated, The tub bath was my favorite thing in this place, now I don't know if I can go back in there. I was pretty proud of myself up until this happened, now I'm not sure. The resident's activities of daily living record documented the resident had received no whirlpool tub baths since the incident.

Based on observation, interview and record review, it was determined the facility failed to ensure residents were not left unattended and/or unsupervised for 120 minutes or more after being assisted into the whirlpool room (WP) for one (#53) of four sampled residents who used the whirlpool. The resident was placed in the WP room in a tub filled with water and left unattended, unsupervised, without access to the call light, the ability to exit the tub and open the door to the WP room, if she could reach the door. The facility failed to implement it's policy to provide supervision during care and not neglect the resident. The failure to provide supervision caused the resident to feel abandoned, helpless and fearful while being neglected as well as fearing physical harm and mental anguish. This caused mental harm to the resident due to the fact she is no longer able to enjoy the one thing she liked the most at the facility without fear of abandonment. The facility immediately suspended the staff member responsible for the action, and an immediate investigation was begun. The facility immediately provided an in-service for all staff members present during the incident, provided written witness accounts of the incident from all staff involved. The facility provided an in-service for all staff members the night of the incident and again the day following the incident. Facility staff was interviewed regarding the in-services and verified the information had been provided by facility administration. The facility identified 57 residents residing in the facility. Findings: Resident #53 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. An annual assessment, dated 03/14/16, documented the resident was cognitively intact, hard of hearing, exhibited clear speech, was able to make herself understood and able to understand others. The assessment further documented the resident considered the choice of choosing between a tub bath and/or a shower to be very important and required supervision during bathing. A care plan, last updated 03/19/16, documented the resident had a self care deficit related to an unsteady gait, history of falls, dementia and the potential to have a decline in function. The care plan goals documented the resident would maintain her current level of function. On 04/26/16 at 10:00 a.m., a review of the facilities 'Reportable Incidents' was reviewed from 01/01/16 through 04/26/16. An incident report, dated 04/22/16 at 6:05 p.m., documented, Res (resident) found by CNA (certified nurse aide) in tub. Res stated she had been left in tub since around 1600 (4:00 p.m.) hrs, (hours) & (and) that another CNA had left her in the tub alone. The report documented the physician and family were notified of the incident. A nurse note, dated 04/22/16 at (illegible time), documented, Res was assisted into whirlpool bath via hydraulic lift chair @ (at) about 1600 hrs. CNA who initiated bath had to leave shift, but passed off care to another CNA, giving her report on Res in WP bath & asking her (new CNA) to stay w/(with) Res while she bathed. At some point p/(after) CNA who had assumed care left Res in WP & went to start getting Res up for evening meal. Toward end of dinner CNA, (#2) came to charge nurse in DR (dining room) & stated that Res had been left in WP, alone since just p/ 1600 hrs. The time was 1800 hrs (6:00 p.m.) CNA's assisted Res out of WP & to get dressed. When I questioned CNA who left Res in WP, she stated that she had given Res emergency call light before leaving her alone in WP room. Nurse told CNA, (#1) that this was unacceptable, that policy for Res safety states that NO RES are to be left unattended in showers or WP bath d/t (due to) Safety, & that policy is posted on walls . A nurse note, dated 04/24/16 at 10:00 p.m., documented, When this nurse went to give the res her night time meds (medications) she noticed that the res had been crying. She talked to the res, and the res said she had been crying all day. She was upset over the incident that happened Friday. She said, 'I was so mad at the time' I couldn't cry, and now I can't stop crying. On 04/26/16 at 10:30 a.m., the director of nurses (DON) was asked to show the surveyor the WP room. The door to the room had a five button key pad for which a 3 digit code would unlock the door. The room was observed to be approximately 8 x 10 feet, with a small whirlpool tub in the middle near the rear wall. A call light/cord hung on the wall to the left side of the tub. One small chair sat in the corner near the door to the room. A laminated sign observed attached to a bulletin board above the tub documented, Do Not Leave Residents Unattended in the Whirlpool Room. The DON was asked how many residents were allowed to use the WP room unsupervised. She stated none were. The DON left the room, but immediately re-keyed the door and re-entered. As she stuck her head inside the door, she stated, If you don't know how to open this door, you cant get out of here. She stated the dead bolt on the door had to be disengaged before the door lock would release. For clarification, she was asked to demonstrate for the surveyor. The DON held the doorknob and then grabbed and twisted the deadbolt lock above the door handle and pulled the door open. She was then asked if a resident left unattended in the WP room would be able to access the door to get out. She stated, Not unless they know how to open it. She was asked if she thought that was safe. She stated, No. She further stated. I don't know why it hasn't been fixed. On 04/26/16 at 11:30 a.m., CNA #2 was interviewed and asked about the above incident. She stated the resident had been placed in the WP room by her and another staff member who had elected to stay over and assist the evening shift CNAs. She was asked if the evening shift had been short staffed that day. She stated no, but One CNA (#1) was late. She was asked what she remembered about the incident. She stated she noticed the resident was not at her usual place in the dining room for dinner. She stated she reported it to her charge nurse, licensed practical nurse (LPN) #1 and went to look for the resident. She stated she went up and down the halls looking for her as she continued to assist other residents to the dining room for dinner. Once all of the residents were in the dining room, she continued to look for the missing resident. While walking near the nurse's desk she stated she heard a faint cry for help, as she passed the whirlpool room. She stated she opened the door to find resident #53, crying and shivering, sitting in the empty whirlpool tub. She stated she alerted the charge nurse, and the resident was assisted out of the tub. The resident was then dried off and provided blankets for warmth. She was then assisted back to her room and dressed. The CNA was then asked if she thought the resident could have opened the door, had she managed to get out of the tub. The CNA was quiet for a moment and then said, No. She probably couldn't have opened it. She was asked what the resident's demeanor was after she was found in the empty whirlpool tub. She stated the resident was .very upset. She was cold, mad and hungry. The CNA stated the DON was immediately notified of the incident by the charge nurse and then said, (CNA #1) knows we are never to leave a resident in the WP room. I don't know what was wrong with her. On 04/26/16 at 11:45 a.m., the DON was interviewed regarding the incident. She was asked what knowledge she had of the incident. The DON stated, (CNA #1) left (Resident #53) unattended in the tub. She was asked what the facility's response was to ensure an incident like this would not happen again. She stated our policy has always been to not leave residents unattended in the whirlpool room. In addition to the policy, the staff member involved was immediately suspended and an investigation was started. At the conclusion of the investigation, the CNA was terminated. All staff were immediately in-serviced the same night regarding leaving residents unattended. She further stated the CNA involved was reported to the state nurse aide registry for abuse and neglect, compliance rounds were being conducted daily to ensure no residents were left unattended in the WP room. The DON was then asked what was being implemented for independent residents who didn't want or require supervision with bathing, but choose to use the WP. She stated, Nope, can't do it, showers are one thing and whirlpools are totally different. They could drown. At 12:10 p.m., an interview was conducted with the administrator (ADM). She was asked what the facility's response to the incident was. She stated the staff was in-serviced that same night and the incident would be presented during the next QA (quality assurance) meeting to discuss how to keep this from happening again. We are also planning a re-in-service on our next pay day to cover this again. The ADM further stated, In the meantime, staff is not allowed to leave anyone unattended in the WP room. On 04/26/16, from 11:00 a.m. to 11:55 a.m., interviews were conducted with four alert and oriented residents who utilized the whirlpool room on a regular basis. When asked if they had ever been left unattended in the whirlpool room, two of the four stated they had been left unattended. When asked if they had been left unattended in the whirlpool room this week (since the incident), they stated they had not. From 10:30 a.m. to 12:15 p.m., interviews were conducted with the staff regarding leaving residents unattended in the WP room. CNA # 3 was interviewed and asked which of her residents utilized the WP room on a regular basis. She stated resident #57, #53 and one other who only uses the WP room. She was asked what the facility policy was regarding use of the WP room. She stated. Residents are not to be left alone in the tub room under any circumstances. She further stated the facility had just presented an in-service regarding abuse and leaving residents unattended in the WP room. CNA #4 was asked if she had any knowledge of residents being left unattended in the WP room before or since the incident. She stated, Residents are never to be left alone in the WP room. Prior to the in-service she stated, On occasion, I would leave for 2 to 3 minutes to grab supplies, but made sure they had the call light. CNA #5 was asked if she had any knowledge of residents being left unattended in the WP room before or since the incident. She stated she did not. She stated she made sure residents were able to reach the call light. She further stated she received an in-service regarding leaving residents unattended in the WP room. CNA #2 was interviewed again and asked if she had received any in-services recently. She stated she did and they were not to leave any resident alone in the WP room. She was asked how she handled residents who didn't want her in the WP room with them. She identified one resident who didn't want staff in the room with him during bathing and that she allowed him privacy by standing outside the door, until he had covered himself with a towel. CNA #6 was interviewed and asked the same questions. She stated she received an in-service in which it was reported residents are never to be left unattended in the WP room. She further stated she was told if she needed something while in the WP room she was to use the call light or yell out the door. On 04/26/16 at 1:00 p.m., an interview was conducted with resident #53. The resident was alert and oriented to person, place and time. She was observed to be dressed appropriately and was well groomed. The resident was asked to tell the surveyor of her encounter in the WP room on 04/22/16. The resident stated, I thought I was gonna have to jump out of it (WP tub). It made me so mad that girl left me in there like that. She stated she was taken into the whirlpool room by CNA #2 and certified medication aide (CMA) #1. She was asked if she remembered the time she was taken into the tub room. She stated she was placed in the whirlpool tub around 4:00 p.m. by two staff members. CMA #1 left the room and returned with CNA #1. The resident stated CNA #1 sat on the chair near the door for a little while and then said, It's too hot in here. I'll be right back. CNA #1 then left the room. The resident was asked if the CNA gave her the call light before she left the tub room. She stated she did not. The resident stated as she waited for the CNA to return, the water inside the tub turned cold, and she begin to get chilled and started to feel like she had been abandoned. She stated she began to look around for the call light, but the call light cord was hanging on the wall, well out of her reach. She then stated she began to look for something to throw at the door, but could only find a plastic cup. She stated she threw the plastic cup at the door, but the noise it made was not loud enough for anyone to hear. The resident stated she began to get scared and kept trying to think of things to do to get attention from anyone outside. She also stated she feared no one would remember she was there. She stated the water became really cold and she managed to maneuver the drain on the tub to allow the water out. She was asked how long she was in the tub without any water. She stated she wasn't sure and just remembered being afraid, cold and unable to get out. She stated she felt very afraid and helpless and had not felt that way since she had been there. She stated she thought they were going to leave her there all night. She stated her only course of action was to continue to call out for help and finally (CNA #2) heard her cries for help and opened the door. The resident was asked how long she thought she had been in the WP room. She stated, They took me in around 4:00 p.m., and when I got back to my room, it was after 6:30 p.m. She was asked if she had received any more whirlpool tub baths since the incident. She stated, The tub bath was my favorite thing in this place, now I don't know if I can go back in there. I was pretty proud of myself up until this happened, now I'm not sure. The resident's activities of daily living record documented the resident had received no whirlpool tub baths since the incident.

Based on record review and interview, it was determined the facility failed to notify the physician of a significant change of condition for 2 (#2 and #4) of 11 sampled residents. Both of the residents had repeatedly experienced unintentional severe weight loss over a period of several months. Their physicians had not been notified of the severe weight loss. Forty-five residents resided in the facility. Findings: 1. Resident #4 had [DIAGNOSES REDACTED]. The care plan, dated 07/22/12 and most recently reviewed/revised on 03/28/13, did not address the resident's actual severe weight loss as a problem. The significant change in status assessment, dated 03/16/13, documented the resident had moderate cognitive impairment and had experienced weight loss of 5% or more in the last month or 10% or more in the last 6 months and was not on a physician-prescribed weight-loss regimen. The facility's monthly weight report documented the resident's weights were as follows: 07/2012 - 159.4 pounds 08/2012 - 165.4 pounds 09/2012 - 163.4 pounds 10/2012 - 157.4 pounds 11/2012 - 156.6 pounds 12/2012 - 147.0 pounds - a severe weight loss of 6.13% in 30 days and 10.03% in 90 days 01/2013 - 136.6 pounds - a severe weight loss of 7.07% in 30 days, 13.21% in 90 days and 14.3% in 180 days 02/2013 - 139.8 pounds - a severe weight loss of 10.72% in 90 days and 15.66% in 180 days 03/2013 - 132 pounds - a severe weight loss of 5.57% in 30 days, 10.2 % in 90 days and 19.21% in 180 days 04/2013 - 129.3 pounds - a severe weight loss of 17.85% in 180 days There was no documentation to indicate the resident's physician was notified in 01/2013 regarding the resident's 30-day, 90-day and 180-day severe weight loss which should have been identified during the review of the monthly weights in early 01/2013. There was no documentation to indicate the resident's physician was notified in 02/2013 regarding the resident's 90-day and 180-day severe weight loss which should have been identified during the review of the monthly weights in early 02/2013. There was no documentation to indicate the resident's physician was notified until 03/28/13, regarding the resident's 30-day, 90-day and 180-day severe weight loss. The severe weight loss should have been identified during the review of the monthly weights in early 03/2013. There was no documentation to indicate the resident's physician was notified in 04/2013 regarding the resident's 180-day severe weight loss which should have been identified during the review of the monthly weights in early 04/2013. On 04/16/13 at 10:20 a.m., the surveyor asked the director of nurses (DON) when the residents' monthly weights were obtained. She stated the residents were weighed between the 1st and 5th of each month. The surveyor asked who in the facility reviewed the monthly weights. She stated the weight committee reviewed the monthly weights. On 04/17/13 at 8:05 a.m., the surveyor reviewed the resident's weights with the administrator and the DON. The surveyor asked if the physician had been notified of the resident's severe weight loss in 12/2012, 01/2013, 02/2012, 03/2013 and/or 04/2013. The DON stated the physician was notified on 03/28/13 and gave an order for [REDACTED]. She acknowledged the notification of the physician in 03/2013 would have been approximately 3 weeks after the resident's monthly weight was obtained. 2. Resident #2 had [DIAGNOSES REDACTED]. The care plan, dated 11/28/12, and most recently reviewed/revised 02/28/13, documented the resident had significant weight loss. The goal was that the "resident's weights will slowly stabilize and will not exhibit significant weight loss through next review." Interventions were to "obtain weights as indicated / as ordered and inform (physician) of significant weight loss" and to "offer snacks as ordered / per resident's request and assist resident to eat." A hand written, undated intervention for "fortified shakes" had been added to the intervention column. A significant change in status assessment, dated 02/19/13, documented the resident had moderate cognitive impairment; required extensive assistance with transfer, dressing, toilet use, eating and hygiene; did not ambulate; was incontinent of bowel and bladder; and had experienced weight loss of 5% or more in the last month or 10% or more in the last 6 months and was not on a physician-prescribed weight-loss regimen. The facility's monthly weight report documented the resident's weights were as follows: 11/2012 - 125.8 pounds 12/2012 - 118.3 pounds - a severe weight loss of 5.96% in 30 days 01/2013 - 112.2 pounds - a severe weight loss of 5.15% in 30 days 02/2013 - 108.6 pounds - a severe weight loss of 13.67% in 90 days 03/2013 - 110 pounds 04/2013 - 111 pounds A physician's orders [REDACTED]. A physician's telephone order, dated 12/19/12, documented the resident was to be administered (Resource) 2.0 60 cc with the medication pass. There was no documentation to indicate the resident's physician was notified of her severe 30-day weight loss prior to 12/19/12. The severe weight loss should have been identified during the review of the monthly weights in early 12/2012. There was no documentation to indicate the resident's physician had been notified regarding her ongoing severe weight loss at any time during 01/2013. The registered dietitian's nutritional recommendations report, dated 02/28/13, documented the resident's weight was "(down)". No dietary recommendations and/or physician's response was documented. There was no documentation to indicate the resident's physician was notified in 02/2013 regarding the resident's 90-day severe weight loss which should have been identified during the review of the monthly weights in early 02/2013. On 04/16/13 at 10:20 a.m., the surveyor reviewed the resident's weights with the DON and asked if the physician had been notified of the resident's severe weight loss in 12/2012, 01/2013 and/or 02/2013. The DON stated the physician had ordered Resource 2.0 on 12/19/12. She acknowledged the physician had not been notified of the severe weight losses in 01/2013 and/or 02/2013.

Based on record review, observation and interview, it was determined the facility failed to recognize severe weight loss and intervene to prevent further weight loss. This affected 2 (#2 and #4) of 4 sampled residents whose clinical records were reviewed for weight loss. This deficient practice resulted in actual harm and substandard quality of care for resident #4 who had experienced severe weight loss during 11 time frames between 12/2012 and 04/2013. Also, resident #2 had experienced severe weight loss during 3 time frames between 11/2012 and 02/2013. For both residents, the physician had not been notified of the severe weight loss, no interventions had been initiated to prevent further weight loss, and the care plan had not been revised and/or reviewed to consider if additional interventions were appropriate to prevent further weight loss. The facility's Resident Census and Conditions of Residents documented 3 residents had unplanned significant weight loss/gain. Findings: 1. Resident #4 had [DIAGNOSES REDACTED]. The care plan, dated 07/22/12 and most recently reviewed/revised on 03/28/13, documented the resident "has potential nutritional problem (related to) Dementia (diagnoses)." The goal was that the resident "will comply with recommended diet daily through review date." Interventions included that "Nursing and Dietary monitor my weight and my meal percentages. If necessary a Dietary referral will be made." Interventions added, which were not dated, included weekly weights, med pass 2.0 60 cc (cubic centimeters) 4 times daily and fortified shakes with meals. Supercereal with breakfast was added as an intervention on 03/28/13. The significant change in status assessment, dated 03/16/13, documented the resident had moderate cognitive impairment; required supervision with transfer and ambulation; required limited assistance with dressing, eating and personal hygiene; was dependent upon staff for bathing; was continent of bladder and bowel; and had experienced weight loss of 5% or more in the last month or 10% or more in the last 6 months and was not on a physician-prescribed weight-loss regimen. The facility's monthly weight report documented the resident's weights were as follows: 07/2012 - 159.4 pounds 08/2012 - 165.4 pounds 09/2012 - 163.4 pounds 10/2012 - 157.4 pounds 11/2012 - 156.6 pounds 12/2012 - 147.0 pounds - a severe weight loss of 6.13% in 30 days and 10.03% in 90 days 01/2013 - 136.6 pounds - a severe weight loss of 7.07% in 30 days, 13.21% in 90 days and 14.3% in 180 days 02/2013 - 139.8 pounds - a severe weight loss of 10.72% in 90 days and 15.66% in 180 days 03/2013 - 132 pounds - a severe weight loss of 5.57% in 30 days, 10.2 % in 90 days and 19.21% in 180 days 04/2013 - 129.3 pounds - a severe weight loss of 17.85% in 180 days The consultant dietitian's charting log, dated 12/18/12, documented the dietitian recommended (Resource) 2.0 60 cc 4 times daily. The log documented the resident had a 10% weight loss in 1 month. There was no documentation to indicate the resident's physician was notified in 01/2013 regarding the resident's 30-day, 90-day and 180-day severe weight loss which should have been identified during the review of the monthly weights in early 01/2013. The consultant dietitian's charting log, dated 01/25/13, did not list the resident's name as having weight loss, although she had experienced severe weight loss during the previous 30-day, 90-day and 180-day periods. A physician's telephone order, dated 02/14/13, documented the Resource 2.0 was to be discontinued due to the resident's refusal. There was no documentation to indicate the resident's physician was notified in 02/2013 regarding the resident's 90-day and 180-day severe weight loss which should have been identified during the review of the monthly weights in early 02/2013. The registered dietitian's nutritional recommendations report, dated 02/28/13, documented the resident's weight was "(down)." The dietitian recommended the fortified shakes with meals be continued. (No additional nutritional interventions were considered/initiated even though the resident had continued to experience severe unintended weight loss while she was being provided the fortified shakes with meals. Also, the Resource 2.0 had been discontinued on 02/14/13.) A nutritional review, dated 03/13/13, completed by the dietary manager, documented the resident's current weight was 132 pounds; her meal intake was 37%; she received an 8 ounce fortified shake 3 times daily and consumed 100% of the fortified shake. The nutritional review did not mention the resident's severe weight loss during the previous 6 months nor were any additional interventions for the prevention of further weight loss documented. A nurse's note, dated 03/21/13, documented: "...(Resident) recently started on Hospice (due to) decline, (weight) loss and (increase) in Dementia. (Resident continues to (ambulate) most of the day, (increase) in sleeping noted. (Resident) eats 37% of meals, but drinks 100% of fortified shakes. (Resident's) weight 132 (pounds), (resident) has had 8 (pound weight) loss. (Resident's) physician, family (and) dietitian aware. (Resident) refuses med pass. Will (continue) to monitor resident." The registered dietitian's nutritional recommendations report, dated 03/25/13, documented the resident's weight was "(down)," a loss of 19% during the past 6 months. The dietitian recommended an appetite stimulant and supercereal. The registered dietitian's recommendation letter, dated 03/25/13, documented the dietitian notified the physician of the resident's 19% weight loss during the past 6 months. The dietitian informed the physician the resident had refused the (Resource) 2.0. She asked the physician if the facility could administer an appetite stimulant and supercereal with breakfast. The physician declined the recommendation for the appetite stimulant because the resident was "on Hospice." The physician agreed to the recommendation the resident receive supercereal for breakfast. There was no documentation to indicate the resident's physician was notified until 03/28/13, regarding the resident's 30-day, 90-day and 180-day severe weight loss . The severe weight loss should have been identified during the review of the monthly weights in early 03/2013. There was no documentation to indicate the physician was notified in 04/2013 regarding the resident's 180-day severe weight loss which should have been identified during review of the monthly weights in early 04/2013. On 04/15/13 at 12:20 p.m., the surveyor observed the resident being fed by a staff member in the dining room. Also, throughout the 3 1/2 day survey, the surveyor observed the resident ambulating in the halls with a staff member. On 04/16/13 at 10:20 a.m., the surveyor asked the director of nurses (DON) when the residents' monthly weights were obtained. She stated the residents were weighed between the 1st and 5th of each month. On 04/17/13 at 8:05 a.m., the surveyor reviewed the resident's weights with the administrator and the DON. The surveyor asked if the physician had been notified of the resident's severe weight loss in 12/2012, 01/2013, 02/2012, 03/2013 and/or 04/2013. The DON stated the physician was notified on 03/28/13 and gave an order for [REDACTED]. She acknowledged the notification of the physician in 03/2013 would have been approximately 3 weeks after the resident's monthly weight was obtained. The surveyor asked if, prior to 03/28/13, any intervention had been initiated to prevent further weight loss. The DON stated fortified shakes had been ordered with meals on 11/03/12. The surveyor asked if the fortified shakes with meals had prevented further severe weight loss. The DON stated, "No." The surveyor asked if any other nutritional/caloric supplement had been considered/ordered when the Resource 2.0 was discontinued on 02/14/13. The DON stated, "No." The surveyor asked if the resident's actual severe weight loss had been care planned. She reviewed the care plan and stated, "No." The surveyor asked if the care plan goals and interventions had been reviewed/revised when the resident's severe weight loss continued month after month. The DON stated, "It doesn't appear so." The surveyor asked if the consultant dietitian had recommended any additional nutritional interventions in 01/2013 or 02/2013. The DON stated, "No." The surveyor showed the DON the consultant dietitian's charting log, dated 01/25/13, and asked if the dietitian had recognized the resident's severe weight loss. She stated, "No." The surveyor asked if the resident's name was on the dietitian's weight loss list for 01/2013. The DON stated, "No." 2. Resident #2 had [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The care plan, dated 11/28/12, and most recently reviewed/revised 02/28/13, documented the resident had significant weight loss. The goal was that "resident's weights will slowly stabilize and will not exhibit significant weight loss through next review." Interventions were to "obtain weights as indicated / as ordered and inform (physician) of significant weight loss" and to "offer snacks as ordered / per resident's request and assist resident to eat." A hand written, undated intervention for "fortified shakes" had been added to the intervention column. A significant change in status assessment, dated 02/19/13, documented the resident had moderate cognitive impairment; required extensive assistance with transfer, dressing, toilet use, eating and hygiene; did not ambulate; was incontinent of bowel and bladder; and had experienced weight loss of 5% or more in the last month or 10% or more in the last 6 months and was not on a physician-prescribed weight-loss regimen. The facility's monthly weight report documented the resident's weights were as follows: 11/2012 - 125.8 pounds 12/2012 - 118.3 pounds - a severe weight loss of 5.96% in 30 days 01/2013 - 112.2 pounds - a severe weight loss of 5.15% in 30 days 02/2013 - 108.6 pounds - a severe weight loss of 13.67% in 90 days 03/2013 - 110 pounds 04/2013 - 111 pounds The consultant dietitian's charting log, dated 12/18/12, documented the dietitian recommended (Resource) 2.0 60 cc (cubic centimeters) 4 times daily. The log documented the resident had a 6% weight loss during the past month. A physician's orders [REDACTED]. A physician's telephone order, dated 12/19/13, documented the resident was to be administered (Resource) 2.0 60 cc with the medication pass. There was no documentation to indicate the resident's physician was notified of her severe 30-day weight loss prior to 12/19/12. The severe weight loss which should have been identified during the review of the monthly weights in early 12/2012. The consultant dietitian's charting log, dated 01/25/13, documented the dietitian recommended [MEDICATION NAME] and to increase the (Resource) 2.0 to 90 cc four times daily. The log documented: "5% (weight times) 1 (month)." There was no documentation to indicate the resident's physician had been notified regarding her ongoing severe weight loss at any time during 01/2013. A physician's telephone order, dated 02/14/13, documented the Resource 2.0 was to be discontinued due to the resident's refusal. There was no documentation to indicate any additional intervention to prevent further weight loss had been considered/implemented. The registered dietitian's nutritional recommendations report, dated 02/28/13, documented the resident's weight was "(down)". No dietary recommendations and/or physician's response was documented. There was no documentation to indicate the resident's physician was notified in 02/2013 regarding the resident's severe 90-day severe weight loss which should have been identified during the review of the monthly weights in early 02/2013. The registered dietitian's nutritional recommendations report, dated 03/25/13, documented the resident's weight was "(down)." No dietary recommendations and/or physician's response was documented. On 04/16/13 at 10:20 a.m., the surveyor reviewed the resident's weights with the DON and asked if the physician had been notified of the resident's severe weight loss in 12/2012, 01/2013 and/or 02/2013. The DON stated the physician had ordered Resource 2.0 on 12/19/12. She acknowledged the physician had not been notified of the severe weight losses in 01/2013 and/or 02/2013. The surveyor asked if any interventions had been initiated to prevent further weight loss. The DON stated, "Not other than encouraging snacks." The surveyor asked if the care plan had been reviewed/revised to initiate additional interventions. The DON stated, "No." The surveyor asked if the resident's weight was taken weekly. She stated, "No." The surveyor asked when monthly weights were reviewed to determine if the resident's weight loss was significant/severe. She stated weights were reviewed at a weight meeting on 02/06/13. On 04/18/13 at 9:28 a.m., the surveyor showed the care plan intervention to inform the physician of significant weight loss to the DON and asked if the care plan had been followed. The DON stated, "According to the chart, no."

Based on observations, record review and interviews, it was determined the facility failed to maintain an effective quality assurance (QA) program to identify, assess, monitor and implement corrective interventions to address problems and prevent further occurrences. The facility's QA committee failed to identify systems failures pertaining to recognition of and intervention for residents who had experienced significant/severe weight loss. This deficient practice resulted in actual harm and substandard quality of care. Findings: The facility failed to recognize severe weight loss and intervene to prevent further weight loss. This affected 2 (#2 and #4) of 4 sampled residents whose clinical records were reviewed for weight loss. This deficient practice resulted in actual harm and substandard quality of care for resident #4 who had experienced severe weight loss during 11 time frames between 12/2012 and 04/2013. Also, resident #2 had experienced severe weight loss during 3 time frames between 11/2012 and 02/2013. For both residents, the physician had not been notified of the severe weight loss, no interventions had been initiated to prevent further weight loss, and the care plan had not been revised and/or reviewed to consider if additional interventions were appropriate to prevent further weight loss. The facility's Resident Census and Conditions of Residents documented 3 residents had unplanned significant weight loss/gain. On 04/18/13 at 9:50 a.m., the surveyor asked the administrator if the QA committee had functioned effectively to identify systems failures pertaining to the identification of residents with significant/severe weight loss, assessment to determine the cause of significant/severe weight loss, initiation of interventions to prevent further weight loss, notification of the physician when a resident had significant/severe weight loss, and review/revision of the care plan of a resident with significant/severe weight loss. She stated, "No."

Based on record review, observation and staff interview, it was determined the facility failed to ensure services were provided to maintain a resident's ability to ambulate. This affected 1 (#2) of 2 sampled residents whose clinical records were reviewed for maintenance of their ability to perform activities of daily living (ADLs). The deficient practice resulted in harm to the resident when the facility did not intervene as she declined from ambulating with supervision to not ambulating within a 6-week period. The Resident Census and Conditions of Residents documented 9 residents were independently ambulatory and 6 residents ambulated with assistance or an assistive device. Forty-five residents resided in the facility. Findings: Resident #2 had [DIAGNOSES REDACTED]. A nurse's note, dated 11/08/12, documented the resident "(ambulated) through out facility (without) difficulty..." The admission assessment, dated 11/19/12, documented the resident had moderate cognitive impairment and ambulated with supervision. The care plan, dated 11/28/12, and most recently reviewed/revised 02/28/13, documented the resident "has limited physical mobility (related to) Dementia (diagnosis). The goal was for the resident to "maintain current level of mobility able to walk unassisted through review date." The intervention was as follows: "MOBILITY: (Resident) is able to walk unassisted with the use of railing." Following the care plan review on 02/28/13, the facility had documented "(Continue Plan of Care)." A nurse's note, dated 12/05/12, documented the resident "(ambulated) through out facility (without) difficulty..." A nurse's note, dated 12/17/12 at 4:45 a.m., documented the resident "...was able to walk much better last night than the night before..." There was no documentation in the clinical record to indicate the resident had ambulated since the nurse's note, dated 12/17/12, had been written. Nurse's notes documented the resident's mode for mobility after 12/17/12 was a wheelchair which she self-propelled. The significant change in status assessment, dated 02/19/13, documented the resident had moderate cognitive impairment and did not ambulate during the entire 7 day period prior to the assessment date. Throughout the 3 1/2 day survey, the surveyor frequently observed the resident self-propelling in her wheelchair in the dining room, the lobby or the halls. On 04/16/13 at 10:20 a.m., the surveyor asked the director of nurses (DON) what the facility had done to maintain the resident's ability to ambulate. She stated the resident had never received restorative services. The surveyor asked if the facility had provided any services to maintain the resident's ability to ambulate. The DON stated, "No." On 04/16/13 at 12:53 a.m., the surveyor asked the restorative aide #1 if the resident had ever been assessed to determine if she would benefit from restorative services. She stated the resident had not been assessed or considered for restorative services.