Every finding on record at Methodist Health and Rehab

Based on observation, record review and interviews, the facility failed to ensure an allegation of abuse was reported in a timely manner to ensure accountability, preserve evidence, and prevent further harm for one (Resident #101) of two residents reviewed. The findings include: Review of Medical Diagnosis Report revealed Resident #101 was admitted to the facility with diagnoses that included dementia, osteoporosis and epilepsy. Review of an annual Minimum Data Set [MDS] with an Assessment Reference Date [ARD] of 04/27/2026, and Staff Assessment for Mental Status [SAMS] score of 3, which indicated the resident was severely impaired for daily decision making. Review of Resident #101's Care Plan revealed the resident was dependent on staff for intellectual, emotional, and social needs related to cognitive impairment with an initiation date of 04/27/2022. The care plan also included interventions to encourage Resident #101 to participate in activities: pets, parties. The care plan indicated Resident #101 was one to one (indicating one staff member should be designated to provide care solely to this resident) when the resident became non-verbal or confused. Review of Resident #101's reportable with a discovery date of 4/04/25 at 2:25 AM, was submitted to the Office of Long-Term Care [OLTC] on 04/04/2026 at 10:38 AM. The reportable indicated police, family, administration, and physician were notified [of the incident]. On 06/09/2026 at 3:04 PM, Certified Nursing Assistant [CNA] #10 confirmed working in the closed unit and said suspected abuse should be reported to the Administrator and Director of Nursing [DON] immediately. CNA #10 was not aware of any employee to resident abuse and stated the types of abuse were physical, verbal and sexual. During an interview on 06/09/2026 at 3:11 PM, Licensed Practical Nurse [LPN] #11 stated she was not aware of any residents being pushed or shoved by staff and was not aware of any resident being pulled down by the back of their shirt or pants because it would not be appropriate. LPN #11 stated, Suspected abuse should be reported to the Administrator and DON, and after hours, staff should call the on-call nurse immediately. LPN #11 stated the different types of abuse were verbal, emotional and physical. During an interview on 06/10/2026 at 3:01 PM, the Administrator stated they were not here when a CNA pulled Resident #101 down by the back of their clothing, but it was not appropriate because it was a dignity issue and could have caused Resident #101 to fall and become injured. The Administer revealed CNA #9 was terminated [following the incident]. The Administrator stated that for abuse or suspected abuse, the administrator was to be called right away regardless of the time, the victim should be assessed and separated from the alleged perpetrator. The Administrator revealed that the alleged perpetrator should be suspended during investigation, and Office of Long-Term care contacted within two hours. The Administrator revealed staff are in-serviced on abuse several times a year and they know to call me right away. The Administrator revealed that the incident [with CNA #9 and Resident #101] was not reported in a two-hour period. During an interview on 06/10/2026 at 3:17 PM, the DON stated that while working late the security officer called the DON to the security office. The DON revealed watching a video that showed CNA #9 pulling Resident #101 down to a couch in the closed unit and pushing Resident #101's arm away. DON said, I immediately went to assess Resident #101. DON stated it was time for CNA #9 to leave for the day, CNA #9 was taken to off the hall and told she could not work with Resident #101. The DON stated the different types of abuse were physical, mental, financial, neglect. The DON stated she considered pulling residents down by their clothing and bending and pushing residents away by the arm to be abuse. The DON stated, CNA #9 was suspended then terminated. The DON revealed staff were trained on abuse when hired, and multiple times a year, but CNA #9 had not worked at the facility long. The DON stated that as the Assistant Director of Nursing [ADON] at the time of the incident, the DON did not personally report to the Office Long-Term Care. During a telephone interview on 06/10/2026 at 5:00 PM, CNA #9 stated Resident #101 had gotten extremely agitated including hitting CNA #9, despite multiple attempts to calm the resident down. CNA #9 stated, I was trying to get safe, but she was one to one. CNA #9 revealed trying to keep Resident #101 on the couch until her partner came out of another room because CNA #9 was not feeling well. CNA #9 denied pulling Resident #9 down by resident's clothing and said, I was just redirecting [the resident] to stay on the couch. CNA #9 denied any abuse and stated that when the DON told her she could not care for the resident, CNA #9 left and went to their car. During an interview on 06/11/2026 at 9:33 AM, the Security Officer [SO] revealed working the night CNA #9 had an incident with Resident #101 in April of 2025. The SO stated, I was watching video and noticed a quick flash of white, so I went back to the camera and there was a CNA (identified as CNA #9) wearing a white sweater sitting on the couch in the closed unit with Resident #101. The Administrator asked SO to play video from that night and SO to narrate. The SO revealed Resident #101 was seen repeatedly trying to get up and was being pulled down several times from the back of their pants and/or shirt. The SO pointed out several times where Resident #101 tried to reach out to CNA #9 and was violently pushed away resulting in a scratch on one of residents arms. The SO stated security had no contact with CNA #9. During an interview on 06/11/2026 at 10:00 AM, Registered Nurse [RN]/CNA class instructor, and former administrator until 12/08/2025 stated, CNA #9 claimed to be protecting herself and unborn child because Resident #101 was coming at her. The video showed CNA #9 kept grabbing the back of Resident #101 pants and pulling [the resident] down to the couch in the closed unit. RN/CNA class instructor revealed the incident occurred on the 11PM-7AM shift. She stated, CNA #9 had been trained on how to deal with dementia residents and was terminated because the CNA showed no remorse for the situation. RN/CNA class instructor revealed that this incident was abuse and should have been reported in two hours from discovery. RN/CNA class instructor asked to resume the interview after review of the reportable. During a follow up interview on 06/11/2026 at 10:38 AM, the DON (ADON at the time of the incident) revealed reporting the incident to RN #12 and was not sure when RN/CNA class instructor was notified. The DON stated after watching the video CNA #9 was suspended and witness statements were taken. During an interview on 06/11/2026 at 10:46 AM, RN/CNA instructor, who was the administrator at the time of the incident, stated after reviewing the reportable she remembered that notification was made when she arrived to work about 6:58 AM on 04/04/2025. RN/CNA instructor stated she thought since there was no injury she had more than a 2-hour window to report. RN/CNA class instructor stated staff should have made the notification immediately, but I thought there was 2 hours when there was an injury. RN/CNA class instructor stated the incident should have been submitted in a 2-hour window because you would want to prevent anything from happening to anyone else. Review of CNA #9's employee file contained a document titled, Job Title: CNA which indicated on page 13 that the CNA must be able to be tactful with residents, possess integrity and ethical awareness and cannot possess a direct threat to residents in the facility. Residents must be treated with kindness, dignity and respect. CNA #9 signed the document on 02/12/2025. CNA #9's employee file contained a document titled, Employee Orientation Day 2 signed on 02/17/2025 by CNA #9 which addressed reporting and preventing abuse. Review of a facility policy titled, Abuse Prevention and Procedure & Abuse Investigation Procedure, reviewed 03/02/2020, indicated a residents have the right to be free of abuse. Abuse includes the willful infliction of injury and unreasonable confinement, intimidation and mental anguish. Physical abuse includes placing a resident in a secluded spot as punishment. Abuse should be reported immediately. Report to the charge nurse immediately and they will contact administration and start witness statement; alleged perpetrator should be suspended during the investigation. Review of a facility policy titled Abuse, Neglect, misappropriation and Exploitation, revised 10/18/2022, revealed all personnel including staff, physician, administration and owners will report all allegations of witnessed or suspected abuse or neglect to the designee (administrator) immediately so a report can be made according to state laws and regulations.

Based on observation, record review and interview, the facility failed to ensure one (Resident #101) of two residents reviewed was free from abuse that had the potential to cause mental anguish and/or physical harm. The findings include: Review of Medical Diagnosis Report revealed Resident #101 was admitted to the facility with diagnoses which included dementia, osteoporosis and epilepsy. Review of the annual Minimum Data Set [MDS] with an Assessment Reference Date [ARD] of 04/27/2026, and a Staff Assessment for Mental Status [SAMS] score of 3, which indicated the resident was severely impaired for daily decision making. Review of Resident #101's Care Plan revealed the resident was dependent on staff for intellectual, emotional and social needs related to cognitive impairment with an initiation date of 04/27/2022. The care plan included interventions to encourage Resident #101 to participate in activities: pets, parties, and to be one to one when Resident #101 became non-verbal or confused. Review of Resident #101's reportable with a discovery date of 04/04/2025 at 2:25 AM and submitted to the Office of Long-Term Care [OLTC] on 4/04/2026 at 10:38 AM, revealed a security officer was monitoring cameras and DON was alerted to come view cameras. At 2:20 AM it was noted a female CNA (identified as CNA #9) was seated on the couch in the closed unit next to Resident #101 and resident was trying to get up off the couch. CNA #9 appeared to pull Resident #101 back down to a sitting position on the couch by grasping the back waist of the pants and pulling Resident #101 down several times. CNA #9 was described as grasping Resident #101's left arm, then bending the arm and pushing it away when resident reached for CNA #9. The document indicated that the police, family, administration and physician were notified. No injuries were documented, and two cognitive residents interviewed denied abuse. Review of CNA #9's employee file contained a job description for CNA #9 titled , Job Title: CNA with a description on page 13 that included [the CNA] must be able to be tactful with residents, possess integrity and ethical awareness and cannot possess a direct threat to residents in the facility. Residents must be treated with kindness, dignity and respect per Resident Rights. CNA #9 signed the job description on 02/12/2025. CNA #9's employee file contained documents for Employee Orientation Day 2 signed on 02/17/2025 by CNA #9 which addressed reporting and preventing abuse. During an interview on 06/10/2026 at 3:17 PM, the Director of Nursing [DON] stated that while working late the security officer called the DON to the security office. The DON revealed watching a video that showed Certified Nursing Assistant [CNA] #9 pulling Resident #101 down to a couch in the closed unit and pushing Resident #101's arm away several times. The DON said, I immediately went to assess Resident #101. The DON said Resident #101 appeared to display increased agitation. CNA #9 was taken off hall and informed could not work with Resident #101. CNA #9 denied abusing Resident #101 and was told there was video footage of the abuse taking place. The DON stated the different types of abuse were physical, mental, financial, and neglect. The DON stated they considered pulling Residents down by their clothing and bending and pushing residents away by the arm to be abuse. The DON stated, CNA #9 was suspended then terminated. The DON revealed staff were trained on abuse on hire and multiple times a year, but that CNA #9 had not worked at the facility long. The DON indicated that as the Assistant Director of Nursing [ADON] at the time of the incident, the DON did not personally report to the Office of Long-Term Care and RN #12 was notified immediately. During a telephone interview on 06/10/2026 at 5:00 PM, CNA #9 stated Resident #101 had gotten extremely agitated including hitting CNA #9, despite multiple attempts to calm the resident down. CNA #9 stated I was trying to get safe, but the resident was 1:1. CNA #9 revealed she had been trying to keep Resident #101 on the couch until her partner came out of another room because CNA #9 was not feeling well. CNA #9 denied pulling Resident #9 down by their clothing and said, I was just redirecting [the resident]to stay on the couch. CNA #9 denied any abuse and stated that when the DON told CNA #9 not to care for the resident any longer CNA #9 left and went to her car. CNA #9 said she was called to return to the facility to fill out a witness statement. During an interview on 06/11/2026 at 9:33 AM, the Security Officer [SO] revealed working the night CNA #9 had an incident with Resident #101 in April of 2025. SO said, I was watching video and noticed a quick flash of white, so I went back to the camera and there was a CNA (identified as CNA #9) wearing a white sweater sitting on the couch in the closed unit with Resident #101. The Administrator asked SO to play video footage from that night and for the SO to narrate. SO revealed Resident #101 was seen repeatedly trying to get up and was being pulled down several times from the back of the pants and/or shirt. SO pointed out several times where Resident #101 tried to reach out to CNA #9 and was violently pushed away. SO indicated security had no contact with CNA #9. During an interview on 06/11/2026 at 10:00 AM, Registered Nurse [RN]/CNA class instructor, and former administrator until 12/08/2025 stated, CNA #9 claimed to be protecting herself and her unborn child because Resident #101 was coming at her, but video showed CNA #9 kept grabbing the back of Resident #101 pants or shirt and pulling resident down to the couch in the closed unit. RN/CNA class instructor revealed the incident occurred on the 11 PM-7 AM shift, on 04/04/2025. RN/CNA instructor indicated CNA #9 was trained on how to deal with dementia residents and was terminated because CNA #9 did not show any remorse. RN/CNA class instructor revealed that this incident was abuse and should have been reported within hours of discovery. RN/CNA Class Instructor stated it was a sad situation and Resident #101 could not understand. On 6/11/2026 at 10:38 AM, the DON revealed that witness statements were started right away and all residents on the closed unit were checked on with no concerns found. Reviewed abuse in-service signature sheet showing all staff were in-serviced on abuse from 5/05/2026-6/03/2026. Reviewed in-service education material titled Abuse Recognizing, Reporting and Preventing, revealed residents have the right to be free from abuse, neglect and exploitation. Unreasonable confinement, punishment causing harm or mental anguish is considered abuse. Abuse can come from caregivers, spouses, visitors and family. Placing someone in a secluded spot and hitting or slapping could be considered physical abuse. Review of a facility policy titled, Abuse Prevention and Procedure & Abuse Investigation Procedure, with a review date of 03/02/2020, revealed, residents have the right to be free of abuse. Abuse includes the willful infliction of injury and unreasonable confinement, intimidation and mental anguish. Physical abuse includes placing a resident in a secluded spot as punishment. Abuse should be reported immediately. Report to the charge nurse immediately and they will contact administration and start witness statement; alleged perpetrator should be suspended during the investigation. The survey team verified the termination of CNA #9, the facility's investigation, and the facility's retraining on the topic of abuse that to include all staff, resulting in this incident being cited as past non-compliance.

Based on observations, interviews, and record review the facility failed to ensure Resident #67 received the proper assistive device to prevent accidents and safely transfer from bed to wheelchair using a lift. Specifically, staff utilized a bariatric size sling to transfer Resident #67, when the resident required a medium sized sling, resulting in the resident sliding out of the sling and falling to the floor. The findings include: A review of admission Record revealed Resident #67 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation, type 2 diabetes mellitus, peripheral vascular disease, left knee osteoarthritis, severe protein calorie malnutrition and affective mood disorder. Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date of 05/12/2026 revealed Resident #67 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was independent in daily decision making. Further review indicated the resident had impairment of both sides of the upper and lower extremities. The MDS also indicated Resident #67's functional ability for mobility was dependent on staff for chair/bed to chair transfer. Review of a Progress Note dated 05/29/2026 at 10:21 AM, indicated that during transfer with a mechanical sit to stand lift, Resident #67 slid out of lift pad down to the floor onto buttocks. The progress note also revealed lift pad being used does appear large for resident's size. Review of Resident #67's Care Plan with a revision date of 06/02/2026 indicated the resident was a high risk for falls related to gait/balance problems. The care plan interventions indicated the resident had a fall on 05/29/2026 and all staff were in-serviced on ensuring the lift pad is the correct size for the resident prior to any transfer as well as ensuring residents have proper footwear prior to any transfer. A review of Resident #67's Order Summary revealed an order dated 05/29/2026 that indicated the resident had a potential for injury due to fall without head injury. Interventions for the order were as follows: 1) Vital Signs every shift times 48 hours, and 2) Examine for injuries two times a day for 2 days. An order dated 05/29/2026 indicated redness to left shoulder post fall on 05/29/2029, Interventions for the order were as follows: monitor for injury, pain, or decreased ROM [range of motion] to LUE [left upper extremity] two times a day. During an interview on 06/09/2026 at 2:42 PM Resident #67 stated CNA #3 was transferring the resident using a mechanical sit to stand lift from the resident's bed to the wheelchair. The resident reported the sling CNA #3 used was like an oversized sheet. Resident #67 stated she was not the only one who used it. The resident also reported several of the CNAs had said the sling was too big, but they would adapt the sling and use it anyway. Resident #67 stated [after the fall] the resident was sore for a couple of days and stated regarding the fall it did not feel good. During a phone interview on 06/11/2026 at 11:28 AM, CNA #3 stated she was not sure how it was described but the resident's care plan would indicate to her which sling should be used to transfer Resident #67. She reported the sling she used to transfer the resident was too big so she took it off and tightened it up and it felt right. She indicated Resident #67 was being transferred from the resident's bed to the wheelchair and before arriving at the wheelchair the resident started slipping out of the sling and went to the floor. During an observation and interview on 06/09/2026 at 9:43 AM, CNA #13 indicated resident information such as transfer status and which sling to use could be found on the resident sheet in the worksheet binder that was at the nurses' station. She added that the CNAs should look at the worksheet binder daily for resident information. During an interview on 06/11/2026 at 9:52 AM, the Director of Nursing (DON) indicated the facility had recently started a color-coded system for identifying correct sling sizes. She reported Resident #67 did not have a specific sling size at the time of the fall. The DON indicated that CNA #3 stated to the DON that the sling looked too big and other slings were available on the hall and in the laundry room. During an interview on 06/11/2026 at 12:11 PM, the Administrator reported we had a hole in the system, we did not know we had different sizes of slings. She reported before Resident #67 fell from the sling the staff thought there was one sling size. She reported the staff did not even know where the bariatric sling came from. The Administrator stated, upper management did not know to teach anything different because we did not know there was more than one [sling]. She reported that since the incident the facility has started a color-coded system for identifying correct sling sizes. She indicated a mandatory check-off for proper sling and lift use would conclude later this week for all CNAs. A review of Instructions for use of [name brand] sling, revealed on pages 2 and 3 that the right type and size of slings should be used after proper assessment of each patient/resident's size, condition and the type of lifting situation. Page 11 of the instructions also revealed, before approaching the resident, the caregiver shall always tell the resident what they are going to do and have the correct size sling ready. A review of a facility policy titled, Transfers, with a revised date of 05/29/24, indicated all transfers will be done as per the resident's individualized care plan unless otherwise contraindicated to ensure safe transfers of residents between surfaces. The policy also indicated mechanical lifts require two persons, and manufacturer guidelines should be followed.

Based on observations, interviews and facility document review, it was determined that the facility failed to ensure the survey results were readily available for residents and families to easily view, with the potential to affect all 120 residents who resided in the facility. The findings include: Review of the facility admission Packet provided by the facility to residents and their representatives at admission did not reference the resident's right to ready access to survey results. Review of the Resident Council meeting minutes did not contain any record of the residents' right to survey being provided to the residents. During an observation on 06/11/2026 at 4:26 PM, this surveyor observed that the posted resident rights displayed on the wall of the facility did not include the right to see the results of previous surveys. During an interview while present in a resident council meeting on 06/10/2026 at 2:02 PM, Resident #71 indicated they did not know where the survey results were kept and had not seen it. Resident #61, Resident #86, Resident #88, Resident #92, Resident #106, and Resident #123 who were also present in the resident council meeting relayed that they did not know about any survey results or their location either. All residents present were cognitively intact per BIMS scores. During an observation and interview on 06/10/2026 at approximately 2:30 PM, this surveyor searched the common areas of the facility that were easily accessible by residents and visitors and was unable to locate the documentation that included the survey results. The Director of Nursing (DON) was asked for the location of the results that were available to residents and visitors, was initially unsure of their location, but left to search before returning with a survey results book. During a follow-up observation and interview on 06/10/2026, at 2:45 PM, this surveyor observed the DON return the survey results book to the security officer (SO) who replaced it in the drawer to the left of his desk. The SO desk was located near the 24-hour coded guest and employee entrance at the side of the facility. The DON was asked to confirm this copy of the survey results was the only one available for review and stated the book that had been provided was the only copy maintained for this purpose. There was no survey results book located near the front entrance. The area the desk was located in was accessible to employees, staff, and visitors, but the book was stored in a drawer; anyone needing access to the book to review the survey results would have to ask facility staff to provide the results in order to view them.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure foods were covered or sealed in the freezer and or refrigerator; dietary staff thoroughly washed their hands and changed gloves when contaminated and dietary staff and visitors wear hair restraints when in the kitchen. The findings: 1. On 10/22/24 at 11:12 AM, Dietary Aide (DA) #1 used a rag to clean the top of the food cart and then pushed it to the clean side of the dish washing machine. Without washing her hands, she picked up plates and bowls to be used in portioning the lunch meal and placed them on the cart, using her fingers inside the bowls and plates. During an interview DA #1 stated she should have washed her hands. 2. On10/22/24 at 11:13 AM, DA #9, who was in the dish washing machine room, had hair on his chin with no beard restraint. 3. On 10/22/24 at 11:16 AM, DA #2 picked up cartons of ice cream from the refrigerator and placed them on the cart near the refrigerator. Without washing his hands, he picked up glasses by their rims and placed them on the cart to be used in serving beverages to the residents for lunch. 4. On 10/22/24 at 10:22 AM, an opened box of dinner rolls were on a shelf in the freezer. The box was not covered or sealed. 5. On 10/22/24 at 10:31 AM, the following observations were made on a shelf in the freezer: a. An opened box of pizza dough. The box was not covered or sealed. b. An opened bag of dumplings, the bag had no opened date. c. An opened bag of hamburger buns. The bag was not sealed. 6. On 10/22/24 at 11:39 AM, Dietary Aide (DA) #3 was wearing gloves on her hands when she wiped off spilled oil around the deep fryer with a rag, contaminating the gloves. DA #3 removed fries from the bag and placed them in the deep fryer basket to be cooked and served to the residents for lunch. At 11:42 AM, the DA #3, picked up tray cards and placed them on the counter. However, with the same contaminated gloves, DA #3 picked up the plates and placed them on the counter, touching the inside with the contaminated gloves, which would be used for plating food. At 11:43 AM, DA #3 used the same gloved hand to push grilled cheese down on the grill. DA#3, when interviewed, stated she should have changed gloves and washed her hands. 7. On 10/22/24 at 11:46 AM, an opened bottle of soy sauce, dated 8/31/2024, was on a shelf below the food preparation counter. Some of the sauce had already been partially used. The manufacturer's specification on the bottle indicated to refrigerator after opening. 8. On 10/22/24 at 12:06 PM, Dietary Aide (DA) #2 was on the tray line in the kitchenette, opposite the main dining room, serving lunch meal, DA #2 picked tray cards and placed them on the counter, used a pan to write the date on the tray card and pulled his sleeves up. Without washing hands, DA #2 picked up bowls to be used in portioning food items to be served to the residents for lunch and placed them on the counter with his fingers inside the bowls. At 1:15 PM, DA #2 stated he should have washed his hands. 9. On 10/22/24 at 12:09 PM, DC #3 wiped gloved hands on her apron. Without changing gloves and washing her hands, DC #3 removed cantaloupe and honey dew from the refrigerator and placed them on the cutting board. She sliced them and arranged the pieces on the plates to be served to the residents who asked for it. DC #3, when interviewed, stated she should have washed her hands. 10. On 10/22/24 at12:05 PM, Dietary Aide #4, assisting with lunch meal service, picked up condiments, cartons of milk, shakes, cans of soda and placed them on the trays. Without washing hands, DA #4 picked up glasses that contained beverages by their rims and placed them on the meal trays to be served to the residents for lunch. DA #4, when interviewed, stated she should have washed her hands. 11. On 10/22/24 at 12:10 PM, Dietary Aide #5 was on the tray line in the kitchen serving lunch meal, picked up tray cards and placed them on the trays, contaminating her hands. Without washing her hands, DA #5 picked up bowls to be used in portioning soup and placed them on the counter with fingers inside of them. DA #5, when interviewed, stated she should have washed her hands. 12. On 10/22/24 at 12:16 PM, Dietary [NAME] (DC) #3 was wearing gloves on her hands when she removed strawberries from the original container and placed them on the cutting board. After slicing the strawberries, she arranged them on the plate. While holding the glove box, she took gloves from the box and put them on, contaminating them in the process. Without washing her hands, DC #3 picked up sliced strawberries and placed them on the plate to be served to the resident who asked for it. DC #3 did not rinse strawberries before processing them for consumption. DC #3, when interviewed, stated she should have washed her hands. 13. On 10/22/24 at 12:30 PM, Dietary Aide (DA) #6, while holding the glove box, took gloves from the box and put them on, contaminating them in the process. Without washing her hands, DA #6 picked up the diced tomatoes from the refrigerator and sprinkled them on top of the plated salad to be served to the residents who asked for it. DA #6, when interviewed, stated she should have washed her. 14. On 10/22/24 at 12:35 PM, DA #6 turned on the sink faucet and washed her hands. After, washing her hands, she turned off the faucet, used a tissue to wipe off the water around the sink. Without rewashing her hands, DA #6 then put on new gloves and picked up pans, placing them on the counter using her contaminated gloved fingers. DA #6 removed fried chicken tenders from the deep fryer basket and placed them on the cutting board and began slicing them. DA #6, when interviewed, stated she should have washed her hands. 15. On 10/22/24 at 4:07 PM, DA #6 had gloves on her hands when she washed the blender bowl and blade in the 3-compartment sink. After washing them, she removed the gloves that had been saturated with water and threw them away. Placed new gloves on her hands, contaminating them. Without changing gloves and washing her hands, DA #6 picked up a clean blade and attached it to the base of the blender to be used in pureeing food items, to be served to the residents who required pureed diets for supper. At 4:08 PM, when DA #6 was ready to put beans into the blender. The surveyor immediately interviewed DA #6 who stated she should have washed her hands. 16. On 10/22/24 at 4:20 PM, Dietary Aide (DA) # 7 lifted a trash and threw away tissue paper. Without washing her hands, DA #7, Picked up glasses by their rims and poured beverages to be served to the residents for supper. DA #7, when interviewed, stated she should have washed her hands. 17. On 10/23/24 at 1:30 PM, Dietary [NAME] (DC #10 had hair on his chin was around the food preparation counter with no beard restraint. 18. On 10/23/24 at 1:40 PM, there were two visitors with long hair and long beards in the kitchen. One wore a hat with hair handing out and had no beard restraint. The second visitor with long hair also had no restraints on his hair or beard. 19. A facility policy titled, Hand Washing and Glove use initiated 5/1/2019, and provided by Food and Beverage Director indicated, hands should be washed before beginning work and when in contact with unsanitary surfaces.

Based on interview, and record review the facility failed to formulate an advance directive or have an acknowledgement of an advance directive on file for 2 (Resident # 108, Resident #10) of 8 sampled residents. The findings are: 1. Review of an Order Summary Report indicated, Resident #108 had a diagnosis of personal history of Transient Ischemic Attack. A review of Resident #108's electronic medical record revealed, there was not an advance directive or an acknowledgement of an advance directive on file. On 10/22/24 at 2:28 PM, the Admissions Director indicated Resident #108 did not have an advance directive, or an acknowledgement of an advance directive on file. He indicated that the advance directive should be formulated or acknowledged upon admission. Review of Resident #10 ' s quarterly Minimum Data Set with an Assessment Reference Data 08/29/2024 revealed a Brief Interview for Mental Status (BIMS) of 6 with medical diagnoses of dementia, Alzheimer's disease and post-traumatic stress disorder. On 10/22/24 at 10:38 AM, Resident #10's electronic medical records contained a Physician ' s Order for Life Sustaining Treatment form without any acknowledgement of advance directive information or option provided to the Resident's Representative On 10/22/24 at 1:27PM, Admissions Director and Administrator stated, the resident representative took the admissions packet home to read and fill out. Resident Representative failed to sign the Advance Directive Acknowledgment form. On 10/24/24 12:12PM, Admissions Director confirmed that the Advance Directive was overlooked. A Policy for Advance Directives and Do Not Resuscitate (DNR), reviewed and revised 3/6/2023 and 5/29/2024 showed an Advance Directive is a written, signed and witnessed instruction, which state your choices about medical treatment recognized under state law relating to the health care when the individual is incapacitated. Each competent person has the right to make their own health care decisions. Decisions are to be informed, reasonable choices that include the right to refuse or discontinue life-sustaining treatment. On admission, the facility representative will determine whether the resident has an Advance Directive and advise the responsible party of their right to establish one. The facility Social Service Department will identify the primary decision-maker. A BIMS of 7 or lower does not have the ability to establish an advance directive.

Based on observation, record review, and interview, the facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents for 2 of 2 meals observed. The findings are: 1. The menu for the lunch meal indicated the residents who received pureed diets were to receive 4 ounces (1/2 cup) of pureed shredded lettuce salad and two #8 scoops (1 cup) of chicken and dumpling. a. On 10/22/24 at 12:48 PM, Dietary Aide (DA) #4 used one #8 scoop (1/2 cup) to serve a single portion of pureed chicken and dumpling to the residents on pureed diets, instead of two #8 scoops which was equivalent to 1 cup. b. There was no pureed salad served to the residents on pureed diets for lunch, instead of 4 ounces (1/2 cup) of pureed salad. c. On 10/22/24 at 5:10 PM, DA #5 stated, a replacement should have been given for the pureed salad. d. On 10/22/24 at 5:23 PM, Food and Beverage Director also stated, something else should have been given to the residents in place of the salad. 2. The menu for the supper meal indicated the residents who received pureed diets were to receive 6 ounce (3/4 cup) of pureed baked potato soup. a. On 10/22/24 at 5:07 PM, Dietary Aide (DA) #5 used a 4-ounce spoon to serve a single portion of pureed chicken and dumpling to the residents on pureed diets. During an interview, DA #5 stated that the spoon used was 4 ounces. 3. During an observation on 10/22/24 5:02 PM, the Executive Chef used a knife to dice breaded fried fish, to be served to the residents on mechanical soft diets. He poured diced fish into a pan and placed it on the steam table. When interviewed the Executive Chef stated they do not grind fish, rather they use a knife to chop it. On 10/22/24 at 5:03 PM, the Food and Beverage Director stated mechanical soft diets were supposed to have ground fish and not chopped fish. The physician order will specify if they were supposed to receive chopped meat. On 10/22/24 at 5:22 PM, Dietary Aide (DA) #8 was asked about the size of the breaded fish served to the residents on mechanical soft diets she stated it was 1 to 2 square centimeters (0.39-0.79 inches). DA #8 picked up a crunch piece of the breaded fish and stated, the crunch piece of the breaded fish might be difficult to chew for someone on mechanical diet. On 10/22/24 at 5:23 PM, the Executive Chef and Food and Beverage Director confirmed the size of diced, breaded, fried fish served to the residents on mechanical soft diets were 1 to 2 square centimeters and had crunchy pieces.

50505 Based on observation and interview, the facility failed to ensure 2 (room [ROOM NUMBER], and room [ROOM NUMBER]) rooms were clean to maintain a homelike environment. The findings are: 1. On 10/21/24 at 11:30 AM, trash was observed behind the nightstand in room [ROOM NUMBER]. There was a white cup, an ice cream lid, peanuts, peanut container, pencils, and paper behind the nightstand. On 10/21/24 at 12:30 PM, trash was observed behind the nightstand in room [ROOM NUMBER]. There was a white cup, an ice cream lid, peanuts, peanut container, pencils, and paper behind the nightstand. On 10/21/24 at 2:15 PM, trash was observed behind the nightstand in room [ROOM NUMBER]. There was a white cup, an ice cream lid, peanuts, peanut container, pencils, and paper behind the nightstand. On 10/21/24 at 2:18 PM, Housekeeper #11 indicated there was trash, tissue, and other things behind the nightstand in room [ROOM NUMBER]. Housekeeper #11 indicated that rooms should be cleaned every day, and as needed. On 10/21/24 at 2:19 PM, Housekeeper #12 indicated, there was trash behind the nightstand in room [ROOM NUMBER]. Housekeeper #12 indicated that rooms should be cleaned every day, and whenever dirty. 2. During an observation on 10/21/2024 at 1:56 PM, a black pedestal fan was sitting at bedside in room [ROOM NUMBER] B. Gray/beige, fuzzy-like particles were noted on the fan blades and the fan protective cover. The pedestal base of the fan had large white/beige splatters of an unknown substance on the surface. During an observation on 10/22/2024 at 10:24 AM, a black pedestal fan was sitting at bedside of room [ROOM NUMBER] B. Gray/beige, fuzzy-like particles were noted on the fan blades and the fan protective cover. The pedestal base of the fan had large white/beige splatters of an unknown substance on the surface. During a concurrent observation and interview on 10/23/2024 at 4:20 PM, after being shown the pedestal fan in room [ROOM NUMBER] B, the Administrator confirmed the fan was uncleaned and it was important for the fan to be clean because those particles could be breathed in and could cause a respiratory infection. During a concurrent observation and interview on 10/23/2024 at 4:20 PM, after being shown the pedestal fan in room [ROOM NUMBER] B, the Infection Preventionist (IP) confirmed the fan was not clean and took the fan apart and confirmed that the fan would be cleaned. The IP stated that the particles could lead to respiratory issues. On 10/24/24 at 8:30 AM, Administrator stated the facility did not have a policy for fan use or fan cleaning.

Based on interview, record review, facility document review, and facility policy review, it was determined the facility failed to ensure administration of correct medication to correct resident for 1 (Resident #76) of 1 sample mix residents for medication administration. The findings are: Review of Resident #76's Care Plan with an initiated date of 04/28/2024 noted the resident had an allergy to statin medications. Review of Resident #76's Medication Administration Records (MAR) dated June 2024 noted, the physician ordered the following medications: Amlodipine 5 (milligrams) mg for high blood pressure Fenofibrate 54mg for high cholesterol Aricept 5mg for dementia Melatonin 6mg for insomnia Namenda XR Extended Release (ER) 24- hour (HR) 28mg (memantine) for dementia Fenofibrate 54mg for cholesterol due to the allergy to statins. Review of the Medication Error Report dated June 1, 2024, revealed Certified Medication Assistant (CMA) #13 reported that both Resident #76 and Resident #47's medication were taken to the secured unit dining room where both residents had their dinner trays. Both residents take their medications better crushed and with their meal. CMA #13 labeled each medication cup with first names of each resident. CMA #13 called Resident #76 by first name; Resident #76 responded. CMA #13 gave Resident #76 a bite of the medication. Resident #76 had already swallowed the medication. CMA #13 then immediately realized the medications were mixed up and Resident #76 received Resident #47 medication. CMA #13 notified the nurse who then called the chain of command. CMA #13 checked Resident #76 blood pressure which was 140/80. The medications that Resident #76 received were: Atorvastatin 20 mg Amlodipine 5mg Buspirone 7.5mg Aricept 10mg Hydralazine Melatonin 6mg Mirtazapine 7.5mg Namenda 10mg Resident #76 was given a lower dose than prescribed by the physician, Namenda XR ER 24HR 28MG (memantine). Review of the Resident #47 Physician Orders with a start date of 5/1/2024 noted: Atorvastatin 20 mg Amlodipine 5mg Buspirone 7.5mg Aricept 10mg Hydralazine 100mg Melatonin 6mg Mirtazapine 7.5mg Namenda 10mg. On 10/23/2024 at 10:03AM, during an interview with the Assistant Director of Nursing (ADON), ADON confirmed, when Resident #76 was given the wrong medication, the vital signs were monitored. When the blood pressure dropped Resident #76 was then sent to the emergency room . CMA #13 received one on one training. During an interview with the Director of Nursing (DON) on 10/23/2024 at 10:10AM, DON confirmed, the CMA #13 pulled Resident #47 and Resident #76's medications at the same time. Both residents receive crushed medications. Some of the medications were the same for each resident. CMA #13 received counseling with action plan of one-on-one training with four weeks of supervised medication pass (June 14, 22, 25 and July 5, 2024) and 30 days of probation. During an interview with DON on 10/23/2024 at 4:19PM, she confirmed not all staff that administered medication were provided in-service training at that time. CMA #13 did not follow protocol. A skill check off was completed with other medication technicians and nurses. During an interview with CMA #13 on 10/23/2024 at 4:10PM, she confirmed Resident #76 was provided the wrong medication. CMA #13 was rushing to get the medications to Resident #76 and Resident #47 before they ate. CMA #13 carried both residents initialed medication cups into the secured unit dining room, in the same hand. CMA # 13 grabbed the spoon from Resident #47's cup and gave Resident #76 the medicine. CMA #13 knew Resident #47 had lots of blood pressure medications. CMA #13 took Resident #76's blood pressure while the nurse contacted the chain of command. Resident #76 and Resident #47 prefer their medications during mealtime. CMA #13 stated medications need to be pulled for one resident at time, so a medication error is not made, to ensure the right medication is given to the right resident and do the five rights of medication administration. After my one-on-one training, I was watched for four weeks, and I am on probation for three months. During an interview with CMA #14 on 10/24/2024 at 8:55AM, she confirmed they (the staff) are to ensure residents receive correct medication by asking their name and birthday. Only one medication at a time should be pulled so you don't get them mixed up or make a medication error. During an interview with CMA #15 on 10/24/2024 at 8:57AM, she confirmed they are to ensure residents receive correct medication and compare medication cards to the Medication Administration Record. Only one medication at a time is pulled so you do not make a mistake, a medication error or give the wrong medication to the wrong resident. During an interview with Licensed Practicing Nurse #16 on 10/24/2024 at 9:35AM, she confirmed they are to ensure residents receive correct medication, verify the resident's medication orders against the Medication Administration Record, and verify name and date of birth by asking resident. Only one medication at a time should be pulled so you do not get them mixed up and to decrease the risk of a medication error. During an interview with Licensed Practicing Nurse #17 on 10/24/2024 at 9:40AM, he confirmed they are to ensure residents receive correct medication, double check the resident ' s Medication Administration Record against the medication card. Check the name, date of birth and picture against the Medication Administration Record. Only one medication at a time is pulled so you do not make a medication error. Review of the facility policy and procedure titled Medication Administration with a revision date of 5/29/2024 noted, check Electronic Medication Administration Record and verify resident, greet and identify the resident. Do not crush or manipulate extended-release medications.

Based on observation and interview, the facility failed to ensure pureed food items were blended to a smooth, lump-free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 1 of 2 meals observed. The findings are: 1. On 10/22/24 at 11:58 AM, the following observations were made on the steam table: a. A pan of pureed, English peas had a soupy consistency and was gritty. b. A pan of gravy was lumpy and was not smooth 2. On 10/23/24 at 1:36 PM, during and interview the Dietary Manager stated the pureed English peas were a little thin, it is gritty because of the skin, it is hard to puree the skin and they should have pureed it a little longer. She further stated the gravy had been chunky. 3. On 10/23/24 at 1:36 PM, the Food and Beverage director stated the pureed English peas were a little thin, it is gritty because of the skin, it is hard to puree the skin and they should have pureed it a little longer.

Based on observation and interview, the facility failed to ensure foods stored in the refrigerator, and dry storage area were covered, sealed and dated to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen, failed to ensure foods were dated the day received to assure first in, first out usage to prevent potential for food bone illness, expired food items were promptly removed from stock to prevent potential food borne illness for residents who received meal trays from I of I kitchen, dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen, failed to ensure 2 of 4 ice machines were maintained in clean and sanitary condition to prevent contamination of airborne particles. These failed practices had the potential to affect 112 residents who received meals from the kitchen and 20 residents who received ice from the ice machine on [NAME] Hall (total census:113) as documented on a list provided by the Assistant Dietary Supervisor on [DATE] at 08:01 a.m. The findings are: 1. [DATE] at 11:19 a.m., initial tour of the kitchen was led by the Assistant Dietary supervisor. The following observations were made in the freezer: a. An opened but tied off bag of long [NAME] doughnuts in box with no open date. b. An opened bag of waffles not closed with no open date. c. An opened bag of wheat rolls not closed with no open date. d. An open box of Chicken enchiladas with no open date. e. An open box of garlic bread with no open date f. An open box of angel cakes with no open date 2. On [DATE] at 11:25 a.m., the following observations were made in the walk-in refrigerator. All the following dressings were open with no open date. a. 2 of 2 containers of mayonnaise. b. 1 ranch dressing. c. 1 Caesar dressing. d. 2 thousand Island dressing e. 1 Bar-B-Que sauce. f. catalina dressing. 3. On [DATE] at 11:30 a.m., the following observations were made in the dry storage area. a. 17 individual servings of mini wheat cereal with an expiration date of [DATE]. b. A flat box containing 14 individual cans of tomato soup did not have a received date upon observation. Dietary Supervisor wrote [DATE] on boxes and stated Oh those were received yesterday that is why I carry this marker. As he showed it to the surveyors 4. On [DATE] at 10:28 AM, the following observations were made on a shelf above the food preparation counter. a. Two of the 2 boxes of cornstarch were on a shelf; the boxes were not covered. b. Two of the 2 boxes of baking soda were on a shelf, the boxes were not covered. c. An opened bag of fruit punch was on a shelf, the bag was not sealed. d. An opened bag of coconut flakes was on a shelf, the bag did not have a date of when it was opened or received. e. A container of baking powder was on a shelf, the container had no opening date. f. A container of ground oregano was on a shelf, the container did not have a date of when it was opened or received. g. A container of thyme leaves, was not dated. h. A container of rosemary, was not dated. 5. On [DATE] at 10:36 AM, an opened bottle of cranberry juice was on a shelf in the refrigerator that had an expiration date of [DATE]. 6. On [DATE] at 10:44 AM The following observations were made in the walk-in refrigerator. a. Four bags of white bread, the bags were not dated. b. Two bags of wheat bread, the bags were not dated. c. Two bags of hoagies, the bags were not dated. d. Three bags of brand name wheat bread, the bags were not dated. e. One bag of hamburger buns, the bag was not dated. f. Four and ,d+[DATE] packages of hot buns, the bags were not dated. g. One bag of great value wheat bread with love, the bag was not dated. h. Two packages of marble rye bread, the packages had no date when received. 7. On [DATE] at 10:51 AM observed a bag of bagels on a shelf, the bag had no received date on it. 8. On [DATE] at 10:54 AM, the following observations were made on a shelf below the food preparation counter in the kitchen. a. An opened box of cream wheat, the box was not covered. b. 2 opened boxes of kosher salts, the boxes were not covered. c. A 1.3 gallon of balsamic vinegar, the gallon did not have a date of when it was opened or received. d. A bag of [NAME] rice, there was no date when received or opened on the bag. 9. On [DATE] at 11:09 AM the ice machine in the kitchen had accumulation of pink/black slimy around the area where ice formed before dropping to the ice collector. The surveyor asked the Assistant Dietary Supervisor to wipe the pink/black residue around the area where the ice formed. She did so, pink/black slimy residue easily transferred to the tissue. The surveyor asked the Dietary Supervisor, how often do you clean the ice machine and who uses the ice from the ice machine? We use it to fill beverages served to the residents at meals. The maintenance man cleans it. 10. On [DATE] at 11:13 PM, 12 boxes of salt were on a shelf in the storage room, the boxes had no received date on the boxes. 11. On [DATE] at11:17 AM Dietary Employee (DE) #1 pushed a cart that contained clean dishes towards the open cabinet by the ice machine where clean dishes were being stored. Without washing her hands, she picked up clean dishes and placed them on the shelf with her fingers touching the inside of the plates and bowls. On [DATE] at 09:08 AM, the surveyor asked the DE #1 what you should have done after touching dirty objects and before handling clean equipment? She stated, Washed my hands. 12. On [DATE] at11:22 AM DE #2 had gloves on her hands when she washed the blender bowl and blade in the 3-compartment sink. After washing them, she removed the gloves that had been saturated with water and threw them away. Without washing her hands, she picked up a clean blade and attached it to the base of the blender to be used in pureeing food items to be served to the residents who required pureed diets for lunch. At 11:24 AM When she was ready to put baked chicken breasts into the blender. The surveyor immediately asked the DE #2 what you should have done after touching dirty objects and before handling clean equipment? She stated, Washed my hands. 13. On [DATE] at 11:29 AM DE #3 had gloves on hands when she pushed a cart out of the way. Without washing her hands, she picked up plates to be used in plating dessert and placed them on the trays with her gloved fingers inside the plates. On [DATE] at 09:08 AM, the surveyor asked her what you should have done after touching dirty objects and before handling clean equipment? She stated, Washed my hands. 14. On [DATE] at 11:47 AM DE #1 washed blender bowl and blade in the 3-compartment sink. After washing the blender bowl and the blade, she picked the blade and attached it to the base of the blender to be used in pureeing food items to be served to the residents who received pureed diets. The employee did not wash her hands before she picked up the blade and attached it to the base of the blender. 15. On [DATE] at 11:48 AM DE #4 had gloves on her hands when she opened the refrigerator and removed a bag of French fries. Without changing gloves and washing her hands, she removed two boiled eggs from a container on a pan of ice and placed them in bowl to be served to the residents who requested boiled eggs with their lunch meal. When the bowl that contained boiled eggs was placed on the shelf attached to the steam table. The surveyor immediately asked DE #4 what you should have done after touching dirty objects and before handling clean equipment? She stated, Washed my hands. 16. On [DATE] at 01:31 PM. a container of cottage cheese on a shelf in the refrigerator in the clean utility room on Northwest Hall had expiration date of [DATE]. 17. On [DATE] at 01:34 PM, the following observations were made in the clean utility room on [NAME] Hall. a. The plastic panel on the right-side corner of the ice machine, close to the ice had slimy pink residue on it. The surveyor asked the Assistant Dietary Supervisor to wipe the pink residue. She did so, pink slimy residue easily transferred to the tissue. The surveyor asked the Assistant Dietary Supervisor, How often do you clean the ice machine and who uses the ice from the ice machine? She stated, That's the ice the CNAs [Certified Nursing Assistants] use for the water pitchers in the residents' rooms. The maintenance man cleans it. On [DATE] at 02:50 PM The surveyor asked the Maintenance Supervisor how often do clean the ice machines? He stated, We clean it every 6 months according to the manufacture suggestion. The light comes on automatically when it's dirty. b. A box of lasagna was in the freezer; the box had no received date. 18. The facility policy titled, Hand washing and glove use. Provided the Dietary Supervisor on [DATE] at 08:01 AM, documented. a. Hand washing is a priority for infection control. b. Hands must be washed prior to beginning work, when following contact with any unsanitary surface and opening c. Gloves may be used when working with food to avoid contact with hands. Gloves must be worn when touching any ready to eat food.

Based on observation, interview and record review the facility failed to ensure nail care was provided to two (Resident #18, #75) of 23 sampled residents (Resident #34, #17, #81, #37, #9, #26, #3, #98, #93, #110, #8, #83, #86, #64, #74, #103, #5, #88, #70, #96, #44, #63) who are dependent for nail care according to a list provided by Licensed Practical Nurse (LPN) #4 on 3/3/23 at 2:42 PM. The findings are: 1. Resident #18 admission Minimum Data Set (MDS) noted the resident requires extensive assistance with personal hygiene. a. On 7/31/23 at 12:37 PM, Resident #18 family member stated the resident was concerned about his fingernails, and stated they needed to be cleaned. She continued to describe how the resident's nails were observed to have dirt underneath them. b. On 7/31/23 at 12:50 PM observed Resident #18 in bed with his hands on top of the blanket. Observed resident's nails to be approximately 1/4 inch beyond the fingertip. Several nails contained a blackish, brown substance underneath them. The Resident stated, yeah I need to get that out of there. c. On 8/3/23 at 9:45 AM a review of the electronic medical record revealed a physician's order, with an order date of 7/31/23: noting the nurse to assess and complete finger/toenail care if needed every week, due to anticoagulant use and an order with an order date of 7/31/23 for the nurse to assess and complete finger/toenail care if needed for anticoagulant use. 2. On 08/02/23 at 12:45 PM observed Resident #75 sitting in the dining room. All the Resident's nails contained a blackish/brown substance underneath them. The Resident stated, yeah, I need to get them to clean that out. b. On 8/3/23 at 10:00 AM a review of the electronic medical record revealed a physician's order, with an order date of 5/19/23 for the nurse to assess and complete finger/toenail care if needed every week for diabetes mellitus and an order, with an order date of 5/19/23 for the nurse to assess and complete finger/toenail care if needed for Diabetes Mellitus. 3. On 08/03/23 at 3:20 PM the surveyor asked the Director of Nursing (DON) when a resident's nails should be cleaned. She stated, nails should be cleaned every day. They are supposed to be trimmed on shower days and residents who are Diabetic are checked weekly. 4. On 8/3/23 at 3:25 PM Licensed Practical Nurse (LPN) #4 reported that the facility does not have a policy specific to nail care. 5. On 8/4/23 at 9:20 AM the surveyor asked Certified Nursing Assistant (CNA) #3 when a resident's nails should be cleaned and/or clipped. CNA#3 stated, they should be cleaned daily. If they are diabetic, then we have to tell the nurses. We can file or shape the nails, and the same with toes, we just can't clip them.

Based on observations, interviews, and record review, the facility failed to ensure that medications were dated when opened, failed to ensure resident names were on an opened and used insulin pen, and failed to discard expired medication in 3 of 5 medication carts in the facility. The findings include: 1. On [DATE] at 09:14 a.m. observed the medication cart on the 200 hall with a vial of Levemir 100 units/mL (milliliter) vial noted without an opened date on the vial or packaging for Resident #9. Observed an opened and used Ozempic injection pen with no open date noted on the pen or packaging. 2. On [DATE] at 09:23 a.m. the surveyor asked Licensed Practical Nurse (LPN) #1, are insulin vials supposed to be labeled with an open date when opened, and why? Licensed Practical Nurse (LPN) #1 responded, It should have an open and an expiration date, so we know the expiration date, the receive date does not always match up when it was removed from the refrigerator. The surveyor asked, who is responsible for ensuring the insulin vials are dated? LPN #1 responded, The ADON [Assistant Director of Nurses] checks the dates daily and we check the dates before administration. 3. On [DATE] at 09:45 a.m. observed the North [NAME] medication cart and medication storage room. A tube of Refresh P.M. ointment was opened with no open date noted on the tube or packaging for Resident #5. A Novolog Flex Pen Syringe noted ER (emergency) Kit with an open date of [DATE] and was not labeled with a name on the syringe or packaging. 4. On [DATE] at 10:01 a.m., the Surveyor asked LPN #2, is eye ointment to be dated upon opening and who is responsible for dating the tube upon opening? LPN #2 stated, Yes, I'm pretty sure. First person to use it and with an expiration date. 5. On [DATE] at 10:12 a.m., observed a Novolog insulin vial with an expiration date of [DATE] for Resident #26 on [NAME] medication cart. On [DATE] at 10:16 a.m. the surveyor asked LPN #3, who is responsible for ensuring the dates are checked on insulin vials and removed from the medication cart when expired? LPN # 3 stated, the nurse is responsible. The surveyor asked, What is the reason for pulling the medication off the cart when expired? LPN # 3 responded, To make sure you do not give and expired drug. On [DATE] at 1:29 pm the surveyor asked LPN #3 did you administer this morning's dose of Novolog insulin? LPN #3 responded Yes. The surveyor asked, did you use the vial that was in the drawer of the medication cart? LPN #3 responded, Yes, I thought it was the open date not the expiration date. On [DATE] at 2:24 pm the surveyor asked the Director of Nurses (DON) how many days is Novolog and Levemir insulin usable once opened? The DON replied, 28 days for Novolog. 28 days for Levemir I think but I will double check. The surveyor asked, is insulin supposed to be dated when opened and why? The DON replied, yes, so we know the use by date and know when to order more. The surveyor asked the DON should a Novolog Flex Pen have a resident's name on it and how many days is it good for? The DON replied, yes, I will look and see how many days the pen is good for. The surveyor asked who is responsible for dating the insulin after the initial opening? The DON replied, it should be the nurse. The surveyor asked who is responsible for ensuring medications are stored and disposed of properly? The DON replied, the charge nurse. The surveyor asked the DON, is the eye gel tube supposed to have an open date? The DON replied, yes. A package insert provided by the Assistant Administrator on [DATE] at 7:56 a.m. recommended Ozempic pen can be stored for 56 days at a controlled room temperature, or in a refrigerator after opened. A package insert provided by the Assistant Administrator on [DATE] at 7:56 a.m. noted Levemir injection, after vials have been opened, can be stored in the refrigerator or at room temperature and also noted the vials should be thrown away after 42 days, even if they still have insulin left in them. A package insert provided by the Assistant Administrator on [DATE] at 7:56 a.m. noted Novolog Flex Pen should be thrown away after 28 days even if it still has insulin left in it. A package insert provided by the Assistant Administrator on [DATE] at 7:56 a.m. noted throw away all opened Novolog vials after 28 days, even if they still have insulin left in them. A policy provided by the Director of Nursing (DON) on [DATE] at 3:46 p.m. documented .Medication Storage .to provide guidelines to ensure all medications housed on premises will be stored in the medication rooms according to manufacturer's guidelines and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security .scope of responsibility: nursing .unused medications: the pharmacy and all medication rooms are routinely inspected by the DON .or designee for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels .those medications are destroyed in accordance with our guidelines for medication destruction .

Based on observation, interview, and record review the facility failed to ensure a catheter was secured to prevent the potential for trauma for 1 (Resident #3) of 4 (Resident #3, #17, #18, and #70) sampled residents. The findings are: Resident #3 had a diagnosis of neuromuscular dysfunction of the bladder. A review of a care plan, last revised on 1/20/23 noted a goal that the resident will be/remain free from catheter-related trauma through review date. On 8/03/23 at 8:18 AM Certified Nurse Aide (CNA) #1 provided catheter care for Resident #3. There was no anchor, or strap securing the catheter, to keep the catheter from pulling. On 8/03/23 at 8:19 AM the surveyor asked CNA #1, How do you ensure the catheter is secure, and is not pulled. She stated, The nurses sometimes have a Velcro type strap they put on. On 8/03/23 at 4:06 PM the surveyor asked the Assistant Administrator How is Resident #3 catheter securely anchored to prevent excessive tension on her catheter? She stated, leg strap, and further stated she was not sure why there was no anchor attached to the catheter to prevent tension. On 8/04/23 at 8:48 AM the surveyor asked CNA #2, How is Resident #3 catheter securely anchored to prevent excessive tension on her catheter? She stated, Like a leg band. I have her catheter on one side of the bed. Can you tell me why she didn't have anything anchored to the catheter to prevent the catheter from pulling? She stated, To be honest I didn't know about that. On 8/04/23 at 9:41 AM the surveyor asked the Director of Nurse, How is Resident #3 catheter securely anchored to prevent excessive tension on the catheter? She stated, There should be a leg band. The surveyor asked, can you tell me why she didn't have an anchor attached to her catheter to prevent tension on 8/03/23? She stated, I assume when they changed the catheter, they forgot to replace it. A review of the facility policy titled, Catheter Care, last revised on 3/3/20 noted, properly secure indwelling catheters after insertion to prevent movement and urethral traction.

Based on observation, and interview the facility failed to ensure 1 (Resident #70) of 1 sampled resident that depended on staff for positioning was properly positioned in bed. The findings are: Resident #70 had a diagnosis of Alzheimer's disease, and vascular dementia. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/25/23 documented that his cognitive skills for decision making were extremely impaired. He required extensive 2-plus persons physical assistance for bed mobility. A review of a care plan for Resident #70, last revised on 2/10/23 revealed the resident requires total assistance by 1 staff member to turn and reposition while in bed and may require assistance of two staff members to move up into bed. On 7/31/23 at 11:43 AM Resident #70 was in bed. His head was against the wall on the left side. On 8/04/23 at 8:49 AM the surveyor asked Certified Nurse Assistant (CNA) #2, Can you tell me how the staff keep Resident #70 head from leaning on the wall? She stated, we have a couple of pillows to help sit him up. We have one pillow under his head, and one against the window. He tends to lean towards the wall. The surveyor asked, what could happen if a resident's head is positioned on the wall? She stated, I'm pretty sure it could cause a pressure sore. On 8/04/23 at 9:39 AM the surveyor asked the Director of Nurses (DON), Can you tell me how the staff keep Resident #70 head from leaning on the wall? She stated, they should be repositioning him, and using pillows. His head should not be on the wall. The surveyor asked, what could happen if a resident's head is positioned on the wall? She stated, Skin breakdown, and head injuries, especially if he was having involuntary movement. On 8/04/23 at 10:05 AM observed Resident #70 in bed with a pillow under his head. He did not have a pillow between the wall and his head. His bed was pushed against the wall.

Based on observation, interview, and record review the facility failed to ensure that privacy was maintained during incontinent care for 1 (Resident #105) of 18 (Resident #3, #9, #17, #18, #33, #44, #63, #64, #70, #74, #81, #86, #88, #90, #93, #103, #105, and #110) sampled residents that depended on staff to provide incontinent care. The findings are: On 8/01/23 at 10:57 AM the door opened to Resident #105 room. Observed Resident #105 roommate exiting the room in his wheelchair. Resident #105 was turned to the wall and his buttocks was exposed. Certified Nurse Aide (CNA) #4, and CNA #2 were in the room providing incontinent care. On 8/01/23 at 1:33 PM the surveyor asked CNA #2 can you tell me why the privacy curtain was not pulled while you were providing incontinent care for Resident #105? She stated, Honestly it was a mistake. The surveyor asked, should the privacy curtain be pulled so that Resident #105 was not exposed during incontinent care? She stated, Yes. On 8/01/23 at 1:49 PM the surveyor asked CNA #4, can you tell me why the privacy curtain was not pulled while you were providing incontinent care for Resident #105? She stated, I didn't know that Resident #8 was going to come out the room. The surveyor asked, should the privacy curtain be pulled so that Resident #105 was not exposed during incontinent care? She stated, Yes. On 8/03/23 at 3:56 PM the surveyor asked the Assistant Administrator, What should the staff do to maintain privacy for residents while providing care? She stated, pull the curtain and shut the door. The surveyor asked, if the staff is providing incontinent care when should they pull the privacy curtain? She stated, before they begin the incontinent care. On 8/04/23 at 9:37 AM the surveyor asked the Director of Nurse (DON), what should the staff do to maintain privacy for residents while providing care? She stated, close the curtains all the way around, close the blinds, and close the door. The surveyor asked, if the staff is providing incontinent care when should they pull the privacy curtain? She stated, before they provide care. On 8/04/23 at 7:56 AM the Assistant Administrator provided a policy titled, Privacy and Dignity. It documented, Purpose: To provide guidelines for ensuring the facility protects and promotes resident privacy and treats each resident with respect and dignity as well as cares for each resident in a manner that maintains or enhances resident's quality of life .Always pull privacy curtain in your semi-private rooms when providing care

Based on interview and record review the facility failed to ensure a PRN (as needed) medication was reviewed every 14 days for 1 (Resident # 110) of 3 (Resident #26, #103, and 110) sampled residents. The findings are: A review of the mediation records indicated that Resident #110 had an order for Hydroxyzine HCl (an antihistamine) Tablet 10 MG Give 1 tablet by mouth every 4 hours as needed for anxiety. The Hydroxyzine was ordered 5/22/23. A review of Resident #110 Medication Regimen Review for February 2023 through July 2023 did not indicate that the PRN Hydroxyzine was reviewed and failed to reveal a rationale to indicate why she needed to continue the medication. On 8/02/23 03:28 PM the surveyor asked LPN #1, When was the last time did Resident #110 received her prn hydroxyzine? She stated, she hasn't gotten it this month so far. On 8/02/23 at 03:36 PM the surveyor asked Registered Nurse (RN) #1, How often is Resident #110 Hydroxyzine renewed? She stated, I would have to ask my DON I'm new and not sure of policy. On 8/3/23 at 4:00 PM the surveyor asked the Assistant Administrator, How often is as needed anxiety medication continued, reduced, discontinued, or otherwise modified? She stated, I'm assuming 14 days. The surveyor asked, Can you tell me why the PRN Hydroxyzine 10mg wasn't reviewed and renewed every 14 days? She stated, No I can't. On 8/4/23 at 9:38 AM the surveyor asked the Director of Nurses (DON), How often is as needed anxiety medication continued, reduced, discontinued, or otherwise modified? She stated it should be every 14 days unless otherwise specified. The surveyor asked, Can you tell me why Resident #110 PRN Hydroxyzine 10mg wasn't reviewed and renewed every 14 days? She stated, I just assume it got missed. Review of the facility policy titled, Medication-Unnecessary Medications, last updated 3/4/20 noted, Pharmacy consultant review monthly and prn.

Based on observation and interview, the facility failed to ensure Dietary Staff washed their hands and changed gloves between dirty and clean tasks and before handling clean equipment or food items; failed to ensure food items stored in the freezer or refrigerator were sealed or covered; failed to ensure expired food items were promptly removed/discarded on or before the expiration or use by dates; hot foods were maintained at or above 135 degrees Fahrenheit on the steam table while awaiting service, to prevent potential food borne illness for residents who received meals from 1 of 1 kitchens and failed to ensure 1 (Clean Utility Room on West Hall) of 5 ice machines were maintained in clean and sanitary condition to decrease the potential for food borne illness for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 102 residents who received ice on West Hall and 102 residents who received meals from the kitchen (total census:103), according to the list provided by the Dietary Supervisor on [DATE] at 11:58 AM. The findings are: 1. On [DATE] at 11:15 AM, the following observations were made in the walk-in freezer: a. One open box of biscuit dough was stored on a shelf in the walk-in freezer. The box of biscuit dough was not covered or sealed. b. One open box of baked biscuits was stored on a shelf in the walk-in freezer. The box of baked biscuits was not covered or sealed. c. One open box of bread sticks was stored on a shelf in the walk-in freezer. The box of bread sticks was not covered or sealed. d. One open box of cinnamon rolls was stored on a shelf in the walk-in freezer. The box was not covered or sealed. e. One open bag of chicken was stored on a shelf in the walk-in freezer. The box was not covered or sealed. 2. On [DATE] at 11:21 AM, the following observations were made in the walk-in refrigerator: a. One box of heavy cream was stored on a shelf in the walk-in refrigerator. The box was not completely closed. b. There were three open bags of flour tortilla on a shelf in the walk-in refrigerator. The bags were not sealed. c. One open pan of leftover mashed potatoes was stored on a shelf in the walk-in refrigerator. The pan was not covered. d. One pan of quiche was stored on a shelf in the walk-in refrigerator. The pan was not covered. 3. On [DATE] at 11:30 AM, the following observations were made in the two door refrigerator: a. One open ziplock bag that contained slices of ham was stored on a shelf refrigerator. The bag was not sealed. b. One open box of bacon was stored on a shelf in the refrigerator. The box was not covered or sealed. c. One open container of cheese was stored on a shelf in the refrigerator. The container was not covered. 4. On [DATE] at 11:35 AM, the following observations were made in the one door freezer: a. One open bag of breaded chicken was stored on a shelf in the freezer. The bag of breaded chicken was not sealed. b. One open box of hot dogs was stored on a shelf in the freezer. The box was not covered or sealed. 5. On [DATE] at 12:04 PM, the temperature of the food items when read and tested on the steamtable by Dietary Employee #2 was: Pureed broccoli 122.5 degrees Fahrenheit. The pureed broccoli was not reheated before being served to the residents on pureed diets for lunch meal. On [DATE] at 3:12 PM, Dietary Employee #4 was asked, What should you have done when the food items were not hot enough to be served to the residents? She stated, I should pull it out and reheat it to 165 degrees Fahrenheit. 6. On [DATE] at 12:27 PM, Dietary Employee #2 turned on the sink faucet and washed a blender bowl and blade. He then turned off the faucet. Without washing his hands, he picked a clean blade and attached it to the base of the blender to be used in pureeing food items to be served to the residents who received pureed diets for lunch. 7. On [DATE] at 12:44 PM, Dietary Employee #5 was wearing gloves on her hands. She picked up a container of chicken salad from the cooler and placed it on the counter by the steamtable. At 12:46 PM, she removed slices of bread from the bread bag and placed them on a plate. She used a spoon to place chicken salad on a slice of bread to be served to the resident who had requested a chicken salad sandwich with their lunch meal. At 12:48 PM, without washing her hands, she picked up a paper plate from the cabinet below the steam table and placed it on the counter. With her contaminated gloved hands, she then used the same gloved hand to pick up the chicken salad sandwich from a paper plate and placed it on a regular plate to be serve to the resident who requested a chicken salad sandwich. 8. On [DATE] at 2:01 PM, Dietary Employee #2 was on the tray line serving the lunch meal with gloves on his hands. He picked up tray cards and placed them on the trays, contaminating the gloves. Without changing gloves and washing his hands, he picked up plates and placed them on the trays with gloved hands touching the interior surfaces of the plates. 9. On [DATE] at 2:04 PM, Dietary Employee #2 was asked to check the temperature of the hot food items served from the steamtable that were on the cart by the kitchen window and on the counter to be delivered to the residents who received their meal trays in their rooms for lunch meal service, the temperatures were: a. Quiche - 98.2 degrees Fahrenheit. b. Baked chicken breast - 105 Degrees Fahrenheit. c. Rice - 112.6 degrees Fahrenheit. The above food items were not reheated before being served to the residents. 10. On [DATE] at 7:45 AM, Dietary Employee #4 was on the tray line serving the breakfast meal. With gloves on she picked up tray cards and placed them on the counter contaminating her gloves. Without changing gloves and washing her hands, she removed slices of bread from the bread bag and placed them on a toaster. She then, used her contaminated gloved hand to remove slices of bread from the toaster and placed them on the plates to be served to the residents who asked for toast. 11. On [DATE] at 7:53 AM, Dietary Employee #3 placed a beard net on contaminating his hands. Without washing his hand, he pulled gloves from the glove box and placed them on his hands contaminating the gloves. He picked up clean plates with his contaminated gloved fingers touching the interior surfaces of the plates and placed them on the counter to be served to the residents for breakfast meal. At 10:04 AM, Dietary Employee #3 was asked, What should you have done after touching dirty objects and before handling clean equipment? He stated, Washed hands. 12. On [DATE] at 10:51 AM, the following observations were made in the refrigerator in the Clean Utility Room on the West Hall: a. Five cartons of jello was stored on a shelf in the refrigerator with an expiration date of [DATE]. b. A 46 fluid ounce container of nectar orange juice was stored on a shelf in the refrigerator with an expiration date of [DATE]. 13. The inside right corner of the ice machine panel in the Clean Utility Room on West Hall had wet rust across its surface that easily wiped off when Dietary Employee #4 wiped it with a tissue. Dietary Employee #4 was asked, Who uses the ice from the ice machine. She stated, That's the ice the CNAs [Certified Nursing Assistants] use for the water pitchers in the residents' rooms. At 11:02 AM, the Housekeeping Supervisor was asked, How often do you clean the ice machine? She stated, Once a week. 14. The facility policy titled, Hand Hygiene, provided by Dietary Employee #4 on [DATE] at 11:58 AM documented, . Hand hygiene is the single most important procedure for preventing cross infection and to prevent the spread of germs to patients from the hands of healthcare workers. Hand hygiene should be practiced at key points in time when in the direct patient care areas to disrupt the transmission of germs to patients including: Before putting on and after removing disposable gloves . After contact with contaminated surfaces (even if gloves are worn) .

Based on observation, record review and interview, the facility failed to ensure residents' meals were consistently served at regularly scheduled times to provide residents with a dependable eating schedule for 1 of 1 meal service observed. The failed practice had the potential to affect 102 residents who received meals from the kitchen (total census:103), according to the list provided by the Dietary Employee #4 on 5/10/2022 at 11:58 AM. The findings are: 1. The facility mealtimes, documented on a form provided by the Dietary Employee #4 on 5/10/2022 at 11:58 AM were 7:00 AM for breakfast, 11:30 AM for lunch, and 4:30 PM for supper. 2. On 05/09/22 at 1:15 PM, Resident #357 stated, The food is always late at night. It can be 7 [7:00 PM] or 8 [8:00 PM] before we get trays. It's late every day. I get hungry waiting on the food. 3. On 05/09/22 at 12:30 PM, Resident #58 was in her room and stated, .I'm hungry, where's my food . Resident #58's tray was served at 1:14 PM. 4. On 5/10/2022 at 8:42 AM, Resident #58 was asked if she was still waiting for her breakfast. She stated, .Yes, and I'm hungry . No trays were observed on the hall. 5. On 05/10/22 at 10:26 AM, Dietary Employee #4 was asked what time the last tray was sent out. She stated, We start at 7:00 AM and the last tray went out at 9:30 AM. Sometimes it's from 7:00 AM to 9:45 AM. Dietary Employee #4 was asked why the lunch meal on 5/9/2022 and breakfast meal on 5/10/2022 took over 2 hours to be served to all the residents in the facility. Dietary Employee #4 stated, We have 3 new dietary staff that just started. I am the only one serving. We need someone to be serving from the steamtable in the kitchen. 6. On 5/10/22 at 11:00 AM, the Resident Council met in the activity room. When asked if the food is delivered hot, the group replied, Most of the time. The Council President stated, If you eat in your room, you are really taking the chance that your food will be late and cold. When asked about mealtimes, specifically the late delivery times for trays on the hall, the council president described, This is an ongoing problem that we have been talking about for a long time. I even talked to the manager. When you want to eat in your room you are really taking a chance. The group reported that breakfast has historically been delivered as late at 11:00 AM.

Based on observation, interview and record review, the facility failed to ensure fingernails were regularly trimmed and cleaned to promote good personal hygiene and grooming for 4 (Residents #21, #40, #45 and #357) of 20 (Residents #4, #9, #10, #12, #21, #31, #36, #39, #45, #47, #49, #60, #71, #73, #79, #81, #91, #92, #94 and #107) residents who required assistance with nail care according to a list provided by the Administrator on 5/12/2022 at 11:08 AM. The findings are: 1. Resident #21 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . a. The Care Plan with a revision date of 03/01/22 documented . BATHING/SHOWERING: Check nail length and clean on bath day and as necessary. Report any changes to the nurse. CNAs [Certified Nursing Assistants] do NOT cut resident's nails . b. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . c. On 05/09/22 at 1:45 PM, Resident #21 stated, .My nails need to be cut . The nails of both hands extended 1/4 inch past the end of his fingers, were jagged and had brown debris under all of the nails. d. On 05/10/22 at 12:41 PM, Resident #21 was up in the Main Dining Room eating lunch. Resident #21 stated he had a shower this am, and his nails were clean but still long and jagged. Resident #21 stated, .[Licensed Practical Nurse (LPN) #6], the nurse, is supposed to cut them today . e. On 05/11/22 at 10:42 AM, the Treatment Nurse was asked, Who is responsible for the diabetic nail care? The Treatment Nurse stated, .The Charge Nurses are responsible for diabetic nail care, unless an issue pops up, then they will get me or the ADON [Assistant Director of Nursing]. We will get involved with the treatment . f. On 05/11/22 at 2:42 PM, Resident #21 was up in the Dining Room for an activity. His fingernail on both hands were jagged and extended ¼ inch past the end of his fingers. g. On 05/12/22 at 10:53 AM, Resident #21's nails were observed with the Director of Nursing (DON) Resident #21 stated, .They were cut yesterday or today . The DON ran her finger over the nails of his right hand and stated, .they could use a little more trim, they're still a little long . 2. Resident #45 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . a. The Care Plan with an initiated date of 04/12/19 documented, .BATHING/SHOWERING: Check nail length and clean on bath day and as necessary. Report any changes to the nurse. CNAs do NOT cut resident's nails . b. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . c. The May 2022 Treatment Administration Record (TAR) documented Resident #45 had nail care on 5/7/22, 2 days prior to the first observation of the resident ' s long jagged nails. d. On 05/09/22 at 1:04 PM, Resident #45 was while dozing in her wheelchair. Her fingernails were 1/8 to 1/4 inch past the end of her fingers and had brown debris under the nails. The fingernails of her left hand, middle and ring finger were 1/4 inch long, yellow, dry, and jagged with brown debris under them. e. On 05/10/22 at 9:11 AM, Resident #45 was resting in bed. The fingernail of the left index finger was approximately 3/16 of an inch long from the end of the finger with brown debris under the nails. The middle and ring finger were 1/4 inch long, yellow, dry, and jagged with brown debris under them. f. On 05/10/22 at 3:28 PM, Resident #45 was asked if she preferred her nails to be left long. She stated, .No, they need to be cut . She was asked, Have you scratched yourself with them? She stated, .No . She was asked, Have you said anything to the staff about wanting your nails cut? She stated, .I don't think so, I don't remember . g. On 05/12/22 at 10:32 AM, the DON was asked to describe Resident #45's fingernails. She stated, .They are definitely unclean, some are long and jagged . The DON was asked, Should nail care be provided to residents who require assistance? She stated, .Yes . She was asked, Who is responsible for diabetic nail care? She stated, .The charge nurses are . She was asked, According to the documentation on Resident #45's TAR, nail care was provided on 5/7/2022. Does it look like her nail care was provided 2 days prior to our entry on 5/9/2022? She stated, .No, if it looked like this on Monday, it couldn't have been provided on Saturday . 3. Resident #40 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS with an ARD of 3/17/22 documented the resident scored 9 (8-12 indicates moderately cognitively impaired) on a BIMS and required extensive physical assistance of 1 person for personal hygiene and bathing activity itself did not occur or family and/or non-facility staff provided care 100% of the time for that activity over the entire 7-day lookback period. a. The Care Plan with an initiated date of 01/07/22 documented, .The resident has an ADL [activities of daily living] self-care performance deficit . BATHING/SHOWERING: Check nail length and trim and clean on bath day and as necessary . b. On 05/09/22 at 12:13 PM, Resident #40 was sitting in a recliner in his room. His fingernails were approximately 1/2 inch long and jagged. Resident #40 was asked, Do you like them [fingernails] that long? He said, No, they look like weapons and look at this one. They break off and get hung on stuff. c. On 05/10/22 at 11:20 AM, Resident #40 was sitting in a recliner in his room. His fingernails were approximately 1/2 inch long and jagged. d. On 05/10/22 at 2:21 PM, LPN #1 was asked, Does his fingernails need trimmed and cleaned? She said, Yes, I'll go do it now. 4. Resident #357 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission MDS with an ARD of 5/6/22 documented the resident scored 15 (13-15 indicates cognitively intact) on a BIMS and required extensive physical assistance of 1 person for personal hygiene and physical help limited to transfer only of two plus persons with bathing. a. The Care Plan with an initiated date of 05/09/22 documented, .The resident has an ADL self-care performance deficit BATHING/SHOWERING: Check nail length and trim and clean on bath day and as necessary . b. On 05/09/22 at 1:31 PM, Resident #357 was sitting in the recliner. Her fingernails were approximately 1/4 inch long and jagged with a brown substance under them. c. On 05/10/22 at 11:27 AM, Resident #357 was sitting in the recliner. Her fingernails were approximately 1/4 inch long and jagged with a brown substance under them. d. On 05/10/22 at 12:58 PM, Resident #357 was sitting in the recliner. Her fingernails were approximately 1/4 inch long and jagged with a brown substance under them. e. On 05/10/22 at 2:21 PM, LPN #1 was asked, Does her fingernails need trimmed and cleaned? She said, Yes, I'll go do it now. 5. The facility policy titled, Finger Nail Care, provided by the Administrator on 5/12/2022 at 11:45 AM documented, .The hands and nails are frequently the source of infection especially if dirt is allowed to collect under the nails. Nails must be cleaned regularly. Long irregular nails on a confused or irritated resident can be a source of scratches causing further infection. Special care is needed for the diabetic resident who does not heal rapidly and who develops infections very easily ., Diabetics and residents receiving anticoagulants must have a doctor's order for nail care and the procedure must be done by licensed personnel only .

Based on observation, record review, and interview, the facility failed to ensure pressure ulcers were assessed and measured at least weekly to determine improvement or deterioration and physician ordered wound care was implemented to promote healing for 5 of 5 sampled residents (Resident #21, 67, 70, 53 and 40) who had pressure ulcers. These failed practices resulted in a pattern of harm to Resident #21 whose pressure ulcer deteriorated and had the potential to cause more than minimal harm to 6 residents who had pressure ulcers according to a list provided by the Director of Nursing (DON) on [DATE]. The findings are: 1. Resident #21 had [DIAGNOSES REDACTED]. The Significant Change in Condition (MDS) with an Assessment Reference Date (ARD) of [DATE] documented the resident was severely impaired in cognitive skills per a Staff Assessment for Mental Status (SAMS); and required extensive assistance with bed mobility, transfers, dressing, toilet use and bathing. a. The Care Plan with a initiation date of [DATE] documented, .The resident's Pressure injury will show signs of healing and remain free from infection by/through review date. Administer treatments as ordered and monitor for effectiveness. Follow facility policies/protocols for the prevention/treatment of [REDACTED].>b. A physician order [REDACTED]. c. A Physician order [REDACTED]. d. The Wound Evaluation note dated [DATE] documented, Stage 3 measurements of area 11.57 cm², length 3.53 cm, width 4.18 cm . e. A physician Order dated [DATE] at 5:16 pm documented, Cleanse pressure injury on coccyx with normal saline, apply [MEDICATION NAME] 500mg (milligrams) (crushed) to wound bed, pack with [MEDICATION NAME] lined [MEDICATION NAME] then cover with bordered sacral dressing one time a day for wound healing until [DATE] 23:59 (11:59 pm). f. The February 2021 Treatment Administration Record (TAR) did not document treatments were performed to Resident #21's stage 3 pressure ulcer on [DATE], [DATE], [DATE] and [DATE]. g. The Wound Evaluation note dated [DATE] documented, Stage 3 measurements of the area 17.55 cm², length 3.55 cm and width 6.49 cm . h. On [DATE] at 11:53 AM, Licensed Practical Nurse (LPN) #4 was asked how often wounds should be measured. LPN #4 stated, When I do the dressing change, I measure it. If it is daily, then I measure it twice a week. LPN #4 was asked what the policy stated when the measurements should be done. LPN #4 stated, I am not sure what the policy says. LPN #4 was asked why there were not at least weekly measurements located in the chart. LPN #4 stated, The last treatment nurse left her position. So the floor nurses took over doing treatments. Most nurses don't know anything about the wound care module, they just click it off in the Treatment Administration Record (TAR). i. On [DATE] at 12:23 PM, LPN #4 was asked after assessing the wound what was her opinion on the wound. LPN #4 stated, With it not being open it would be important to keep the pressure off by using the foam dressing and having her wear the boot while she is in bed. LPN #4 was asked if the resident should have had a treatment performed since [DATE]. LPN #4 stated, Yes. She should have. There should have been something in place. j. On [DATE] at 1:38 PM, the Director of Nursing (DON) was asked to provide the documentation of Resident #21 ' s wound care orders and weekly wound measurements. k. On [DATE] at 2:53 PM, the DON stated, There is no additional orders or proof that the treatments or measurements were done. The Treatment Nurse left on [DATE] and the nurses on the floor should have picked up all the treatments. Our new treatment nurse just started on February 8, 2021. I can't find a specific wound care policy. l. On [DATE] at 12:17 PM, the DON was asked how do you know that Resident #21 wound was reevaluated on [DATE]. The DON stated, I would have to ask the nurse that documented it was done but from what I looked at and read it was not reevaluated. The DON was asked why there was no order written for wound care until [DATE] if the wound was reevaluated on [DATE]. The DON stated, When she reevaluated the wound, she should have called the doctor that day, but it was not done until the new treatment nurse started. The DON was asked who was responsible for wound care when there was no treatment nurse, or the treatment nurse was working the floor. The DON stated, The nurses on the floor, the resident's normal nurse is responsible for the wound care and that should include the measurements. The DON was asked what she had been doing to ensure that wound care and monitoring was being performed. The DON stated, I have been here for 3 weeks. Last week we started a weight and skin meeting to discuss anyone with weight loss or skin issues. m. On [DATE] at 2:05 PM, LPN #6 was asked if she evaluated Resident #21 pressure ulcer on [DATE]. LPN #6 stated, Yes. I did reevaluate the wound. She was staying about the same, no worsening from what I had seen. LPN #6 was asked what steps were taken when the wound was reevaluated. LPN #6 stated, I went in and I cleaned the wound. I measured it and compared it to the previous times that I had measured her wound. LPN #6 was asked if she could recall what the measurements of the wounds were at that time. LPN #6 stated, I can't remember. LPN #6 was asked if she documented the measurements in the medical record. LPN #6 stated, No. I did not document it in the medical record. I may have written it on a piece of paper, but I can't remember. LPN #6 was asked if she used the iPad to take a picture and measure the wound. LPN #6 stated, No. I measured it with the paper ruler, I did not document it in the medical record. I did check it off on the Treatment Administration Record (TAR). LPN #6 was asked if she notified the doctor regarding the status of the pressure ulcer or to obtain new orders. LPN #6 stated, I did call the doctor that night and informed them of the wound status and they said they would follow-up on the next visit. They said to continue what we were doing at that moment. LPN #6 was asked if she wrote the order to continue the treatment. LPN #6 stated, I did not write a new order. I thought it was still in the computer what I had knowledge of. LPN #6 was asked what provider or doctor that she spoke to. LPN #6 stated, I can't remember. LPN #6 was asked if she documented her conversation with the doctor in the medical record. LPN #6 stated, No, I did not. 2. Resident #40 had [DIAGNOSES REDACTED]. The Significant Change in Condition Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] documented the resident scored 3 (,[DATE] indicates severe cognitive impairment) on a Brief Interview for Mental Status (BIMS); and required extensive assistance with bed mobility, transfers, dressing, toilet use and bathing. a. A physician order [REDACTED]. Re-eval pressure injury to right heel one time only until [DATE] 18:00 (6:00 pm). b. The Wound Evaluation dated [DATE] documented wound measurements of Area < 0.1 cm², Length 0.18 cm, Width 0.22 cm. c. A physician order [REDACTED]. d. A physician order [REDACTED]. e. The Care Plan with an initiation date of [DATE] documented, The resident's Pressure injury will show signs of healing and remain free from infection by/through review date. Administer treatments as ordered and monitor for effectiveness. 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 (doctor) . f. The [DATE] Treatment Administration Record did not document any treatment was performed to Resident #40's Stage 2 pressure ulcer on the right heel on [DATE] and physician orders [REDACTED]. g. The Wound Evaluation note dated [DATE] documented wound measurements of Area 3.92 cm, Length 2 cm, Width 2.45 cm. h. A physician order [REDACTED]. i. The February (2021) Treatment Administration Record did not document a treatment was performed to Resident #40's Stage 2 pressure ulcer to the right heel on [DATE], [DATE], [DATE]. As of [DATE] there was no documentation in the clinical record the wound was not re-evaluated on [DATE] and no new orders were obtained for wound care until [DATE]. j. On [DATE] at 11:53 AM, LPN #4 was asked what treatment Resident #40's was receiving. LPN #4 stated, She has a wound on her heel. I believe it is wound cleanser with a padded foam dressing to keep the pressure off. It is not open. LPN #4 was asked how often Resident #40 received wound care. LPN #4 stated, Daily. LPN #4 was asked to review the TAR. The TAR identified that the current wound care orders expired on [DATE] and the wound was to be reassessed for further orders. LPN #4 was asked why there was not treatment performed on [DATE] and [DATE]. LPN #4 stated, I don't work on weekends and on the 17th (2021). I worked 16 hours on the floor. The floor nurses do the treatments on the days I am not here. On the 17th I was not working as the treatment nurse. LPN #4 was asked if she had reassessed Resident #40 ' s wound. LPN #4 stated, No. I would have reviewed it today and put a new order into place. LPN #4 was asked if she worked as the treatment nurse on ,[DATE] and ,[DATE]. LPN #4 stated, I worked as the treatment nurse on the 18th, but I worked 3pm-11pm (3:00 p.m. - 11:00 p.m.) on February 19, 2021. LPN #4 was asked if wound care had been performed since February 16, 2021. LPN #4 stated, No. She has a boot in place to keep the pressure off if it, but no treatment has been done. 3. On [DATE] at 12:42 PM, LPN #4 was asked if body audits were performed on the residents. LPN #4 stated, Yes. Body audits are done weekly for 3 weeks on new admissions and then quarterly. LPN #4 was asked who was responsible for performing the body audits. LPN #4 stated, The wound care nurse does the quarterly audits. LPN #4 was asked if there were any policies that she was aware of regarding treatments, wound care, and body audits. LPN #4 stated, Not that I know of, I have not been shown any. 4. On [DATE] at 1:37 PM, the Director of Nursing (DON) was asked when skin audits were being performed. The DON stated, I believe the nurses do them weekly and the CNA's (Certified Nursing Assistant) inspect the skin daily. The DON was asked where that information was documented in the chart. The DON stated, I will have to check and get back to you. 5. On [DATE] at 1:49 PM, the DON provided a copy of the schedule for weekly skin audits to be performed by the nurse. The DON stated, Here is a schedule of when the resident should have a skin audit done but there is no documentation to prove it is being done. The CNAs document in their point of care documentation any skin issues daily. The DON was asked if the nurses looked at the CNAs ' documentation to identify any skin issues. The DON stated, Obviously not. 6. Resident # 67 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status (SAMS); required extensive assist for bed mobility, dressing, toilet use, eating, and personal hygiene; was totally dependent for transfers, was always incontinent of bowel and bladder, and did not refuse/reject care; was at risk for pressure ulcers / injuries; had unhealed pressure ulcers / injuries; had 1 stage 2 pressure ulcer; and required pressure relieving device for chair / bed. a. The Care Plan with an initiated date of [DATE] documented, .Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate . b. The Care Plan with a revision date of [DATE] documented, .The resident has . Stage 2 pressure injury to sacrum . Administer treatments as ordered and monitor for effectiveness . Assess/record/monitor wound healing weekly. Measure length, width and depth where possible. Assess and document status or wound perimeter, wound bed and healing progress . c. A wound report dated [DATE] documented, .pressure ulcer to sacrum . Stage II . 0.7 cm (centimeters) x (by) 1.47 cm x 0.72 cm x 0.3 cm . There were no wound measurements documented for Resident #67 from [DATE] through [DATE]. d. A wound report dated [DATE] documented, .pressure ulcer to sacrum . Stage II . 0.7 cm x 1.33 cm x 0.69 cm x 0.2 cm . e. A wound report dated [DATE] documented., .pressure ulcer to sacrum . Stage II . 0.96 cm x 1.44 cm x 0.98 cm x 0.2 cm . There were no wound measurements documented for Resident #67 from [DATE] through [DATE]. f. The wound report dated [DATE] documented, .Stage II on Coccyx .0.69cm x 0.85 cm x 1.1 cm. g. A physician order [REDACTED].Cleanse pressure injury to sacrum with normal saline -pat dry- apply [MEDICATION NAME] blue to wound bed then cover with bordered sacral dressing one time a day every Mon (Monday), Wed (Wednesday), Fri (Friday) for wound healing until [DATE] . h. A physician order [REDACTED].Cleanse pressure injury to sacrum with normal saline -pat dry- apply [MEDICATION NAME] blue to wound bed then cover with bordered sacral dressing one time a day every Mon, Wed, Fri for wound healing until [DATE] . i. A physician order [REDACTED].Re-eval (reevaluate) pressure injury to sacrum one time only for re-eval until [DATE] . j. On [DATE] at 06:00 PM, A telephone interview was conducted with R #67's spouse. She was asked about resident having any pressure ulcers. R #67's spouse stated, He had pressure ulcers to the inside of the knee and ankle bone, but that healed up. They told me he has one on his tailbone. I just found out about it during the care plan meeting. k. A wound report dated [DATE] documented, .pressure ulcer to sacrum .Stage II .0.44 cm x 0.78 cm x 0.78 cm . l. The wound report dated [DATE] documented, .Stage II on Coccyx .0.84 cm x 0.91cm x 1.3 cm m. There were no wound measurements documented for Resident #67 from [DATE] through [DATE]. n. A wound report dated [DATE] documented, .pressure ulcer to sacrum .Stage II .0.35 cm x 0.66 cm x 0.66 cm . o. On [DATE] at 02:58 PM, The Director of Nursing (DON) was asked, Do you have any weekly measurements, treatment changes, and family/physician notifications. The DON stated, I have nothing for Resident #67. 7. Resident #70 had [DIAGNOSES REDACTED]. The Significant change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] documented the resident scored 13 (,[DATE] indicates cognitively intact) on a Brief Interview for Mental Status (BIMS),; required extensive assistance of 2 persons for bed mobility, transfers, dressing, personal hygiene, toilet use; had a supra pubic foley catheter; was always incontinent of bowel; received oxygen therapy; and received Hospice care; is at risk for pressure ulcers; has one or more unhealed pressure wounds; had 1 stage 2 pressure ulcer; had 1 unstageable pressure ulcer due to coverage of wound bed by slough and / or eschar. a. The Care Plan with a revision date of [DATE] documented, .When present: assess/record/monitor wound healing at least weekly. 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) . When present: weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate . b. A wound report on [DATE] documented, .A new Stage II pressure ulcer on coccyx . 2.0 cm x 1.78 cm x 1.66 cm . c. The Care Plan with a revision date of [DATE] documented, .Duoderm to coccyx x (times) 14 days for stage 2 pressure injury . Monitor/document/report PRN (as needed) any changes in skin status: appearance, color, wound healing, s/sx (signs and symptoms) of infection, wound size (length X width X depth), stage . d. A wound report dated [DATE] documented, .Stage II pressure ulcer on coccyx . 1.68 cm x 1.12 cm x 1.12 cm . There was no documentation of weekly wound measurements until [DATE]. e. A wound report dated [DATE] documented, .Stage II pressure ulcer on coccyx . 1.47 cm x 2.09 cm x 0.93 cm. f. A wound report dated [DATE] documented, .A new unstageable pressure ulcer to sacrum . 2.09 cm x 1.9 cm x 1.37 cm . g. A wound report dated [DATE] documented, .Stage II pressure ulcer on coccyx . 0.69 cm x 0.85 cm x 1.1.cm . There were no wound measurements documented for 13 days for Resident #70 until [DATE]. h. A wound report on [DATE] documented, .Unstageable pressure ulcer to sacrum .2.45 cm x 1.93 cm x 1.56 cm . There was no documentation of weekly wound measurements until [DATE]. i. A physician order [REDACTED].Cleanse pressure injury on coccyx with wound cleanser -pat dry- apply [MEDICATION NAME] Ag then cover with bordered dressing for 21 days one time a day every Mon, Wed, Fri until [DATE] . j. A physician order [REDACTED].Re-eval pressure injury to coccyx one time only until [DATE] . k. A physician order [REDACTED].Cleanse pressure injury on sacrum with wound cleanser -pat dry- apply [MEDICATION NAME] Ag then cover with bordered dressing for 21 days one time a day every Mon, Wed, Fri until [DATE] . l. A physician order [REDACTED].Re-eval pressure injury to sacrum one time only for re-eval until [DATE] . m. On [DATE] at 02:42 PM, Resident #70 was asked, Do you have a wound? Resident #70 stated, Yes, on my bottom. n. A wound report dated [DATE] documented, .Stage II pressure ulcer on coccyx .0.84 cm x 0.91 cm x 1.36 cm . There was no documentation of weekly wound measurements until [DATE]. o. A wound report dated [DATE] documented, .Stage II to sacrum .2.06 cm x 1.52 cm x 2.76 cm . There was no documentation of weekly wound measurements until [DATE]. p. A wound report dated [DATE] documented, Stage II pressure ulcer on coccyx .0.85 cm x 0.85 cm x 1.25 cm . q. A wound report dated [DATE] documented, .Stage II to sacrum .2.11 cm x 1.63 cm x 1.63 cm . 8. Resident #53 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set with an Assessment Reference Date of [DATE] documented resident scored 15 (,[DATE] indicates cognitively intact) on a Brief Interview of Mental Status and required extensive assistance of two persons for bed mobility and total dependence of two persons for transfers; was at risk for developing pressure ulcers; and required a pressure relieving device for the bed. a. The Plan of Care with a revision date of [DATE] documented, The resident has potential for pressure injury related to repaired bed mobility and incontinence of bowel and bladder .deep tissue injury to sacrum .Administer treatments as ordered and monitor for effectiveness. b. The Physician order [REDACTED]. c. The Would Evaluation dated [DATE] documented the resident wound on coccyx measured, Surface Area 0.33 cm, Length 0.56, Width 0.82. d. On [DATE] at 12:44 PM, the Treatment Nurse was asked, How do you determine the difference in a deep tissue injury and pressure sore? She stated, Deep tissue does not have any open areas, pressure area has area of epidermis missing. (Picture dated February 10,2021 was shown to treatment nurse) The Treatment Nurse was asked, Can you tell me if the resident ' s sacrum has an open area? She stated, Yes. It does look open. The Treatment Nurse was asked, Does it look like a deep tissue injury? She stated, No. Its pressure. The Treatment Nurse was asked, Should this wound be staged as pressure? She stated, Yes. e. On [DATE] at 1:01 PM, the Director of Nursing was asked, If a resident has an open area on coccyx should it be staged pressure or deep tissue? She stated, If it ' s on a bony prominence and its open then it would need to be staged. If it ' s not open then it could be deep tissue. A photograph of the resident ' s wound dated [DATE], and [DATE] was shown to the DON at this time. After observing the pictures DON stated, It is defiantly open. f. On [DATE] at 01:48 PM, this Surveyor observed the Treatment Nurse complete R #53's wound treatment and there was an open area noted to sacrum. The wound measured area 0.62 c.m x (by) 0.56 cm x 1.37 cm.

Complaint # (AR 920) was substantiated, all or in part, with these findings: Based on observation, record review, and interview, the facility failed to ensure adequate supervision was provided to prevent elopement, as evidenced by failure to ensure increased supervision was provided during periods of increased exit-seeking behaviors; failure to ensure staff responded promptly to an exit door alarm; and, failure to ensure staff thoroughly checked the area outside the building after a door alarm sounded for 1 (Resident #1) of 6 (Residents #1, #2, #3, #4, #5, and #6) case mix residents who were at risk for elopement. These failed practices resulted in Immediate Jeopardy, which caused, or could have caused serious harm, injury or death to Resident #1, who exited the building at 3:30 a.m., unnoticed by staff and remained outside, alone, for more than 30 minutes, with access to a busy street and wooded area, and had the potential to cause more than minimal harm to 18 residents who were at risk for elopement, according to a list provided by the Director of Nursing (DON) on 5/8/19 at 10:35 a.m. The facility removed the Immediate Jeopardy on 5/5/19, prior to the survey entrance date, when they placed the resident on one-on-one monitoring; however, there were underlying deficient practices that remained uncorrected at the time of the survey. The Administrator was informed of the removed Immediate Jeopardy condition on 5/8/19 at 4:30 p.m. The findings are: Resident #1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/31/19 documented the resident scored 3 (0-7 indicates severe cognitive impairment) on a Brief Interview for Mental Status (BIMS); exhibited no wandering behaviors; and used a walker to assist with ambulation. a. A physician's orders [REDACTED].Roam Alert on for safety . Check every shift for placement . b. The Care Plan dated 11/16/18 and revised 4/19/19 documented, .Problem . I have impaired cognition and have difficulty communicating . I am at risk for anxiety, restlessness and elopement . Approach / Intervention . Monitor my mood, notify nurse if I am restless, anxious or making attempts to leave facility . Monitor me when my visitors leave . Monitor me when I am ambulating off unit . Roam alert to wrist or ankle for safety . Check every shift for placement . c. A Resident Locator Alert assessment dated [DATE] documented, .Is Resident ambulatory or self-mobile in wheelchair . Yes . Resident is cognitively impaired, with poor decision-making skills, and / or pertinent diagnosis (e.g. (for example) Dementia, Alzheimer's, Delusions, Hallucinations, [MEDICAL CONDITION]) . Yes . Resident has history (within the last 90 days) of wandering, exit-seeking behavior, or elopement attempts . Yes . Resident making statements that they are leaving, or seeking to find someone or something . Yes . Score . 4 . (A score of 3 or more indicates a need for a locator alert) . d. A Nurse's Note dated 4/1/19 at 10:41 a.m. documented, .on Q (every) 15 min (minutes) checks r/t (related to) trying to leave facility. Has had no behavioral issues and is very pleasant when staff goes to check on him . e. A Nurse's Note dated 4/5/19 at 1:16 p.m. documented, .No further exit-seeking behaviors noted. Resident continues to roam the halls and is easily redirected to activities, meals and toileting . f. A Nurse's Note dated 5/1/19 at 8:33 a.m. documented, .Resident was found increasingly confused this morning, exit-seeking, unsteady gait and diaphoretic. CBG (Capillary Blood Glucose) 160 (after breakfast), BP (Blood Pressure) 122/60, (Temperature) 96.9 ax (axillary), (Heart Rate / Pulse) 86, Respirations 17, and pulse ox (Pulse Oxygenation / saturation) 92%. UTI (Urinary Tract Infection) protocol initiated. Physician notified. New order received STAT (immediate) CMP (Comprehensive Metabolic Panel), CBC (Complete Blood Count), UA (Urinalysis) . g. A Resident Locator Alert assessment dated [DATE] documented, .Is Resident ambulatory or self-mobile in wheelchair . Yes . Resident is cognitively impaired, with poor decision-making skills, and / or pertinent diagnosis (e.g. Dementia, Alzheimer's, Delusions, Hallucinations, [MEDICAL CONDITION]) . Yes . Resident has history (within the last 90 days) of wandering, exit-seeking behavior, or elopement attempts . Yes . Resident making statements that they are leaving, or seeking to find someone or something . Yes .Score . 4 . (A score of 3 or more indicates a need for a locator alert) . h. A Urinalysis laboratory report dated 5/3/19 at 10:24 a.m. documented no infection and a culture was not indicated. i. A Nurse's Note dated 5/5/19 at 8:12 a.m. and written / signed by the Director of Nursing (DON) documented, .Received call from the Administrator that staff reported to her that resident had wandered out of the Care Center and entered the Assisted Living Facility next door. He was pleasant and cooperative, stating that he was 'looking for a ride to the drugstore.' Resident was assessed by Charge Nurse with no negative findings. Physician and family notified. All are in agreement that evaluation by geri-psych (Geriatric Psychiatric Facility / Provider) is indicated at this time . j. The Office of Long Term Care (OLTC) Incident and Accident Report, Division of Medical Services (DMS) form 7734, dated 5/5/19 documented, .On 5/5/19 at 4:00 a.m., resident wandered out of the building and entered the campus Assisted Living next door. Assisted Living staff notified Charge Nurse (Licensed Practical Nurse (LPN) #1) at (facility name) and she, (LPN #1), and (Certified Nursing Assistant (CNA) #3) went to walk him back to his room. He was pleasant and cooperative. Resident stated that, 'I need a ride to the drug store.' Resident was assessed by (LPN #1) with no negative findings. Resident was placed on Q (every) 15 checks. Consulted with family and physician and both agree that geri-psych (Geriatric Psychiatric Facility / Provider) consult is indicated at this time. Resident placed on 1:1 (one-on-one monitoring) pending placement . k. On 5/7/19 at 3:20 p.m., the facility doors were checked with the Maintenance Director for proper functioning. The door at the end of the West Long Hall was checked, and the alarm was noted to be at a low volume. The surveyor walked to the Nurse's station at the other end of the hall. LPN #2, who was sitting at the Nurse's Station, was asked if she could hear a door alarm. She stated, No. LPN #3 was standing by the Nurse's Station and was asked if she could hear a door alarm. She stated, No. CNA #7 was standing by the Nurse's Station and was asked if he could hear a door alarm. He stated, No. The distance from the West Long Hall exit door to the Nurse's Station was measured by the Maintenance Director as 118.8 feet. l. On 5/8/19 at 6:55 a.m., CNA #1, who worked the 11:00 p.m. to 7:00 a.m. shift on 5/4/19 to 5/5/19, was asked if she was familiar with Resident #1. She stated, I know who you are talking about. One night I walked the halls with him for like 2 hours because he wanted to go home. His wife and kids were waiting for him out in the car, he thought. She was asked if he wore a Roam Alert bracelet. She stated, I think he did. In the last few days, he came down to the end of West Hall and was shaking on the doors. She was asked if he had ever gotten out before. She stated, Not that I know of. m. On 5/8/19 at 7:05 a.m., the Maintenance Director measured the distance from the door the resident exited from to the door he entered at the Assisted Living facility. The distance was 432 feet. n. On 5/8/19 at 7:10 a.m., CNA #2, who worked the 11:00 p.m. to 7:00 a.m. shift on 5/4/19 to 5/5/19, was asked if she knew Resident #1. She stated, Yes. He roams a lot at night. Just walking. He is sometimes looking for his parents or his car. Every once in a while, he'll go to the doors and try to get out. She was asked how he got out of the building on the morning of 5/5/19. She stated, I guess he held down the door long enough for it to open. She was asked what the facility should do to keep residents like that from getting out of the building. She stated, I guess pay attention to the Roam Alerts on the computer or check on the residents more than every 2 hours. She was asked what she would do if she heard a door alarm. She stated, I go check it. I will open the door and see if there's anyone outside. Then, turn the alarm off. o. On 5/8/19 at 8:38 a.m., LPN #1, who worked the 11:00 p.m. to 7:00 a.m. shift on 5/4/19 to 5/5/19, was asked if she was familiar with Resident #1. She stated, Yes. I was his nurse last weekend. He's confused. He walks around. He's pleasant. I was not aware he was an exit-seeker until Saturday night. Sometime early in the shift, maybe between 12 to 1 (12:00 a.m. to 1:00 a.m.), the front door alarm went off. So, I went to it, and there was an aide; I think it was (CNA #3), and (Resident #1). He was trying to go out the front door. He said he needed to go get groceries. We redirected him and, he went to his room and laid down. When staff made their next round, he was still in bed. She was asked if supervision was increased for him since he was observed by herself and other staff exit-seeking that shift. She stated, I told staff to keep an eye on him. She was asked if she implemented a set schedule of checks, like every 15-minute checks. She stated, No. She was asked what happened next. She stated, The next thing I know, I'm on North (North Hall) and the phone rings, and it's the Assisted Living facility telling me he was over there. Me and (CNA #3) went to get him. She was asked how he got out of the building. She stated, That's what I wanted to know. But I found out later that the volume on my computer was down. I didn't know it. It would have alerted me that he triggered a door. p. On 5/8/18 at 8:58 a.m., Registered Nurse (RN) #1 was asked if she was familiar with Resident #1. She stated, Yes. He's very confused but easily redirected. He's very sweet. She was asked if he was considered to be at risk for elopement. She stated, Yes, he was at risk. He's ambulatory. He likes to walk the halls. He had a Roam Alert bracelet on. I placed it on him when he was admitted because I asked a family member if he needed it, and they said, 'Yes.' He doesn't try to leave every day, but he was having a bit more confusion like Thursday or Friday. His lab work was negative. She was asked how the facility should have prevented him from getting outside the building. She stated, The alarm should have gone off so staff should have checked to see why. She was asked what staff would do to check that. She stated, They should see if the door is open, and the computer should show them where the resident last was. There should be an audible and visual alert that shows you where he last was. If a resident with a bracelet gets close enough to trigger the system, it will alert. Staff should go outside and check if a door alarm is going off. She was asked if she felt supervision should be increased when there is a resident who is displaying obvious exit-seeking behaviors. She stated, We have Q (every) 15-minute check forms at the desk for the nurses to use if needed. I'm not sure why that wasn't done. She was asked if she felt it was okay for staff to silence a door alarm without going outside to check for residents. She stated, I don't think that's okay. She was asked if she was aware of the volume being down on LPN #1's laptop at the time of the elopement on 5/5/19. She stated, No, I was not aware of that. q. On 5/8/19 at 9:10 a.m., video footage of the elopement was reviewed. The video showed the resident approach the smoke area door at 3:24 a.m. He pressed on the door for a few seconds, but then walked away because the door did not open; however, he had triggered the alarm and the door opening sequence which caused the door to unlock 15 seconds later. At 3:30 a.m., the resident came back to the door, pushed on it and it opened. He walked outside. CNA #5 approached the door and was observed swiping his badge to silence the door alarm at 3:35 a.m., 11 minutes after the door alarm was activated. He did not go outside to search the area. An outside camera showed the resident walking along a sidewalk behind the nursing home at 3:47 a.m. The resident eventually was able to get into the Assisted Living facility at approximately 3:58 a.m., 34 minutes after he initially went outside. r. On 5/8/19 at 9:44 a.m., CNA #3, who worked the 11:00 p.m. to 7:00 a.m. shift on 5/4/19 to 5/5/19, was asked if she was familiar with Resident #1. She stated, Yes. I was one of his CNAs. I went with the nurse to get him that morning. He's very confused. Laid back. That night, all night, he thought his family was there to take him to the drug store. He's not like that every night, but when he is, it's a one-track mind. He was pushing on all the doors. We watched him try to get out the front door several times that shift. She was asked if he had ever eloped before. She stated, Not that I know of. She was asked how he got out that morning. She stated, If you push long enough, by default, the doors automatically unlock after pushing on it. She was asked if she was told to increase his supervision that shift, such as doing every 15-minute checks, since he was actively exit-seeking much of the shift. She stated, No. I was not told to do Q (every) 15-minute checks or anything like that, but I've been a CNA for a long time, so I just know. She was asked what she would do if she heard a door alarm. She stated, I see if someone is trying to go out, and then go out to look. s. On 5/8/19 at 10:25 a.m., CNA #4, who worked the 11:00 p.m. to 7:00 a.m. shift on 5/4/19 to 5/5/19, was asked if she was familiar with Resident #1. She stated, Yes. He walks down North Hall a lot. He likes to go to the exit and try to get out. He does it often, but not every day. Sometimes he will push on the door. Sometimes he will just look out and say he's looking for his wife. I didn't see him at all that night. When we got done with our second rounds, (LPN #1) got a call telling her one of the residents was over there in Assisted Living . t. On 5/8/19 at 11:08 a.m., CNA #5, who worked the 11:00 p.m. to 7:00 a.m. shift on 5/4/19 to 5/5/19, was asked about Resident #1. He stated, He was asleep for most of the shift. I was on the Front Hall, but went to Northwest for a little while. He was asked if the resident is a wanderer. He stated, Yeah, he wanders around the building, but on 11:00 p.m. to 7:00 a.m. he's usually sleeping. He was asked if he, at some point, went and silenced a door alarm at the break / smoking area door. He stated, Yes. I don't remember when it was, but I was walking and heard the alarm and went and swiped my badge to silence it. That door alarm goes off all the time. He was asked why the door alarm goes off all the time. He stated, I don't know. When you come through it, you can swipe to come in or out, and after you leave the door, it'll go off again. He was asked if he had reported that to anyone. He stated, No. I have not. He was asked if he went outside and checked the area when he silenced the door alarm. He stated, No. He was asked, why not and stated, Because of that door sometimes just going off. He was asked if it had ever occurred to him that a resident might have gone out that door. He stated, No. He was asked if this elopement incident had triggered him to tell someone, like the DON, that there was a problem with the door. He stated, No, but it probably should have. He was asked if he knew of any other doors that had problems with functioning properly. He stated, Not that I know of. u. On 5/8/19 at 11:30 a.m., CNA #6, who worked the 11:00 p.m. to 7:00 a.m. shift on 5/4/19 to 5/5/19, was asked if she was familiar with Resident #1. She stated, Yes. He sometimes comes to West and tries to get out our door, or he sits in the Day Room. She was asked if she remembered seeing him last Saturday night. She stated, I don't remember seeing him. Some nights he's there, some not. She was asked if he was an elopement risk. She stated, Probably. He's confused and he tries to get out the door. It was either Saturday or Sunday when he tried to get out the door. She was asked if she was aware of any problems with any of the doors functioning properly. She stated, No. v. The facility's policy titled Wandering or Elopement, provided by the Director of Nursing on 5/8/19, documented, .Purpose: To provide guidelines to follow to help create a safe environment for residents who are at risk for 'unsafe wandering' or elopement . Scope of Responsibility: . All facility staff . Definition: .Elopement is defined as slipping away secretly, running away, leaving without accompaniment or knowledge of the staff . Elopement occurs when a resident leaves the premises or a safe area without authorization and / or any necessary supervision to do so . Procedure: Upon admission an assessment will be completed to identify risks . Reassessment will be completed on a quarterly basis, with a significant change in condition, and PRN (as needed) . For residents identified at risk: A Roam Alert Device will be placed on residents with a score of 3 or more on the Elopement Risk Assessment . Care Plan will address the Roam Alert and other interventions to promote a safe environment and reduce unsafe wandering . The Roam Alert device will be checked for placement every shift and documented by the Charge Nurse in the Treatment Record (TAR} and the nursing assistant in the E-Care . A battery check for the Roam Alert device will be made monthly as well as PRN . documentation of battery function will be made in the E-Care . Technical difficulties or malfunctions will be reported to (Name) . If Roam Alert System is not functioning, institute q (every) 15 minute visual checks on all resident with a Roam Alert device . If doors are not secure post a staff member at each malfunctioning door until repaired . All facility staff will assist residents with redirection when they observe unsafe wandering or exit seeking behavior . Documentation will be made in the EMR (Electronic Medical Record) utilizing the Behavior Documentation assessment . w. The facility removed the Immediate Jeopardy and reduced the scope and severity to [NAME] on 5/5/19, prior to the survey entrance date, by implementing the following, according to a list provided by the DON on 5/8/19 at 8:58 a.m.: 1.) On 5/5/19, the resident was assessed with [REDACTED]. 2.) On 5/5/19, every 15-minute checks (were implemented); 3.) On 5/5/19, the DON arrived at the facility and placed the resident on one-on-one; 4.) On 5/5/19, in-serviced staff on looking outside when alarm is going off before resetting the alarm; 5.) On 5/5/19, called all nurses in the facility to make sure the volume was turned up on their computer; 6.) On 5/5/19, called (alarm company) and they came and checked to ensure door and alarm was functioning properly; door and alarm was working correctly; 7.) On 5/5/19 at 12:36 p.m., Resident was sent to geri-psych for evaluation and treatment; 8.) Helped family find placement for Secure Unit following evaluation and treatment. x. On 5/8/19 at 2:02 p.m , the Administrator stated the Alarm Company was contacted and had been to the facility today to install alarm enhancers to make the door alarms louder. She was asked when they contacted the Alarm Company to come out and add this feature and stated, It was yesterday, after you and (Maintenance) made your rounds on the doors.

Complaint # (AR 423) was substantiated, all or in part, with these findings: Based on record review and interview, the facility failed to ensure a transfer was conducted with a Safety Sure Sling and 2-person assistance for a resident with severe osteoporosis and osteopenia, as per the plan of care, which resulted in injury to the resident, and failed to ensure direct care staff immediately informed a licensed nurse of an audible 'pop' during the transfer and resident's complaints of knee pain immediately after the transfer, to enable the nurse to assess, identify and promptly notify the physician of any injury for 1 (Resident #1) of 1 case mix resident who required the use of the Safety Sure Sling for transfer. The failed practices resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury or death to Resident #1, who sustained a fracture of the distal femur when staff conducted a 2-person manual transfer, and had the potential to cause more than minimal harm to 5 residents who required a 2-person transfer with the Safety Sure Sling, as documented on a list provided by Medical Records Employee #1 on 9/13/17 at 2:21 p.m. The Administrator was informed of the Immediate Jeopardy condition on 9/13/17 at 2:00 p.m. The findings are: 1. Resident #1 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) with an Assessment Reference Date of 8/17/17 documented the resident scored 13 (13 - 15 indicates cognitively intact) on a Brief Interview for Mental Status, required extensive 2 person assistance for transfers, and had functional limitation in range of motion on both sides in the upper and lower extremities. a. The Plan of Care updated on 3/20/17 documented, .Problem Onset . 9/8/16 .Problem/Need . Resident is requiring extensive to total assistance with most ADLs (Activities of Daily Living) . Approaches . 3/20/17 . (change) to a Safety Sure Sling (plus) 2 CNAs (Certified Nursing Assistants) for all transfers . b. An Office of Long Term Care Witness Statement dated 8/26/17 and written by Licensed Practical Nurse (LPN) #1 documented, .On August 24th (2017), (CNA #1) asked me to look at (Resident #1's) right knee. She states that she is complaining more with pain to her knees. (CNA #1) stated that Saturday (8/19/17) when she gave shower and transferred her (Resident #1) back to bed, she heard a 'pop'. I checked her knees. The right knee looks normal and the left knee is swollen, which it is normally swollen. And resident (is) able to move both knees. Today, 8/26/17, one of the weekend option girls thought it was swollen more than normal. (Physician's Name) notified and order received to get an x-ray of left knee . c. An x-ray final result dated 8/26/17 documented, .Knee 3 views . Left . Reason for Exam . Injury . Views . AP (anterior / posterior) and lateral views left knee . Findings . Is severely Osteopenic with fracture distal femur with some dorsal displacement distal fragment. Not clear if this is an old ununited fracture or acute fracture. Severe degenerative changes medial lateral compartments . Impression . Severe Osteopenia with fracture distal femur as above . d. An Office of Long Term Care Witness Statement Form dated 8/28/17 and written by CNA #1 documented, .On Saturday 8/19/17 after I took (Resident #1) shower (she was) ready to go to the bed. I called for help. (CNA #2) from the weekend helped me transfer (Resident #1) from her wheelchair to her bed. I heard the voice 'cacked' from her body. I think because we turned wrong way and she screamed and say 'hurt my leg' . e. An Office of Long Term Care Witness Statement Form dated 8/29/17 and written by CNA #2 documented, .On 8/19/17 assisted resident from chair to bed. Transfer went awkward and more weight was put on one side. Once (the) transfer was complete, I left room, leaving resident's aid to finish care. I did not notice any signs of discomfort . f. An Office of Long Term Care (OLTC) Incident and Accident Next Day Reporting Form, Division of Medical Services (DMS) form 7734, dated 8/29/17 documented, .Summary of Incident . On 8/28/17 (Resident #1's) radiological reports from (Hospital) were reviewed by DON (Director of Nursing). AP (anterior / posterior) and lateral views of left knee findings . 'Is severely Osteopenic with fracture distal femur .' In a report from (LPN #1) on 8/26/17 reported that she had assessed (Resident #1's) knee on 8/24/17 after (CNA #1) reported to her that (Resident #1) was complaining of more pain. (CNA #1) reported to (LPN #1) 8/24/17 that on 8/19/17 she had heard a pop. (LPN #1's) assessment on 8/24/17 was unchanged from (Resident #1's) normal. Both knees were assessed with [REDACTED].#1) (some swelling is normal). On 8/26/17 (Resident #1) was sent to (Hospital) by (LPN #1) with additional swelling to left knee. On 8/28/17 at (3:30 p.m.) (CNA #1) was questioned by DON and Administrator in two separate interviews regarding the care (Resident #1) received on 8/19/17. (CNA #1) described transferring (Resident #1) using a sling transfer assisted by (CNA #2). (CNA #1) described that she heard 'the voice cracked from her body, I think because we turned the wrong way and she screamed and said it hurt her leg.' (CNA #1) denies dropping (Resident #1) and stated she did not fall to the floor. DON and Administrator spoke with (CNA #2) whose recollection of events on 8/19/17 does not match (CNA #1). (CNA #2) denies any sound or pain occurred during transfer. (Resident #1) has a long history of pain to the left knee and a history of pathological fractures with Osteoporosis and Osteoarthritis. Per radiological report, it is unclear if (Resident #1's) injury is new or old .(LPN #2) confirmed that he was not informed on 8/19/17 of any concerns regarding (Resident #1) . (CNA #1) was provided on-on-one in-service by Administrator regarding the importance of reporting immediately to Charge Nurse any abnormal issues with the residents . (Resident #1) was returned to the facility on [DATE] with a knee immobilizer . g. The Facility Investigation Report for Abuse, Neglect, Misappropriation of Property and Exploitation of Residents in Long-Term Care Facilities, DMS form 762 dated 8/31/17 documented, .An in-service was given to all North Hall staff on 8/30/17 outlining the severe Osteopenia (Resident #1) has and the care requirements necessary. All staff on the hall was reminded of the need to report immediately anything out of the norm (normal). Care Plan was modified to address the fracture . (Physician's Name) assessment was that the fracture was a consequence of severe Osteoporosis / Osteopenia and represented a pathological fracture. In conversation with (Resident #1's Son) the history of pathological fractures was confirmed. In an interview with the DON, (Resident #1) stated that she was dropped about a week ago and that her hip and knee were broken as a result. (Resident #1) was unable to say what the date of occurrence was or who the CNAs were. (Resident #1) was unaware that she had a knee immobilizer on at the time of the interview . Findings: Injury of unknown origin with pathological fracture secondary to Osteoporosis. (Resident #1) has a long history of pain to the left knee and a history of pathological fractures with Osteoporosis and Osteoarthritis. Per radiological report it is unclear if (Resident #1's) injury is new or old. Per (Physician) the injury is a pathological fracture. Unable to determine if resident sustained [REDACTED]. (Physician) maintains that a fracture on that date would have resulted in clinical symptoms before 8/26/17 . h. An in-service document dated 8/30/17 indicated the DON presented training specific to Resident #1's care needs to all staff assigned to the North Hall, where Resident #1 resides. The in-service documented, .Resident has severe Osteopenia, which means her bones are extremely brittle. We must be very careful when providing care. Please keep this in mind always. If any kind of incident happens, such as signs of sudden pain, guarding of a limb, or anything that you feel out of the norm, please report this to your nurse immediately . i. A Doctor's Progress Note dated 8/31/17 at 7:00 a.m. documented, .The fracture deformity of the distal femoral metaphysis is in my professional opinion and experience is a consequence of severe Osteoporosis / Osteopenia and represents a pathological fracture . This note was signed by the resident's physician. j. On 9/13/17 at 9:31 a.m., the Director of Nursing (DON) was asked about Resident #1's injury and stated, .(CNA #1) did not report to anyone on the 19th (8/19/17) that (Resident #1) complained that they hurt her leg or she heard a popping sound. (CNA #2) said she didn't hear a popping sound or (Resident #1) complain that her leg was hurt. I reported it, but there was no suspicion of abuse, just an injury of unknown origin on the 26th (8/26/17). On the 24th (8/24/17), the assessment of her knee was normal for her, but she had a change of increase in swelling and complaining of pain on 8/26/17, at which time we sent her to the ER (emergency room ). The Medical Director said that if there was an injury on 8/19/17 it would not have taken until 8/26/17 to show up. The DON stated Resident #1 does complain of pain with all movement due to her severe Osteoporosis and Osteoarthritis. k. On 9/13/17 at 10:33 a.m., Licensed Practical Nurse (LPN) #1 was asked about the incident with Resident #1. She stated, (CNA #1) reported to me on 8/24/17. When I assessed her (Resident #1) on the 24th (8/24/17), she had swelling to her left knee, but she always has swelling. When I moved her legs, there was no signs or reports of pain. (Resident #1) had increased swelling on 8/26/17, so that's when we sent (Resident #1) to the hospital. l. On 9/13/17 at 11:00 a.m., CNA #2 was asked about the incident with Resident #1 and stated, I helped (CNA #1) transfer (Resident #1). I was in there during the entire transfer. We used a sling (Safety Sure sling and) gait belt transfer to transfer her from her wheelchair to her bed. It was a little awkward for me due to height difference in me and (CNA #1). There was no complaint from (Resident #1) at all during the transfer. m. On 9/13/17 at 11:20 a.m., CNA #1 was asked about the incident with Resident #1 and stated, That day, (Resident #1) was in her wheelchair, and (CNA #2) came to help me transfer her from her wheelchair to her bed. We used the sling transfer. While moving her, I heard a 'clack.' I don't know if it came from her belly, arm or where. Then she said, 'I hurt my knee.' She didn't say which knee. I can't remember if (CNA #2) was still in the room when (Resident #1) said she hurt her knee. I didn't see anything different with her knees. I didn't tell the nurse because (Resident #1) complains all the time when we transfer her. I didn't think I needed to tell the nurse since after the transfer she was in bed sleeping and wasn't complaining of pain. When I checked on her after that, she was sleeping and had no more complaints of pain. She complains of pain all the time, but she did not complain more than normal. n. On 9/13/17 at 12:18 p.m., CNA #1 called the surveyor's mobile phone and stated she needed to tell the surveyor something. She stated no sling was used during the transfer conducted on 8/19/17. The Surveyor was not in a private setting at this time and informed CNA #1 she would call her back for additional information. o. On 9/13/17 at 1:11 p.m., the Surveyor returned CNA #1's telephone call, and the CNA stated, We were in a hurry and didn't use the sling. (CNA #2) was there with me when we transferred her (Resident #1). (CNA #2) knew we were supposed to use the sling. We each got under one of her legs and arms. Her bottom went down. We lifted her up again. She never touched the floor. We never dropped her. She is heavy. Before we got her in the bed, I heard the 'pop'. p. On 9/13/17 at 1:20 p.m., the Surveyor contacted CNA #2 by telephone and asked about Resident #1's transfer on 8/19/17. CNA #2 stated, I'm trying to remember. I was having some medical issues at that time. I came off medication cold turkey. I can't remember. What I remember, is we used a sling lift. q. On 9/13/17 at 1:50 p.m., CNA #3 described to the Surveyor how the staff were supposed to transfer Resident #1 with the Safety Sure Sling and a gait belt. She stated the gait belt should be placed around the resident's waist, and the sling should be positioned under the resident's bottom for support and stability of the resident. She also stated they used this type of transfer for Resident #1, .because of her severe Arthritis, and she is unable to bear much weight during a regular gait belt transfer. This makes it possible to transfer her safely without having to use a mechanical lift. r. On 9/13/17 at 3:17 p.m., the surveyor attempted to interview Resident #1 about the incident on 8/19/17. The resident was unable to answer questions related to the incident. s. The Immediate Jeopardy was removed on 9/13/17 at 4:40 p.m. by implementing the following Plan of Removal. This reduced the scope / severity to H (due to the greater than 1-month period during which CNA #1 failed to inform the facility of her failure to follow the resident's care planned method of transfer, which delayed and complicated the diagnostic process and prevented the facility from being able to adequately address the failed practices prior to the survey). Immediate Jeopardy - Plan of Removal - Inappropriate Transfer Identify: On 9/13/17 at (2:00 p.m.) the DON identified five residents, (Resident #1) and four other non-case mix residents who utilize a Safety Sure Transfer Sling. On 9/13/17 at (4:15 p.m.), (Registered Nurse (RN) #1) reevaluated (Resident #1's) mode of transfer and determined that the Safety Sure Sling is the most appropriate method of transfer. Corrective action: On 9/13/17 at (3:00 p.m.) the DON or designee began in-service to 7 to 3 (7:00 a.m. to 3:00 p.m. shift), 3 to 11 (3:00 p.m. to 11:00 p.m. shift) and all other nursing staff regarding use of Safety Sure Transfer Sling, failure to follow the Care Plan regarding the mode of transfer, failure to immediately report to the nurse a change in condition, and false documentation. In-service will be provided to all nursing staff by the DON or designee prior to next scheduled shift of work, or at the time of hire for all new employees. Beginning on 9/13/17 at (4:30 p.m.) all transfers on (Resident #1) will be observed by an RN or LPN for six weeks, then weekly until substantial compliance is obtained. Monitoring: The DON or designee will monitor staff during any type of transfer daily (times) one week (one per hall per day), then three times per week (times) three weeks (one per hall per day), then weekly (one per hall per day) until substantial compliance is obtained to ensure the safety of residents during transfers.

Based on observations, record review, and interview, the facility's Quality Assurance Committee (QAC) failed to identify and promptly develop a plan to correct a deficient practice regarding failure to follow manufacturer's guidelines for the use of bed rails with the MA 80 air loss mattress to prevent falls for 1 of 1 (Resident #15) case mix resident who had an MA 80 air loss mattress on her bed. This failed practice had the potential to cause serious injury, harm or death for Resident #15, who used the MA 80 air loss mattress without the required side rails and fell from the bed, and had the potential to affect only this resident (the only resident in the facility with this mattress in use), according a list provided by the Administrator on 7/13/17 at 8:00 a.m. The facility was informed of the Immediate Jeopardy on 7/12/17 at 12:00 p.m. The findings are: 1. On 7/14/17 at 8:30 a.m., the Administrator was asked, Has your Quality Assurance Committee identified any problems with the use of bedrails on the air loss mattress? She replied, To my knowledge, we have never discussed that in QA. 2. Resident #15 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/29/17 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment for mental Status, required extensive assistance of 2 plus staff for bed mobility, totally dependent on staff for transfers, was not steady - only able to stabilize with staff assistance with surface to surface transfers, and had falls since admission or last assessment with one resulting in non-major injury. a. The Plan of Care, not dated, documented, Problem onset: 1/24/17 Resident has potential for falls and is at risk for serious injury if fall occurs 2nd to [DIAGNOSES REDACTED]. Check res (resident) hourly at husbands request . 5/8/17-For fall 5/6/17 Residents bed will be kept in low position with fall mat beside the bed when resident is in bed b. An Resident Incident report dated 5/6/17 at 5:45 a.m documented, Resident found on floor on stomach next to bed, repositioned for comfort, ease of resp (respiration) and ROM (range of motion). Resident noted with raise abrasion to right side of forehead and quarter size areas bilateral knees with improvement noted with 30 minutes. No other visible injuries note. Body pillow noted on bed staff stated pillow slightly wedged under left arm between resident and window. Resident assisted back to bed via lift and this LPN (Licensed Practical Nurse) and CNA's (Certified Nursing Assistants) removing pillow from low air loss bed. The follow-up documented, Assessed resident's room, bed, low air loss mattress, furniture, call light and pillows with no issues noted. Call light was not on because resident is unable to use call light 2nd (secondary) to physical and cognitive medical condition. Nursing staff reported that resident had been turned and repositioned onto her right side about 20 minutes prior to being found on the floor beside her bed. c. Nurses notes dated 5/10/17 at 12:42 p.m. documented, Had lengthy conversation with resident's husband regarding fall interventions. He expressed that he still desires to have (Resident #15) remain on a low air loss mattress. He stated that he feels like the benefit of the low air loss mattress outweighs the resident of falling out of the bed again. He expressed concern that if the low air loss mattress was removed from the bed, his wife would develop skin breakdown. d. On 7/11/17 at 9:30 a.m., during a telephone interview, the spouse stated that when he came in she (wife) looked horrible. She had fell out of the bed. They said maybe the air mattress kicked her out. e. On 7/11/17 at 12:00 p.m., the spouse stated, They won't put a side rail on her bed as they say it is a restraint. She can't move. If there had been a rail there we might not be having this conversation The report (x-ray) says she does not have a concussion. But she's an invalid, how did she fall out? . The air mattress could have lost pressure, they were not sure. How long she laid there, I don't know. f. The manufacturer's guidelines for the Mattress MA 80 and MA 85 dated 2009 and copied on 7/12/17 at 10:45 a.m. documented, The MA 80 series and MA 8 series system MUST be installed on a medical bed frames with side rails. g. On 7/12/17 at 10:45 a.m., the Administrator was asked Has (Resident #15's) husband ever requested side rails to be put on her bed? She replied, Well I'm sure he has, but I'd have to look it up and see. h. On 7/12/17 at 10:59 a.m., the Director of Nursing was asked, Has (Resident #15's) husband ever requested side rails to be put on her bed? She replied, My recollection is yes, he probably has, but we have tried to explain the entrapment issue with a low air loss mattress. i. On 7/12/17 at 11:00 a.m., the resident was in bed on a MA 80 mattress with no side rails in place. j. On 7/12/17 at 4:30 p.m., the facility furnished additional manufacturer's guidelines, which documented, The (company name) mattress MUST fit firmly against the bed frame AND bedside rails to prevent patient entrapment. 3. On 7/12/17 at 12:45 p.m., the Immediate Jeopardy was removed and the scope/severity was lowered to E when the facility implemented the following plan of removal: a. On 7/12/17 at 12:45 p.m., the resident's mattress was changed to a Panacea mattress. b. On 7/12/17 at 2:00 p.m., the purchasing staff checked all brands of air loss mattresses being used in the facility with the manufacturer's guidelines to ensure compliance. c. On 7/12/17 at 1:15 p.m., the Hospice agency was notified that the MA 80 and MA 85 mattress will no longer be allowed in the facility. d. On 7/12/17 at 1:45 p.m., all RNs (Registered Nurses) and LPN (Licensed Practical Nurse) staff were inserviced regarding the MA 80/85 mattress ban from the building. e. All new medical equipment will be evaluated by purchasing staff prior to placement on the unit. f. Medical records will identify the type of mattress for each resident and document on the treatment administration record and electronic chart. Staff will sign off on the type of mattress every shift. The DON will review and report any negative findings to the QA (Quality Assurance) on a quarterly basis.

Based on observations, record review, and interview, nursing administration failed to ensure manufacturer's guidelines were followed for the use of bed rails with the MA 80 air loss mattress to prevent falls for 1 of 1 (Resident #15) case mix resident who had an MA 80 air loss mattress on their bed. This failed practice had the potential to cause serious injury, harm or death for Resident #15, who used the MA 80 air loss mattress without required side rails and fell from the bed and had the potential to affect only this one resident according a list provided by the Administrator on 7/13/17 at 8:00 a.m. The facility was informed of the Immediate Jeopardy on 7/12/17 at 12:00 p.m. The findings are: 1. The Director of Nurse's job description furnished by the facility on 7/14/17 at 9:09 a.m. documented, The primary purpose of your job position is to plan, organize, develop and direct the overall operation of our Nursing Service Department in accordance with current federal, state and local standards guidelines and regulations that govern our facility, and as may be directed by the Administrator and the Medical Director to ensure that the highest degree of quality care is maintained at all times . 2. Resident #15 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/29/17 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment for mental Status, required extensive assistance of 2 plus staff for bed mobility, totally dependent on staff for transfers, was not steady - only able to stabilize with staff assistance with surface to surface transfers, and had falls since admission or last assessment with one resulting in non-major injury. a. The Plan of Care, not dated, documented, Problem onset: 1/24/17 Resident has potential for falls and is at risk for serious injury if fall occurs 2nd to [DIAGNOSES REDACTED]. Check res (resident) hourly at husbands request . 5/8/17-For fall 5/6/17 Residents bed will be kept in low position with fall mat beside the bed when resident is in bed b. An Resident Incident report dated 5/6/17 at 5:45 a.m documented, Resident found on floor on stomach next to bed, repositioned for comfort, ease of resp (respiration) and ROM (range of motion). Resident noted with raise abrasion to right side of forehead and quarter size areas bilateral knees with improvement noted with 30 minutes. No other visible injuries note. Body pillow noted on bed staff stated pillow slightly wedged under left arm between resident and window. Resident assisted back to bed via lift and this LPN (Licensed Practical Nurse) and CNA's (Certified Nursing Assistants) removing pillow from low air loss bed. The follow-up documented, Assessed resident's room, bed, low air loss mattress, furniture, call light and pillows with no issues noted. Call light was not on because resident is unable to use call light 2nd (secondary) to physical and cognitive medical condition. Nursing staff reported that resident had been turned and repositioned onto her right side about 20 minutes prior to being found on the floor beside her bed. c. Nurses notes dated 5/10/17 at 12:42 p.m. documented, Had lengthy conversation with resident's husband regarding fall interventions. He expressed that he still desires to have (Resident #15) remain on a low air loss mattress. He stated that he feels like the benefit of the low air loss mattress outweighs the resident of falling out of the bed again. He expressed concern that if the low air loss mattress was removed from the bed, his wife would develop skin breakdown. d. On 7/11/17 at 9:30 a.m., during a telephone interview, the spouse stated that when he came in she (wife) looked horrible. She had fell out of the bed. They said maybe the air mattress kicked her out. e. On 7/11/17 at 12:00 p.m., the spouse stated, They won't put a side rail on her bed as they say it is a restraint. She can't move. If there had been a rail there we might not be having this conversation The report (x-ray) says she does not have a concussion. But she's an invalid, how did she fall out? . The air mattress could have lost pressure, they were not sure. How long she laid there, I don't know. f. The manufacturer's guidelines for the Mattress MA 80 and MA 85 dated 2009 and copied on 7/12/17 at 10:45 a.m. documented, The MA 80 series and MA 8 series system MUST be installed on a medical bed frames with side rails. g. On 7/12/17 at 10:45 a.m., the Administrator was asked Has (Resident #15's) husband ever requested side rails to be put on her bed? She replied, Well I'm sure he has but I'd have to look it up and see. h. On 7/12/17 at 10:59 a.m., the Director of Nursing was asked, Has (Resident #15's) husband ever requested side rails to be put on her bed? She replied, My recollection is yes, he probably has but we have tried to explain the entrapment issue with a low air loss mattress. i. On 7/12/17 at 11:00 a.m., the resident was in bed on a MA 80 mattress and there were no side rails in place. 3. On 7/12/17 at 12:45 p.m., the Immediate Jeopardy was removed and the scope/severity was lowered to a E when the facility implemented the following plan of removal. a. On 7/12/17 at 12:45 p.m., the resident's mattress was changed to a Panacea mattress. b. On 7/12/17 at 2:00 p.m., the Purchasing staff checked all brands of air loss mattress being used in the facility with manufacturer's guidelines to ensure compliance. c. On 7/12/17 at 1:15 p.m., the Hospice agency was notified that the MA 80 and MA 85 mattress will no longer be allowed in the facility. d. On 7/12/17 at 1:45 p.m., all RN's (Registered Nurses) and LPN staff were inserviced regarding the MA 80/85 mattress ban from the building. e. All new medical equipment will be evaluated by Purchasing staff prior to placement on the unit. f. Medical records will identify the type of mattress for each resident and document on the treatment administration record and electronic chart. Staff will sign off on the type of mattress every shift. The DON will review and report any negative findings to the QA (Quality Assurance) on a quarterly basis. k. On 7/12/17 at 4:30 p.m., the facility furnished the manufacturer's guidelines dated 2017, which documented, The Invocare mattress MUST fit firmly against the bed frame AND bedside rails to prevent patient entrapment.

Based on observation, record review, and interview, the facility failed to ensure the manufacturer's instructions were followed for the use of bed rails with an MA 80 air loss mattress to prevent falls for 1 of 1 (Resident #15) case mix resident who had an MA 80 air loss mattress in use. This failed practice resulted in immediate jeopardy, which caused or could have caused serious harm, injury or death for Resident #15, who used the MA 80 air loss mattress without the required side rails, fell from the bed and had the potential to affect only this one resident according a list provided by the Administrator on 7/13/17 at 8:00 a.m. The facility was informed of the Immediate Jeopardy on 7/12/17 at 12:00 p.m. The finding are: 1. Resident #15 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/29/17 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment for mental Status, required extensive assistance of 2 plus staff for bed mobility, totally dependent on staff for transfers, was not steady - only able to stabilize with staff assistance with surface to surface transfers, and had falls since admission or last assessment with one resulting in non-major injury. a. The Plan of Care, not dated, documented, Problem onset: 1/24/17 Resident has potential for falls and is at risk for serious injury if fall occurs 2nd to [DIAGNOSES REDACTED]. Check res (resident) hourly at husbands request . 5/8/17-For fall 5/6/17 Residents bed will be kept in low position with fall mat beside the bed when resident is in bed b. An Resident Incident report dated 5/6/17 at 5:45 a.m documented, Resident found on floor on stomach next to bed, repositioned for comfort, ease of resp (respiration) and ROM (range of motion). Resident noted with raise abrasion to right side of forehead and quarter size areas bilateral knees with improvement noted with 30 minutes. No other visible injuries note. Body pillow noted on bed staff stated pillow slightly wedged under left arm between resident and window. Resident assisted back to bed via lift and this LPN (Licensed Practical Nurse) and CNA's (Certified Nursing Assistants) removing pillow from low air loss bed. The follow-up documented, Assessed resident's room, bed, low air loss mattress, furniture, call light and pillows with no issues noted. Call light was not on because resident is unable to use call light 2nd (secondary) to physical and cognitive medical condition. Nursing staff reported that resident had been turned and repositioned onto her right side about 20 minutes prior to being found on the floor beside her bed. c. Nurses notes dated 5/10/17 at 12:42 p.m. documented, Had lengthy conversation with resident's husband regarding fall interventions. He expressed that he still desires to have (Resident #15) remain on a low air loss mattress. He stated that he feels like the benefit of the low air loss mattress outweighs the resident of falling out of the bed again. He expressed concern that if the low air loss mattress was removed from the bed, his wife would develop skin breakdown. d. On 7/11/17 at 9:30 a.m., during a telephone interview, the spouse stated that when he came in she (wife) looked horrible. She had fell out of the bed. They said maybe the air mattress kicked her out. e. On 7/11/17 at 12:00 p.m., the spouse stated, They won't put a side rail on her bed as they say it is a restraint. She can't move. If there had been a rail there we might not be having this conversation The report (x-ray) says she does not have a concussion. But she's an invalid, how did she fall out? . The air mattress could have lost pressure, they were not sure. How long she laid there, I don't know. f. The manufacturer's guidelines for the Mattress MA 80 and MA 85 dated 2009 and copied on 7/12/17 at 10:45 a.m. documented, The MA 80 series and MA 8 series system MUST be installed on a medical bed frames with side rails. g. On 7/12/17 at 10:45 a.m., the Administrator was asked Has (Resident #15's) husband ever requested side rails to be put on her bed? She replied, Well I'm sure he has, but I'd have to look it up and see. h. On 7/12/17 at 10:59 a.m., the Director of Nursing was asked, Has (Resident #15's) husband ever requested side rails to be put on her bed? She replied, My recollection is yes, he probably has, but we have tried to explain the entrapment issue with a low air loss mattress. i. On 7/12/17 at 11:00 a.m., the resident was in bed on a MA 80 mattress and there were no side rail in place. j. On 7/12/17 at 4:30 p.m., the facility furnished additional manufacturer's guidelines, which documented, The (company name) mattress MUST fit firmly against the bed frame AND bedside rails to prevent patient entrapment. 2. On 7/12/17 at 12:45 p.m., the Immediate Jeopardy was removed and the scope/severity was lowered to E when the facility implemented the following plan of removal: a. On 7/12/17 at 12:45 p.m., the resident's mattress was changed to a Panacea mattress. b. On 7/12/17 at 2:00 p.m., the purchasing staff checked all brands of air loss mattresses being used in the facility with the manufacturer's guidelines to ensure compliance. c. On 7/12/17 at 1:15 p.m., the Hospice agency was notified that the MA 80 and MA 85 mattress will no longer be allowed in the facility. d. On 7/12/17 at 1:45 p.m., all RN's (Registered Nurses) and LPN (Licensed Practical Nurse) staff were inserviced regarding the MA 80/85 mattress ban from the building. e. All new medical equipment will be evaluated by purchasing staff prior to placement on the unit. f. Medical records will identify the type of mattress for each resident and document on the treatment administration record and electronic chart. Staff will sign off on the type of mattress every shift. The DON will review and report any negative findings to the QA (Quality Assurance) on a quarterly basis.

Complaint # (AR 247) was substantiated, all or in part, in these findings. Based on observation, record review, and interview, the facility failed to ensure calorie and protein needs were calculated, the Registered Dietician (RD) was promptly consulted and interventions were developed and implemented after a significant weight loss was identified to prevent further weight loss for 2 (Residents #2 and #22) and failed to ensure meal consumption was accurately documented to provide the RD, physician and other interdisciplinary team members with accurate information and facilitate development of effective interventions to prevent ongoing weight loss for 1 (Resident #2) of 11 (Resident #1, 2, 3, 5, 6, 8, 9, 13, 18, 19, and 22 (closed record)) case mix residents who were at risk for weight loss. This failed practice resulted in a pattern of harm for Residents #2 and #22, who experienced severe weight losses, and had the potential to cause more than minimal harm to 42 residents who were at risk for weight loss, according to a list provided by Registered Nurse (RN) #1 on 7/13/17. The findings are: 1. Resident #2 had a [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of 6/8/17 documented the resident was severely impaired in cognitive skills for daily decision-making per a Staff Assessment for Mental Status (SAMS), required extensive assistance of one person for eating, had a swallowing disorder, and had experienced a weight loss of 5% or more in the past 30 days or 10% or more in the last 180 days. a. The resident's weight record for documented the resident weighed 157 pounds in January 2017 and 149 pounds in 2/26/17, a weight loss of 8 pounds (5.09%) in a 30-day period. There was no documentation of any nutritional interventions until 3/6/17. b. A Care Plan problem dated 3/6/17 (last updated 4/18/17) documented, Resident needs mechanically altered diet due to risk for aspiration and has now had a significant weight loss (3/6/17). Resident requires extensive assist with eating. The planned interventions included, Monitor for appetite, weight loss and texture tolerance, encourage increased po (oral) intake, Regular puree (diet) - honey thick liquids, Medpass 2.0 (three) ounces by mouth twice daily for nutritional support and spoon feed resident all meals. c. The Dietary Interdisciplinary meeting notes dated 3/7/17 at 10:51 a.m. documented, Resident is 148 lbs. (pounds) (referring to February 2017 weight) - (decreased) 9 lbs in 30 days (5.7%), -14 lbs in 90 days (8.6%), -18 lbs in 180 days, (10.8%). Reweigh on 2/26/17 was 149 lbs. Ideal (weight) 172 (pounds), BMI (body mass index) 21 and intake 37%. Med Pass 2.0 three ounces twice daily. Add to weekly weights. There was no documentation in the clinical record of an assessment to determine the resident's calorie and protein needs to ensure the resident received the additional calories necessary to prevent further weight loss. d. The resident's weight record for March 2017 documented the resident's weight was 152 pounds, a gain of 3 pounds. The resident's weight record for April 2017 documented the resident's weight was 151 pounds; a loss of 1 pound. e. The Departmental Notes dated 4/17/17 at 2:51 p.m. documented, Weight loss/decline: Discussed at length again with resident's daughter. (Resident #2) continued weight loss, frequent respiratory infections with aspiration of food, Stage II to coccyx and continued cognitive decline. She verbalizes that she understands that the resident very frequently aspirates any oral intake causing frequent respiratory infections and that she still does not want a feeding tube as she believes it would be an extraordinary measure that would merely prolong his discomfort and understands that he continues to lose weight. She notes that he was very active man and would not like his current lifestyle and would want to pass with dignity. She continues to want to keep his treatment goal to be comfort related and would rather not send him to hospital, having all treatments done here instead noting that the benefits of hospitalization do not outweigh the hardship hospitalization for him. She is in agreement to hospice, but only if he develops uncontrollable discomfort. We will continue to monitor him closely and stay in touch regarding any changes in his condition. f. The resident's weight record for May 2017 documented the resident weighed 143 pounds, June 2017 the resident weighed 142 pounds and July 2017 weighed 140 pounds. This represented a severe weight loss of 9.27% weight loss in a 3-month period. The resident's weight in January was 157, and in July, the weight was 140, which represented a severe weight loss of 10.82% in 6 months. There was no documentation in the clinical record, as of July 2017, of an assessment to determine the resident's calorie and protein needs to ensure the resident received the additional calories necessary to prevent further weight loss. g. On 7/10/17 at 6:15 p.m., the resident was served a pureed diet with honey thickened liquids. He was spoon fed by Certified Nursing Assistant (CNA) #7, who stated, He always eats everything on his tray. At 7:00 p.m., he had consumed 100% of the food and fluids served. No seconds or additional food was offered after the resident finished his meal. A Nutrition Roster entry dated 7/10/17 at 8:40 p.m. for the above meal, entered by CNA #7, documented the resident consumed 25% of the dinner meal and that an alternative was offered. h. On 7/11/17 at 12:25 p.m., the resident was served a pureed diet with honey thickened liquids. He was spoon fed by CNA #4. At 1:00 p.m., the resident had consumed 100% of the food and fluids that were on his tray. No seconds or additional food was offered after the resident finished his meal. A Nutrition Roster entry dated 7/11/17 at 2:55 p.m. by CNA #8 documented the resident consumed 75% of the above lunch meal. i. The Departmental Notes dated 7/11/17 at 7:40 p.m. documented, Talked with resident's daughter again at length regarding options for her father with his inability to meet his nutritional needs orally. She continues to not want a feeding tube as she does not feel her father would have wanted that at all. She is not opposed to hospice but she feels that her father is not in pain so he does not need hospice. She does understand that his condition is deteriorating and that he is in the dying process. We will keep in communication should any other needs arise. j. On 7/12/17 at 4:30 p.m., the Food Service Supervisor was asked if any nutritional interventions had been implemented to address the resident's weight loss and stated, I believe he is getting [MEDICATION NAME], it started on 4/18/17 for low [MEDICATION NAME]. We put him on Med Pass 2.0, three ounces BID . have no other interventions. k. On 7/12/17 at 5:50 p.m., the Food Service Supervisor stated that she did not add any additional food to the resident's tray because, .he aspirates. She was asked, Could you not send out a health shake, Ensure pudding or other supplement between meals? She stated, No, because he chokes. l. Departmental Notes dated 7/13/17 at 8:08 a.m. by the Registered Dietician (RD) documented, RD assessment/update from last assessment completed on 5/25/17: Currently 71 (inches), 139# (pounds) followed in IDT meetings 3/7, 3/15, 4/19, 5/2, 6/3 and upcoming meeting (7/18). Weight 6/1/17 147#, 6/22/17 at 144#, 6/29/17 at 142#, 7/13/17 at 139#. IDW (ideal weight) =172#, now at 81% of IBW, BMI 19.3 (low end of normal for age). Weight throughout the month of June had been fairly stable from 142-147#. PO (oral) has declined over the past week (per intake records). He is being fed/assisted with meals in room to enhance a more calmer atmosphere at meals, Diet is Regular/puree, Honey thick liquids. [MEDICATION NAME] daily with med pass 2.0 (three ounces, BID). PO intakes at 35-40% x 15 meals, 25-50% [MEDICATION NAME] and 25-50% med pass. 'PES (Problem, Etiology and Signs): unintentional weight loss related to decreased appetite/oral intakes, as evidenced by weight loss of 5.4% within 6 weeks, 9.7% within 90 days. Needs: based on current weight: 139# . 1579-1890 kcal (kilocalories) . minimum of 63 g (grams) protein with optimal intake for healing of PU (pressure ulcer) = 76.9 protein . Needs met with current diet order; but, with oral intakes < (less than) 50%, weight maintenance is not occurring. Goals: meet needs as assessed, continue diet + (plus) oral supplements, continue weekly weight. Recommendations: continued weight loss anticipated with poor oral intakes and cognitive loss unless an alternate feeding route is established. Which, at this time, has been addressed with family and is not desired. Hospice has also been discussed. Will continue diet and oral supplements as ordered, per MD. Patient unable to verbalize needs. CDM (Certified Dietary Manager) continues to provide foods/beverages (as tolerated) per family members recall for favorite foods. RD to follow on subsequent visit 7/18/17. There was no documentation in this note of any recommendations made by the RD for any interventions regarding the severe weight loss. 2. Resident #22 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 3/30/17 documented the resident was severely impaired in cognitive skills for daily decision making per a SAMS, required extensive assistance with eating, weighed 87 pounds and had experienced a weight loss of 5% or more in the past 30 days or 10% or more in the last 180 days. A Department Note dated 5/24/17 at 1:59 p.m. documented, Called to room by CNAs, no respirations noted or v/s (vital signs) found . The following information was obtained from Resident #22's closed record. a. The Care Plan with a Problem Onset Date of 10/12/16 documented, .Problem Onset: Resident requires assistance with eating due to [MEDICAL CONDITION], has a dx (diagnosis) of [MEDICAL CONDITIONS] with episodes of [MEDICAL CONDITION], and takes a daily diuretic medication, has a dx of anorexia, and resident has severe cognitive loss which puts her at risk for weight loss . The approaches, which were not individually dated, documented, Monitor and document meals, snacks consumed . Notify physician of weight loss or gain per facility policy . assist resident to eat . Regular Mechanical soft diet .Ensure pudding at 2:00 PM daily for supplement . b. The facility's Food Service Supervisor documented the following weights for the resident: 1/18/17: 91 pounds 2/15/17: 90 pounds 3/15/17: 87 pounds 4/25/17: 83 pounds The resident lost a total of 8 pounds (8.79%) in a 3-month period. There was no documentation in the clinical record of any new interventions that were put in place during the above timeframe, until 3/22/17 when the Ensure pudding was initiated. c. The Dietary Review provided by the Food Service Supervisor (FSS) dated 2/21/17 documented, .90 lbs. - 18 lbs. (loss) in 180 days, (16.7 %). Ideal body weight 100, BMI 18, and intake 60%. Continues on hospice care. Family and physician aware. Continue monitor. The Dietary Review dated 3/22/17 documented, .87 lbs, 16 lbs (loss) in 180 days, (15.5%). Ideal body weight 100, BMI 17, and intake 65%. Add Ensure Pudding at 2 PM. Continues on Hospice Care. Family and physician aware. Continue to monitor. d. The Nutrition Roster with meal percentages, provided by the Food Service Supervisor on 7/12/17 at 2:29 p.m., documented from 1/1/17 through 5/16/16, a total of 93 occasions when the resident consumed 25% or more of her meal in March 2017, and a total of 90 occasions when the resident consumed 25% or more in April 2017. e. A Departmental Note dated 3/31/17 at 10:26 a.m., documented, .QR (quarterly) note for 3/30/17: Diet Regular Mech (mechanical) Soft. Trays three times to room. Spoon-fed by staff. Average percent of meals times 15 is 93%. Resident is alert. Chewing problems. Oral care done daily. On Hospice. Monthly weights only per Hospice. Weight is 87 lbs, down (16%) in 180 days. New order on 3/23/17 for Ensure pudding 1-4 oz (ounces) at 2PM. Average percent of intake times 5 days is 40%. Will continue with plan of care. f. A Departmental Note dated 4/4/17 at 3:01 p.m. documented, Role: License Nurses, Category: Care Plan Conference: .Daughter here for care plan meeting. Went over meds (medications), weight, diet, and care. No concerns voiced at this time. g. A Departmental Note dated 5/18/17 documented, Role: License Nurses, Category: MD (Medical Doctor) . Called needing to see as attending physician secondary to recent events. Medicines have been reviewed. Orders have been reviewed. Orders to be signed . PO intake is satisfactory. h. A facility document titled, Weights, provided by the Administrator on 7/13/17 at 2:56 p.m. documented, Procedure . ADON (Assistant Director of Nursing) will analyze for potential causes of weight loss or gain, and if indicated develop interventions . weight gain or loss of 7.5% in 90 days. i. On 7/12/17 at 11:31 a.m., the Food Service Supervisor (FSS) was asked, Why was there not any interventions implemented in April 2017 when the resident had a weight loss of 8.79% and was still consuming 25% to 100%? The FSS stated, We changed her diet to mechanical soft, and at that time, her intake was 93%. That was in March of this year, she was placed on Ensure pudding at 2:00 p.m. only, on 3/23/17.