Every finding on record at Montereau, Inc.

Based on observation, record review, and interview, the facility failed to ensure a care plan was developed to address immediate needs of residents for 2 (#1 and #48) of 8 sampled residents reviewed for care plans.The administrator identified 56 residents resided in the facility.Findings:1.On 03/30/26 at 2:20 p.m., Resident #1 was observed in a wheelchair in their room with a urinary catheter in place.A physician order for Resident #1, dated 02/27/26, showed to admit the resident to the SNF.A physician order for Resident #1, dated 02/27/26, showed the resident had an order for apixiban (an anticoagulant) 5 mg every morning and at bedtime.An admission assessment for Resident #1, dated 03/05/26, showed the resident had medical diagnoses including atrial fibrillation and heart failure. The assessment showed Resident #1 had an indwelling urinary catheter and they were on anticoagulant therapy.A care plan for Resident #1, revised 03/15/26, showed focus areas for anticoagulant therapy and catheter use, but did not show interventions for those areas.On 04/02/26 at 2:10 p.m., the ADON stated the care plan for Resident #1 should have interventions for anticoagulant therapy and urinary catheter care, including EBP.2. A physician order for Resident #48, dated 03/11/26, showed to admit the resident to the SNF.A physician order for Resident #48, dated 03/11/26, showed to obtain weights daily.A physician order for Resident #48, dated 03/13/26, showed Lasix (a diuretic) 20 mg every 48 hours as needed for shortness of breath.An admission assessment for Resident #48, dated 03/15/26, showed the resident had medical diagnoses including pneumonia, atrial fibrillation, heart failure, and urinary tract infection in last 30 days.A physician order for Resident #48, dated 03/17/26, showed EBP for multidrug-resistant organisms of the urine.A medication administration record for Resident #48, dated 03/2026, showed Lasix was administered, in addition to regular doses, on 03/15/26, 03/22/26, 03/26/26, and 03/31/26 for shortness of breath.A care plan for Resident #48, dated 03/12/26, showed focus areas for malnutrition and potential impairment to skin integrity.On 04/02/26 at 2:15 p.m., the ADON stated the care plan for Resident #48 should have goals and interventions, including the admission diagnosis of pneumonia and EBP.

Based on record review and interview, the facility failed to ensure medications were administered according to physician orders for 1 (#56) of 1 sampled resident reviewed for timely administration of medications. The administrator identified 56 residents resided in the facility. Findings: An admission record for Resident #56, dated 08/07/24, showed the resident had diagnoses which included dementia, restless leg syndrome, and anxiety.Physician orders for Resident #56, dated 08/09/24, showed to administer the following: a. ropinirole (dopamine agonist) 2 mg, give one tablet by mouth at bedtime andb. ropinirole 1 mg, give one tablet by mouth two times a day. A policy titled Medication Reordering, revised 2025, read in part, each time a nurse is administering medications and observes a seven day supply or less, that nurse will reorder the medication, time permitting.A Medication Record for Resident #56, dated December 2025, showed missed doses for the following:a. ropinirole 1 mg on 12/17/25 at 3:00 p.m., because the medication was on order and awaiting delivery andb. ropinirole 1 mg on 12/25/25 at 7:00 a.m., because the medication was on order and awaiting delivery. A quarterly assessment for Resident #56, dated 02/06/26, showed the resident had a brief interview for mental status score of 10 which indicated the resident was moderately impaired in cognition. On 04/07/26 at 10:23 a.m., CMA #1 stated medication should be reordered when seven doses of medication were left. CMA #1 stated if the medication was not delivered when expected the pharmacy should be called. On 04/07/26 at 10:45 a.m., LPN #2 stated they should order medication when there was a one-week supply left. LPN #2 stated If the mediation did not arrive when expected they called the pharmacy and they would deliver it the same day. On 04/07/26 at 11:10 a.m., the ADON stated medications should be reordered when there is a one-week supply left. The ADON stated If it was ordered by 4:00 p.m., the medication would be delivered the same day. The ADON stated if the medication was ordered after 4:00 p.m., it would arrive with the morning delivery the next day. They stated If the medication did not arrive when expected the CMA or the nurse should call the pharmacy.

Based on observation and interview, the facility failed to ensure medications were secured for 2 (first floor North treatment cart #2 and second floor South treatment cart #2) of 2 treatment carts observed to be unlocked and unattended.The DON identified six treatment carts and six medication carts in the facility. Findings: 1.On 10/27/25 at 1:57 p.m., in the chateau on the second floor, the South treatment cart #2 was observed to be unlocked next to the nursing station. Three staff were observed to be behind the nurses' station and one staff was observed to be in front of the nurses' station. On 10/27/25 at 1:59 p.m., two staff were observed to be behind the nurses' station and the one staff in the front of the nursing station left. One staff remained behind the nurses' station, talking with a contracted provider. On 10/27/25 at 2:01 p.m., LPN #2 was observed behind the nurses' station, talking to a nursing student then left the nurses' station. The unlocked cart was unattended. The cart contained the following: a. Hysept solution, read in part, keep out of reach of children (topical antiseptic);b. insulin;c. ipratropium nasal spray (used to treat runny noses);d. Narcan (an opioid antagonist);e. triad wound cleaner; f. lidocaine patches (used to relieve pain);g. iodine (an antiseptic);h. silver gel (an antimicrobial); [NAME]. Sani-cloths (disinfectant wipes). On 10/27/25 at 2:03 p.m., LPN #2 returned to the nurses' station. On 10/27/25 at 2:05 p.m., LPN #2 stated the cart was a treatment cart. They stated the key was kept under the trash bags in the open compartment on the side of the cart. LPN #2 stated medications were on the treatment cart. They stated the protocol for the cart was to ensure they were locked and did not have an answer for why the cart was unlocked and unattended. They stated they left the keys in the side compartment for easy access to the cart. LPN #2 did not lock cart and walked away from the cart, leaving out of eyesight.On 10/27/25 at 2:14 p.m., LPN #3 walked by the unlocked cart and locked the cart and stated to LPN #2 to Keep that cart locked.On 10/27/25 at 2:54 p.m., LPN #3 stated the carts were to be locked at all times and the keys kept on the nurse. On 10/27/25 at 2:25 p.m., the DON stated if the cart were out of sight, the cart should have been locked, and the keys should be kept out of sight. They stated it was best policy to keep the keys on them. The DON stated they monitored to ensure the carts were locked by completing rounds. 2. On 10/28/25 at 1:59 p.m., the first floor North treatment cart #2 was observed to be unlocked. The cart was around the corner from the nurses' desk with the lock facing away from the desk. On 10/28/25 at 2:05 p.m., the DON was observed to walk past the cart going down the hall and stopped to speak to the nurse at the desk. The DON did not acknowledge the unlocked cart. A CNA stopped at the cart and obtained some gloves off the top of the cart and entered into a resident's room. On 10/28/25 at 2:07 p.m., LPN #4 was observed to leave the nurses' station and enter into the documentation room. On 10/28/25 at 2:07 p.m., LPN #1 was stopped and stated the cart was the first floor North treatment cart and should not be left unlocked and unattended. They stated they forgot to lock the cart.On 10/27/25 at 2:25 p.m., the DON stated if the cart were out of sight, the cart should have been locked, and the keys should be kept of sight. They stated it was best policy for the nurses to keep the keys on them. The DON stated they monitored to ensure the carts were locked by completing rounds.

Based on record review and interview, the facility failed to provide sufficient staff to answer call lights in a timely manner for 1 (#1) of 3 sampled residents reviewed for call light response.The DON identified 46 residents resided at the facility. Findings:Review of the Alarms by Room report, dated 08/07/25 through 08/25/25, for Resident #1, showed:a. on 08/07/25 at 4:11 p.m., call light initiated on bed for 1 hour 19 minutes 18 seconds;b. on 08/07/25 at 4:33 p.m., call light initiated on bath for 30 minutes 46 seconds; c. on 08/07/25 at 5:06 p.m., bath call light initiated on for 27 minutes 8 seconds;d. on 08/08/25 at 5:11 a.m., call light initiated on bed for 1 hour 6 minutes 12 seconds; e. on 08/12/25 at 12:35 a.m., bed call light initiated on for 59 minutes 54 seconds; f. on 08/15/25 at 8:09 a.m., bed call light initiated on for 38 minutes 30 seconds; g. on 08/20/25 at 5:24 p.m., bed call light initiated on for 45 minutes 6 seconds; h. 08/21/25 call log until 6:00 p.m., showed call light times up to 23 minutes;i. 08/22/25 at 5:50 p.m., bed call light initiated on 27 minutes 13 seconds; andj. 08/25/25 at 3:16 p.m., bed call light initiated on for 3 hour 15 minutes 17 seconds.A progress note, dated 08/08/25 at 12:38 p.m., showed Resident #1 called out for help from their room. The note showed Resident #1 was observed on the floor in the bathroom, on their knees, with their pants around their ankles. The note showed Resident #1 stated, I pulled the call bell for 45 minutes; I've been calling, and no one came; I did not fall; I slid down off the toilet. The note showed Resident #1 was assessed for injury and assisted to their wheelchair with two staff, vitals checked, the medical doctor, DON, and family notified. The note showed neurological checks were initiated. An admission assessment, dated 08/10/25, showed Resident #1 admitted on [DATE] with a BIMS of 15 which indicated they were cognitively intact for daily decision making. The assessment showed diagnoses which included heart failure, hypertension, and renal insufficiency. The assessment showed Resident #1 required setup assistance for eating, partial to moderate assistance with oral care, substantial to maximum assistance with shower/bath, transfers, hygiene, and lower body dressing. The assessment showed Resident #1 was dependent for bed to chair transfers and walking. A progress note, dated 08/21/25, showed Resident #1 had complained their call light was not answered promptly. The note showed Resident #1 stated the call light wait time was between 40 and 45 minutes. The note showed when the record of call light response times was reviewed, it was discovered response times were 45 seconds to 6 minutes. On 10/29/25 at 12:25 p.m., Resident #1 stated care by the CNAs was pretty good, but they had told the DON they should have gotten better care because several times at night, they had to call the security desk to get someone to answer their call light because it would take 15 to 30 minutes. They stated they were lucid and knew what was going on. Resident #1 stated they were on furosemide (diuretic) so when they had to go to the restroom, they had to go right away, but was a fall risk and was not supposed to go by themself to the bathroom. They stated staff would not come to help them get off the toilet. Resident #1 stated one time they slid down off the toilet and crawled toward the door after sitting on the toilet at least 30 minutes, maybe a little longer. They stated staff said they had fell, but they did not. They stated they had intentionally gotten on the floor.On 10/30/25 at 10:22 a.m., the DON stated most of the time call lights were responded to promptly. They stated residents did not hear the light in their room, it was silent, so time could get away from them. The DON stated is was not always accurate what their perception of time and the real time was. On 10/30/25 at 12:46 p.m., the DON stated they had reviewed the call light response time on 08/21/25. They stated Ack time was the time a call light was acknowledged on the iPad then staff have to click it off in the room. The DON reviewed the call light log for 08/21/25 and stated they were not sure what Resident #1 wanted, but there were a lot of call light punches. They stated they could not tell when the CNA came in or if they forgot to turn off the light and acknowledge the light. The DON stated Resident #1 was close to the nurses' station and they could hear Resident #1 if they were calling out. They stated they thought in the morning could have been a time when staff were rounding and busy with other things, they may have forgotten.On 10/30/25 at 2:09 p.m., LPN #1 stated Resident #1 stated they did not fall and they crawled to the door. LPN #1 stated they did not ask the CNAs if they had checked on Resident #1 or when Resident #1 was last checked on, it was during mealtime. They stated the expected call light response time was eight minutes. On 10/31/25 at 10:27 a.m., ADON #1 stated residents would complain about not answering the call lights timely. They stated they felt they were answered in a timely manner, during mealtime it could be longer, but 10 to 15 minutes was timely. On 10/31/25 at 10:58 a.m., CNA #1 stated two minutes was the expected call light response time. They stated the call lights showed if it is a bed cord or bathroom. On 10/31/25 at 11:00 a.m., CNA #2 stated the expected call light response time should only be a minute unless staff were busy with someone else. They stated they carried an iPad with them, acknowledged the call light, and when they entered the room would turn off the call light. On 10/31/25 at 1:06 p.m., ADON #1 provided in-service information for call lights dated 07/03/25, 07/30/25, 08/17/25, 08/25/25. They stated on 08/15/25 through 08/17/25 they installed televisions at the nursing station to monitor the call lights as well as the iPads they already had in place. On 10/31/25 at 1:58 p.m., CNA #3 stated they always tried to answer the call lights within two minutes. They stated they were working with another CNA and would answer the call light for Resident #1 together. CNA #3 stated they had answered the call light for Resident #1 multiple times alone, but they needed the other CNA to assist with helping Resident #1 off the toilet. CNA #3 stated when they checked on Resident #1 the day of the toilet incident, Resident #1 stated they needed a few more minutes. They stated they were serving dinner and informed the nurse Resident #1 was on the toilet and to keep an eye out because they were serving dinner. CNA #3 stated the nurse went missing, and the CNAs were passing dinner, not answering call lights. On 10/31/25 at 3:47 p.m., LPN #1 stated they heard Resident #1 yelling when they returned from lunch. They stated there were maybe two CNAs on the floor and the DON was there. LPN #1 stated the North nurses covered for the South nurses and vice versa.On 10/31/25 at 3:56 p.m., the DON stated they monitored the call light report randomly and if there was a complaint or issue. They stated they did not know why Resident #1 had long call light times. The DON stated call light response depended on what the person wanted or what was going on, but at the latest 10 minutes was reasonable. They stated in the past a CNA would acknowledge the light, but forget to turn it off in the room. They stated the iPad will continue to sound until the call light was acknowledge.

Based on record review and interview, the facility failed to ensure appointments were scheduled for a resident for 1 (#1) of 3 sampled residents reviewed for appointments.The DON identified 46 residents resided in the facility.Findings:An admission assessment, dated 08/10/25, showed Resident #1 had a diagnosis of heart failure and a BIMS score of 15 which indicated the resident was cognitively intact for daily decision making.A progress note, dated 08/13/25 at 11:13 p.m., showed Resident #1 had a nosebleed and was sent to the emergency room for evaluation and treatment.Hospital discharge paperwork, dated 08/13/25, showed Resident #1 was evaluated in the emergency room for a nosebleed. The hospital discharge paperwork, read in part, Follow-up with ENT for further evaluation of your recurrent nosebleeds. The hospital discharge paperwork showed Resident #1 was to follow-up with an ENT physician within five to seven days.A progress note, dated 08/14/25 at 2:47 a.m., showed Resident #1 had returned to the facility from the hospital.Review of the clinical record for Resident #1 and the facility appointment log, dated 08/01/25 through 08/29/25, did not show a follow-up appointment with an ENT physician had been scheduled for Resident #1. On 10/29/25 at 12:34 p.m., Resident #1 stated they had not been notified they had been scheduled or attended an ENT physician appointment during their stay at the facility. Resident #1 stated they had discharged from the facility on 08/26/25.On 10/29/25 at 1:12 p.m., ADON #1 stated they were responsible to schedule appointments for the residents. They stated they reviewed hospital records to obtain the appointments/referrals needed. ADON #1 stated Resident #1 had attended a cardiology appointment during their stay at the facility and upon discharge was scheduled an appointment with their primary care physician. They stated they would review the clinical record regarding other appointments/referrals for Resident #1.On 10/30/25 at 1:23 p.m., ADON #1 stated they had reviewed the clinical record and the hospital record for Resident #1. ADON #1 stated they had not identified at the time of readmission to the facility, from the emergency room visit on 08/13/25, Resident #1 required an appointment/referral for a follow-up appointment with an ENT physician. On 10/31/25 at 3:30 p.m., the DON stated ADON #1 was responsible to schedule appointments for the residents. The DON stated they did not know if monitoring was in place to ensure appointments and referrals were scheduled for the residents. The DON stated they did not know why Resident #1 had not been scheduled a follow-up appointment with an ENT physician.

Based on record review and interview, the facility failed to ensure nutritional supplements were implemented for the treatment of pressure ulcers for 1 (#3) of 2 sampled residents reviewed for nutritional supplements.The DON identified 20 residents received nutritional supplements. Findings:An admission assessment, dated 10/11/25, showed Resident #3 had a BIMS of 03, which indicated they were severely cognitively impaired for daily decision making. The assessment showed Resident #3 had diagnoses which included coronary artery disease, hypertension, and Alzheimer's disease.A Comprehensive Nutrition Assessment, dated 10/13/25, showed Resident #3 had an increased protein need related to physiological changes as evidenced by the presence of a stage three pressure ulcer to the coccyx. The assessment showed an intervention to add liquid protein twice a day to optimize protein intake.A physician's order for Resident #3, dated 10/13/25, showed to give one packet of active liquid protein by mouth two times a day for wound, in order to optimize protein intake for wound healing. An October 2025 medication/treatment administration record for Resident #3 showed the active liquid protein was not administered eight out of 30 opportunities. The active liquid protein was not administered on 10/15/25 and 10/16/25 at 7:00 a.m., 10/18/25 at 7:00 a.m. and 7:00 p.m., 10/19/25 at 7:00 a.m., 10/20/25 at 7:00 a.m. and 7:00 p.m., and 10/22/25 at 7:00 a.m. An Orders - Administration Note, dated 10/15/25 at 8:08 a.m., showed no reason for the active liquid protein to not be administered.An Orders - Administration Note, dated 10/16/25 at 9:57 a.m., showed the reason for active liquid protein to not be administered as awaiting dose from pharmacy and not available.An Orders - Administration Note, dated 10/18/25 at 9:05 a.m., showed the active liquid protein was not administered because they had asked the nurse and the nurse did not know what it was.An Orders - Administration Note, dated 10/18/25 at 7:32 p.m., showed the active liquid protein was not administered due to being on order.An Orders - Administration Note, dated 10/19/25 at 9:48 a.m., showed the active liquid protein was not administered due to on hold, medication reorder.An Orders - Administration Note, dated 10/20/25 at 12:19 p.m., showed the active liquid protein was not administered due to drug on order.An Orders - Administration Note, dated 10/20/25 at 7:28 p.m., showed the active liquid protein was not administered due to waiting on pharmacy.An Orders - Administration Note, dated 10/22/25 at 7:46 a.m., showed the active liquid protein was not administered but did not provide a reason.On 10/31/25 at 10:55 a.m., LPN #5 stated medications were ordered through the electronic clinical record. They stated once the medication was ordered they would receive a message with when to expect delivery. LPN #5 showed the electronic record which displayed the medication was received on 10/21/25, but also showed the medication was re-ordered the same day. They stated if a medication was not available to administer, they were to notify the physician. LPN #5 stated if a medication was ordered one time a day the medication would be administered when it arrived, but if it were ordered more than one time a day, the first dose may be held due to not being available.On 10/31/25 at 4:34 p.m., ADON #1 stated the dietician ordered the liquid protein and it should be house stock. They stated they did not know why the active liquid protein was not administered. ADON #1 stated the nurse was responsible to ensure medication was ordered and administered.

Based on record review and interview, the facility failed to ensure medications were administered at the ordered time for 1 (#1) of 3 sampled residents reviewed for medication administration.The DON identified 46 residents received medications in the facility. Findings:An undated Medication Administration policy, read in part, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection.Ensure that the six rights of medication administration are followed .e. Right time .Example guidelines for Medication Administration (unless otherwise ordered by physician), this list is not all-inclusive .Medication timing .BID 7am-11am, 7pm-11pmAn admission assessment, dated 08/10/25, showed Resident #1 had a BIMS of 15 which indicated they were cognitively intact for daily decision making. The assessment showed diagnoses which included heart failure, hypertension, and renal insufficiency.A physician's order, dated 08/18/25, showed to administer Lasix (a diuretic medication) 60 mg BID at 7:00 a.m. and 2:00 p.m. for edema.A care plan, dated 08/19/25, showed a focus for diuretic therapy with interventions which included to administer diuretic medications as ordered by physician.A Medication Admin [administration] Audit Report, dated 08/01/25 to 08/31/25, showed on 08/19/25 Lasix 60 mg two times a day was to be administered at 7:00 a.m. and was administered at 7:35 a.m. A physician's order, dated 08/19/25, showed to administer Lasix 40 mg twice a day at 7:00 a.m. and 2:00 p.m. for edema.A Medication Admin Audit Report, dated 08/01/25 to 08/31/25, showed Lasix 40 mg was ordered to be administered at 7:00 a.m. The audit report showed four doses which were not administered at the ordered time:a. on 08/20/25 Lasix 40 mg was administered at 9:18 a.m.;b. on 08/21/25 Lasix 40 mg was administered at 11:35 a.m.;c. on 08/24/25 Lasix 40 mg was administered at 8:59 a.m.; and d. on 08/25/25 Lasix 40 mg was administered at 8:26 a.m. On 10/30/25 at 2:06 p.m., LPN #1 stated if the medication were ordered at a set time, they had an hour before and an hour after to administer the medication. They stated in the morning Resident #1 wanted their Lasix early, but one day they wanted it a little later. LPN #1 stated they might have charted later on some after they administered the Lasix. They stated they did not know why some were past the ordered time.On 10/31/25 at 3:34 p.m., the DON stated the protocol for the timeframe of administration if a medication was ordered at a specific time was an hour before and an hour after the ordered time. They stated the nurse should let them know if medications were administered late.

On [DATE], a past non-compliance Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to assess, monitor, and intervene for a resident with a history of skin breakdown. The facility failed to accurately identify the status of a resident at high risk for skin breakdown, failed to accurately and timely document the resident's skin condition, failed to accurately care plan, provide, and monitor the success or failure of interventions for the resident's deteriorating skin condition, and failed to communicate the resident's deteriorating skin condition to other disciplines of the resident's care team. Based on record review and interview, the facility failed to assess, monitor, and intervene for 1 (#1) of 7 sampled residents who had pressure ulcers/wounds or were at high risk for the development of pressure ulcers/wounds. The facility's Census and Condition, dated [DATE], showed five residents with pressure ulcers and 41 resident receiving preventative skin care. Findings: The rehabilitation hospital's Discharge summary, dated [DATE], showed a wound assessment with pictures was performed. The wound assessment documented a stage II sheering was present on the right buttocks and the right heel wound was resolved. The Montereau clinical admission assessment, dated [DATE], showed moisture associated skin damage to the resident's right gluteus was present on admission. There was no documentation of a deep tissue injury, wounds, or other skin issues. The Functional Abilities and Goals - admission form, dated [DATE], [DATE], and [DATE], showed the resident required partial to moderate assistance with bed mobility, transfers, and ambulation. The skilled nurse's note, dated [DATE], showed the resident had moisture associated skin damage to their right gluteus which was present on/since admission. There was no documentation of a deep tissue injury, wounds, or other skin issues. There were no other documented skin concerns/conditions. The skin check, dated [DATE], created on [DATE], showed the resident had moisture associated skin damage to the right gluteus. The skin check showed the moisture associated skin damage was present on admission. There was no documentation of a deep tissue injury, wounds, or other skin issues. The baseline care plan, dated [DATE], did not address skin issues/concerns. The skilled nurse's note, dated [DATE], showed the resident had moisture associated skin damage to their right gluteus which was present on/since admission. There was no documentation of a deep tissue injury, wounds, or other skin issues. The Brief Interview for Mental Status Evaluation, dated [DATE], showed the resident was cognitively intact in daily decision making. The admission MDS assessment, dated [DATE], showed the resident had a stroke affecting the right side of the body; was cognitively intact with a BIMS score of 13; displayed no behaviors such as refusal of care; required partial/moderate to substantial/maximal assistance with most activities of daily living; had no pressure ulcers but was at risk for pressure ulcers and had moisture associated skin damage. The admission assessment documented the facility utilized a pressure reducing device for chair/bed and applied ointments/medications to areas other than the resident's feet. There was no documentation of a deep tissue injury, wounds, or other skin issues. The shower sheet, dated [DATE], showed the resident refused their shower. The shower sheet did not address if the resident had skin issues/concerns. The skilled nurse's note, dated [DATE], showed the resident had moisture associated skin damage to their right gluteus which was present on/since admission. There was no documentation of a deep tissue injury, wounds, or other skin issues. The Braden scale used to determine the risk of developing pressure ulcers, dated [DATE] (created [DATE]), showed a score of 20 which indicated the resident was at low risk for developing a pressure ulcer. The physical therapy treatment encounter note, dated [DATE], showed the resident had decreased motivation and participation in therapy. The note also showed a CNA reported to the therapist the resident had decreased oral intake and an increased need for assistance with transfers. The shower sheet, dated [DATE], showed the resident received a shower and had no skin issues/concerns on visual inspection. The skin check, dated [DATE] (created on [DATE]), showed the resident had moisture associated skin damage to the right gluteus. The skin check showed the moisture associated skin damage was present on admission. There was no documentation of a deep tissue injury, wounds, or other skin issues. The shower sheet, dated [DATE], documented the Resident #1 refused their shower. The shower sheet did not address if the Resident #1 had skin issues/concerns. The multidisciplinary care conference, dated [DATE], did not address the resident's skin condition. The physician's progress note, dated [DATE], showed the resident's chief complaint was sacral pain, debility, and weakness. The skilled nurse's note, dated [DATE], showed the resident had moisture associated skin damage to their right gluteus which was present on/since admission. There was no documentation of a deep tissue injury, wounds, or other skin issues. The Braden scale, dated [DATE] [but created [DATE]], showed a score of 20 which indicated the resident was at low risk for developing a pressure ulcer. The shower sheet, dated [DATE], documented the Resident #1 refused their shower. The shower sheet did not address if Resident #1 had skin issues/concerns. The skin check, dated [DATE], (created on [DATE]), showed the resident had moisture associated skin damage to the right gluteus. The skin check showed the moisture associated skin damage was present on admission. There was no documentation of a deep tissue injury, wounds, or other skin issues. The physical therapy treatment encounter notes, dated [DATE], showed the resident initially refused therapy due to sacral wound pain. The note read in part, PTA [physical therapy assistant] added w/c [wheelchair] cushion to decrease risk of further skin breakdown. The treatment record, dated February 2025, showed the first ordered dressing (leptospermum honey dressing) was applied on [DATE]. The physical therapy treatment encounter notes, dated [DATE], showed the resident refused therapy due to buttock pain from wound. The note also reported the resident was not eating. The shower sheet, dated [DATE], documented the resident refused their shower. The shower sheet did not address if the resident had skin issues/concerns. A physician's order, dated [DATE], showed the resident was placed on enhanced barrier precautions due to the resident the existence of a pressure ulcer. The physician's progress note, dated [DATE], showed the resident complained of sacral pain, debility, and weakness. The progress note showed the resident reported some sacral pain when seated in their wheelchair for extended periods. The progress note showed the resident's sensation was mildly decreased in their lower extremities with right hemiparesis. The Braden scale, dated [DATE] [but created [DATE]], showed a score of 18 which indicated the resident was at a mild risk for developing a pressure ulcer. The shower sheet, dated [DATE], showed the Resident #1 refused their shower. The shower sheet did not address if Resident #1 had skin issues/concerns. The skilled nurse's note, dated [DATE], showed the resident had moisture associated skin damage to their right gluteus which was present on/since admission. There was no documentation of a deep tissue injury, wounds, or other skin issues. The skin check, dated [DATE] (created on [DATE]), showed the resident had moisture associated skin damage to the right gluteus. The skin check showed the moisture associated skin damage was present on admission. There was no other documented skin concerns/conditions. The care plan, dated [DATE], showed the resident was at risk for skin breakdown related to their occasional incontinence and had moisture associated skin damage to the buttock. The goal was to develop clean and intact skin by the review date. The interventions included educating the resident / family / caregivers of causative factors and measures to prevent skin injury; to follow facility protocols for treatment of injury; to keep the resident's skin clean and dry; to use lotion on the resident's dry skin; and to monitor / document the location, size and treatment of skin injury; to report abnormalities, failure to heal, and/or signs and symptoms of skin / wound infection such as maceration of the skin to the physician. The care plan did not address the resident's pressure ulcer. The Weekly Wound Tracking Worksheet, dated [DATE] through [DATE], showed the resident had wounds on their sacrum, right heel, and left foot. The skilled nursing note, dated [DATE], read in part, skin warm & dry, skin color WNL [within normal limits] and turgor is normal. Skin Issue #001: Skin issue has been evaluated. Location: Right gluteus. Issue type: Moisture associated skin damage (MASD). Wound was present on admission. Measurements not documented as part of this assessment. Reason measurements not documented as part of this assessment: na. Skin note: WNL. The physician's progress note, dated [DATE], showed the resident had a sacral wound. The progress note, showed nursing staff were to clean the site with normal saline, apply leptospermum honey (a medicated gel used for the treatment of wounds), and cover with a border foam dressing. The physician's progress note, dated [DATE] showed the resident complained of sacral pain. The wound care physician's progress note, dated [DATE], showed an unstageable pressure ulcer to the sacrum due to full thickness necrosis with serosanguinous exudate; 50% thick adherent devitalized necrotic tissue, 30% slough, 10% granulation tissue, and 10% viable dermis was present. The wound care physician's progress note showed the wound was present for greater than 30 days and was noted to be present on admission per staff. The wound measured 4.2 x 3.5 x 0.1cm (centimeter) and was mechanically debrided (to cut away the nonviable tissues) to a depth of 0.5cm. The wound progress was exacerbated due to an unclear cause. The resident's objective of the wound care was to maintain healing. A daily dressing was ordered. The dressing consisted of leptospermum honey and calcium alginate applied daily and covered with a gauze island bordered dressing. The wound physician's progress note also showed the presence of a stage 1 pressure wound on the resident's right heel and a non-pressure wound on the left foot. The progress note showed to apply skin prep (an ointment) twice daily to each site. The wound care physician progress note showed the physician recommended the addition of a protein supplementation per facility formulary and protocol, noting the resident's preferred flavor was chocolate. The skilled nurse's note, dated [DATE], showed the resident had moisture associated skin damage to their right gluteus which was present on/since admission. There was no documentation of a deep tissue injury, wounds, or other skin issues. The skin check, dated [DATE] [but created on [DATE]], showed the resident had moisture associated skin damage to the right gluteus. The skin check showed the moisture associated skin damage was present on admission. There was no documentation of a deep tissue injury, wounds, or other skin issues. The Long-Term Care Evaluation form, dated [DATE], showed the resident's buttock was red and they had a stage IV pressure ulcer / injury to the sacrum they documented was present since admission. The evaluation form showed the resident had a stage I right heel pressure ulcer / injury was present on admission. The evaluation form showed the resident had a left plantar foot trauma injury present on admission. There were no other documented skin concerns/conditions. The skilled nurse's note, dated [DATE], showed the resident had moisture associated skin damage to their right gluteus which was present on/since admission. There was no documentation of a deep tissue injury, wounds, or other skin issues. The shower sheet, dated [DATE], showed the resident refused their shower. The shower sheet did not address if the resident had skin issues/concerns. The wound care physician's progress note, dated [DATE], showed a stage IV pressure ulcer (full-thickness tissue loss with exposed bone, tendon, or muscle) to the sacrum with sero-sanguinous exudate and 90% thick adherent devitalized necrotic tissue and 10% viable dermis. The wound care physician's progress note read in part that the wound was present for greater than 37 days and was noted to be present on admission per staff. The wound measured 4.2 x 3.7 x 0.1cm and was mechanically debrided to a depth of 1.7cm. A daily dressing was ordered. The dressing consisted of leptospermum honey and calcium alginate applied to the wound and covered with a gauze island bordered dressing daily for 23 days. The skilled nurse's note, dated [DATE] at 3:35 p.m., showed the resident had moisture associated skin damage to their right gluteus which was present on/since admission. There was no documentation of a deep tissue injury, wounds, or other skin issues. The wound weekly observation tool, dated [DATE] at 9:45 p.m., showed the sacral wound was a suspected deep tissue injury, present on admission, which worsened into a stage IV pressure ulcer with necrotic tissue and serosanguinous drainage present. The current treatment read in part, may use Santyl is [sic] available, Medihoney/calcium alginate/ island border dressing daily protein supplement. The skilled nurse's note, dated [DATE] at 9:45 p.m., showed the resident had a stage IV pressure ulcer / injury to the sacrum they documented was present since admission. The evaluation form showed the resident had a stage I right heel pressure ulcer / injury they documented was present on admission. The evaluation form showed the resident had a left plantar foot trauma injury they documented was also present on admission. There were no other documented skin concerns/conditions. The Weekly Wound Tracking Worksheet, dated [DATE] through [DATE], showed the resident had wounds on their sacrum and right heel. The sacral wound was 100% necrotic tissue with moderate serosanguinous exudate and measured 5x3.4x0.1cm. The right heel, stage I, measured 6x3cm. The skilled nurse's note, dated [DATE], showed the resident had a stage IV pressure ulcer / injury to the sacrum they documented was present since admission. The evaluation form showed the resident had a stage I right heel pressure ulcer / injury they documented was present on admission. The evaluation form showed the resident had a left plantar foot trauma injury they documented was also present on admission. There were no other documented skin concerns/conditions. The shower sheet, dated [DATE], showed the resident refused their shower. The shower sheet did not address if the resident had skin issues/concerns. The shower sheet, dated [DATE], showed the resident received their shower and had a right arm skin tear, and a bedsore upon visual inspection. The wound care physician's progress note, dated [DATE], showed a stage IV pressure ulcer to the sacrum with serosanguinous exudate and 100% thick adherent devitalized necrotic tissue. The wound care physician's progress note read in part that the wound was present for greater than 44 days and was noted to be present on admission per staff. The wound measured 5.0 x 3.4 x 0.1cm and was mechanically debrided to a depth of 0.3cm. The wound progress was exacerbated due to the resident not eating much per the resident's spouse, and the resident's preference to lay supine (on their back). The resident's objective of the wound care was to maintain healing. A daily dressing was ordered. The dressing consisted of leptospermum honey and calcium alginate applied to the wound and covered with a gauze island bordered dressing daily for 16 days. The wound care physician progress note showed the physician recommended a low air loss mattress for the resident, noting the resident preferred to lay supine. The wound weekly observation tool, dated [DATE], showed the sacral wound as a suspected deep tissue injury, present on admission, which worsened into a stage IV pressure ulcer with necrotic tissue and serosanguinous drainage present. The current treatment read in part, Medihoney, calcium alginate gauze island with bdr [border] daily. The wound observation tool showed the wound did not have an odor. The treatment record, dated [DATE], showed the daily sacral wound dressing was dressed on [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. The Weekly Wound Tracking Worksheet, dated [DATE] through [DATE], showed the resident had wounds on their sacrum, right heel, and right forearm. The tracking worksheet documented the addition of a low air loss mattress to the pressure ulcer interventions. A physician's order, dated [DATE], showed to cleanse the wound to the sacrum with wound cleanser, apply Santyl, and cover with a gauze island dressing with border daily. The wound care physician's progress note, dated [DATE], showed a stage IV pressure ulcer to the sacrum with moderate serous exudate and 100% thick adherent devitalized necrotic tissue. The wound care physician's progress note read in part that the wound was present for greater than 51 days and was noted to be present on admission per staff. The wound measured 6.0 x 5.0 x 0.5cm and was mechanically debrided to a depth of 0.9cm. The wound progress was exacerbated due to the generalized decline of the resident, their nutritional compromise, and the resident's preference to lay supine. The resident's healing potential was shown as poor, and the objective of the wound care was changed to palliative. A twice daily dressing was ordered. The wound care physician progress note showed the physician recommended a low air loss mattress for the resident, noting the resident preferred to lay supine. The skin check, dated [DATE], showed the resident had a stage IV pressure ulcer to the sacrum. The skin check showed the stage IV pressure ulcer was present on admission. There were other documented skin concerns to the right heel and right upper arm. The death certificate, dated [DATE], documented Resident #1 expired on [DATE]. The immediate cause of death was due to a Streptococcus viridans bacteremia infected sacral decubitus ulcer and severe sepsis. The hospital Discharge summary, dated [DATE], showed the resident was admitted to the hospital on [DATE]. The emergency room note read in part, The patient presents today with worsening sacral decubitus ulcer. On examination does appear infected is very malodorous. Unstageable .CT [computerized tomography] the pelvis shows sacral coccygeal decubitus ulcer with dissecting soft tissue gas along the right gluteus maximus [NAME] [sic - muscles] base may be related to tunneling of the decubitus ulcer versus necrotizing and infection. Also sacrococcygeal osteomyelitis was seen and there was no drainable fluid collection seen. The discharge summary showed the resident was admitted with severe sepsis secondary to an infected decubitus ulcer with acute metabolic encephalopathy, an infected sacral decubitus ulcer, sacrococcygeal osteomyelitis, and acute metabolic encephalopathy. The discharge summary showed the resident expired on [DATE] with final diagnoses of severe sepsis secondary to infect decubitus ulcer acute metabolic encephalopathy; Streptococcus viridans, Clostridium and Bacteroides bacteremia; infected sacral decubitus ulcer; sacrococcygeal osteomyelitis; cardiomyopathy; metabolic acidosis; dysphagia; hypernatremia; symptomatic anemia; acute metabolic encephalopathy; neurocognitive disorder without behavioral disturbances; type 2 diabetes mellitus with hyperglycemia; history of stroke; hypernatremia; and hypokalemia. The hospital discharge summary read in part, [AGE] year-old presented for evaluation of worsening decubitus wound and altered mental status. Patient was admitted and was found to have severe sepsis secondary to sacral decubitus ulcer and sacrococcygeal osteomyelitis. Surgery team were consulted and patient underwent surgical debridement. ID team were consulted and assisted in management. Patient was initiated on IV antibiotics. Patient continued to deteriorate during the course of the hospitalization with poor appetite, high risk for aspiration and worsening mentation. After extensive discussion with the patient's family they wished [Resident #1] to be DNR. Patient's clinical condition continued to deteriorate and [the resident] passed away on [DATE] On [DATE] at 4:11 p.m., RN (registered nurse) #1 stated they admitted Resident #1. The RN stated another nurse performed the admission assessment and documented the resident had moisture associated skin damage and a small open area on the right buttock, which was covered with a dressing. RN #1 stated they were unable to find measurements in the EMR (electronic medical record) of the small open area identified on the admission assessment. RN #1 stated the measurements would be documented on the facility wound log. The RN stated the facility was without a wound nurse when Resident #1 was admitted . RN #1 stated during that time, they followed the wound physician on their rounds and filled in the wound log with the information they received from the wound physician. The RN stated during that time, the floor nurses were responsible for performing wound care and communicating any changes to the family, physician, and nursing administration. RN #1 stated the floor nurses were responsible for performing weekly skin checks which automatically showed on the nurses' computer screen as they came due. The RN stated the current wound care nurse also performed some of the weekly skin checks for residents assessed as high risk for skin breakdown. The RN stated the skin check, dated [DATE], showed Resident #1 had moisture associated skin damage on the right gluteus. RN #1 stated the skin check did not identify there was a dressing present on Resident #1. The RN stated there were no treatment orders related to skin or wound care until the pressure ulcer was identified. RN #1 stated the resident's pressure ulcer was identified on [DATE]. On [DATE] at 4:50 p.m., LPN (licensed practical nurse) #1 identified themselves as the new wound nurse. The LPN stated they started work in [DATE] and had three to four weeks of orientation during which they followed RN #1 and/or the wound care physician. LPN #1 stated they were working with administration to build a system where LPN #1 would assess high risk residents and have another nurse or the assigned floor nurse for the area perform the rest of the skin assessments. The LPN stated they rounded to each nurses' station daily and asked if there were any new issues. The LPN stated the nurses informed them of any skin concerns verbally or through email. LPN #1 reviewed the clinical record for Resident #1 and stated there was no ordered treatment for the moisture associated skin damage and no ordered treatment for wounds for Resident #1 until the pressure ulcer was identified on [DATE]. On [DATE] at 5:30 p.m., the DON (director of nursing) stated they started in February 2025. The DON stated the nurses were to notify the physician and family of any changes in condition. The DON stated any physician's orders they received were to be documented and followed. The DON stated the facility monitored this through the resident's care plan, during care plan meetings, and during weekly meetings with therapy, the lead nurses, the ADON, MDS nurse, dietary department, the wound nurse, and the DON. The DON stated the administrator attended the weekly meeting at times as well. The DON stated during the weekly meeting, they reviewed information from the nurses' notes, resident labs, the care plan meetings, and the wound nurses' notes. The DON reviewed the clinical record for Resident #1. The DON stated there was an order for a leptospermum honey dressing and a protein supplement ordered on [DATE]. The DON was asked if there were treatment orders for skin care and/or wound dressing on admission. The DON remained silent. The DON was asked if the resident's care plan addressed any skin concerns. The DON stated the diabetic care plan showed to check all of the body for breaks in skin and the resident's moisture associated skin damage was care planned. The DON stated the resident's admission MDS showed the resident had moisture associated skin damage and interventions which included a pressure reducing device for the chair/bed and the application of ointments/medications other than to feet. The DON stated there was no documentation Resident #1 had a deep tissue injury or an unstageable pressure ulcer on admission. The DON stated there was no documentation that ointments were applied to the resident's skin to manage/address the moisture associated skin damage or to manage/address wound prevention. The DON stated the wound physician's documentation of the location of the pressure ulcer did not match the location of the moisture associated skin damage or dressing identified the admission assessment. The DON stated the wound physician ordered a daily dressing of leptospermum honey and calcium alginate covered with an island border dressing on [DATE]. The DON stated the nurse practitioner for Resident #1 wrote the same order in their progress note dated [DATE]. The DON stated the treatment sheet documented the order was for a daily dressing change but was scheduled in the EMR to perform the dressing only three times a week: on Tuesday, Thursday, and Sunday. The DON stated they did not see a note or order to clarify why the schedule for dressing change did not match the wound physician's ordered frequency for wound care/dressing. The DON reviewed the weekly Braden scale and skin checks for Resident #1. The DON stated the Braden scale and skin checks were documented as late entries and were not done until [DATE] and [DATE], respectively. The DON stated the late entries meant information on the Braden scale and skin checks were not available for the QA team to review in their weekly meetings. The DON stated the facility identified there was a problem with skin assessments and developed a QA plan. The DON stated they in-serviced the nursing staff to keep skin clean/dry, to monitor residents for early signs of skin changes, and to communicate those changes to their charge nurse, wound nurse, and lead nurses. The DON stated they developed a process to monitor their wound tracking/interventions and communicated the information to the MDS nurse to add to the residents' care plan. The DON stated facility nursing staff performed a skin sweep where they assessed the skin of all their residents to rule out the possibility of undocumented skin issues/concerns and ensure the facility was in regulatory compliance. The DON stated the facility recently hired more nursing staff, including a new wound nurse, and an additional ADON (assistant director of nursing). The DON stated ADON #2 was hired to monitor QA which included reviewing resident charts to ensure accurate and complete documentation. The DON stated they added new policies/procedures for skin/wound assessments, interventions, and treatment orders; better defined the lead nurse responsibilities, and who was responsible for monitoring to ensure weekly skin documentation was done with interventions in place for any skin issues/concerns. The DON stated prior to hiring ADON #2, ADON #1 was responsible for reviewing the clinical records but had other duties as well. The DON stated they were ultimately responsible for ensuring the nursing staff performed their duties based on the physician's orders, the resident's plan of care, nursing standards of practice, and the facility policies.

Based on observation, record review, and interview, the facility failed to ensure enhanced barrier precautions were utilized during indwelling urinary catheter care for two (#4 and #6) of three sampled residents who were reviewed with indwelling urinary catheters. The DON identified eight residents with indwelling urinary catheters and 25 residents on enhanced barrier precautions. Findings: The Enhanced Barrier Precautions policy, dated March 2024, read in part, .EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities .Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include .device care or use .urinary catheter . 1. Resident #4 had diagnoses which included obstructive and reflux uropathy. The admission assessment, dated 07/03/24, documented the resident had an indwelling urinary catheter. A Physician's Order, dated 07/19/24, read in part, .Place resident on Enhanced Barrier Precautions due to the presence of a [catheter] . On 10/11/24 at 10:48 a.m., CNA #1 was observed to provide indwelling urinary catheter care to Resident #4. A bin with PPE was observed outside the resident's door and signage indicating enhanced barrier precautions was observed on the resident's door frame. CNA #1 was not observed to utilize a gown during catheter care. On 10/11/24 at 12:15 p.m., CNA #1 stated they were to use gloves and gowns during catheter care but had not thought about it when they provided catheter care to Resident #4. 2. Resident #6 had diagnoses which included obstructive and reflux uropathy. The quarterly assessment, dated 09/20/24, documented the resident had an indwelling urinary catheter. A Physician's Order, dated 07/19/24, read in part, .Place resident on Enhanced Barrier Precautions due to the presence of a [catheter] . On 10/11/24 at 11:36 a.m., CNA #2 was observed to provide indwelling urinary catheter care to Resident #6. A bin with PPE was observed outside the resident's door and signage indicating enhanced barrier precautions was observed on the resident's door frame. CNA #2 was not observed to utilize a gown during catheter care. On 10/11/24 at 12:13 p.m., CNA #2 stated they were to wear a gown and gloves for catheter care, but they had forgotten to don a gown. On 10/11/24 at 12:32 p.m., the DON stated resident's on enhanced barrier precautions had signage on their doors and PPE outside of the rooms. They stated the infection preventionist had educated staff regarding PPE use when residents were on enhanced barrier precautions. On 10/11/24 at 12:42 p.m., the infection preventionist stated for residents who had devices such as catheters, staff were to utilize a gown and gloves during care of that device. They stated they had educated staff and did not know why gowns were not used during catheter care.

46216 Based on record review and interview the facility failed to ensure residents were offered the choice to formulate an advanced directive for three (#7, 40, and #208) of seven sampled residents whose advance directive acknowledgements were reviewed. The administrator identified 67 residents who resided in the facility. Findings: A Residents Rights Regarding Treatment and Advance Directives, policy, undated, read in part .On admission, the facility will determine if the resident has executed an advance directive, and if not, determine weather the resident would like to formulate an advance directive . 1. Resident #7 was admitted on [DATE] with diagnoses which included dementia and dysphagia. A physician's order, dated 1/31/23, documented Resident #7 was a full code. A care plan, revised on 06/27/24, documented Resident #7 was a full code. Resident #7's medical record did not contain an advance directive acknowledgement and there was no social services assessment documenting the resident's choice. 2. Resident #40 was admitted on [DATE] with diagnoses which included Alzheimer's and sepsis. A care plan, revised on 10/19/23, documented Resident #40 was a DNR. A social service assessment dated , 07/13/23, did not contain information regarding Residents #40 choice to accept or decline an advanced directive. 47453 3. Resident #208 was admitted to the facility on [DATE]. A Social Service History and Initial assessment dated [DATE] reviewed, section B(advanced care planning) had no information regarding advance directives. On 07/03/24 at 10:34 a.m., the Social services dir. was asked what is the facility policy for acknowledgement of advance directives upon admission. They stated there is no form that states the resident does or does not have advance directives. On 07/03/24 at 12:15 p.m., the Social services dir. was asked were the advance directives forms given back to the survey team new forms made on 07/03/04, they stated yes. They were asked if the form for Resident #208 was signed on 07/03/24, they stated yes. Resident #208 admitted on [DATE].

46216 Based on observation, record review, and interview the facility failed to ensure that a resident was treated with dignity and respect for one (#7) of one resident sampled for dignity and respect. The Administrator identified 67 residents resided in the facility. Findings: A Promoting/Maintaining Resident Dignity policy, undated, read in part, It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. The policy also read, All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights. Resident #7 was admitted on [DATE] with diagnoses which included dementia and dysphagia. Resident #7's annual assessment, dated 05/04/24, documented the resident was dependent on staff for assistance with all ADL's. A physician's order, dated 01/23/23, documented regular pureed texture diet with nectar thick consistency liquids. On 07/02/24 at 1:37 p.m., Resident #7 was observed sitting near the nurses station with an 8 x 10 sheet of paper on the side of their chair that read nectar thick liquids and an 8 x 10 sheet of paper above their head that read Resident's name and nectar thick liquids. On 07/02/24 at 1:59 p.m., RN #1 stated the signage should not be visible to the public. On 07/02/24 at 2:04 p.m., RN #1 stated the signage should not be on Resident #7's chair. They stated that staff could see the resident's diets by reviewing the care plan and looking at the lunch tickets that are available during meal times

Based on record review, and interview, the facility failed to develop a comprehensive care plan for four(#40, 41, 50, and #111) of seventeen sampled residents reviewed for comprehensive care plan completion. The Administrator identified 67 residents resided in the facility. Findings. A Comprehensive Care Plans policy, undated, read in part, .The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment . 1. Resident #50 had diagnoses which included cellulitis of abdominal wall and multiple sclerosis. Resident #50 admitted on [DATE], a comprehensive care plan was not completed after admission MDS assessment completed on 05/18/24. On 07/03/24 at 8:15 a.m., MDS Coordinator #1 was asked the facility policy for completion of a comprehensive careplan. They stated, if the resident is the facility for more than 21 days, a comprehensive care plan must be completed. The MDS Coordinator #1 was asked to review the care plan for Resident #50, and was then asked if the care plan in Resident #50's chart was a comprehensive care plan. They stated, it is not a fully completed comprehensive care plan. 2. Resident #41 had diagnoses which included hypertension, fracture of the left femur, and transient ischemic attack. Resident #41 admitted [DATE], a comprehensive care plan was not completed after admission MDS assessment completed on 04/25/24. On 07/03/24 at 9:23 a.m., MDS Coordinator #1 was asked the facility policy for completion of a comprehensive careplan. They stated, if the resident is the facility for more than 21 days, a comprehensive care plan must be completed. The MDS Coordinator #1 was asked to review the care plan for Resident #41, and was then asked if the care plan in Resident #41's chart was a comprehensive care plan. They stated, it is not a fully completed comprehensive care plan. 3. Resident #111 had diagnoses which included cerebral infarction, congestive heart failure, and heart failure. Resident #111 admitted on [DATE], a comprehensive care plan was not completed after admission MDS assessment completed on 06/17/24. On 07/08/24 at 9:54 a.m., MDS Coordinator #2 was asked the facility policy for completion of a comprehensive careplan. They stated, if the resident is the facility for more than 21 days, a comprehensive care plan must be completed. The MDS Coordinator #2 was asked to review the care plan for Resident #111, and was then asked if the care plan in Resident #111's chart was a comprehensive care plan. They stated, No, it is not done. 46216 4. Resident #40 admitted on [DATE] with diagnoses of Alzheimer's disease and morbid (severe) obesity due to excess calories. Resident #40's care plan dated 10/17/23, documented, nutritional problem: malnutrition risk with weight fluctuation and sporadic PO intake related to dementia and to weigh weekly and PRN. Resident #40's medical record documented 31 of 37 opportunities to obtain the residents weights were missed. On 07/08/24 at 9:56 a.m., MDS Coordinator #2 stated Resident #40's care plan documented they were to be weigh weekly and that they were not being weighed according to their plan of care.

Based on record review and interview, the facility failed to implement their abuse policy by immediately reporting abuse for one of three sampled residents reviewed for abuse. The Administrator identified 67 residents resided in the facility. Findings: The Abuse policy, dated 2023, read in parts .physical abuse includes yelling, slapping, pinching, kicking, and controlling behavior through corporal punishment .mental abuse includes, but not limited to, nursing home staff taking or using photographs or recordings in any manner that would demean or humiliate a resident. Resident #2 had diagnoses which included cognitive communication deficit, displaced intertrochanteric fracture, and depression. On 04/01/24 at 12:57 p.m., The administrator stated on 03/18/24, at approximately 5:30 a.m., CNA #1 witnessed and videotaped CNA #2 yelling and kicking resident #2. The incident was reported to the administrator at 2:30 p.m. on 03/18/24. The Administrator stated they immediately reported the incident to OSDH, began an investigation and terminated CNA #2. They stated CNA #1 did not report it immediately because she was afraid of CNA #2. The Administrator stated the CNA #1 should have stopped the abuse and reported it immediately.

Based on observation and interview, the facility failed to ensure resident food was prepared and served in a sanitary manner. The Resident Census and Conditions of Residents form documented 61 residents received their meals from the kitchen. Findings: On 05/16/23 at 12:17 p.m., the noon meal service was observed on the 100 hall kitchenette. Dietary Aide #2 was observed to not have a hair net. The dietary aide was observed to have a beard and mustache and was not wearing a beard guard. Cook #3 and Dietary Aide #2 were observed to exit the kitchenette and enter the pantry then re-enter the kitchenette without washing their hands multiple times. A hand washing sink was observed in the kitchenette. On 05/16/23 at 1:22 p.m., the kitchen staff was observed leaving the kitchen area, patting residents on the back, and then returning to kitchen area serving trays without changing gloves or washing their hands. On 05/18/23 at 10:38 a.m., the garbage can next to the hand wash sink in the main kitchen was observed to not be covered. On 05/18/23 at 10:40 a.m., four separate unidentified kitchen staff were observed to have jewelry on such as rings, bracelets, and watches, while they were preparing food. On 05/18/23 at 11:00 a.m., Cook #2 was observed to carry a large uncovered garbage can to the preparation station by the rim of the can. The cook did not wash her hands and then was observed to cut up fresh watermelon for the noon meal. On 05/18/23 at 11:18 a.m., Cook #2 was observed during the preparation of macaroni salad. The cook was observed to go to the spice storage area and pour a handful of kosher salt into her bare hand and return to the container of macaroni salad, pour the salt into the salad, and stir the salt in. On 05/18/23 at 11: 20 a.m., Dietary Aide #1 was observed to place his bare hand into a piping bag to fully open it while waiting for the pureed hotdogs. On 05/18/23 at 11:50 a.m., the facility's dietitian and the DM, who were present during the observations, were asked about the wearing of jewelry and the open trash containers. The dietitian confirmed the garbage should be covered and staff should not be wearing jewelry while prepping food. She then confirmed she also witnessed Cook #2 handling the garbage can then cutting the watermelon without first washing her hands, as well as placing salt in her hand then adding it to the macaroni salad. She was informed of the kitchenette observation on the first day of survey where Dietary Aide #2 was observed without a hairnet or beard guard while serving food. She confirmed the staff hair and beards should always have been covered and confirmed the staff should have washed their hands when they exited the kitchenette and then re-entered.

Based on observation, record review, and interview, the facility failed to attempt to use appropriate alternatives prior to utilizing a side or bed rail, assess the risk for entrapment, review the risks and benefits of bed rails with the resident or resident representative, and/or obtain informed consent prior to use of bed rails for three (#7, 53, and #120) of seven residents reviewed for accidents. The Resident Census and Conditions of Residents form documented 61 residents resided in the facility. Findings: 1. Res #7 had diagnoses which included COPD and dementia. An Admission assessment, dated 03/09/23, documented the resident was severely impaired in cognition, required extensive to total assistance with ADLs, and did not walk. The assessment documented the resident did not have range of motion impairment. The resident's Care Plan was reviewed and did not document a plan of care regarding the use of bed or side rails. A Significant Change assessment, dated 05/02/23, documented the resident was severely impaired in cognition, required extensive to total assistance with ADLs, and did not walk. The assessment documented the resident did not have a range of motion impairment. On 05/16/23 at 1:55 p.m., quarter side rails were observed up on both sides of the resident's bed. On 05/19/23 at 8:44 a.m., the DON was asked for the side rail assessment. On 05/19/23 at 3:03 p.m., the DON was asked again for the side rail assessment. She stated the staff were continuing to search for the side rail assessment. 2. Res #53 had diagnoses which included fracture of unspecified neck of right femur, age related osteoporosis without current pathological fracture, Alzheimer's disease, difficulty walking, and unsteadiness on feet. A Care Plan, dated 04/22/23, did not document a care plan related to use of side rails. A Side Rail assessment, dated 04/22/23, documented side rails were indicated to promote bed mobility. The assessment did not assess the resident for the possibility of entrapment. The assessment's consent section, which had been completed on the admitted , did not document interventions tried prior to use of side rails or specific risks associated with use of side rails for this resident, including the risk for entrapment. An Admission assessment, dated 04/28/23, documented the resident was severely impaired in cognition and required extensive assistance with most ADLs. The assessment documented the resident had experienced falls. On 05/18/23 at 2:21 p.m., personal cares were observed on Res #53. The resident's bed was observed to have side rails up on both sides of the bed. 3. Res #120 was admitted on [DATE], and had diagnoses which included displaced fracture of base of neck of left femur, after care following joint replacement surgery. A Side Rail assessment, dated 05/12/23, documented side rails were indicated to promote bed mobility. The assessment did not assess the resident for the possibility of entrapment. The assessment's consent section, which had been completed on the admitted , did not document interventions tried prior to use of side rails or specific risks associated with use of side rails for this resident, including the risk for entrapment. A Base-Line Care Plan, initiated on 05/12/23, did not document a plan of care related to side rail usage. On 05/17/23 at 9:56 a.m., the resident's bed was observed to have quarter rails up on both sides of the bed and the bed was equipped with a low air loss mattress. On 05/19/23 at 9:49 a.m., the DON stated she was not familiar with the informed consent for side/bed rail use. At that time, the administrator stated she was not aware the use of side rails or bed rails required informed consent or that residents could have been injured with the use of side rails.

Based on record review and interview the facility failed to ensure medical records were readily accessible and systematically organized. The Resident Census and Conditions of Residents form documented 61 residents resided in the facility. Findings: 1. Res #7 had diagnoses which included pneumonia, COPD, dementia, and urinary tract infection. On 05/16/23 at 1:55 p.m., quarter side rails were observed up on both sides of the resident's bed. On 05/19/23 at 8:44 a.m., the DON was asked for the side rail assessment. The DON stated the medical records department was unorganized at this time and, as with other records requested, the staff were having to look through stacks of papers to find the documentation. On 05/19/23 at 3:03 p.m., the DON was asked again for the side rail assessment. She stated the staff were continuing to search for the side rail assessment. She stated the facility had recently changed documentation systems and the medical records department had a large backlog of documents to scan into the computer. The DON stated the form had not been located as of yet. The form was not provided before the survey was completed. 2. Res #16's care plan was reviewed and did not contain a plan of care related to the resident having dementia. On 05/17/23 at 10:37 a.m., the resident was observed sitting in the common area with another resident. The resident was unable to respond to questions or speak. The resident was observed watching the television. On 05/18/23 at 9:08 p.m., MDS Coordinator #1 stated all care plans were in print at the nurse station where the nursing staff could read the care plans. On 05/18/23 at 10:01 a.m., an interview was conducted with the charge nurse about the dementia care plan and he stated he could not find one for the resident. On 05/18/23 at 10:17 a.m., MDS coordinator #1 was observed searching for the hard copies of the residents' care plans at the nursing desk, but she could not find the copies. She stated she guessed they had moved the hard copies of the care plans because they used to be in a drawer.

Based on observation, record review, and interview, the facility failed to follow the menu for pureed diet and ensure the meals met the nutritional needs of the residents. The Resident Census and Conditions of Residents form documented 11 residents had mechanically altered diets including pureed and all chopped food. Findings: On 05/18/23 at 11:12 a.m., Cook #1 was observed while preparing pureed meals for three residents. Two were to receive hot dogs with buns and one was to receive pork on a bun as the main dish. Cook #1 was observed to place a four ounce portion of pork into a blender, added beef broth, and a thickening agent, and blended it until the desired consistency was obtained. Cook #1 then handed the blender to Dietary Aide #1 who placed approximately 1/3 of the pork into a piping bag and piped a portion onto a resident's plate who was to receive a pureed diet and had requested pork on a bun. The dietary aide was observed to dispose of the remainder of pork in the piping bag and empty the remainder of the pork in the blender and take the blender to be washed. On 05/18/23 at 11:22 a.m., Cook #1 was observed to puree the buns by adding three buns to the blender along with heavy cream, hot water, and a thickening agent and blended it until the desired consistency was obtained. Cook #1 then handed the blender container to Dietary Aide #1 who was observed to place approximately 1/2 of the mixture in a piping bag and piped some of the mixture onto two plates to approximate the appearance of buns. Dietary Aide #1 was then observed to dispose of the remainder in the piping bag and the remainder of the contents of the blender. The plate with the pork mixture was not observed to have a portion of the pureed buns piped onto it. On 05/18/23 at 11:27 a.m., Cook #1 was observed to place four hot dogs into a blender and puree them along with broth and a thickening agent and blend them until the desired consistency was obtained. He then was observed to hand the mixture to Dietary Aide #1 who placed approximately 1/3 of the mixture into a piping bag and was observed to pipe a portion of the mixture onto the two plates which had the pureed buns and approximated a hot dog shape. Dietary Aide #1 was then observed to dispose of the remainder in the piping bag and the remainder of the contents in the blender. On 05/18/23 at 11:35 a.m., Cook #1 was observed to place four chocolate chip cookies with added heavy cream into a blender and blend them until he achieved the desired consistency. He was then observed to hand the blend contents off to Dietary Aide #1 who utilized a scoop to place some of the mixture into three small ramekin bowls. Dietary Aide #1 then piped whipped cream onto the mixture in the ramekin bowls and added a small amount of chocolate syrup. The dietary aide was then observed to dispose of the remainder of the mixture in the piping bag and the remainder of the contents of the blender. On 05/18/23 at 11:40 a.m., Cook #1 and Dietary Aide #1 were observed to place the pureed hotdog and buns, pureed Pork without a bun and pureed cookies in metal pans and cover them with plastic wrap. They were then observed to place the plates in the metal pans into a cart and which were taken to the unit for distribution to residents. The meals were sent out without pureed potato salad, macaroni salad, or baked beans. At that time the dietitian stated the pureed potato salad, macaroni salad, or baked beans were not ready and they would take them out when they were prepared. At 05/18/23 at 11:45 a.m., Cook #1 was asked how much pork had he pureed. He replied 4 ounces. He was asked if the resident received four ounces of pork since there was so much left over. He stated he did not know. The cook was asked about how many hot dogs he prepared and he stated four. He was then asked if the residents received the appropriate amount of protein since there was so much left over in the blender container and in the piping bag. At that time, the dietitian, who had also watched the puree preparation, confirmed the residents did not receive the required amount of protein and the facility would come up with a plan to ensure the residents received the correct amount of protein when receiving an altered diet since the puree process increased the volume so much. On 05/18/23 at 1:30 p.m., the DM brought copies of the pureed residents' lunch choice cards. The cards documented the residents were to have received four ounces of hotdogs or four ounces of pork along with a bun and four ounces of chocolate chip cookie. One card indicated the resident wanted potato salad, baked beans, and a chocolate chip cookie. The second card indicated the resident wanted macaroni salad and pears, and the third card indicated the resident wanted potato salad, baked beans, and chocolate chip cookies.

Based on observation, record review, and interview, the facility failed to ensure care plans were developed that reflected the needs of the residents for three (#27, and #53) of 19 residents whose care plans were reviewed. The facility failed to develop care plans for: a. pain for Res #53. b. antidepessant medication for Res #27. The Resident Census and Conditions of Residents form documented 61 residents resided in the facility. Findings: 1. Res #53 had diagnoses which included fracture of unspecified part of neck of right femur. A care plan, initiated on 04/22/23, did not document a care plan to address the resident's pain needs. A physician order, dated 04/22/23, documented to administer acetaminophen 325 mg every six hours as needed for pain. This order was discontinued on 05/12/23. An Admission assessment, dated 04/28/23, documented the resident was severely impaired in cognition, required extensive assistance with most ADLs, and did not walk. The assessment documented the resident had a primary diagnosis of fractures and other multiple trauma, had experienced occasional pain, and had a hip fracture. The assessment documented the resident had a repair of a fracture of the pelvis, hip, leg, or ankle and received opioid medications for seven days during the seven day assessment period. A physician order, dated 04/29/23, documented the facility was to administer hydrocodone with acetaminophen 5-325 mg every 6 hours for a diagnosis of pain. A physician order, dated 05/12/23, documented the facility was to administer acetaminophen 325 mg two tablets every eight hours for pain. On 05/18/23 at 2:21 p.m., the resident was observed receiving personal care by CNA #1. During the cares the resident moaned and gasped when being repositioned for the cares. CNA #1 asked if the resident was hurting and the resident indicated it was painful to be repositioned. After the cares were concluded, the resident was unable to be interviewed. On 05/18/23 at 3:26 p.m., MDS Coordinator #2 reviewed the resident's care plan and stated the only part of the care plan which addressed pain was in the insomnia care plan where it documented if the resident was unable to sleep at night to check for pain. She confirmed this resident's care plan needed a plan to address pain. 46909 2. Res #27 had diagnoses which included major depression disorder. An Annual assessment, dated 07/20/22 documented the the resident received antidepressant medication. The resident's care plan was reviewed and did not contain a plan of care related to the resident's use of antidepressant medications. A Physician's Order, dated on 02/07/23, documented the resident was taking sertraline (an antidepressant medication) 25 mg, two tablets every day. A Quarterly assessment, dated 04/17/23, documented the resident received antidepressant medication. On 05/17/23 at 9:31 a.m., the resident was observed in her bed watching television. On 05/18/23 at 9:08 a.m., MDS Coordinator #1 stated she was unsure if she developed a care plan related to the resident receiving antidepressant medication. On 05/18/23 at 10:17 a.m., an observation was made of MDS Coordinator #1 searching for the hard copy of the residents' care plan at the nurse station and could not locate the hard copies. The MDS coordinator stated she guessed they had moved the hard copy of the care plans because they used to be in a drawer at the nurse station.

Based on observation, record review, and interview, the facility failed to ensure assessments accurately reflected the residents' status for two (#26 and #34) of 19 residents whose assessments were reviewed. The Resident Census and Conditions of Residents form documented 61 residents resided in the facility. Findings: 1. Res #26 had diagnoses which included Alzheimer's disease, anxiety disorder, major depression disorder, and unspecified symptoms and signs involving cognitive functions and awareness. The resident's Admission assessment, dated 10/22/22, documented the resident was severely impaired in cognition and documented the resident had signs and symptoms of delirium including inattention and disorganized thinking. The assessment documented the resident had verbal behavioral symptoms directed toward others, rejection of care, and wandering for one to three days of the assessment period. The assessment documented the resident received antipsychotics, antianxiety, and antidepressant medications. The resident's Quarterly assessment, dated 04/20/23, documented the resident was moderately impaired in cognitive skills for daily decision and had the signs and symptoms of delirium including inattention and disorganized thinking. The assessment documented the resident had verbal behavioral symptoms directed toward others, rejection of care, and wandering for one to three days of the assessment period. The assessment documented the resident received antianxiety and antidepressant medications. On 05/18/23 at 9:03 a.m., MDS Coordinator #1 reported documentation of the resident's signs and symptoms of delirium were her normal behaviors and not actually delirium. The MDS coordinator stated when the resident first came in she had symptoms and coded it that way, but as she had been here longer they have determined it was her normal. The MDS coordinator stated she wondered why the CAA triggered to care plan for delirium. 2. Res #34 had diagnoses which included dementia. A Quarterly assessment, dated 02/10/23, documented Res #34 required extensive to total assistance with most ADLs. The assessment documented the resident had a range of motion impairment on both sides of the lower extremities. On 05/16/23 at 1:15 p.m., the resident was observed sitting on a wheelchair in the television room. Music was playing and she was moving both of her legs and arms in time with the music. The resident was at times observed to pat her legs with her hands and tap her feet by moving her ankles. On 05/19/23 at 8:55 a.m., MDS Coordinator #1 reviewed the Quarterly assessment, dated 02/10/23, and confirmed this resident did not have a functional limitation in range of motion or limited ability to move a joint which interfered with daily functioning. The MDS coordinator confirmed this resident had been wheelchair bound for a long time and it did not interfere with her ADLs or safety.

Based on observation, record review, and interview, the facility failed to utilize their antibiotic stewardship policy to monitor antibiotic use for one (#7) of one resident reviewed for antibiotic use. The Resident Census and Conditions of Residents form documented 61 residents resided in the facility. Findings: A facility policy, titled Antibiotic Stewardship Program, dated August 2022, read in part, .4 .a. Antibiotic use protocols: i. Nursing team members shall assess residents who are suspected of having infection and notify the physician .iii. The Loeb Minimum Criteria may be used to determine whether to treat and infection with antibiotics . Res #7's Admission assessment, dated 03/09/23, documented the resident was severely impaired in cognition and required extensive assistance with most ADLs. A physician order, dated 04/03/23, documented the facility was to administer Macrobid 100 mg two times a day for a diagnosis of urinary tract infection for seven days. A review of the resident's clinical records did not document information as to why the physician ordered the antibiotic or any signs or symptoms the resident may have experienced which may have caused the staff to contact the physician. On 05/19/23 at 12:55 p.m., the IP stated the nursing staff had been educated to utilize a Loeb assessment or make a note in the resident's clinical record of the signs and symptoms the resident experienced when calling the physician or nurse practitioner for an order for antibiotics. She stated the staff should have documented the signs and symptoms of concern in this case but unfortunately she was unable to locate any documentation of the reason the staff wanted to conduct a urinalysis. The IP stated she followed up when the culture and sensitivity came in to determine if the antibiotic ordered was appropriate.

Based on observation, interview, and record review it was determined the facility failed to prevent severe weight loss for two (#2 and #3) of two sampled residents with severe weight loss. This resulted in actual harm for: ~resident #3, who had a severe weight loss of 19.2% in six months, 10.3% in three months, and 10.5% in one month; and ~resident #2, who had a severe weight loss of 11.4% in three months. Four residents were identified with severe/significant weight loss within the last 180 days. Findings: A policy titled, Weight monitoring management, documented, "...3. The Licensed Nurse will analyze the resident's weight to identify variances and trends over periods of days, weeks, months as appropriate; document the analysis, and any variance. If weight is 5% +/- in the last 30 days, 7.5% +/- in the last 90 days or 10% +/- in the last 180 days, the new weight will be validated at that time by a licensed staff nurse...Document on the Weight Record form any special instructions for the individual being weighed....4. Assign a staff member to review weights not later than the day after the weights are taken...Comparisons must be made for one, three and six month intervals...Significant weight changes, subtle, continuous weight changes, and cyclical changes must be identified and followed up for the well-being of the resident. Further assessment and appropriate interventions must be initiated...5. The staff member assigned the task of reviewing the weight is to note issues such as, but not limited to, the following in the comments column of the Weight Record Form: a. 'Physician, family and resident was notified of weight changes...'...b. The resident's weight issue is referred to Nutrition at Risk Committee for care plan management to determine whether or not the problem will need to be reviewed as a significant change. Record approaches on the Care Plan Records or other comparable document. c. The resident's weight issue is 'referred to the interdisciplinary Care Plan Team...'....e. The assigned staff member is to present all variances to the Nutrition at Risk Committee. The composition of the committee should include the Director of Nursing, Clinical Dietitian, Dietary Services Manager...Charge nurse and Assistant Director of Nursing. The Administrator will be informed of the findings and recommendations of the committee." A policy titled, Nutrition at risk committee protocol, documented, "In recognition of the fact that large weight variances, particularly weight loss trends, are a significant risk factor for both, morbidity and mortality, this community will closely follow weight change trends in each resident for each month. Weight variances (greater or equal to) 5% in one month, (greater or equal to) 71/2 in three months, or (greater or equal to) 10% in six months will be thoroughly assessed for causative factors using the following procedures:...4. The ADON will submit a list to the Director of Nursing of all residents who show a significant/severe weight change...within two working days...6. The ADON will then place a 'NAR COMMITTEE SIGNIFICANT/SEVERE WEIGHT CHANGE REPORT' sheet on each applicable resident's medical record...It is the responsibility of the NAR Committee member to fill in their portion of their weight change report within two working days, showing the action taken by each discipline. 7. The Clinical Dietitian will be notified and then, the NAR Committee will meet to discuss resident observations/assessments, and develop an interdisciplinary plan to correct undesirable weight change. 8. The Attending Physician will be contacted by nursing to identify resident weight change and the NAR Committee's recommendations. Order will be obtained at this time, per NAR Committee recommendations...9. The NAR Committee will meet approximately two weeks following the first monthly meeting to review progress of residents. Residents with significant/severe weight change will be reviewed approximately every two weeks, until weight change is no longer significant." 1. Resident #3 was admitted to the facility with [DIAGNOSES REDACTED]. The facility's weight record documented the following 2011 weights: April - 143.2 pounds, May - 134.4 pounds, June - 138 pounds, July - 123.5 pounds, August - 120 pounds, September - 124.2 pounds, October - 120.8 pounds, and November - 115.4 pounds. The clinical record review revealed the resident was hospitalized from [DATE] through 05/31/11. A care plan, dated 06/07/11, documented, "...problem: resident has potential for alteration in nutritional status...She needs monitoring of nutritional status...to maintain physical well being...Goal: resident (name withheld) will consume 75-100% of meals for the next 90 days. She will have adequate nutrition...as shown by no significant weight loss...approach:...offer supplement or alternate if she eats less than 50% of meal served or refuses meal...Monitor weight and report any weight gain or loss of 5% in 30 days, 7.5% in 90 days, or 10% in 180 days...administer supplements as per physician orders:...Be aware she does not like the health shakes so staff will have to find alternate supplements for her...dietary consult as needed...monitor food intake, chart percentage consumed..." The care plan was not updated to include the resident's severe weight loss since June 2011 and did not include any new interventions to prevent further weight loss. A monthly weight record, dated 07/01/11, documented, "...Discussed c Dr need for appetite stimulant on 6/28/11. Did not want to add any meds at that time..." The monthly weight record failed to address the outcome regarding the need for an appetite stimulant. A dietitian progress note, dated 07/07/11, documented, "wt 123.5# decreased 10.51% x 1 mo. pt continues on regular diet c 1/2 portions. p/o intake avg 50%. sig wt decrease likely r/t hospitalization ...diet c health shakes adequate. cont diet, health shakes & encourage po intake." A dietitian progress note, dated 08/17/11, documented, "...diet adequate. will monitor prn." The dietitian progress note failed to address the 18 pound severe weight loss of 13% for the last two months. There was no documentation the physician had been notified of the resident's 18 pound weight loss. A quarterly assessment, dated 09/07/11, documented the resident's weight was 123 pounds and no weight loss had occurred. The quarterly assessment failed to address the 18 pound severe weight loss of 13% for the last two months. A dietary progress noted, dated 09/20/11, documented, "wt. 123.2 #. Diet order is regular half portion. weight has been stable the last two months. appetite is fair...we will continue to monitor her." The dietary progress note failed to address the 13.8 pound severe weight loss of 10% for the last three months. There was no documentation the physician had been notified of the resident's 13.8 pound weight loss. A dietary progress note, dated 10/22/11, documented, "wt: 119.8# diet order is regular half portions c health shakes....weight is ok appetite is fair...we will continueing (sic) monitor her..." The dietary progress note failed to address the 18.2 pound severe weight loss of 13.1% in the last four months. There was no documentation the physician had been notified of the resident's 18.2 pound weight loss. A physician nursing home visit, dated 10/25/11, documented the resident's weight was 120.4 pounds. There was no new dietary interventions addressed regarding the resident's weight loss of 3.4 pounds in one month. A physician nursing home visit, dated 11/0611, documented no weight for the resident and a significant weight loss from last visit. There was no new dietary interventions addressed regarding the residents weight loss of 5.4 pounds in one month. A dietary progress note, dated 11/27/11, documented, "wt: 111.4# diet order is regular with health shakes. Resident ask for small portions. Weight is been up and down. appetite is (sic) fair. resident chooses what she wants at meal times. we will continue monitor her..." The dietary progress note failed to address the 8.4 pounds severe weight loss of 7% in one month, 26.6 pounds, a 12.8 pounds severe weight loss of 10.3% in three months, and 26.6 pounds severe weight loss of 19.2% weight loss in five months. The nursing progress notes were reviewed for the last six months and had not addressed the resident's severe weight loss or physician notification of the severe weight loss. On 11/30/11, at 12:23 p.m., the resident stated she had asked for 1/2 portions. She stated, "Yes, but I never get half portions." She was asked if she had gotten health shakes. She stated, "Sometimes. "She was asked if she liked the health shakes. She stated, "Yes, they are good." At 12:35 p.m., the resident was observed to have eaten 60% of her noon meal. She was not offered a health shake. At 3:52 p.m., the DON was asked if she was aware the resident had an ongoing severe weight loss since June 2011. She stated, "No." She was asked where the nutritional interventions were for residents with weight loss. She stated, "In the dietary and nurses' notes." She was asked why the care plan was not updated to include the resident's severe weight loss and new interventions to prevent further weight loss. She stated, "I don't know." She was asked who monitored resident care plans and assessments to ensure they were up to date and complete. She did not respond. The DON and ADON were asked if the physician was notified of the severe weight loss. The DON stated, "I don't recall." 2. Resident #2 had a [DIAGNOSES REDACTED]. A nutritional assessment, dated 02/16/11, documented, "...wt: 86.8 lbs...Appetite/Intakes: ...poor..." The facility's weight record documented the following 2011 weights: August - 91.2 pounds, September - 87.2 pounds, October - 83.4 pounds, and November - 79.8 pounds. A nutritional care plan, dated 09/06/11, documented, "Problem: ...potential for alteration in nutrition due to progression of her Dementia and hx of Dysphagia...Goal: ...will have adequate nutrition as shown by not further significant weight loss this 90 days...Approach: Offer supplement or alternate if she eats less that 50% of meal served...Monitor weight and report any weight gain or loss of 5% in 30 days, 7.5% in 90 days, or 10% in 180 days...Administer supplements as per physicians orders...Dietary consult as needed..." The monthly nurses' summary dated, September 2011, was reviewed for documentation regarding the resident's weight loss and physician notification. There was no documentation to address the resident's weight loss of 4 pounds in one month. There was no documentation the physician had been notified of the resident's poor appetite or the 4 pound weight loss. A dietary note, dated 09/30/11, documented, "Wt: 89.6#...weight stable. Appetite is fair. We will continuering (sic) monitoring her..." The resident had experienced a 7.8 pound weight loss from August through October 2011. There were no October 2011 dietary notes to address the resident's weight loss and provide new interventions for the prevention of further weight loss. There was no documentation the physician had been notified of the 7.8 pound weight loss in the past two months. A physician's orders [REDACTED]. The monthly nurses' summary dated, October 2011, was reviewed for documentation regarding the resident's weight loss. There was no documentation to address the resident's weight loss of 7.8 pounds in two months. There was no documentation the physician had been notified of the 7.8 pound weight loss in the past two months. A physician's orders [REDACTED]. A November 2011 physician's progress note did not address the resident's severe weight loss of 11.4 pounds in three months. The area for the weights to be documented was left blank. The monthly nurses' summary dated, November 2011, was reviewed for documentation regarding the resident's severe weight loss and physician notification. There was no documentation to address the resident's severe weight loss of 11.4 pounds in three months. There was no documentation the physician had been notified of the severe weight loss of 11.4 pounds in three months. A dietary note, dated 11/02/11, documented, "Wt. 79.8...staff feed (sic) resident. Weight is (sic) been up and down. Will continuering (sic) monitor her." The dietary note failed to address the resident's severe weight loss of 11.4 pounds (12.5%) in three months. An RD note, dated 11/16/11, documented, "Noted Wt loss of 6% in past month - significant cont. to assist w/feeds and enc PO intake, provide house supplement between meals as needed. Provide MVI..." The RD note failed to address the resident's severe weight loss of 11.4 pounds (12.5%) in three months. The dietitian did not address any new interventions for the prevention of further weight loss. There was no documentation the dietitian had notified the physician of the resident's continued weight loss from August through November which resulted in a severe weight loss of 11.4 pounds in three months. A skilled assessment, dated 11/19/11, documented the resident required extensive assistance with meals, and the resident had not experienced a weight loss in the last 30 days. The nutritional care plan had not been updated to address the resident's continued weight loss from August - 91.2 pounds through November 2011 - 79.8 pounds. This constituted a severe weight loss of 11.4 pounds (12.5%) in three months. The care plan did not address new interventions for the prevention of further weight loss. On 11/29/11 at 12:15 p.m., the resident received her lunch meal. The resident received soup, roll, green beans, mashed potatoes/gravy, chopped meat, and a cookie. The resident's diet card documented the resident did not like potatoes. The resident did not eat her potatoes. On 11/30/11 at 12:05 p.m., the resident's diet card documented the resident did not like rice and spinach. At 12:15 p.m., the resident received her lunch meal. The resident received rice, spinach, fish, and a roll. The resident did not eat the rice or the spinach. At 12:35 p.m., CNA #1 was asked if the resident was finished with her lunch meal. She stated, "Yes." She was asked how much the resident had eaten. She stated, "About 25%." She was asked what do you do when she eats less than 50%. She stated, "Give her a health shake." The CNA was asked if the resident was to receive a health shake with her meals regardless of the amount she ate. She stated, "Yes." At 12:55 p.m., dietary aide #1 was asked why the resident received foods she did not like. She stated, "She should not have." On 11/30/11 at 3:52 p.m., the DON was asked what nutritional interventions had been provided since the resident had experienced a severe weight loss. She stated, "Trying to feed her and offer her different foods." The DON was asked where the documentation would be that addressed the nutritional interventions. She stated, "They should be in the dietary notes and the nurses' notes." She was asked where the documentation would be to show the physician had been notified of the resident's weight loss. She stated, "It should be on the doctor's progress notes or the nurses' notes. The DON was handed the physician's November progress note to indicate where the weight documentation would be. She stated, "It's blank." At 4:45 p.m., the DON was asked why the resident's severe weight loss of 11.4 pounds from August through November 2011 had not been addressed in the nurses' notes. She stated, "The charge nurses do the monthly summaries." She was asked who monitored the charge nurses to ensure they were addressing weight loss. No response was given. The DON was asked why the severe weight loss had not been addressed in the nutritional care plan. She stated, "I don't know." She was asked if it should have been. She stated, "Yes." On 12/01/11 at 2:13 p.m., the MDS/care plan coordinator was asked why the severe weight loss had not been addressed on the nutritional care plan and why new interventions had not been addressed. She stated, "We had a different care plan person. She is no longer here. No one caught it." The DON was asked why the physician had not been notified of the resident's severe weight loss of 11.4 pounds in three months. She stated, "I don't know why." The DON stated, "We have a good policy and protocol (weight loss). We just haven't followed it."