Every finding on record at Morrow Manor Nursing Center

Based on medical record review, facility staff interview, and review of facility investigation reports, the facility failed to provide adequate supervision to one resident (Resident #4) who required substantial/maximal assistance with bathing, resulting in a fall with fracture. Actual harm occurred on 03/19/25 when Resident #4 was left unattended in the shower. Resident #4 fell and sustained a fracture to the right humerus (upper arm bone). This affected one (Resident #4) of one resident reviewed for falls. The facility census was 28. Findings include:Review of Resident #4's medical record revealed an admission date of 02/14/25 with diagnoses including severe protein-calorie malnutrition, nondisplaced fracture of surgical neck of right humerus (03/24/25), chronic obstructive pulmonary disease, hypertension, schizoaffective disorder, schizophrenia, chronic pain syndrome, and personality disorder. Review of Resident #4's fall risk assessment dated [DATE] revealed the resident was at high risk for falls. Review of Resident #4's quarterly Minimum Data Set (MDS) assessment, dated 02/21/25 documented Resident #4 was alert and oriented and required substantial/maximal assistance with bathing. Review of Resident #4's plan of care, dated 03/24/25, revealed she had an activity of daily living self-care performance deficit related to requiring assistance with bathing, hygiene, toileting, and dressing. Interventions included therapy as ordered, teaching and encouraging the resident to request assistance to toilet, and showers twice a week per preference. Review of Resident #4's plan of care, dated 03/24/25, revealed she had an alteration in self-mobility and was at risk for falls related to weakness, medication regimen, and mental health issues. Interventions included assisting with bed mobility, transfers and ambulation, monitoring medications for side effects, ensuring the resident was wearing appropriate footwear and added 03/24/25 nonskid strips to the shower floor and staff to be present in the shower and bath to provide assistance. Review of Resident #4's progress note, dated 03/19/25 at 3:15 P.M., documented the nurse was alerted by the Certified Nursing Assistant (CNA) #161that she was needed. Resident #4 was found in the shower room laying unclothed on her right side. CNA #112 was with the resident and had placed a blanket over the resident and another blanket under the resident's head. CNA #112 reported she had been with another resident when she heard someone yelling for help, when she went to investigate, she found Resident #4 in the shower by herself. The nurse asked the resident what happened, and she replied she had slid. Resident #4 was assisted to roll onto her back; there were no open areas or discolorations noted and no lengthening (to her legs). The resident reported pain to her right shoulder and had slight right sided weakness. The resident was assisted up to the shower bench to be dressed and then transferred to the wheelchair. Her right shoulder was sitting lower than her left shoulder. The resident reported pain and rated the pain a two on a one to ten scale. The physician was notified and ordered a stat X-ray to the right shoulder. Review of Resident #4's fall investigation, incorrectly dated 03/19/23, documented the nurse arrived to find the resident lying on her right side. CNA #112 reported she heard a yell from the shower room and found the Resident #4 lying on the floor with the shower bench over her. CNA #161, who was caring for Resident #4 that morning, reported she had been told by the morning aide (CNA #135) she could leave the resident in the shower room by herself. The resident stated she slid. A related factor was improper use of equipment, the shower room. The immediate intervention was to not leave her alone in the shower room. Review of the witness statement from Licensed Practical Nurse (LPN) #141, dated 03/19/25, revealed CNA #161 told her she was needed in the shower room. She entered the room to find CNA #112 kneeling by Resident #4, who was laying unclothed, wet, and on her right side. CNA #112 said Resident #4 had been in the room alone. Resident #4 stated she slid. LPN #141 assessed the resident and found that her right shoulder was lower than her left shoulder, with decreased range of motion, and pain. The physician was notified with a new order for an X-ray. The physician, Administrator, Director of Nursing (DON), and family were notified. LPN #141 spoke to CNA #161 who said CNA #135 told her it was okay to leave the resident in the shower room by herself. LPN #141 educated CNA #161 not to leave any resident unattended in the shower room. Review of the witness statement from CNA #161, dated 03/19/25, revealed she had brought Resident #4 to the shower room and set her up. She reported CNA #135 had told her the resident was fine showering herself. CNA #161 assisted the resident in getting her undressed and made sure she was comfortable. CNA #161 asked the resident if she needed help and the resident said no. CNA #161 went to help another resident and when she came back to check on Resident #4 she found she had fallen. Review of the witness statement from CNA #112 dated 03/19/25 revealed she had begun lifting another resident in their room when she heard someone yelling for help. She laid the resident she was assisting back down and went to see who yelled. She found Resident #4 lying in the shower room on her right side. The shower was still running, and the shower chair was tipped over her. CNA #112 pulled the emergency cord, removed the shower chair, and turned off the water. She additionally covered the resident with a blanket and put a blanket under her head. CNA #161 arrived and was asked to get the nurse; the nurse took over from there. Review of Resident #4's progress note dated 03/19/25 at 4:00 P.M. revealed the aide was instructed to not leave the resident in the shower room unattended. Review of Resident #4's progress note, dated 03/19/25 at 5:29 P.M., revealed the right shoulder X-ray result was received, the physician stated he wanted to confer with another physician to discuss next options. Review of Resident #4's X-ray, dated 03/19/25, revealed an acute comminuted fracture through the greater tuberosity of the proximal right humerus. An inferior glenohumeral dislocation was suspected. Review of Resident #4's Computed Tomography (CT) scan completed 03/19/25 revealed a fracture was present but there was no dislocation. Review of Resident #4's root cause analysis, dated 03/19/25, revealed the resident had been set up in the shower room and reported she could complete a shower on her own. CNA #135 told CNA #161 the resident could be left in the shower alone. The resident washed, stood up from the shower chair to get a towel and slipped and fell to the floor. Contributing factors included the resident was unattended due to CNA #161 being new, the floor was wet and there were no nonskid strips in place causing the smooth floor to be slippery when wet, the emergency cord was not used as the resident was not instructed to use the cord when done by CNA #161 the resident was not listed as a fall risk, and the shower seat bench was smooth. The steps taken were to update the shower list to indicate residents that require assistance, placing grip strips on the shower room floor, and posting laminated signage to use the emergency cord. Review of Resident #4's progress note dated 03/20/25 revealed the physician called the facility on 03/19/25 at 8:09 P.M. and requested the resident be sent to the hospital to do a CT scan of the right shoulder. On 03/19/25 at 8:35 P.M. the ambulance arrived for the resident, and they left at 8:45 P.M. The emergency room called on 03/20/25 at 12:20 A.M. and reported they were sending the resident back. She was in a sling and needed to follow up with physician. At 12:33 A.M. the resident returned to the facility. During an interview on 08/18/25 at 3:24 P.M., the Assistant Director of Nursing (ADON) #117 verified Resident #4 was left alone in the shower when her medical record indicated she needed assistance. Additionally, the shower floor was slippery without grip strips and the resident had not been instructed to use the emergency cord for assistance. ADON #117 verified she was a high fall risk according to her last fall risk assessment. ADON #117 verified the fall resulted in a fracture.

Based on observation, interview, and review of facility policy the facility failed to ensure food was served in a sanitary manner. This had the potential to affect 27 residents of 27 residents who consumed food from the kitchen. The facility identified one resident (#29) who ate nothing by mouth.Findings include: Observation on 08/20/25 of the lunch meal from 11:15 A.M. to 11:40 A.M. revealed Dietary Staff #137 serving the meal. Multiple times throughout the service she was observed using the same serving spoon for two pans of vegetables, one was peas, and the other was a capri mix (broccoli, cauliflower, and carrots). Additionally, during meal service the tongs used to serve the chicken (that was covered in sauce) fell in the container and were visibly soiled. The cook continued using these tongs soiling her gloves. She was then observed getting bread to make a sandwich for Resident #17 who had a finger food diet. Using her soiled gloves she reached into the bag and touched the bread and then prepared the sandwich. The cook changed gloves without washing her hands. She continued using the soiled tongs and was then observed using the microwave. Without washing her hands or changing her gloves, she returned to the serving line and was observed getting bread to make a sandwich for Resident #16 who had a finger food diet. Reaching into the bag and touching the bread.Interview on 08/20/25 at 11:40 A.M. with Dietary Staff #137 verified the above observation.Review of the policy 'handwashing' undated, revealed employees should wash their hands after handling soiled equipment or utensils, following contact with any unsanitary surface, and before putting on disposable gloves. Disposable gloves should not be substituted for proper handwashing.

Based on interview, record review and facility policy review the facility failed to ensure resident funds were timely dispersed to the resident's representative in a timely manner. This affected one resident (#34) of one reviewed for dispersed funds. The facility census was 28.Findings include:Review of Resident #34's closed medical records revealed an admission date of [DATE] and a deceased date of [DATE].Interview on [DATE] at 2:12 P.M. with Business Office Manager (BOM) #145 revealed she had received information a check had been issued in the amount of $6523.67 on [DATE] for Resident #34. BOM #145 stated she was unaware of the date when Resident #34's funds had been issued to her power of attorney (POA) and stated she had only been aware the funds had been dispersed. BOM #145 stated she was unaware of when funds were to be dispersed following a residents passing.Telephone interview on [DATE] at 2:36 P.M. with Corporate Accounts Receivable (CAR) #160 revealed she had created the paperwork for a refund of Resident #34's funds on [DATE] and had given the paperwork to the owner of the company. CAR #160 stated she had not received the paperwork back from the owner and stated she had turned it in again on [DATE] and stated she was then given authorization to disperse the funds on [DATE] in the amount of $6253.67. CAR #160 stated she was unaware of a timeframe as to when funds were supposed to be dispersed following a residents death.Review of facility policy titled Resident Rights-Medicaid/Medicare Coverage/Liability Notice undated, revealed the facility must refund a residents representative any and all funds within thirty days from the residents' date of discharge. This deficiency represents non-compliance investigated under complaint 1395310.

Based on interview, medical record review, review of Depakote (antiepileptic) prescribing information, and review of facility provided articles, the facility failed to ensure Resident #7 had the appropriate diagnoses for prescribed psychotropics. This affected one resident (#7) of five residents reviewed for unnecessary medications. The facility census was 28.Findings include:Review of Resident #7's medical record revealed an admission date of 06/26/25 with diagnoses including Alzheimer's disease, dementia, hereditary and idiopathic neuropathy, and gastro-esophageal reflux disease without esophagitis.Review of Resident #7's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severely impaired cognition. She received an antipsychotic, antidepressant, antibiotic and anticonvulsant medication. Review of Resident #7's plan of care dated 07/14/25 revealed the resident was on anticonvulsant therapy related to mood. Interventions included monitoring for side effects and obtaining laboratory test (labs) as ordered.Review of Resident #7's physician order dated 07/10/25 revealed an order for Sertraline (antidepressant) 50 milligrams (mg) one tablet by mouth one time a day for mood.Review of Resident #7's physician order dated 07/23/25 revealed an order for Depakote 125 mg twice a day for Alzheimer's disease. Review of Resident #7's medical record revealed no documentation indicating the physician was aware that Depakote was not indicated for dementia and why it was appropriate for the resident.Review of the article provided on 08/21/25 at 9:14 A.M. by the Director of Nursing (DON) revealed it was from Very Well Health a website created by health experts. The article was titled 'Depakote and the Treatment of Agitation in Alzheimer's' dated 04/12/24 revealed Depakote was a drug that was classified as an antiseizure medication. It was also used to prevent migraine headaches and to decrease manic episodes in bipolar disorder. Some physicians had begun to use the medication to treat behaviors in Alzheimer's disease and dementia. However, this use was considered off-label and was not approved by the US Food and Drug Administration (FDA). However, research showed that it was not an effective treatment of behaviors in dementia. Review of Depakote prescribing information at depakotehcp.com/prescribing-information revealed Depakote delayed release was an anti-epileptic drug indicated for the treatment of seizures, prophylaxis of migraine headaches, and treatment of manic episodes associated with bipolar disorderInterview on 08/21/25 at 9:14 A.M. with the Director of Nursing (DON) revealed the pharmacist reviewed the VeryWell Health article with the physician when he prescribed the Depakote. She verified this was not documented anywhere and the article indicated it was not an approved or effective treatment. There was no documentation indicating why Depakote was necessary for Resident #7. Additionally, she verified Sertraline was prescribed for mood, which was not a diagnosis.Review of Resident #7's physician order provided by Assistant Director of Nursing (ADON) #117 on 08/21/25 at 9:33 A.M. revealed Sertraline 50 mg one time a day was now prescribed for major depressive disorder.Interview on 08/21/25 at 9:33 A.M. with ADON #117 revealed the diagnosis for Sertraline had been updated. However, she verified this had not been a diagnosis for Resident #7 prior to 08/21/25 and there was no documentation indicating this was an appropriate diagnosis for the resident.

Based on record review and facility staff interview the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) was completed timely. This affected one residents (#11) of four residents reviewed for PASRR. The facility census was 28. Findings include: Review of Resident #11's medical record revealed an admission date of 02/01/23 with diagnoses including unspecified dementia with agitation (07/30/25), bipolar disorder, generalized anxiety disorder, delusional disorders, and hallucinations. Review of Resident #11's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed severely impaired cognition. Review of Resident #11's medical record on 08/18/25 revealed the only Preadmission Screening and Resident Review (PASRR) was completed 04/04/22, prior to the residents admission to the facility. Interview on 08/18/25 at 2:15 P.M. with Clerical Worker #145 revealed she completed PASRR's when she was told a resident had a significant change in condition. She was unaware a PASRR was to be completed upon admission.

Based on medical record review and staff interview the facility failed to ensure care plans reflected specific activity of daily living (ADL) needs. This affected two residents (#4 and #6) out of two residents reviewed for care planning. The census was 28.Findings include: 1. Review of the medical record for Resident #6, revealed an admission date of 7/29/25. Diagnoses included but were not limited to tachycardia, chronic obstructive pulmonary disease, unspecified fracture of right femur, emphysema, unspecified atrial fibrillation, type two diabetes mellitus with hyperglycemia, and hypertension. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a moderate cognitive impairment. The resident was assessed to require assistance with bathing, hygiene, dressing, toileting and to use incontinent products. Review of Resident #6's care plan revealed there was no focus for ADLs or for oxygen administration. Interview on 08/19/25 at 2:16 P.M. with Assistant Director of Nursing #117 confirmed there was no care plan focus for ADLs or oxygen administration for Resident #6. 2. Review of Resident #4's medical record revealed an admission date of 02/14/25 with diagnoses including severe protein-calorie malnutrition, nondisplaced fracture of surgical neck of right humerus (03/24/25), schizoaffective disorder, schizophrenia, chronic pain syndrome, and personality disorder. Review of Resident #4's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she had intact cognition. She required substantial/maximal assistance with bathing. Review of Resident #4's plan of care dated 03/24/25 revealed she had an activity of daily living (ADL) self-care performance deficit related to requiring assistance with bathing, hygiene, toileting, and dressing. Interventions included therapy as ordered, teaching and encouraging the resident to request assistance to toilet and showers twice a week per preference. The plan of care did not address the specific level of assistance the resident required with her ADL's. Interview on 08/20/25 at 10:56 A.M. with Assistant Director of Nursing (ADON) #117 verified the care plan did not specify the level of assistance Resident #4 needed.

Based on record review, interview, and review of the facilities policy the facility failed to educate Resident #3 related to his medication refusals and notify the physician of the refusals. This affected one resident (#3) of one resident reviewed for mood and behavior. The facility failed to have hospice orders and detailed care plans in place for Residents #1 and Resident #29. This affected two residents (#1 and #29) of two residents reviewed for hospice. Finally, the facility failed to have a diet order and to have documentation of skilled assessments for Resident #29. This affected one resident (#29) of 18 resident records reviewed. The facility census was 28.Findings include: 1. Review of Resident #3's medical record revealed an admission date of 07/10/25 with diagnoses including diabetes mellitus, other obstructive and reflux uropathy, venous insufficiency, major depressive disorder, unspecified psychosis, chronic pain syndrome, chronic systolic heart failure, and chronic respiratory failure with hypoxia. Review of Resident #3's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he had intact cognition. He was receiving an anticoagulant, hypoglycemic, and diuretic medication. Review of Resident #3's plan of care dated 07/23/25 revealed he was taking antiplatelet medication. Interventions included administering medications as ordered, handling gently when moving, monitoring and reporting any abnormal findings and monitoring for excessive bleeding or bruising. Review of Resident #3's plan of care dated 07/23/25 revealed the resident was on diuretic therapy related to chronic heart failure. Interventions included administering medications as ordered, monitoring for medication interactions, reporting pertinent labs, and observing for side effects. Review of Resident #3's plan of care revised 07/23/25 revealed the resident was at risk for prolonged bleeding related to anticoagulant due to clots. Interventions included administering medication as ordered and monitoring for signs of anticoagulant complications. Review of Resident #3' plan of care revised 08/07/25 revealed the resident was at nutrition risk, at risk for significant weight loss, and at risk for altered fluid maintenance related to diagnoses, consuming less than 75% of diet at times, use of therapeutic diet, use of diuretic, and significant weight gain on 08/07/25. Interventions included providing diet as ordered, monitoring weights, assisting with meals as needed, obtaining and monitoring laboratory testing as ordered, monitor and report to the physician signs of dysphagia, and weighing as ordered and report to physician if not in within range. Review of Resident #3's physician's orders revealed the following orders aspirin one tablet at bedtime, Ezetimibe (a cholesterol medication) 10 milligrams (mg) one tablet by mouth one time a day, Entresto (a heart failure medication) 24 mg 26 mg half a tablet by mouth two times a day, Eliquis (an anticoagulant) five mg twice a day, dated 07/10/25. Folic Acid (vitamin) 1 mg one tablet by mouth one time a day, Lasix (diuretic) 20 mg one time a day, dated 07/11/25. Wegovy (a weight loss medication) Subcutaneous Solution 0.25 milligrams per 0.50 milliliters (ml) 0.5 ml to be injected every Wednesday, Vitamin D 2000 units at bedtime, and Metoprolol (a medication for hypertension) 50 mg one tablet by mouth twice a day, dated 07/16/25 Review of Resident #3's Medication Administration Record (MAR) for July 2025 and from 08/01/25 to 08/18/25 revealed several medication refusals. Aspirin was refused from 07/16/25 to 07/19/25, on 07/21/25, from 07/23/25 to 07/31/25, from 08/02/25 to 08/07/25, from 08/10/25 to 08/16/25, and on 08/18/25. Ezetimibe was refused from 07/16/25 through 07/19/25, from 07/21/25 through 07/25/25, from 07/27/25 through 07/31/25, on 08/01/25, from 08/03/25 through 08/05/25, from 08/10/25 through 08/12/25, and on 08/18/25. Folic Acid was refused 07/17/25 through 07/22/25, from 07/24/25 through 07/27/25, on 07/30/25, on 07/31/25, on 08/01/25, on 08/02/25, from 08/04/25 through 08/15/25, and on 08/18/25. Lasix was refused on 07/18/25 and 08/02/25. Vitamin D was refused from 07/16/25 through 07/19/25, from 07/21/25 through 07/31/25, on 08/01/25 through 08/07/25, from 08/10/25 through 08/16/25, and on 08/18/25. The Wegovy injection was refused on 07/16/25, 07/23/25, 07/30/25, 08/06/25, and 08/13/25. Eliquis was refused for one dose on 07/16/25, 07/19/25, and 07/21/25. [NAME] was refused for one dose on 07/16/25, from 07/18/25 through 07/20/25, 07/24/25, 07/25/25, 07/30/25, 07/31/25, 08/02/25, from 08/04/25 through 08/15/25 and on 08/18/25. [NAME] was refused twice 7/17/25, 07/21/25, 07/22/25, and on 07/26/25. Metoprolol was refused once on 07/16/25, 07/17/25, 07/18/25, and on 07/21/25. Review of Resident #3's progress notes from 07/01/25 through 08/18/25 revealed no evidence Resident #3 was educated on the potential risk of refusing medications. Additionally, there was no evidence anyone asked Resident #3 why he was refusing medications. Finally, there was no documentation the physician was notified of Resident #3's medication refusals. Interview on 08/18/25 at 9:21 A.M. with Resident #3 revealed he is only supposed to be receiving three medications, however, the facility continued to provide him with more medications and he did not know why. Interview on 08/19/25 at 11:35 A.M. with Registered Nurse (RN) #103 revealed Resident #3 was consistent in refusing the same medications but she was not sure why he did so. Interview on 08/19/25 at 12:06 P.M. and 2:01 P.M. with Assistant Director of Nursing (ADON) #117 revealed when a resident refuses medications they should be making a second attempt and documenting education for refusals. She verified there was no documentation about why the resident refused his medication. Interview on 08/20/25 at 9:55 A.M. with Physician #163 revealed he had been unaware until that morning that Resident #3 was refusing medications. He was concerned about the refusal of his heart failure medication and planned to discuss it with the resident. Physician #163 indicated he would expect the nurses to notify him of medication refusals. 2. Review of Resident #1's medical record revealed an admission date of 08/08/24 with diagnoses including Alzheimer's disease, dementia, gastro-esophageal reflux disease, dysphagia, depression, and anxiety. Review of Resident #1's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she had severely impaired cognition. Review of Resident #1's progress note dated 07/23/25 revealed the resident had a hospice consult. Review of Resident #1's hospice comprehensive assessment revealed services began on 07/24/25. Her diagnoses were Alzheimer's disease, dementia, and hypertension. Review of Resident #1's plan of care revised 08/01/25 revealed she had a terminal prognosis and was enrolled in hospice related to a chronic condition with less than six months to live, she received hospice services through on a non facility owned Hospice. Interventions included adjusting provision of ADLs to compensate for residents changing ability, encouraging support system, working cooperatively with hospice team, notifying hospice of any changes. The care plan did not address how to contact hospice or what her admitting diagnosis was. Interview on 08/20/25 at 10:56 A.M. with Assistant Director of Nursing (ADON) #117 verified there were no orders for hospice care. Additionally, the care plan did not address how to contact hospice or what her admitting diagnosis to hospice services was. Review of Resident #1's physician orders revealed it did not address hospice. 3.Review of the medical record for Resident #29, revealed an admission date of 08/15/25. Diagnoses included but were not limited to malignant neoplasm of overlapping sites of oropharynx, post laminectomy syndrome, not elsewhere classified, essential hypertension, and chronic fatigue. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed an admission MDS assessment was in progress. Resident #29 required assistance with bathing, hygiene and dressing. Review of Resident #29's current physician orders for August 2025 revealed no order for nothing by mouth (NPO) or hospice. Resident #29 was admitted to the facility on [DATE] from an outside hospital. Review of Resident #29's hospital discharge paperwork dated 08/15/25 revealed Resident #29 was to be admitted on hospice services and to have nothing by mouth (NPO) upon admission to the facility. Resident additionally had an order to had nothing by mouth (NPO). Further review of Resident #29's medical records revealed skilled assessment from 08/15/25-08/18/25 had not contained daily vital signs. Interview on 08/19/25 at 2:26 P.M. with Assistant Director of Nursing (LPN) #117 verified residents should have a skilled assessment completed twice a day for the first three days after admission to the facility. LPN #117 stated vitals signs were to be documented on the weights and vitals page or in a skilled assessment. Review of Resident #29's vital signs with LPN #117 at time of interview confirmed Resident #29's vitals were only taken once on 08/15/25 and on 08/18/25. Interview on 08/19/25 at 2:41 P.M. with Director of Nursing (DON) verified residents should have had vital signs completed twice a day for the first three days of admission to the facility. Review of Resident #29's medical records with DON at time of interview confirmed Resident #29 did not have vital signs completed twice a day for the first three days of his admission. Additionally, DON confirmed Resident #29 did not have an active nothing by mouth (NPO) or hospice order. Review of the admission Process and Assessments policy dated as revised August 2025 under admission day protocol stated follow suggested guidelines to admission/readmission completion checklist. Review of the Guidelines to admission policy undated stated medications/treatments transcribed and clarified on the medication administration record (MAR) (all medications/orders need signed by two nurses) and nurses admission assessment completed in electronic medical record.

Based on observation, interview, medical record review, and review of facility policy the facility failed to ensure Resident #11's pressure ulcer was timely assessed and appropriately documented. Additionally, they failed to ensure the physician and family were notified of a new pressure ulcer and failed to ensure the appropriate treatment was completed as ordered. This affected one resident (#11) of one resident reviewed for pressure ulcers. The facility census was 28.Findings include:Observation on 08/19/25 at 10:08 A.M. of wound care for Resident #11 with Assistant Director of Nursing (ADON) #117 revealed a dressing that had been completed on 08/19/25. ADON #117 removed the dressing and revealed a small area to her buttocks, ADON #117 reported she was unsure of what the area was and it may have been moisture associated skin damage. ADON #117 verified upon removal of the dressing there was no dressing or calmospetine lotion to the area.Review of Resident #11's medical record revealed an admission date of 02/01/23 with diagnoses including unspecified dementia with agitation, type two diabetes mellitus, bipolar disorder, generalized anxiety disorder, delusional disorders, and hallucinations. Review of Resident #11's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed severely impaired cognition. She had no pressure ulcers but was at risk. Review of Resident #11's medical record revealed her sister-in-law was listed as her power of attorney for care. Review of Resident #11's plan of care dated 02/02/23 revealed she was at risk for alteration in skin integrity related to self-mobility problems, incontinence, and high risk on the Braden scale. Interventions included monitoring skin every day for redness and signs of breakdown, use of house lotion and ointments for skin protection as ordered, pericare after each incontinence, keeping skin clean and dry, pressure reduction mattress on bed, turning and repositioning every two hours, and referring to physician orders for current treatment. Review of the medical record and observations made during the survey confirmed the interventions to reduce the risk for skin alteration were in place as directed by the plan of care. Review of Resident #11's progress notes on 08/18/25 from 08/05/25 to 08/13/25 revealed no mention of a skin impairment, no measurements of a skin impairment, and no family or physician notification of a skin impairment. Review of Resident #11's skin observation documented on 08/14/25 revealed the resident had no wounds or skin concerns. Review of Resident #11's wound nurse practitioner note dated 08/11/25 revealed the resident had a pressure ulcer to her right buttock labeled as an unstageable or deep tissue injury. The area measured four centimeters (cm) by six centimeters. The measurement included deep purple non-blanchable tissue surrounding the open wound. A portion of the deep purple skin flap was trimmed with scissors. Treatment included cleansing the area with normal saline, patting dry, applying a thin layer of calmospetine (moisture barrier cream) or chamosyn cream, applying a slightly moistened collagen sheet and securing with a dry cover dressing daily, and as needed. Additionally, the nurse practitioner recommended a low air loss mattress. The assessment indicated the wound onset date may be different then the date of the assessment. Review of Resident #11's physician order dated 08/11/25 revealed an order related to the residents right buttock wound. Nursing was to cleanse the area with normal saline, pat dry, apply moistened collagen to the open area, apply a thin layer of calmoseptine or chamosyn cream, and cover with a dry dressing daily and as needed if soiled or dislodged. Interview on 08/19/25 at 12:06 P.M. and 3:53 P.M. with the Assistant Director of Nursing (ADON) #117 verified there was no documentation about when the wound started or if the family and physician were notified. It was determined the wound was discovered on 08/10/25. ADON #117 additionally revealed that all current skin conditions should be documented on the skin observations form. ADON #117 verified the 08/14/25 skin observation form incorrectly indicated the residents skin was intact. Review of the policy 'Skin Care and Pressure Ulcer' revised August 2025, revealed skin conditions were to be measured weekly by nursing. The residents responsible party was to be notified of skin treatment changes. All residents with adverse skin conditions that occur after admission will be placed on an episodic care plan. The wound nurse, provider, and the family will be contacted.

Based on record review, observation, and interviews, the facility failed to ensure oxygen signage was used for residents who had oxygen used in their care. This affected one Residents #6, of three reviewed for respiratory care. The facility census was 28. Findings include:1.Review of the medical record for Resident #6, revealed an admission date of 07/29/25. Diagnoses included but were not limited to tachycardia, chronic obstructive pulmonary disease, unspecified fracture of right femur, personal history of pulmonary embolism, hypertensive heart disease without heart failure, emphysema, type two diabetes mellitus with hyperglycemia, and hypertension. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed moderate cognitive impairment. Resident #6 was assessed to require assistance with bathing, hygiene and dressing.Review of the current physician orders for August 2025 for Resident #6 revealed an order for oxygen via nasal cannula (NC) at one to four liters per minute (LPM). Observations on 08/18/2025 at 9:24 AM, 11:43 A.M., and 2:55 P.M. revealed no oxygen warning sign noted to Resident #6's door.Interview on 08/18/25 at 2:57 P.M. with Registered Nurse (RN) #103 confirmed there is no oxygen warning sign on Resident #6's door. Observation on 08/19/25 at 2:57 P.M. revealed Resident #6 was resting in bed and was wearing a nasal cannula. Continued observation revealed no oxygen signage posted outside of Resident #6's room to indicate oxygen was in use. Review of the (facility policy titled) Oxygen Administration, dated April 2008 revealed the facility was to place an oxygen in use sign per facility policy and to place oxygen in use sign on outside of resident's doorway.

Based on observation, record review, staff interview, and policy review, the facility failed to ensure the medication error rate did not exceed five percent (%). The facility had three medication errors of 28 opportunities for an error rate of 10.71%. This affected one Resident (#29) of three residents observed for medication administration. The facility census was 28 residents. Findings include:Review of the medical record for Resident #29, revealed an admission date of 08/15/25. Diagnoses included but were not limited to cancer of the oropharynx (the head and neck area), hypertension. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed cognition assessment was still in progress. Resident #29 was assessed to require assistance with bathing, hygiene and dressing. Review of the medication administration record (MAR) revealed Resident #29 was ordered metoprolol (blood pressure medication) 50 milligrams (mg) via gastrointestinal tube (G-tube feeding tube) two times a day, omeprazole (reduces acid in the stomach) capsule delayed release 20 mg via G-tube one time a day, and gabapentin (nerve pain and restless legs syndrome medication) capsule 300 mg via the g-tube three times a day. Review of Resident #29's physician orders for August 2025 revealed no active orders to combine crushed medications and administer them together via Resident #29's G-tube.Observation of medication administration on 08/19/25 at 8:07 A.M. revealed Registered Nurse (RN) #103 crushed the metoprolol tablet and placed it in a medication cup, RN #103 had then opened the omeprazole capsule and placed it in the same medication cup, RN #103 opened the gabapentin capsule and placed it in the medication cup with the other two medications. RN #103 took the medication cup into Resident #29's room, checked for placement of the G-tube by listening for air, then put water into the medication cup and put all the medications combined into Resident #29's G-tube.Interview on 08/19/25 at 10:41 A.M. with RN #103 revealed an active order must be in place to combine crushed medications together and administer via a g-tube and if no active orders medications were to be given separately.Review of Resident #29's medical records with the Director of Nursing (DON) on 08/19/25 at 10:57 A.M. revealed no active orders to combine Resident #29's medications. DON further stated an order to combine medications was required. Review of facility policy titled Administration of Medications through a Gastric Tube dated July 2007, stated to administer one medication at a time or as ordered, flush the tube between medications if appropriate, and rinse the tube with 30 milliliters (mL) of water after the final medication.

Based on observation, record review, and staff interview, the facility failed to maintain infection control during the medication administration observation when she touched resident's medications with her bare hands and administered them to residents. This affected two (Residents #8 and #19) of five residents observed during medication administration. Furthermore, the facility failed to ensure they initiated and maintained an appropriate Legionella prevention plan. This had the potential to affect all 26 residents residing in the facility. Findings include: 1. Review of the medical record for Resident #19 revealed an admitted [DATE]. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 06/22/22 at 8:00 A.M. revealed Registered Nurse (RN) #133 preparing Resident #19's medications. She dropped the [MEDICATION(S)] medication onto the top of the medication cart and picked up the medication with her bare hands, put it into the medication cup, and administered the medications to the resident. Interview on 06/22/22 at 8:17 A.M. with RN #133 confirmed she touched Resident #19's medications with her bare hands. 2. Review of the medical record for Resident #8 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 06/22/22 at 8:09 A.M. revealed Registered Nurse (RN) #133 preparing Resident #8's medications. She dropped the [MEDICATION(S)] medication onto the top of the medication cart and picked up the medication with her bare hands, put it into the medication cup, and administered the medications to the resident. Interview on 06/22/22 at 8:17 A.M. with RN #133 confirmed she touched Resident #8's medications with her bare hands. 3. Review of the facility's Legionella Prevention Plan revealed the facility had a packet of information pertaining to Legionella, printed from the Centers for Disease Control (CDC), and how the facility could reduce the risk of the infection. Review of the facility's front page of the Water Management Program Binder revealed the previous Administrator signed that she reviewed the plan on 08/04/21 and she stated no changes were to be made to the plan. There was no documented evidence stating what the Legionella Management Plan/Program would be and there was no documented evidence that the facility attempted to test the water for Legionella since September 2017. Review of the facility's form titled Identifying Buildings at Increased Risk revealed the building marked the answer, Yes to two questions, indicating the facility should have a water management program for the building's hot and cold water distribution system. It stated the buildings spa was drained between each use. It also stated the facility had emergency water systems such as fire sprinklers, safety showers and eyes wash stations that were regularly tested and the last test was completed was in March 2019. The plan stated the facility would contact [NAME] for Legionella testing on 04/16/19. Review of the [NAME] CDC Legionella Sampling form revealed they were last at the facility on 09/28/17 to test the facility's water systems. Review of the facility's flow sheet to indicate the flow of water through the building, revealed it was for a completely different building. Interview on 06/22/22 at 1:45 P.M. and 2:12 P.M. with the Administrator confirmed there was no Legionella information pertinent to this facility, he stated he didn't know why that book was even here, and he confirmed nothing had been updated in the Legionella book since 2019 even though the previous Administrator supposedly reviewed and approved the plan in 2021.

Based on record review and staff interview, the facility failed to ensure residents were notified of the reasons for non-coverage of Medicare funds. This affected two (Residents #22 and #230) of two residents reviewed for liability and beneficiary appeal notices. The census was 26. Findings include: 1. A review of the Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review revealed Resident #22 was not issued the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) cut letter. Her Medicare Part A Skilled Services Episode started 03/18/22 and the last covered day of Part A Service was 04/18/22. The facility initiated the discharge from Medicare Part A services when benefit days were not exhausted. 2. A review of the SNF Beneficiary Protection Notification Review revealed Resident #230 was not issued the SNFABN or Notice to Medicare Provider Non-coverage (NOMNC) for services that started 04/21/22 and stopped 04/28/22. Resident #230 did not exhaust all benefit days. On 06/23/22 at 2:10 P.M. an interview with Corporate Liaison Business Office Manager (BOM) #300 verified Resident #22 was not issued the SNFABN cut letter until 06/23/22. She also verified Resident #230 was not issued an SNFABN cut letter nor a NOMNC.

Based on observations, family interview and staff interview, the facility failed to provide a clean and safe environment for the residents. This affected three (Residents #11, #25 and #27) of 17 residents reviewed for physical environment. The facility census was 26. Findings include: On 06/21/22 at 11:49 A.M., a telephone interview with an anonymous family member revealed she felt the floors were very dirty and sticky at times and the facility needed additional cleaning. Observations on 06/21/22 at 12:00 P.M. of the room and bathroom for Residents #11, #25 and #27 revealed the floor had dirty spots of food and skid marks. Observations and interviews on 06/23/22 at 11:59 A.M. of rooms for Residents #11, #25 and #27 with the Administrator verified the floors were dirty and in need of stripping for Resident #11, #25, and #27's room and bathroom. The Administrator verified the bathrooms in both rooms had loose baseboards that protruded from the walls.

Based on medical record review, staff interview, and review of the facility's policy and procedure, the facility failed to ensure the physician documented a rationale for pharmacy recommendations. This affected one (Resident #3) out of five residents reviewed for unnecessary medications. The facility census was 26. Findings include: Review of the medical record for Resident #3 revealed an admitted [DATE]. Diagnoses included depression, dementia, and anxiety. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 had impaired cognition and she had no behaviors. Review of the care plan dated 01/06/20 revealed Resident #3 had a cognitive deficit with the potential for mood/behavior problems. She was at risk for wandering/elopement and wears a wander guard device on her ankle, she received antianxiety and antipsychotic medications and was at risk for adverse effect, and she had the diagnoses of depression, anxiety, [CONDITION(S)] and dementia. Interventions included ton administer anti-anxiety and antipsychotic medications as ordered and monitor for adverse side effects. Review of Resident #3's physician orders revealed orders for [MEDICATION(S)] 0.25 milligrams (mg) twice daily for anxiety and [MEDICATION(S)] 0.25 mg at night for dementia. Review of Resident #3's pharmacy recommendations revealed the following: On 04/13/22 the pharmacist recommended a gradual dose reduction for the resident's [MEDICATION(S)], to change the order from 0.25 mg daily to 0.125 mg daily. The physician declined and no rationale was provided; On 03/16/22, the pharmacist recommended a gradual dose reduction for the resident's [MEDICATION(S)], as she was receiving 0.25 mg twice daily. The physician declined and no rationale was provided; On 01/12/22, the pharmacist recommended a gradual dose reduction for the resident's [MEDICATION(S)], to change the order from 0.25 mg daily to 0.125 mg daily. The physician declined and no rationale was provided; On 12/08/21 the pharmacist recommended a gradual dose reduction for the resident's [MEDICATION(S)], as she was receiving 0.25 mg twice daily. The physician declined and no rationale was provided; On 11/10/21, the pharmacist recommended a gradual dose reduction for the resident's [MEDICATION(S)], to change the order from 0.25 mg daily to 0.125 mg daily. The physician declined and no rationale was provided. Interview on 6/23/22 at 10:19 A.M. with the Director of Nursing (DON) confirmed the physician didn't complete documented rationales for Resident #3's gradual dose reductions on 04/13/22, 03/16/22, 01/12/22, 12/08/21, and 11/10/21 Review of the facility's undated policy and procedure titled Gradual Dose Reduction/Tapering in the Nursing Facility revealed the continued use of medication is in accordance with relevant current standards of practice and the physician has documented the clinical rationale.

Based on medical record review, observation, staff interview, and review of the facility's policy and procedure, the facility failed to ensure their medication error rate less than five percent (%). Out of 28 opportunities, there were two errors to equal 7.14% medication error rate. This affected two residents (#8 and #17) out of five residents observed during medication administration. The facility census was 26. Findings include: 1. Review of the medical record for Resident #17 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan dated 04/26/21, revealed Resident #17 had an alteration in vision and communication related to [CONDITION(S)], [CONDITION(S)] and bilateral corneal transplant. Interventions included to monitor ocular changes and keep glasses and frequently used objects in a consistent area within reach. Review of Resident #17's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 06/22/22 at 7:42 A.M. with Registered Nurse (RN) #133 revealed she administered the [MEDICATION(S)]-[MEDICATION(S)] 2% - 0.5% eye drop to Resident #17's right eye. Interview on 06/22/22 at 7:43 A.M. with RN #133 confirmed she administered the medication in the right eye and it should have been the left eye. She stated Resident #17 receives a lot of eye drops during the day but she didn't think Resident #17 was to receive that specific medication in the right eye at all. 2. Review of the medical record for Resident #8 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the care plan dated 06/09/22 revealed Resident #8 was at risk for malnutrition related to diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #8's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation and interview on 06/22/22 at 8:09 A.M. of medication administration for Resident #8 revealed Registered Nurse (RN) #133 prepared the resident's medications. When she prepared his Vitamin B-12 1,000 mcg, she only prepared one. As she was getting ready to go into Resident #8's room, surveyor intervened and the nurse confirmed she only placed one Vitamin B-12 into the pill cup and the order was for two. Review of the facility's policy and procedure titled Medication Administration Policy, dated January 2010, revealed there are five rights of medication administration (right drug, right dose, right resident, right route, and right time) and drug labels should be read carefully and checked against the order three times.

Based on observation, staff interview, review of the Center for Medicare Medicaid Services (CMS) county color positivity rate, and review of the Center for Disease Control and Prevention guidance for Health Care Facilities, the facility failed to ensure the staff wore eye protection when in resident care areas. This had the potential to affect all 27 residents residing in the facility. Findings include: Observation of the resident care areas throughout the facility on 11/30/20 between 1:00 P.M. to 2:00 P.M. revealed Registered Nurse (RN) #35, Activity Director #40, State tested Nursing Assistant (STNA) #45, STNA #50 and STNA #60 were not wearing eye protection in the resident care areas. Interview with RN #35, Activity Director #40, STNA #45, STNA #50 and STNA #60 on 11/30/20 between 1:00 P.M. to 2:00 P.M. verified they were not wearing eye protection. The staff stated they only wear eye protection in the quarantine rooms, not in all resident areas. Review of the CMS county positivity rate revealed the county the facility resided in was yellow with the weekly positivity rate being 15.9 percent. The testing positivity classification revealed yellow meant the positivity was greater than 10.0 percent over the past 14 days. Review of the Center for Disease Control and Prevention (CDC) guidance for Health Care Facilities, dated 11/04/20, revealed healthcare professionals (HCP) working in facilities located in areas with moderate to substantial community transmission are more likely to encounter asymptomatic or pre-symptomatic patients with [DIAGNOSES REDACTED]-CoV-2 infection. HCP should wear eye protection in addition to their facemask to ensure the eyes, nose, and mouth are all protected from exposure to respiratory secretions during patient care encounters in the facilities with a moderate to substantial community spread.

Based resident and staff interviews, record review and review of the facility's policy, the facility failed to have a grievance committee and inform the residents how to voice a grievance. This affected one (Resident #4) of three residents reviewed for grievances. The facility census was 27. Finding include: Review of Resident #4's medical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/23/20, revealed the resident's cognition was intact. He did not display any behaviors or rejection of care during the assessment period. Interview with Resident #4 on 11/30/20 at 1:20 P.M. stated the facility had a fill in Director of Nursing and he did not know who to tell about his concerns. He stated they stopped giving showers six weeks ago and he was getting bed baths now and he does not know why. Interview on 11/30/20 at 2:00 P.M. with the Administrator stated the facility does not have a grievance committee. She stated the previous Activity Director left in September of 2020 and she was not sure where she put that information. She verified the facility has an interim Director of Nursing. A subsequent e-mail was received from the Administrator on 12/02/20 at 3:50 P.M. and verified she could not find any documentation concerning a Grievance Committee and there was no evidence of an annual meeting as stated in the facility's policy. During a phone interview on 12/01/20 at 11:30 P.M. with Activity Director #40 stated she goes room-to-room to the residents who normally attend the resident council meetings and asked if they had any concerns. She verified she did not go to all of the resident's rooms. She verified she was unaware if the the facility had a grievance committee. Review of the facility's Resident's Grievance Policy, dated 01/2012, stated grievances shall be resolved by a committee composed of the Administrator, two residents and sponsors or outside representatives. The Grievance Committee is to meet at least annually. This deficiency substantiates Complaint Number OH 277.

Based on review of nursing staffing schedules and staff interview, the facility failed to ensure eight consecutive hours of Registered Nurse (RN) coverage daily as required. This had the potential to affect all 27 residents currently residing in the facility. Findings include: Review of the facility staffing schedules revealed no RN had been scheduled to work on the following dates, 04/27/19, 04/28/19, 04/29/19, 04/30/19, 05/02/19, 05/04/19, 05/11/19, 05/12/19, 05/25/19, 05/26/19, 06/08/19, 06/09/19, 06/23/19, 06/23/19, 06/29/19, and 07/13/19. Interview on 07/18/19 at 11:30 A.M. with the Director of Nursing (DON) verified the facility did not have a RN working on the above dates.

Based on observation, staff interview and review of facility policy and procedure, the facility failed to properly store medications in the medication carts. This had the potential to affect all 27 residents receiving medications from the two medication carts. The census was 27. Findings include: An observation on 07/16/19 at 10:15 A.M. of medication cart #1 (storing the front hall residents medications) with Licensed Practical Nurse (LPN) #124 revealed a half white round pill with an 'M' on it, identified as [MEDICATION NAME] 25 milligrams (mg) in the medication cart drawer. At the time of the observation LPN #124 verified the loose pill in the medication cart. This cart stored the medications for Residents #2, #3, #4, #5, #6, #8, #10, #13, #14, #15, #17, #18, #20, #22, #25, #26, and #27. An observation on 07/16/19 at 10:30 A.M. of medication cart #2 (storing the back hall residents medications) with LPN #124 revealed a yellow round pill with the numbers 159 on one side, identified as [MEDICATION NAME] 15 mg, and a light green round pill with an 'H' on one side and 123 on the other side, identified as Ropinirole [MEDICATION NAME] 1 mg in the mediation cart drawer. At the time of the observation, LPN #124 verified the loose pills in the medication cart and indicated the Ropinirole pill did not look familiar to her. This cart stored the medications for Residents #1, #7, #9, #11, #12, #16, #19, #21, #23, and #24. A review of the policy and procedure titled, Storage and Expiration of Medications, Biologicals, Syringes and Needles, dated 10/31/16, revealed the facility should ensure that medication and biologicals for each resident are stored in the containers for which they were originally received.

Based on observation, staff interview, review of dietary menus, and review of facility policy the facility failed to ensure the facility menu was followed. This had to potential to affect 27 residents who received meals from the kitchen. The facility census was 27. Findings include: Review of facility dietary menu for 07/16/19 revealed the meal was to include meat loaf, mashed potatoes, cream corn and a fresh baked roll. Observation of the lunch meal service on 07/16/19 at 12:00 P.M. revealed no fresh baked rolls were served to any of the residents. Interview on 07/16/19 at 12:05 P.M. with Dietary Worker #114 stated the facility stopped ordering the dinner rolls due to there was not enough room in the freezer. Dietary Worker #114 stated the facility has not had dinner rolls for some time. Review of facility policy titled Menus undated, revealed menus shall be written in advance and followed. The Nutrition Professional shall be notified of any permanent menu alterations.

Based on medical record review, surveyor observations, staff interview and policy review, the facility failed to implement interventions to prevent one resident from sustaining a significant weight loss. This resulted in actual harm when one resident sustained [REDACTED]. This affected one (#10) of three residents reviewed for nutrition. The facility identified a total of three residents who have had a significant weight loss. Facility census was 16. Findings include: Review of Resident #10's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of Registered Dietitian (RD) #4's progress notes on 02/17/12, indicated Resident #10's PEG was placed on 02/09/12, due to dysphagia from status [REDACTED]. Another progress note written by RD #4 on 12/10/12, revealed Resident #10 was on a mechanical soft diet with oral intake of 25% at breakfast and 25-100% at dinner. Resident #10 was also receiving Glucerna Shake, a nutritional supplement, four ounces twice daily by mouth. Review of physician progress notes [REDACTED]. The physician stated the weight loss was somewhat concerning and documented the resident used to have a feeding tube, but had been discontinued. The resident's weight will be watched very closely. Review of physician progress notes [REDACTED]. The progress note revealed Resident #10 had significant weight loss at his last visit and felt that she did not appear to have lost more. Another progress note dated 05/01/13, stated we will definitely try to keep a close eye on Resident #10's weight. Review of a quarterly nutritional assessment completed on 04/15/13, by RD #4 stated the resident was not at high nutritional risk. RD #4 progress notes on 04/15/13 indicated oral intake ranged from refusal to 75% with five meal refusals over past week. The progress notes also indicated Resident #10 was orally consuming 50-100% of the nutritional supplement that was ordered four ounces twice daily. RD #4 noted the PEG tube remained in place and receives 100 milliliters of water flushes twice a day and if meal refusals continue may need to begin utilizing PEG tube for nutrition again. Further review of RD #4's progress note on 05/13/13, revealed Resident #10's current body weight was 104 pounds and was a 13.2% significant weight loss in one month of 15.8 pounds, 15.6% significant weight loss in three months of 19.2 pounds and 15.3% in six months of 18.8 pounds. RD#4 indicated the weight loss was due to poor appetite. She also noted oral intake was ranging from refusing to 25% of meals and noted seven meal refusals in the past week. RD #4 recommended to resume tube feed formula of goal rate of Glucerna 1.2 infusing at 45 milliliters every hour. She noted this goal rate would provide a total of 648 kilocalories, 32 grams of protein, and 1034 milliliters of free water. RD #4 indicated this would provide Resident #10 greater than 50% of nutritional needs. Review of plan of care for Resident #10 indicated she was at nutrition risk related to consumes less than 75% of diet, tube feeding, refusal to eat and needs assistance with meals. There was not an initial start date documented on the plan of care. On 04/15/13, the plan of care for nutrition risk was updated to indicate an increase in meal refusals. The plan of care was not updated on 05/13/13, when the significant weight loss occurred and did not reflect the new interventions made on 05/13/13. On 07/01/13, the plan of care for nutritional risk was updated to indicate refusing all meals/significant weight loss. The goals included for Resident #10 was for resident to consume at least 75% of meals and weight will not change significantly. Interventions on the plan of care for Resident #10 included to offer substitutes as requested; feed/assist with meals as needed; encourage to eat and drink; monitor weights; and monitor, document, and report to physician as needed when refusing to eat. Review of meal detail report for Resident #10, revealed she refused meals 15 times for breakfast, 17 times for lunch, and 6 times for dinner in the time frame of 04/01/13 through 05/13/13. Review of nurse's notes from 04/01/13 through 05/13/13, revealed there was no documentation of refusals to eat and physician notification was not documented per the interventions on the plan of care for Resident #10. Review of facility's form entitled "Notification Tracking", revealed no notification to physician of refusal to eat from 04/01/13 through 05/13/13. Review of Nutrition at Risk Resident Monitoring forms on 07/10/13 for Resident #10, revealed Resident #10 was on Nutrition at Risk program from 02/17/12 through 09/24/12 for risk criteria of new or unstable tube feedings and new admission. Resident #10 was restarted on Nutrition at Risk program on 05/13/13 for risk criteria of unplanned significant weight loss, poor oral intake and unstable medical condition expected to result in compromised nutritional status. Record review on weight recordings for Resident #10 on 07/11/13, revealed Resident #10 was weighed on 04/15/13 and 05/13/13. Weight records revealed no reweights were completed. Observation on 07/08/13 at 11:45 A.M., revealed Resident #10 was in the dining room for lunch. State tested Nursing Aide #15 (STNA) was sitting at a table with Resident #10. At 12:00 P.M., STNA #15 was observed feeding Resident #23. Resident #10 had her meal placed in front of her with the tray cover off. At 12:15 P.M., STNA #15 offered Resident #10 one bite of a food item and left the table. STNA #15 was not observed to offer Resident #10 another food item off her plate nor offered an alternate substitute before the tray was removed at 12:32 P.M., by STNA #15. Interview with STNA #15 on 07/08/13 at 12:32 P.M., revealed Resident #15 refused to eat. On 07/09/13 at 1:53 P.M., 2:52 P.M. and 3:44 P. M., revealed Resident #10 was observed in the activity room with Glucerna 1.2 hanging on the pole and the machine was turned off. Interview with Director of Nursing (DON) on 07/09/13 at 3:56 P.M., verified the tube feed was hung at 1:00 P.M. of 1000 milliliters (ml). She also verified that more than 900 milliliters was still in the bag. The DON indicated 40 ml was administered of the 1000 ml of the tube feed that was hung. The physician orders [REDACTED]. Observation of Resident #10 on 07/11/13 between 11:50 A.M. and 12:00 P.M., revealed the resident was observed to have a tray set in front of the resident with no cover and no staff member sitting with Resident #10. Interview with STNA #12 on 07/11/13 at 12:00 P.M., revealed Resident #10 refused the meal. Interview with RD #4 on 07/10/13 at 10:10 A.M., revealed she was aware of Resident #10's significant weight loss and restarted the tube feeding due to the weight loss. She stated the current goals for Resident #10 was to "eat a little bit for pleasure" and to gain weight. RD #4 indicated she observes meal intakes at each weekly visit at the facility and intervenes with residents depending on how many times a resident refuses a meal. RD #4 stated did not intervene with Resident #10 until 05/13/13, because prior to that date, Resident #10 was stable. Further interview revealed that if she documents to watch weight closely that she would initiate weekly weights. RD #4 stated glucerna shakes were discontinued on 05/13/13 due to the tube feedings were started. She indicated the Nutrition at Risk program was for residents that are new residents, wounds, poor oral intake and weight loss. She also stated Nutrition at Risk program consists of weekly meetings and every resident on the program was reviewed weekly and on weekly weights. RD #4 verified that there were no weekly weights for Resident #10. Interview with the DON on 07/10/13 at 10:30 A.M., stated Resident #10 was started on the Nutrition at Risk program on 05/13/13. The DON also stated the physician should be notified within 24 hours when a resident is refusing meals or if a resident has a significant change in condition. Additional interview with the DON on 07/11/13 at 11:30 A.M., stated Resident #10's weight was 103.6 pounds on 07/11/13. The last weekly weight recorded on 07/01/13 on the Nutrition at Risk program form for Resident #10 was 106 pounds. This indicates Resident #10 lost 2.2 pounds in one week or a 2.3% weight loss. Review of undated facility policy entitled, "Nutrition at Risk Program" indicates the nutrition assessment process includes the Nutrition Risk Assessment form with a risk scoring system to assist in identifying resident's at high risk. The policy indicates a score of 12 or greater utilizing this system indicates high risk. The policy further indicates additional criteria including residents who leave more than 50% of their food uneaten at most meals can be considered at high nutrition risk. Review of the undated facility policy entitled, "Weight Protocol" indicates all monthly weights shall be completed by the fifth of each month or per facility policy. The policy further states the dietary professional or designee shall determine which residents need to be reweighed.