Every finding on record at North County Center for Nursing and Rehabilitation

Based on observation, record review, and interview, the facility failed to ensure staff followed infection control practices between residents while administering medications for 3 (#9, 17, and #23) of 8 sampled residents reviewed for medication administration.The DON identified 43 residents were administered medications by facility staff.Findings:On 08/05/25 at 3:53 p.m. CMA #1 was observed going to their medication cart and preparing medications for Res #23. CMA #1 did not sanitize or wash their hands prior to preparing the medications. CMA #1 was then observed taking the plastic cup that contained Res #23's medication, hydrocodone/acetaminophen (pain medication) 7.5 mg / 325 mg tablet and handing it to Res. #23. Res #23 was observed placing the cup to their mouth and taking the medication. The resident was then observed returning the empty medication cup to CMA #1. On 08/05/25 at 3:57 p.m. CMA #1 was observed going to their medication cart and preparing medications for Res #17 directly after returning from administering medications to Res #23. CMA #1 did not sanitize or wash their hands prior to preparing medications. CMA #1 was then observed taking the plastic cup that contained Res #17's medications baclofen (muscle relaxant) 20 mg tablet, cyclobenzaprine (muscle relaxant) 10 gm tablet, and gabapentin (an anticonvulsant) 300 mg capsule and handing Res #17 the cup. CMA #1 assisted Res #17 take the medication into their mouth. On 08/05/25 at 4:05 p.m. CMA #1 was observed going to their medication cart and preparing medications for Res #9 directly after administering medications to Res #17. CMA #1 did not sanitize or wash hands prior to preparing the medication. CMA #1 was the observed preparing Res #9's medications guaifenesin (an expectorant) 100 mg / 5 mg syrup and sucralfate (a gastric protective agent) 1000 mg tablet. CMA #1 was then observed assisting the resident from the laying position to an upright position and then assisted the resident to place the medication into their mouth.A facility policy titled Infection Control Guidelines for All Nursing Procedures, dated 01/2008 read in part, Employees must wash their hands for ten (10) to fifteen (15) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions.e. After handling items potentially contaminated with blood, body fluids, or secretions;A facility policy titled Medication Administration,' dated 2022, showed staff members that administered medications to residents were to wash their hands prior to administering medications.A medication administration record for Res #9, dated 08/01/25 through 08/31/25, showed the resident had been ordered guaifenesin oral syrup 100 mg/ 5 ml at a dose of 20 ml to be taken by mouth every six hours and sucralfate 1000 mg tablet to be taken by mouth every six hours. A medication administration record for Res #17, dated 08/01/25 through 08/31/25, showed the resident had been ordered baclofen 20 mg tablet to be taken by mouth every six hours, cyclobenzaprine 10 mg tablet to be taken by mouth every six hours, and gabapentin 300 mg capsule to be taken every six hours.A medication administration record for Res #23, dated 08/01/25 through 08/31/25, showed the resident had been ordered hydrocodone/acetaminophen 7.5 mg / 325 mg tablet to be taken by mouth every eight hours.On 08/06/25 at 10:44 a.m., the DON stated that each CMA working at the facility had completed training regarding medication administration and infection control. They stated they were trained on hire and annually and knew to clean their hands between residents.

Based on record review and interview, the facility failed to ensure an antipsychotic medication was not prescribed for the diagnosis of dementia for 1 (#25) of 5 sampled residents reviewed for unnecessary medications.The DON identified five residents were prescribed antipsychotic medications.Findings:A facility policy titled Antipsychotic Medication Use, dated April 2007, read in part, Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective.A medication administration record for Res #25, dated 08/01/25 through 08/31/25, showed the resident had been prescribed Seroquel (an antipsychotic) 25mg tablets once in the morning and once at bedtime for unspecified dementia with unspecified severity, with other behavioral disturbances and anxiety. The record showed the resident had been administered the medication twice each day on 08/01/25, 08/02/25, 08/03/25, 08/04/25, and one dose on 08/05/25.On 08/05/25 at 11:49 a.m., CMA #3 was asked if they knew the reason Res #25 was being administered Seroquel. They stated the only behavior they were aware of was the resident would try to leave the facility and often say they needed to be somewhere.On 08/05/25 at 12:01 p.m., licensed practical nurse #1 was asked the reason Res #25 had been prescribed Seroquel. They stated they were prescribed the medication for dementia, behavioral disturbances, and anxiety. They stated the resident would often try to leave the facility stating they needed to go to work.On 08/05/25 at 12:16 p.m., the DON was asked the reason Res #25 was prescribed Seroquel. They stated the resident had been taking the medicine since admission for dementia with behaviors. The DON stated they were aware CMS did not approve the use of Seroquel as a treatment for dementia. They stated they would contact the physician about assigning an appropriate diagnosis for the medicine or ending its use.

Based on record review and interview, the facility failed to ensure an MDS discharge assessment record was transmitted in the required timeframe for 1 (#1) of 14 sampled residents reviewed for MDS assessments.The DON identified 44 residents required MDS assessments to be completed at the facility.Findings:A facility policy titled Electronic Transmission of the MDS, dated [DATE], read in part, All MDS assessments (eg. [for example], admission, annual, significant change, quarterly review, etc. [et cetera]) and discharge and reentry records will be completed and electronically encoded into our facility's MDS information system and transmitted to CMS' QIES [Quality Improvement and Evaluation System] Assessment Submission and Processing (ASAP) system in accordance with current OBRA [Omnibus Budget Reconciliation Act] regulations governing the transmission of MDS data.An undated Transfer/Discharge Report, for Res #1 showed the resident had been discharged from the facility on 03/01/25.On 08/05/25 at 10:33 a.m., the MDS section of Res #1's EMR was reviewed and showed an MDS discharge record, dated 03/01/25, had been completed, but not transmitted.On 08/05/25 at 10:36 a.m., MDS coordinator #1 was asked to describe their process regarding MDS assessments and records. They stated they put together the documents from various sources and assessments they perform. They stated the DON then signed them and the assessments were exported. They were asked to review the MDS section of Res #1's EMR and describe what they found. They stated the discharge records for Res #1 had been completed but not exported. They stated they had made an error by not exporting the document. They stated they understood the MDS process very well and that was an error on their part.On 08/05/25 at 10:58 a.m., the DON was asked to describe their part in the MDS process. They stated they reviewed and signed each MDS as they become due. They were shown Res #1's discharge records from 03/01/25 and asked to comment on what they saw. They stated the record had not been exported. They stated they had not been looking at reports regarding if MDS records had been exported or were incomplete. They stated they had minimal training in the MDS process.On 08/05/25 at 11:03 a.m., corporate nurse consultant #1 was asked about their role in the MDS process. They stated they had been on the job only a few days. They stated their plan for their part in the process was to randomly audit two medical records each week but, considering Res #1's discharge record they would reconsider the number and frequency of their audits.

On 03/12/25, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure residents were discharged with proper notice. On 03/06/25 Resident #1 returned to the facility after an overnight stay with family. Resident #1 was informed they were no longer a resident of the facility and were not allowed to return to the facility. On 03/12/25 at 5:57 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation related to a resident who was not allowed to return to the facility after an overnight stay with family. On 3/12/25 at 6:05 p.m., the DON and the corporate regional administrator were notified of the IJ situation and were asked to provide a plan of removal. On 03/13/25 at 2:35 p.m., an acceptable plan of removal was approved by the Oklahoma State Department of Health. The plan of removal, read in part, North County Immediate Jeopardy Plan of Removal for Failure to Ensure Residents Are Not discharged Without Proper Notice An Immediate Jeopardy has been identified at North County Nursing and Rehabilitation for failure to ensure residents are not discharged without proper notice. According to federal and state regulations, long-term care facilities are required to provide adequate notice to residents or their responsible parties before discharge. Failure to adhere to these guidelines has resulted in non-compliance and potential harm to 1 identified resident resulting in immediate jeopardy. Immediate Steps to Remove Immediate Jeopardy Immediate Review of Current Discharges .Conduct a comprehensive review of all discharges in the past 30 days to identify any residents who may not have received proper notice. Completed by 8:30 p.m. 03/12/2025 . Contact the residents or their responsible parties involved in improper discharges to confirm the lack of notice and address the issue immediately. Completed by 8:30 p.m. 03/12/2025 .Ensure that any affected residents are re-admitted to the facility, if appropriate, or assist them with alternative placement and proper notice. Completed by 8:30 p.m. 03/12/2025 .Review the facility's discharge policy and procedures to verify compliance with all applicable state and federal regulations. Completed by 8:30 p.m. 03/12/2025 Staff Education . Immediately in-serviced all administrative staff, social services, and floor nurse staff regarding the discharge process, emphasizing the legal requirements for proper notice. Completed by 2 p.m. 03/13/2025 .All involved staff will be required to complete the training within 24 hours of the identified Immediate Jeopardy. Completed by 2 p.m. 03/13/2025 Immediate Policy Revision .The facility's discharge policy will be reviewed, updated, and communicated to all administrative staff, social services, and floor nursing staff immediately. The revised policy will outline the following (Completed by 8:30 p.m. 03/12/2025): . The required notice period before discharge. .The process for ensuring residents or responsible parties receive the proper written notice. .A clear record-keeping system for discharge notices. .Steps to take when a discharge does not meet the notice requirements. .Social Services or designee will perform a 30- day follow up with discharge resident(s) or designee and provide referrals to additional resources if needed. Ongoing Monitoring and Audit Procedures .DON or designee will conduct an audit of all discharges 2 times per week for the next 4 weeks to ensure proper notice was given in accordance with regulatory requirements. Documentation will be checked for compliance with facility policies, and any discrepancies will be reported and investigated immediately. Completed by 4/12/2025 at 11:59. p.m. .Administrator or designee will audit once per week for the next 4 weeks to ensure compliance with state and federal regulations are met. Completed by 4/12/2025 at 11:59. p.m. .Designee will spot audit charts quarterly for all discharge documents completed and uploaded to the resident(s) electronic medical record. Ongoing Plan for Ongoing Compliance Continuous Staff Training .Ongoing training sessions will be scheduled annually to reinforce the importance of discharge procedures and to review any updates to policies or regulations. .The facility will ensure all new employees are trained on discharge procedures during their orientation. Ongoing Policy Review and Updates .The discharge policy will be reviewed annually, with input from relevant staff and regulatory updates, to ensure it remains compliant with all state and federal regulatory guidelines. Ongoing .Any necessary revisions will be implemented promptly, and all staff will be educated on the changes. Ongoing Leadership Accountability .Administrator and Director of Nursing will actively monitor and support the implementation of this plan, ensuring that discharge protocols are followed consistently. Ongoing On 03/13/25 at 2:00 p.m., the IJ was lifted when all components of the plan of removal had been verified as completed. Nine staff members from different departments from all shifts were interviewed regarding in-service provided for discharge protocol Documentation of the updated discharge policy and review of recently discharged residents were reviewed. The deficient practice remained at an isolated level with the potential for more than minimal harm. Based on record review and interview, the facility failed to ensure residents were discharged with proper notice for 1 (#1) of 3 sampled residents reviewed for discharge. The BOM identified 45 residents resided in the facility. Findings: Resident #1 had diagnoses which included anoxic brain damage, post traumatic stress syndrome, and bipolar disorder. A quarterly assessment, dated 01/28/25, showed Resident #1 had a brief interview for mental status score (a test for cognitive function) of 6, which was indicative of severe impairment for daily decision making, and that the resident was dependent on a wheelchair for ambulation. An undated Transfer and Discharge policy, read in part, Once admitted , the resident has the right to remain at the facility .The facility's transfer/discharge notice will be provided to the resident and resident's representative in a language and manner in which they can understand. The notice will include all of the following at the time it is provided: a. The specific reason and basis for transfer or discharge. b. The effective date of transfer or discharge. c. The specific location to which the resident is to be transferred or discharged . The facility sign out sheet showed Resident #1 signed out of the facility on 03/05/25 at 1:50 p.m. The sign in sheet showed the resident signed into the facility on [DATE] at 1:45 p.m. On 03/12/25 at 11:52 a.m., BOM #1 stated that on 03/05/25 Resident #1 had asked if they were allowed to leave the facility and stay with family overnight. They stated Resident #1 planned to take a ride sharing company from the facility and a family member would bring them back the next day. The BOM stated they told Resident #1 to go talk to their nurse, get their medications, and be sure and sign themselves out. On 03/12/25 at 12:23 p.m., the DON stated they were notified in their morning staff meeting on 03/06/25 Resident #1 had signed themselves out of the facility permanently the previous day. The DON stated they were present when the resident returned to the facility later on 03/06/25 and signed themselves into the facility. The DON stated when they told Resident #1 they had been informed by the administrator that they had left the facility permanently, the resident stated they had not. The DON stated they then called the administrator. On 03/12/25 at 2:05 p.m., police officer #1 stated they received a call from Resident #1's family member who requested a welfare check on the resident because the facility was not letting the resident return to the facility. Police Officer #1 stated the administrator told them Resident #1 had discharged themselves from the facility the day before. Police Officer #1 stated Resident #1 told them they had only left the facility for an overnight stay and were given 24 hours worth of medication for the overnight stay. Police Officer #1 stated they asked the administrator if the resident could check back into the facility. They stated the administrator refused to allow the resident to return to the facility. Police Officer #1 stated the resident said they had nowhere to go, that they had called and asked family and friends to let them stay with them for even a short while, but no one was willing to allow this. Police office #1 stated the administrator was aware that Resident #1 had nowhere to go, and paid for a one night stay at a hotel for Resident #1. Police Officer #1 stated they drove Resident #1 to the hotel. On 03/12/25 at 4:26 p.m., the regional corporate administrator stated if Resident #1 had not been discharged on 03/05/25, they should have been allowed to return to the facility. On 03/12/25 at 4:41 p.m. the DON stated they were unable to locate any discharge documents for Resident #1. On 03/17/25 at 9:38 a.m., certified medication aide #1 stated on 03/05/25, licensed practical nurse #1 instructed them to prepare 24 hours of medication for Resident #1 because Resident #1 was going on an overnight stay out of the facility. They stated Resident #1 seemed very excited to be going overnight with family, took possession of their 24 hour supply of medications, and told them they would be back the next day.

Based on record review and interview, the facility failed to ensure controlled medications were not misappropriated for three (#4, 7, and #8) of three sampled residents who were reviewed for misappropriation. The DON identified 42 residents who resided in the facility. Findings: The Controlled Substances policy, dated April 2019, read in part, .Controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift . The Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, dated April 2021, read in part, .Residents have the right to be free from .misappropriation of resident property . 1. Resident #4 had diagnoses which included abnormal posture and weakness. Form 283, incident date 06/10/24, read in parts, .DON was notified that LTC resident has a missing narcotic of Hydrocodone 5-325 mg tab qty of 60 are unaccounted for. Medication was delivered on 6/5/24 by pharmacy; the total quantity delivered was 112 tabs. #1 card of 52 tabs is in facility in the med cart. On 6/9/24 the nurse on duty contacted the MD for an order for the medication to be administered. An investigation has been initiated at facility level. APS and Local PD have been contacted .Part C .Investigation is on going at this time .Administration have implemented the charge nurse to oversee med cart counts and sign-off sheets during change of shifts. Administration pull pharmacy delivery manifestations to ensure narcotic medications delivered are accounted for on the cart. DON & CMA pulled extra controlled cards off the cart and logged in for double lock up. DON notified Attorney General on 06/12/24 .Facility investigation completed. Night shift CMAs, [CMA #1 and CMA #2] temporarily put on suspension pending further investigation but her unsubstantiated on both employees. No further evidence had been found. No further medication diversions have occurred [sic] since implementing charge nurse to oversee cart card counts. Clinical Admin staff are auditing the pharmacy delivery manifestations to ensure delivery and accounted mediations are in facility. Extra controlled cards are pulled and placed into double lock up until needed. DCS contacted AG agent on 6/21/24 for any new updates. Attorney General is pending a case # to begin investigation . 2. Resident #8 had diagnoses which included chronic pain. Form 283, incident date 06/12/24, read in parts, .DON was notified that resident medication of Hydrocodone 5-325 mg qty of 30 tabs is unaccounted for. Medication was delivered on 5/30/24 in the amount of 90. Card of 60 tabs are located on the med cart and currently being administered. DON has initiated investigation. Police Depart notified .APS notified .Part C .Investigation is ongoing at this time please see attachments. Administration have implemented the charge nurse to oversee med cart counts and sign-off sheets during change of shifts. Administration pull pharmacy delivery manifestations to ensure narcotic medications delivered are accounted for on the cart. DON & CMA pulled extra controlled cards off the cart and logged in for double lock up. DON notified Attorney General on 06/12/24 on incident .Facility investigation completed. Night shift CMAs, [CMA #1 and CMA #2] temporarily put on suspension pending further investigation but were unsubstantiated on both employees. No further evidence has been found. No further medication diversions have occurred [sic] since implementing charge nurse to oversee cart card counts. Clinical Admin staff are auditing the pharmacy delivery manifestations to ensure delivery and accounted medications are in facility. Extra controlled cards are pulled and placed in double lock up until needed .DCS contacted AG agent on 6/21/24 for any new updates. Attorney General is pending a case # to begin investigation . 3. Resident #7 had diagnoses which included cervical disc degeneration. Form 283, incident date 06/14/24, read in parts, .DON was notified that this resident did not have PRN Hydrocodone card on the cart. Staff notified pharmacy when they discovered a card of #60 tabs had been delivered in March 2024. Resident does not ask for PRN pain medication often. The last documented administration was 4/18/24. Resident has had four administrations per MAR so approximately #56 tabs are un-accounted for. Physician and pain management were notified for new prescription order .Part C .Facility investigation completed. Night shift CMAs, [CMA #1 and CMA #2] temporarily put on suspension pending further investigation but were unsubstantiated on both employees. No further evidence has been found. No further medication diversions have occurred [sic] since implementing charge nurse to oversee cart card counts. Clinical Admin staff are auditing the pharmacy delivery manifestations to ensure delivery and accounted medications are in facility. Extra controlled cards are pulled . Review of the Controlled Substance Card Count Sheet, dated 07/09/24 through 07/14/24, for D hall, revealed the following: a. the controlled medications had not been counted on 07/10/24 for the 3:00 p.m. to 11:00 p.m. or the 11:00 p.m. to 7:00 a.m. shift; b. the on-coming staff signature was blank three times out of 12 opportunities; c. the off-going staff signature was blank five times out of 12 opportunities; and d. the same employee signed as both the on-coming and off-going staff member, on 07/09/24 for the 11:00 p.m. to 7:00 a.m. shift, 07/10/24 for the 6:00 a.m. to 2:00 p.m. shift, 07/11/24 for the 6:00 a.m. to 2:00 p.m. shift, 07/12/24 for the 6:00 a.m. to 2:00 p.m. shift, 07/13/24 for the 7:00 a.m. to 2:30 p.m. shift, and 07/14/24 for the 7:00 a.m. to 11:00 p.m. shift. Review of the Controlled Substance Card Count Sheet, dated 07/15/24 through 07/18/24, for D hall, revealed the following: a. the controlled medications had not been counted on 07/15/24 for the 11:00 p.m. to 7:00 a.m. shift or on 07/18/24 for the 3:00 p.m. to 11:00 p.m. shift; b. the on-coming staff signature was blank one time out of eleven opportunities; c. the off-going staff signature was blank three times out of eleven opportunities; and d. the same employee signed as both the on-coming and off-going staff member, on 07/15/24 for the 7:00 a.m. to 3:00 p.m. shift and the 3:00 p.m. to 11:00 p.m. shift, 07/18/24 for the 6:00 a.m. to 2:00 p.m. shift and the 11:00 p.m. to 7:00 a.m. shift. Review of the Controlled Substance Card Count Sheet, dated 07/19/24 through 07/23/24, for D hall, revealed the following: a. the on-coming staff signature was blank two times out of thirteen opportunities; b. the off-going staff signature was blank two times out of thirteen opportunities; and c. the same employee signed as both the on-coming and off-going staff member, on 07/19/24 for the 7:00 a.m. to 3:00 p.m. shift and the 11:00 p.m. to 7:00 a.m. shift. Review of the Controlled Substance Card Count Sheet, dated 07/23/24 through 07/26/24, for D hall, revealed the following: a. the off-going staff signature was blank two times out of twelve opportunities; and b. the same employee signed as both the on-coming and off-going staff member, on 07/24/24 for the 7:00 a.m. to 3:00 p.m. shift and on 07/25/24 for the 11:00 p.m. to 7:00 a.m. shift. Review of the Controlled Substance Card Count Sheet, dated 07/10/24 through 07/15/24, for F hall, revealed the following: a. the controlled medications had not been counted on 07/10/24 for the 11:00 p.m. to 7:00 a.m. shift, on 07/11/24 on the 7:00 a.m. to 3:00 p.m. shift, or on 07/15/24 for the 7:00 a.m. to 3:00 p.m.; b. the on-coming staff signature was blank three times out of ten opportunities; and c. the off-going staff signature was blank five times out of ten opportunities. Review of the Controlled Substance Card Count Sheet, dated 07/16/24 through 07/19/24, for F hall, revealed the following: a. the controlled medications had not been counted on 07/18/24 for the 3:00 p.m. to 11:00 p.m. or the 11:00 p.m. to 7:00 a.m. shift; b. the on-coming staff signature was blank four times out of 11 opportunities; c. the off-going staff signature was blank four times out of 11 opportunities; and d. the same employee signed as both the on-coming and off-going staff member on 07/16/24 for the 7:00 a.m. to 3:00 p.m. shift and on 07/19/24 for the 5:00 p.m. to 11:00 p.m. Review of the Controlled Substance Card Count Sheet, dated 07/19/24 through 07/24/24, for F hall, revealed the following: a. the controlled medications had not been counted on 07/20/24 for the 3:00 p.m. to 11:00 p.m. shift; b. the on-coming staff signature was blank one time out of 13 opportunities; c. the off-going staff signature was blank two times out of 13 opportunities; and d. the same employee signed as both the on-coming and off-going staff member on 07/19/24 for the 11:00 p.m. to 7:00 a.m. shift and on 07/22/24 for the 3:00 p.m. to 11:00 p.m. shift. On 07/26/24 at 12:53 p.m., the DON stated they had first been made aware of misappropriation of medications when staff reported on 06/09/24 that Resident #10 had a missing card of medications. They stated they counted the medication carts and found no further discrepancies on 06/09/24. The DON stated the consultant pharmacist had reconciled all controlled medications in the facility on 06/10/24 and had not identified any discrepancies. They stated after the pharmacist had reconciled they had been informed by staff Resident #4 was missing controlled medication. The DON stated they reviewed pharmacy delivery manifestations, narcotic records, and medication administration records. They stated during the investigation they had discovered on 06/12/24 Resident #8 was missing controlled medication and on 06/14/24 Resident #7 was missing controlled medication. Upon discovery of the medication misappropriation, the DON stated they inserviced staff about pharmacy and controlled drug procedures, all drug delivery receipts were given to the MDS coordinator to verify the medication on the medication carts, two CMAs were suspended pending investigation, they changed from a three ringed binder for the narcotic record to a bound hard back narcotic book, the charge nurses verified the end of shift controlled medication counting with the CMAs, the facility replaced the missing medications, and any extra cards of controlled medications were locked in the DONs office under double locks. The DON stated when staff needed the card of medication that was locked in their office the CMA and DON signed it out and reconciled the medication together. They stated they reported the misappropriation of medication to the police department, the state agency, and the Attorney General. On 07/26/24 at 2:20 p.m., the DON stated they had the misappropriation on the agenda for the next QA meeting in the coming week. They stated no further medication misappropriation had been identified since 06/14/24. On 07/26/24 at 4:03 p.m., the Controlled Substance Card Count Sheets were reviewed with the DON. They stated they had not been monitoring to ensure staff were reconciling controlled medications at the end of each shift. The DON stated they had the nurses verifying the counts during the investigations and needed to implement that intervention again to ensure compliance. On 07/26/24 at 4:33 p.m., the Controlled Substance Card Count Sheets were reviewed with the administrator. They stated the DON was responsible to monitor to ensure residents were free from medication misappropriation by reviewing the count sheets. The administrator stated the charge nurses needed to verify the reconciliation of controlled medications at the end of each shift again.

Based on record review and interview the facility failed to complete required nurse aide yearly performance reviews for two (CNA #2 and CNA #4 ) whose employee files were reviewed for competencies. The DON identified 13 nurse aides currently employed by the facility. Findings: The employee file for CNA #2 documented the last skills performance was completed on 09/22/22. The employee file for CNA #4 documented the last skills performance was completed on 09/22/22. On 04/04/24 at 11:34 a.m., the DON reviewed the skills performance checklists provided for two CNAs currently working for the facility. The DON stated to their knowledge no skills performance checks had been completed for the year 2023 for current CNAs. The DON stated they were not aware of the requirement.

Based on record review and interview, the facility failed to complete a baseline care plan for three (#31, 45, and #246) of 12 residents whose care plans were reviewed. The DON identified 41 residents who resided in the facility. Findings: 1. Res #31 had diagnoses which included osteomyelitis, stage four pressure ulcer to the left heel, a stage three pressure ulcer to the right heel, diabetes, hypertension, and anxiety. Res #31 was admitted to the facility on [DATE]. The care plan, dated 01/04/24, documented a baseline care plan had been completed six days after admission. On 04/03/24 at 9:19 a.m., the care plan coordinator reviewed the resident's care plan and stated the baseline care plan was completed late. The coordinator stated they completed the baseline care plan upon returning to work. 34945 2. Res #45 was admitted on [DATE] with diagnoses which included non-traumatic intracranial hemorrhage, hypertension, and dementia. The resident's EHR documented a baseline care plan which had been initiated on 02/13/24 which was four days after admission to the facility. On 04/02/24 at 9:25 a.m., MDS coordinator #1 stated the baseline care plan should have been completed within 48 hours of admission. The MDS coordinator stated the admission may have taken place over a weekend and the baseline care plan was not initiated until the care plan staff member returned to work the following week. They stated any nurse could initiate a baseline care plan but it was always completed by the MDS/Care plan staff nurse. 46909 3. Res #246 had diagnoses which included congestive heart failure, dementia, psychotic disturbance, mood disturbance, anxiety, hypertension, and pain syndrome. Res #246 was admitted to the facility on [DATE]. There was not documentation of a baseline care plan in the EHR. On 04/03/24 at 1:40 p.m., the MDS stated the other person helping with the baseline care plans so they have been helping but have fallen behind and did not complete a baseline care plan.

Based on observation, record review, and interview, the facility failed to develop a comprehensive care plan to include the use of bed rails for four (#16, 23, 146, and #246) of four sampled residents reviewed for accident hazards. The DON stated 17 residents at the facility used bed rails. Findings: A policy, titled Care Plans, Comprehensive Person-Centered, dated 03/2022, read in part The comprehensive, person-centered care plan .described the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .and reflects currently recognized standards of practice for problem areas and conditions. 1. Resident #16 had diagnoses which included primary osteoarthritis. A physician's order, dated 11/21/23, documented the resident was allowed to use therapeutic devices as needed to assist with positioning changes. On 04/03/24 at 12:40 p.m., Resident #16 was observed to have an assist bar attached to the left side of their bed. A review of the Resident #16's care plan found the assist bar attached to the resident's bed had not been care planned until 04/02/24. 2. Resident #23 had diagnoses which included multiple sclerosis and generalized muscle weakness. A physician's order, dated 07/25/23, documented the resident was allowed to use therapeutic devices as needed to assist with positioning changes. On 04/01/24 at 8:36 a.m., Resident #23 was observed to have half size bed rails on each side of their bed. The resident stated they had the side rails on their bed since they were admitted on [DATE]. A review of Resident #23's care plan found the two bed side rails had not been care planned until 04/02/24. 3. Resident #146 had diagnoses which included broken internal joint prosthesis. An undated admission record documented the resident was admitted to the facility on [DATE]. A physician's order, dated 01/30/24, documented the resident was allowed to use therapeutic devices as needed to assist with positioning changes. On 04/03/24 at 12:39 p.m., Resident #146 was observed to have side rails attached to the bed they were using. They stated the side rails had been there since they were admitted . A review of Resident #146's care plan found the two bed side rails had not been care planned until 04/03/24. 04/04/24 12:51 p.m., the DON stated the bed side rails had not been care planned for residents #16, 23, and #146 in a timely manner or in accordance with facility policy. 4. Res #246 had diagnoses which included congestive heart failure, dementia, psychotic disturbance, mood disturbance, anxiety, hypertension, and pain syndrome. Res #246 was admitted to the facility on [DATE]. There was not documentation of a comprehensive care plan was available. On 04/03/24 at 1:40 p.m., the MDS stated the other person helping with the assessments and care plans has been out so they helping and have fallen behind with those care plans. They also stated that the comprehensive care plan is complete now.

Based on observation, record review, and interview, the facility failed to attempt alternative interventions prior to the use of bed side rails for three (#16, 23, and #146) of three sampled residents reviewed for accident hazards and failed to assess resident's risk of entrapment prior to use of bed side rails for two (#16 and #146) of three sampled resident reviewed for accident hazards. The DON stated 17 residents at the facility used bed rails. Findings: A policy titled, Bed Safety and Bed Rails, dated 08/2022, read in part, Prior to the installation or use of a side or bed rail, alternatives to the use of side of bed rails are attempted. The policy also documented that after alternatives were concluded to be ineffective the resident would be assessed for their risk associated with the use of bed side rails. 1. Resident #16 had diagnoses which included chronic pain and primary osteoarthritis. An MDS quarterly assessment, dated 02/27/24, documented the resident's cognition was severly impaired. A review of the resident's chart did not find documentation of the attempt to use alternative interventions to the use of bed rails or documentation of a risk assessment performed prior to use of a bed rail. On 04/03/24 at 12:40 p.m., Resident #16 was observed to have an assist bar attached to the left side of their bed. 2. Resident #23 had diagnoses which included multiple sclerosis and generalized muscle weakness. An MDS quarterly assessment, dated 01/30/24, documented the resident's cognition was intact. A review of the resident's chart did not find documentation of the attempt to use alternative interventions to the use of bed rails. On 04/01/24 at 8:36 a.m., Resident #23 was observed to have half size bed rails on each side of their bed. On 04/03/24 at 8:45 a.m., Resident #23 stated they stated no alternative interventions were attempted prior to the use of the side rails. 3. Resident #146 had diagnoses which included a broken internal joint prosthesis. A MDS five day scheduled assessment, dated 02/24/24, documented the resident's cognition was intact. A review of the resident's chart did not find documentation of attempts to use alternative interventions to bed rails or documentation of a risk assessment performed prior to use of bed rails. On 04/03/24 at 10:31 a.m. the DON stated alternative interventions to the bed rails had not been attempted for residents #16, 23, or #146 prior to their use. At 12:39 PM - Resident #146 was observed to have bed side rails attached on each side of their bed. The resident stated they did not use alternatives to the bed rails prior to their use and did not recall a risk assessment being done before using the bed rails. At 12:51 p.m., the DON stated risk assessments had not been performed on residents #16 and #146 prior to use of bed side rails. They stated the facility staff had not been following policy at it related to the use of bed side rails.

Based on observation, record review, and interview, the facility failed to maintain an infection prevention and control program to prevent the transmission of infections: a) for resident #10 during catheter care, b) for resident #21 during incontinent care, and c) implement a water treatment program for the prevention of Legionella. The administrator identifed five residents with a catheter/receive incontinent care. Findings: A handwashing/hand hygiene policy documented .2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 3. Hand hygiene products and supplies (sinks, soap, towels, alcohol-based had rub, etc.) shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies . A policy titled Catheter Care, Urinary documented .Steps in the Procedure .2. Wash and dry your hands thoroughly .5. Put on gloves .11. With non-dominant hand .retract the foreskin of the uncircumcised male resident. Maintain the position of this hand throughout the procedure .18. Discard disposable items into designated containers. Remove gloves and discard into designated container. Wash and dry hands thoroughly . 1. Res #10 had diagnoses which included a stage four pressure ulcer to the sacral region and the lower back, a stage three pressure ulcer to the right heel, and diabetes. A care plan, dated 12/21/23, documented the staff was to wear a gown and gloves while providing care to enhance barrier protection due to a multi-drug resistant organism in the resident's wound to reduce the potential to spread bacteria to other sites of my body or to other people. A physician order, dated 02/20/24, documented the staff was to change the resident's catheter every 30 days for infection control. A quarterly assessment, dated 02/23/24, documented the resident was moderately impaired for daily decision making and had a catheter. A physician order, dated 03/07/24, documented the staff was to provide catheter care every morning and at bedtime. On 04/03/24 at 1:50 p.m., a sign was observed posted by the resident's door. The sign documented .ENHANCED BARRIER PRECAUTIONS EVERYONE MUST: Clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Wear gloves and a gown for the following High-Contact Resident Care Activities .Changing briefs or assisting with toileting, Device care or use: central line, urinary catheter, feeding tube, . CNA #1 entered the resident's room, donned a pair of gloves, and began repositioning the resident from side to side and reaching across the resident to remove a soiled incontinent brief. The CNA was not wearing a gown. Wearing the same gloved hands the CNA obtained some adult wipes from a packet and continued to clean the resident. The staff changed their gloves three more times during the cleaning process the process. The staff did not wash their hands with glove changes. The staff stated they would wash their hands after care was completed. On 04/03/24 at 3:15 p.m., the DON was interviewed regarding catheter care for the resident. The DON stated the CNA should have used PPE identified on the sign posted at the door. The DON stated the CNA should have changed their gloves and washed their hands when moving from a dirty area to a clean area and between task. 2. Res #21 had diagnoses which included hemiplegia and hemiparesis following a cerebral infarction and mixes incontinence. The care plan, dated 03/31/23, documented the resident was incontinent of bowel and bladder. A quarterly assessment, dated 01/04/24, documented the resident was incontinent of bowel and bladder. The assessment documented the resident required partial/moderate assist with toileting. On 04/04/24 at 10:15 a.m., the resident was lying in bed with their call light activated. The resident stated they had been incontinent of bowel and had activated their call light to be cleaned up. CNA #2 entered the resident's room and donned a pair of gloves. The CNA positioned the resident in bed, removed the soiled undergarment, and cleaned the resident's buttock with adult wipes. Using the same gloved hands the CNA placed a clean undergarment on the resident, assisted the resident with dressing, and assisted the resident to their wheelchair. The CNA removed their gloves and washed their hands. On 04/04/24 at 10:37 a.m., CNA #2 stated they should have changed their gloves and washed their hands when they finished incontinent care and before placing a new adult brief on the resident. The CNA stated they did not change their gloves and wash their hands during care. 34945 3. On 04/03/24 at 9:40 a.m., the Administrator stated they had received the new water management program from the corporation when they bought this facility during the previous year. The administrator stated the program had not been instituted as yet. The administrator stated they were going to ask the city who tested the water. When asked the facility did anything to prevent standing water and they stated the management team flushed the toilets in unoccupied rooms when during daily rounds. The administrator was asked for documentation of this and stated there was not documentation of the rounds. The administrator was asked if they had followed the new policy and conducted a risk assessment of the facility. The administrator stated not yet. The administrator was asked if a water management team had been assembled to meet and identify issues and possible responses for identified issues, they stated they had not formed a team. The administrator stated the only thing that he had done was to contact the city to determine who can test the water. The administrator was asked to review the water management program and they stated they had not started the program. At that time, the maintenance supervisor stated they ran water in all the unoccupied rooms and the air conditioners had pipes to drain the condensation from under the units. The maintenance supervision stated they did not have a schematic for the piping in the facility and had not conducted an assessment of the facility to identify areas of potential areas where standing water could have been a problem.

Based on record review and interview the facility failed to complete a quarterly assessment within the required time frame two (#14 and #32) of 13 residents whose assessments were reviewed. The administrator identified 41 residents who currently resided in the facility. Findings: 1. Res #32 had diagnoses which included respiratory failure, congestive heart failure, and cerebrovascular disease. The EHR documented a quarterly assessment, dated 12/15/23, had been completed for the resident. The EHR documented a quarterly assessment, dated 03/15/24, was still in progress. On 04/03/24 at 11:54 a.m., the MDS coordinator reviewed the resident's EHR and stated the quarterly assessment dated [DATE] was not completed and should have been. The staff stated the facility was behind on completion of required MDS assessments. 34945 2. Res #14 had diagnoses which included dementia, schizoaffective disorder, and auditory hallucinations. A quarterly MDS assessment, with an ARD date of 03/12/24, documented in progress on the MDS page of the EHR. On 04/02/24 at 3:13 p.m., MDS coordinator #1 stated the quarterly assessment, dated 03/12/24, had not been completed and submitted on time.

Based on observation, record review, and interview, the facility failed to maintain an ice machine in a sanitary condition. The DON stated all 44 residents received ice from the ice machines. Findings: The facility's Sanitation policy, dated 11/2022, read in part, The food service area is maintained in a clean and sanitary manner. On 04/03/24 at 11:13 a.m., the DM wiped the inside of a ice machine located in a employee only hallway next to the kitchen. The cloth came back with a black substance covering it. The DM stated the ice machine provided ice to the residents. The DM stated the ice machine was cleaned once every six month. At 11:42 a.m., the administrator stated the ice machines were cleaned every six months and they would provide documentation of those cleanings. The administrator offered two invoice for inspection and cleaning of two ice machines, dated 12/29/23 and 01/31/24. They did not have any other documentation. On 04/04/24 at 8:05 a.m., the DM stated they had turned off the ice machine that was found to be dirty and the second had not been working for several weeks and was due for repair. They stated the contractor that would clean the dirty machine was due to come to the facility that day or the next. They stated they would purchase ice from a local vendor until theirs is clean. The stated they do not monitor the ice machines for cleanliness on a schedule and do not document inspection of the ice machines. They stated the machines were scheduled to be cleaned every six months.

Based on observation, record review, and interview the facility failed to ensure residents' nutritional issues were supervised by a physician for one (#34) of two residents sampled for weight loss. The DON identified 41 residents who resided in the facility. Findings: Res #34 was admitted to the facility with diagnoses of tremors, anxiety disorder, weakness, abnormality of gait and mobility, and multiple sclerosis. On 04/19/23 the care plan documents offer supplements or alternates if resident east less than 50% of meals served, or refuses meals. An EHR entry, dated 01/02/24, documented Res #34 had a weight of 145.2 lbs. On 01/26/24 at 07:00 a.m., a dietary order documents, house supplement every day shift for weight loss. An EHR entry, dated 02/04/24, documented Res #34 had a weight of 137.4 lb., a weight loss of 7.8 lbs. A significant change assessment, dated 03/08/24, documented the resident was moderately impaired with cognition and was dependent with all ADLs. The assessment documented the resident had experienced a significant weight loss. On 04/01/24 at 08: 40 a.m., the resident was observed in the dining room eating chocolate ice cream with not supplement offered to resident. On 04/01/24 at 11:23 a.m., the resident was observed in the dining room eating cheescake with no supplement offered to resident. On 04/04/24 at 12:16 p.m., the MDS Coordinator stated the physician was not notified of any significant weight loss on the resident.

Based on observation, record review, and interview, the facility failed to ensure the physician was notified of significant weight loss and failed to implement interventions to maintain and/or prevent further weight loss for one (#34) of two sampled resident reviewed for weight loss. The DON identified 41 residents who resided in the facility. Findings: Res #34 was admitted to the facility with diagnoses of tremors, anxiety disorder, weakness, abnormality of gait and mobility, and multiple sclerosis. On 04/19/23 the care plan documents offer supplements or alternates if resident east less than 50% of meals served, or refuses meals. An EHR entry, dated 01/02/24, documented Res #34 had a weight of 145.2 lbs. On 01/26/24 at 07:00 a.m., a dietary order documents, house supplement every day shift for weight loss. An EHR entry, dated 02/04/24, documented Res #34 had a weight of 137.4 lb., a weight loss of 7.8 lbs. A significant change assessment, dated 03/08/24, documented the resident was moderately impaired with cognition and was dependent with all ADLs. The assessment documented the resident had experienced a significant weight loss. On 04/01/24 at 08: 40 a.m., the resident was observed in the dining room eating chocolate ice cream with not supplement offered to resident. On 04/01/24 at 11:23 a.m., the resident was observed in the dining room eating cheesecake with no supplement offered to resident. On 04/04/24 at 12:16 p.m., the MDS Coordinator stated the physician was not notified of any significant weight loss on the resident.

Based on observation, record review, and interview, the facility failed to conduct regular inspections of resident beds and failed to inspect resident beds for safety prior to the attachment and use of bedrails for three (#16, 23, and #146) of three sampled residents reviewed for accident hazards. The DON stated 17 residents at the facility used bed rails. A Resident Listing Report, dated 04/01/24 documented 44 resident resided at the facility. Findings: A policy titled, Bed Safety and Bed Rails, dated 08/2022, read in part, Bed frames, mattresses and bed rails are checked for compatibility and size prior to use. The policy also read Maintenance staff routinely inspect all beds and related equipment to identify risks and problems including potential entrapment risks. 1. Resident #16 had diagnoses which included chronic pain and primary osteoarthritis. An undated admission record documented the resident was admitted to the facility on [DATE]. A physician's order, dated 11/21/23, documented the resident was allowed to use therapeutic devices as needed to assist with positioning changes. An MDS quarterly assessment, dated 02/27/24, documented the resident's cognition was severely impaired. On 04/03/24 at 12:40 p.m., Resident #16 was observed to have an assist bar attached to the left side of their bed. 2. Resident #23 had diagnoses which included multiple sclerosis and generalized muscle weakness. An undated admission record documented the resident was admitted to the facility on [DATE]. A physician's order, dated 07/25/23, documented the resident was allowed to use therapeutic devices as needed to assist with positioning changes. An MDS quarterly assessment, dated 01/30/24, documented the resident's cognition was intact. On 04/01/24 at 8:36 a.m., Resident #23 was observed to have half size bed rails on each side of their bed. On 04/03/24 at 8:45 a.m., Resident #23 stated they were unaware of any safety assessment or inspections regarding their bed of the use of bed rails prior to the use of their bed. 3. Resident #146 had diagnoses which included broken internal joint prosthesis and infection following surgery. An undated admission record documented the resident was admitted to the facility on [DATE]. A physician's order, dated 01/30/24, documented the resident was allowed to use therapeutic devices as needed to assist with positioning changes. A MDS five day scheduled assessment, dated 02/24/24, documented the resident's cognition was intact. On 04/03/24 at 12:39 p.m., Resident #146 was observed to have side rails attached to the bed they were using. They stated they did not recall and assessments or inspections regarding their bed and bed rails prior to their use of the bed. On 04/04/24 at 8:21 a.m., the Maintenance Supervisor stated they had not been informed the beds required routine inspections or that bed rails required an inspection prior to use. They stated they had not done either. They stated they were unaware of any documentation of routine inspections having been done in the past. At 12:51 p.m., the DON stated they had not been following policy regarding inspections of the beds and bed rails but would do so in the future.

Based on observation, record review, and interview, the facility failed to ensure assessments were encoded and submitted to CMS within seven days of completion of the assessment for one (#16) of 13 residents whose assessments were reviewed. The administrator stated 41 residents were residing in the facility. Findings: Res #16 had diagnoses which included urinary tract infection and cellulitis. The resident's EHR documented a quarterly assessment had been completed on 02/27/24. The EHR documented the facility submitted the assessment on 04/03/24 during the survey. On 04/02/24 at 9:50 a.m., Res #16 was observed in a manual wheelchair moving toward their room. The resident stated they had been receiving an antibiotic for cellulitis in their right leg but did not think they were taking it anymore. On 04/03/24 at 11:59 a.m., MDS coordinator #1 stated someone at the corporate offices had submitted the assessment that morning. They stated the person who submitted the MDS assessment was offsite and not available for interview. The MDS coordinator stated they did not know why this assessment had not been submitted within seven days from completion of the assessment.

Based on record review and interview, the facility failed to ensure an admission assessment for residents were completed within the required timeframe for one (#246) of 13 residents whose assessments were reviewed. The DON identified 41 residents who resided in the facility. Findings: Res #246 had diagnoses which included congestive heart failure, dementia, psychotic disturbance, mood disturbance, anxiety, hypertension, and pain syndrome. Res #246 was admitted to the facility on [DATE]. The EHR did not document an admission assessment had been completed. On 04/03/24 at 1:40 p.m., MDS coordinator #1 stated the staff nurse assigned to complete the MDS assessments had been out for a family emergency. MDS coordinator #1 stated they have been doing all the assessment and had fallen behind.

Based on record review and interview, the facility failed to ensure residents were offered the choice to formulate advanced directives for two (#4 and #7) of two sampled residents reviewed for advanced directives. The DON identified 41 residents resided in the facility. Findings: 1. Res #4 had diagnoses which included chronic kidney disease - stage 3, type 2 diabetes mellitus with diabetic neuropathy, and chronic respiratory failure with hypoxia. The resident's clinical records did not document the resident and/or their representative was offered the choice to formulate an advanced directive. 2. Res #7 had diagnoses which included embolism and thrombosis of unspecified vein, edema, hypokalemia, and cerebral fluid drainage. The resident's clinical records did not document resident and/or their representative were offered the choice to formulate an advanced directive. On 04/01/24 at 10:46 a.m., the social service director stated the facility would starting scanning all advanced directives offered to the resident and/or representative whether they were accepted or refused to show they were offered to them upon admission.

Based on record review and interview, the facility failed to develop a discharge summary including a recapitulation of the resident's stay, a reconciliation of the resident's medications, and a post discharge plan of care, for one (#44) of two residents reviewed for discharge from the facility. The DON identified 41 residents who resided in the facility. Findings: Res #44 had diagnoses which included fracture of the shaft of the right fibula, orthopedic after care, osteoarthritis, chronic stage four kidney disease, and diabetes. An admission assessment, dated 12/28/23, documented the resident was intact in cognition. A discharge, return not anticipated, assessment, dated 01/10/24, was documented in the resident's EHR. A social service note, dated 01/10/24, documented Res #14 was discharged from the facility to be admitted to another facility in a different state and would have been transported by a family member. The note documented the new facility had been contacted and were ready to admit the resident. On 04/02/24 at 11:00 a.m., MDS coordinator #1 stated the discharge summary would have been documented in the nursing notes. The MDS coordinator was asked to review the resident's notes. The MDS coordinator stated the notes did not document a discharge summary and did not have a summary of the resident's stay, what interventions the resident had while in the facility and a reconciliation of the resident's medications.

Based on observation, record review, and interview, the facility failed to ensure physician orders were followed in relation to wound care for one (# 7) of three residents reviewed for wound care. The administrator reported the census was 41. Findings: An undated facility policy titled Wound Care read in part, .The purpose of this procedure is to provide guidelines for the care of wounds to promote healing .Verify that there is a physician's order for this procedure .Report other information in accordance with facility policy and professional standards of practice . Resident #7 had diagnoses which included a pressure ulcer of the sacral region and diabetes mellitus. An admission assessment, dated 11/24/23, documented Resident #7 was cognitively intact and was dependent on staff for transfer. A physician order, dated 02/20/24, documented the sacral wound was to be cleaned with normal saline and a wound vac was to be applied. A Wound Evaluation and Management Summary, dated 03/14/24, documented the wound vac on the sacral wound was to be discontinued and the wound was to be covered with an abdominal pad and gauze. On 03/26/24 at 10:11 a.m., Resident #7 was observed in their room, the wound vac was at the bedside but did not appear to be on. On 03/26/24 at 10:11 a.m., Resident #7 stated that the wound vac had been off since Saturday. The resident stated the nurse working Saturday was unfamiliar with wound vacs and the nurse reported to Resident #7 they would get the other nurse to assist, but never returned. On 03/26/24 at 12:45 p.m., LPN #1 stated that sometimes the wound vac comes off or gets soiled and has to be removed and the nurse on duty is not able to put it back on. LPN #1 also stated they were not sure if the wound vac was supposed to have been discontinued on 03/14/24. They further stated they would contact the wound physician for clarification. On 03/26/24 at 1:30 p.m., the DON stated the nurse that accompanied the wound physician was responsible for putting orders into the resident's medical record. On 03/27/24 at 10:51 a.m., CNA #1 stated that they had provided care for Resident #7 on 03/26/24 and the wound vac had not been in place all day. They also stated that the wound vac came off all the time. On 03/27/24 at 11:35 a.m., the DON stated the charge nurses were responsible for ensuring the wound vac was in place and functioning properly. They also stated that the wound vac had not been discontinued until 03/26/24.

Based on record review, observation, and interview, the facility failed to initiate fall interventions, to reduce the risk of a fall with major injury, for one (#23) of five residents sampled for falls. The Resident Census and Condition of Residents, form documented 39 residents resided in the facility. Findings: A Fall Prevention Program policy, dated 2022, documented in parts, .Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls .The nurse will indicate on the (specify location) the resident's fall risk and initiate interventions on the resident's baseline care plan, in accordance with the resident's level of risk .Each resident's risk factors and environmental hazards will be evaluated when developing the resident's comprehensive plan of care .interventions will be monitored for effectiveness . The plan of care will be revised as needed .When any resident experiences a fall, the facility will .document all assessments and actions . Resident #23 had diagnoses which included traumatic subdural hemorrhage without loss of consciousness and a history of cerebral infarction An Significant Change MDS Assessment, dated 10/26/22, documented the resident did not require a mobility device and was independent with transfers and locomotion. A Care Plan for resident #23, dated 12/30/22, documented the resident had a fall and hit their head. The care plan documented a history of falls, with the most recent fall being August 2022, prior to the current fall on 12/30/22. The care plan documented neuro checks were initiated with 72 hour routine monitoring, to include complaints of pain, new bruises, change in mental status, and vital signs. There was no documentation of new fall interventions initiated for this fall. A Nurse Note, dated 12/30/22 at 1:40 p.m., documented the resident had a fall and hit his head on the wall. The note documented the resident stated, I went to grab the rail in the hallway with my hand and wasn't close enough so I couldn't reach it and fell and hit my head on the wall. The note documented vital signs were obtained and the resident was assisted from the floor. The note documented the resident complained of being dizzy while being assisted from the floor. An Incident Report, dated 12/30/22 at 1:40 p.m., documented resident #23 had a fall and hit their head. The report indicated the resident went to grab the rail in the hallway and was not close enough to reach the rail. The resident fell and hit their head. The report documented neuro checks were started, vital signs were obtained, and the resident was assessed and assisted from the floor. The physician was notified and neuro checks started. There were no new fall interventions documented on the incident report. The Incident Report, dated 12/30/22, had not incuded a root cause to determine the cause of dizziness and the report had not included interventions. A facility Post Fall 72 Hour Monitoring Report, dated 12/30/22 through 01/02/23, documented neuro checks were completed. The report contained no documentation related to monitoring for dizziness. A Fall Risk Assessment for resident #23, dated 12/30/22, documented the resident had a fall score of 7, indicating the resident was a moderate fall risk. An Incident Report, dated 01/02/23 at 10:35 a.m., documented the resident had a witnessed fall in the dining room. The report documeted the resident stated their knee gave out. The resident was assessed for injury, vital signs taken, and assisted from the floor. The report documented there were no new interventions initiated. There was no documentation to indicate a follow up root cause analysis was completed by staff to determine the cause of the fall. A Nurse Note, dated 01/02/23 at 11:03 a.m., documented a CMA witnessed resident #23 walking into the dining room. The CMA reported the resident began to lean forward and was unable to regain their balance and fell landing on their hands and knees. The note documented the resident denied hitting their head and witnesses also reported the resident did not hit their head. There was no injury documented related to this fall. There were no documented interventions after this fall. An Incident Report, dated 01/02/23 at 5:06 p.m., documented resident #23 had a witnessed fall in the dining room. The report documented the resident stated they were dizzy and fell . The resident was assessed, vital signs obtained, and a laceration was noted above the left eye with hematoma noted under the left eye. The resident was sent to the emergency room for evaluation and treatment. The Incident Report, dated 01/02/23, did not incuded a root cause to determine the cause of the fall and the report did not included interventions. A Nurse Note, dated 01/02/23 at 5:20 p.m., documented resident #23 was witnessed falling in the dining room where the resident hit their head. The resident reported feeling dizzy and losing their balance. The resident was assessed, vital signs were obtained, and a laceration was noted above the left eye with hematoma noted under the left eye. The resident was sent to the emergency room . A hospital record History of Present Illness, admitted [DATE], documented the resident had a syncopal episode, falling and hitting their head. The record documented the resident sustained a left superorbital laceration and skin tear to left elbow from falling. The record documented a CT scan of the resident's head was obtained and documented a left frontotemporoparietal subdural hemorrhage with 5 mm of left-to-right midline shift. The physician was consulted and recommended ICU admission for close monitoring and frequent neuro checks. and repeat CT scan in 6 hours. A follow up to the investigation of the incident, dated 01/04/23, documented the IDT met and discussed the resident's recent multiple falls. The resident was still in the hospital at that time. The IDT team addressed the resident's dizziness and impaired balance with falls. The IDT team planned to request hospital records and evaluate for appropriate interventions upon the resident's return from the hospital. A Significant Change MDS Assessment, dated 01/12/23, documented the resident was cognitively intact. The assessment documented the resident required mobility devices of a walker or wheelchair. On 02/21/23 at 1:33 p.m., resident #23 was interviewed and reported having a fall a couple of weeks ago. The resident stated they were walking, turned the corner, their leg did not come down, and they fell . The resident stated the facility responded by sending them to the emergency room . On 02/22/23 at 2:13 p.m., the DON stated she understood there were no new interventions initiated following resident #23's falls on 12/30/22 and 01/02/23. The DON reported monitoring of the resident and neuro checks had been initiated. The DON reported the resident had not been the same since their last fall. The Corporate RN reported there was an IDT meeting while the resident was still hospitalized , with plans to implement interventions upon the resident's return to the facility. She stated the facility started therapy when the resident returned from the hospital. The RN stated with the first two falls, the facility followed physician orders to monitor the resident and complete neuro checks. On 02/22/23 at 3:42 p.m., CMA #1 stated she witnessed the fall the afternoon of 01/02/23. The CMA reported the resident got up to get a glass of tea on their own. The CMA reported she believed the resident walked too fast, lost their balance and fell , hitting their head on the ground. The CMA stated staff called a nurse, the nurse assessed the resident, and the resident was sent to the ER. The CMA reported she was not aware the resident had experienced two or more falls prior to the fall with injury the afternoon of 01/02/23. On 02/22/23 at 4:00 p.m., CNA #1 reported she was not aware resident #23 was a fall risk and had not witnessed previous falls. She stated if she sees the resident go to their room, she follows the resident because they use a wheelchair and has been known to self-transfer from the wheelchair to the bed. The CNA stated it would be helpful to know when a resident was a fall risk. The CNA reported she charts in the EMR and the resident did not have any fall charting interventions. On 02/22/23 at 4:43 p.m., LPN #1 reported being aware resident #23 was a fall risk. The LPN stated the resident had changed cognitively since their fall with injury. The LPN reported the resident would get up and forget they could not walk independently. The LPN stated on the day of the fall with injury, the resident was leaning forward more than usual and walking faster, causing them to be unsteady on their feet. The LPN stated after the fall on the morning of 01/02/23, she walked the resident back to their room and encouraged them to use the call light for assistance. She stated the resident was not using a wheelchair or walker at that time. The LPN stated she spoke with the CNAs about providing the resident extra help with transfers and ambulation, but reported these interventions were not documented. On 02/23/23 at 9:33 a.m., resident #23 was observed using a wheelchair to ambulate in the hall to their room. During the survey process, the resident was not observed to ambulate or get out of their wheelchair on their own. On 02/23/23 at 11:20 a.m., LPN #2 stated the first fall on 01/02/23 was right after breakfast. The LPN reported she was entering the dining room and witnessed the resident on their hands and knees. She stated she assisted with getting the resident up and the resident voiced no complaints of pain. The LPN stated when the resident tried to stand, they were wobbly and unsure on their feet. She stated a wheelchair was offered to take the resident back to their room but the resident refused the wheelchair and insisted they could ambulate. The LPN reported the resident was assessed and one of the aides walked the resident back to their room. The LPN reported she did not document the wheelchair being offered and had not documented the resident's refusal. The LPN reported when the resident fell the second time, the resident was observed getting a drink. She stated when the resident turned around, the resident was observed to walk on their toes, leaning forward, and fell . The LPN stated she moved toward the resident, but the resident fell over before she could get to them. She stated the nurse immediately contacted the physician and sent the resident to the ER. On 02/23/23 at 11:39 a.m., the DON discussed the facility's policy and procedure for addressing falls. She stated it would be the nurse's responsibility to determine the cause of the fall and implement interventions to try and prevent additional falls. The DON stated the nurse should provide communication through the incident report with the IDT team, as to interventions initiated, and provide documentation regarding the incident. She stated the intervention should be appropriate for the individual resident related to the cognition of the resident. The DON reported there were no new interventions initiated for resident #23 for the falls which occurred on 12/30/22 and 01/02/23. The DON stated she had re-educated nursing staff reguarding incident reports and the importance of including immediate action taken, as well as providing the immediate interventions initiated. On 02/23/23 at 12:01 p.m., the Administrator reported he was aware of the incidents with resident #23 and the fall with major injury. The Administrator stated the staff would be working to improve the process for identifying and initiating interventions to prevent falls. On 02/24/23 at 12:59 p.m., the ADON reported the nurse should put an intervention in place when a fall occurs. The ADON stated when the IDT team follows up on the incident, they will look at the incident report and ensure the nurse followed the process and the interventions were appropriate for the individual resident. The ADON reported the investigation would be documented in the IDT note on the IR report. The ADON stated the root cause from resident #23's first fall was found to be the resident reaching for the hand rail and missing the rail. She stated she did not recall if the IDT team discussed the resident's complaints of dizziness. The ADON stated when resident #23 fell the second time, the morning of 01/02/23, she talked through the events with the nurses. She stated she asked if the resident was offered a walker or wheelchair, and stated she instructed staff to continue offering the resident assistance with ambulation. The ADON reported staff stated the resident continued to refuse help at that time. The ADON stated her investigation was not documented and the resident's refusal of a walker or wheelchair was not documented.

Based on observation, interview, and record review, it was determined the facility failed to implement interventions to aid in the prevention of pressure ulcers for one (#20) of three sampled residents who were reviewed for pressure ulcers. This caused actual harm for resident #20 when she sat in a geriatric chair without a pressure relieving device for over three hours without being repositioned. This caused the development of a new stage II pressure ulcer on the resident's coccyx. The facility identified four residents as having pressure ulcers. Findings: Resident #20 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. An admission assessment, dated 03/13/15, documented the resident required extensive assistance with bed mobility, transfers, locomotion, dressing, and toileting. It was documented the resident was at risk for the development of pressure ulcers. The resident's care plan, updated 08/07/15, documented the resident had a problem related to potential skin breakdown. It was documented the resident had a stage II pressure ulcer on the right hip and a stage II pressure ulcer on the left heel. The right hip pressure ulcer measured 6.7 cm(centimeters) x (by) 2.5 cm x an undetermined depth. The left heel pressure ulcer measured 1.7 cm x 2.0 cm x an undetermined depth. The goal was the resident would have no skin breakdown through the review date. Interventions included to assist with positioning every two hours and to monitor the skin with incontinent care and while in the shower. A progress note, dated 08/21/15 at 3:23 p.m., documented the resident had returned to the facility from the hospital at 2:55 p.m. It was documented the resident had foam dressings on some bony areas and a stage II pressure ulcer on her right hip and an area on her coccyx that had a large foam dressing on it. It was also documented the resident had a stage II pressure ulcer to her left heel and that the right heel was purple hued and boggy, but intact. Review of the clinical record revealed physician orders [REDACTED]. On 08/25/15 at approximately 9:00 a.m., licensed practical nurse (LPN) #2 was asked if the resident had any pressure ulcers. He stated she had stage II pressure ulcers on the right buttock area and left heel. On 08/26/15 at 8:13 a.m., the resident was observed in a geriatric chair in the back dining room. There was no cushioning or pressure relieving device in the geriatric chair. At 8:23 a.m., the resident was taken to the back living room. She was not repositioned in her chair. The resident remained in the living area seated in the geriatric chair. She was not observed to be repositioned. At 9:23 a.m., the resident was taken outside in her geriatric chair for a group activity. She was not observed to be repositioned. She remained in the group activity until 10:50 a.m., when she was taken to the main dining room for brunch. The resident was not observed to be repositioned. At 11:31 a.m., hospice aides #1 and #2 were observed propelling the resident from the main dining room to the shower. The resident had remained in the geriatric chair, without being repositioned for over three hours. At 11:40 a.m., the resident was observed in the shower. The resident was noted to have bandages on both heels and one on her right hip. Hospice aide #1 was asked if the resident had any skin breakdown. She stated the resident had a small area on her bottom. On 08/26/15 at 12:05 p.m., LPN #2 and LPN #8, were observed performing a treatment on the resident's right hip pressure ulcer. The resident was rolled to her right side. An open area, approximately 1.5 cm x 1.0 cm, with a white wound bed was observed by the surveyor on the resident's coccyx. LPN #2 did not comment on the area. The resident was rolled to her left, and LPN #2 performed the treatment on the right hip pressure ulcer. LPN #2 began to fastened the resident's brief without addressing the coccyx pressure ulcer. He was asked if the resident had any other breakdown. He stated she had a pressure ulcer on her left heel. He was asked if he had observed anything on the resident's coccyx. He stated, No. The surveyor asked LPN #2 to reposition the resident to her right side. He was shown the pressure ulcer on the resident's coccyx and asked what the area was. LPN #2 stated, She has a new stage II (pressure ulcer). LPN #2 was asked to describe the pressure ulcer. He measured the pressure ulcer and stated it was 1.5 cm x 0.9 cm with red to pink edges and slight drainage. He stated the wound bed was yellow and white. LPN #2 was asked if he had observed the pressure ulcer when the resident was rolled to her right the first time. He stated, No, I didn't. He stated he would obtain a physician's orders [REDACTED].#2 was asked if the hospice aides had reported any new skin breakdown after the resident's shower. He stated, No. LPN #2 was asked how long the resident had been up in the geriatric chair. He stated, About four hours. He was asked why the resident had been up so long without being repositioned. He stated, She is supposed to be repositioned every two hours. LPN #2 was asked why there was no cushioning or pressure relieving device in the resident's chair. He stated, I guess no one has ordered it. At 12:35 p.m., LPN #2 completed the treatment to the resident's left heel pressure ulcer. A nickel sized stage II pressure ulcer with a dark red wound bed was noted to the medial aspect of the left heel. After completing the treatment, LPN #2 began to cover the resident. He was asked if she had any skin breakdown on the right heel. LPN #2 stated, No. The surveyor asked to observe the right heel. After removing the resident's sock, an undated bandage was noted on the right heel. LPN #2 stated he had not seen that dressing before, and it appeared to be a hospital dressing. He removed the dressing, and a white, nonblanching area measuring approximately 0.5 cm x 1.0 cm was noted to the medial aspect of the right heel. The posterior aspect of the right heel was deep red in color. LPN #2 was asked if he was aware of the areas. He stated, No. On 08/26/15 at 12:45 p.m., CNA #5, who cared for the resident was asked if the resident was at risk for developing pressure ulcers. She stated, Yes. She was asked what she was supposed to do to help prevent pressure ulcers. She stated she was to reposition the resident. She stated she had floated the resident with pillows before she got an air overlay mattress on her bed. She stated the resident favored her right side. CNA #5 was asked if she had assisted the resident out of bed on this morning. She stated, Yes. She was asked what time the resident had gotten up. She stated, Around eight. CNA #5 was asked if she had repositioned the resident while she was up in the geriatric chair. She stated, No. She stated since the resident favored her right side, she did not want to do anything that might cause the resident to fall out of her chair. CNA #5 was asked how she knew what interventions she was supposed to implement for the resident. She stated the interventions were listed on the resident's care plan and on her assignments and the nurses told her as well. On 08/26/15 at approximately 1:30 p.m., the DON was asked who was responsible for ensuring interventions identified on the care plan were implemented. She stated it was the responsibility of all the staff. She was asked why the resident was not repositioned for over three hours. She stated she should have been.

Based on observation, interview, and record review, it was determined the facility failed to notify the physician of severe weight loss for 2 (#1 and #5) of nine sampled residents reviewed for weight loss. Resident #5 had experienced a severe weight loss of 10.4% in six months. Resident #1 had experienced an 11.22% severe weight loss in three months and a 5.61% severe weight loss in one month. The resident's census and condition identified 3 residents with an unplanned significant weight loss. Findings: 1. Resident #5 was admitted to the facility with a [DIAGNOSES REDACTED]. A care plan, dated 09/17/08, documented, "Problem: Dietary Concern, Potential for Weight Loss r/t Altered Diet, DX Alzheimer's, HTN, Depression...Goal: Will show no weight loss over the next 90 days...Approaches: ...Monitor for food likes and dislikes...Monthly weights, report significant changes...My weight has been stable. I have a fair appetite...Regular Pureed...I need total assistance with eating d/t limited use of my hands...House supplements TID with meals and between meals...Multi mix added to pureed food for extra protein and calories..." The care plan was last updated on 08/25/10 with no changes documented. A facility weight record documented the following weights: 09/01/10 - 127.4#, 10/01/10 - 126.6#, 11/01/10 - 126#, 12/02/10 - 122.4#, 01/04/11 - 123#, 02/02/11 - 118.1#, and 03/01/11 - 114.1#. This constituted a severe weight loss of 13.3# (10.4%) weight loss in six months, 7.9# (6.2%) weight loss in three months, and a 5# (4%) weight loss in one month. A CDM dietary progress note, dated 10/12/10, documented, "Current weight 126.6 pounds weight has been in stable range...Multi-mix is added to pureed for extra calories and protein. Takes Theragram-M Multi vitamin as a nutritional supplement. Gets House supplement TID with meals." A quarterly assessment, dated 10/31/10, documented the resident was unable to complete the interviews to determine the cognitive skills for daily decision making, was totally dependent on staff for eating, and the resident's weight was 127# and had experienced no weight loss. A CDM dietary progress note, dated 12/23/10, documented, "Current Weight 122.4 pounds did lose 8.2 pounds in six months. Still needs total assistance in eating. Is given extra protein and calories is added to pureed." There were no new dietary interventions addressed regarding the resident's weight loss of 8.2# in six months. The care plan had not been updated to address the resident's weight loss of 8.2# in six months, the resident sleeping during meals and unable to arouse easily, or to address a new goal or new dietary interventions. A December 2010 weight alert meeting report failed to address the resident's gradual weight loss of 5# in three months and provide dietary interventions for the prevention of further weight loss. An RD nutritional risk assessment, dated 01/13/11, documented, "Gets Theragram-Mult Vitamin daily. Eats all meals in assist dining room and needs total assistance in eating." The RD assessment documented a score of 14 which indicated the resident was at high risk for weight loss. This was based on a scale of 0 to 10 with 10 or greater as high risk. The nutritional assessment failed to address the resident's gradual weight loss, the resident sleeping during meals, and new dietary interventions to prevent further weight loss. A quarterly assessment, dated 01/26/11, documented the resident was unable to complete the interviews to determine the cognitive skills for daily decision making, was totally dependent on staff for eating, and the resident's weight was 123# and had experienced no weight loss. A February 2011 weight alert meeting report failed to address the resident's continued weight loss of 9.3# in five months and provide dietary interventions for the prevention of further weight loss. The care plan had not been updated to address the resident's continued severe weight loss of 13.3# (10.4%) in six months, 7.9# (6.2%) weight loss in three months, and a 5# (4%) weight loss in one month. The care plan failed to address new nutritional interventions for the prevention of further weight loss. A current physician's order for March 2011 documented the resident was to receive a regular pureed diet and a house supplement with meals. There was no physician's order for the resident to receive the multi-mix protein powder for extra protein and calories. The resident was observed on 03/15/11 during the lunch meal. At 11:38 a.m. the resident was seated at a table in the assisted dining room. She received her house supplement and drank 100%. At 11:44 a.m., the resident received her lunch tray of pureed food, juice, tea, and 2% milk. The resident was asleep. At 11:54 a.m., CNA #6 called the resident's name and the resident would open her eyes and then close them again. The resident was unable to wake up. CNA #6 asked the resident if she was ready to eat. The resident nodded her head yes. The resident could not wake up and did not take any bites of food. At 12:03 p.m., the resident opened her eyes and the resident took a drink of milk. No bites of food were taken. At 12:17 p.m., CNA #6 was asked if the resident was always that sleepy during her meal times. She stated, "No, she's not. She drank her nutrition drink and milk. She always does." The CNA was asked why the resident was so sleepy that day. She stated, "Not for sure. She is more awake for breakfast." At 2:32 p.m., the DON and the Registered Dietitian were informed of the resident's severe weight loss. They were asked what new nutritional interventions had been implemented. Then RD stated, "She's getting the house supplement." She was asked what new interventions had been implemented. The DON stated, "I don't see anything on the chart." The DON was asked if the physician had been notified of the resident's severe weight loss. She stated, "I don't know." She was asked who notified the physician of the weight loss. She stated, "She does (dietary manager)." The DON was asked if the physician's notification should be in the clinical record. She stated, "Yes." The resident's clinical records revealed the physician had not been notified of the severe weight loss. 2. Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. A facility weight record documented the following weights: 12/02/10 - 134.5#, 01/04/11 - 130.1#, 02/02/11 - 126.5#, and 03/16/11 - 119.4#. This constituted a severe weight loss of 15.5# (11.22%) weight loss in 3 months, and a 7.1# (5.61%) weight loss in one month. A CDM dietary progress note, dated 12/27/10, documented, "Still needs total assistance with meals. Consumes 50 to 75%. Yearly assessment done." The RD assessment documented a score of 14 which indicated the resident was at high risk for weight loss. This was based on a scale of 0 to 10 with 10 or greater as high risk. A CDM dietary progress note, dated 1/13/11, documented, "(name deleted) eats all meals in assist dining room, and consumes 25 to 50% of meals with house supplement Tid with meals and cranberry juice Bid with meals. Diet is regular mech soft (with) ground meat. Dr. Johnson was notified of weight loss." A CDM dietary progress note, dated 1/17/11, documented, "Will add to the diet plus program, which include super cereal, half and half." A January 2011 weight alert meeting report documented, "Current weight 130.1 pounds, loss 14.7 pounds in six months which is 10.15%. Diet (mechanical) soft with ground meat. According to charge nurse sleeps thru a lot of meals, d/t pain meds. At breakfast only meal she really care for. Will add to the diet plus program. Doctor Johnson was notified of weight loss." An RD nutritional progress note, dated 2/14/11, documented, "Boost (supplement) (with) meals - will be given ensure - meal intake - 60% breakfast - 25% lunch and 89% dinner - averaged - 58% or 1276 daily Calorie needed using 25/kg - 1436 - needed - refused supplement 14 times [DATE], - [DATE]. Will ask for clarification and if an appetite stimulant would be in order." No new dietary or nutritional notes were documented after 2/14/11. A nurse's note dated 2/24/11 at 4:00 p.m., documented, "Res resting in bed (with) eyes closed, Res responds slowly to verbal stimuli." A nurse's note, dated 02/25/11 at 9:00 a.m., documented, "...appears to be very tired..." A nurse's note, dated 02/25/11 at 9:00 p.m., documented, "...Refused to get up for supper..." A February 2011 weight alert meeting report failed to address the resident's continued weight loss of 3.6# in one month since the January 2011 weight alert meeting. A care plan, updated 3/9/11, documented, "Problem: Dietary Concern, Potential for weight loss r/t Dementia, [MEDICAL CONDITION], TIA's...Goal: Will continue to consume 75-100% of most meals over the next 90 days. Will show no significant weight loss over the next 90 days...Approaches: ...Monthly weights, report significant changes...Registered dietician consult as needed...I often eat in the assist D. R. and I need assist...Add to diet plus program...House supplements TID (with) meals..." A quarterly assessment, dated 03/07/11, documented the resident had severely impaired cognitive skills and short term memory problems, had a poor appetite the previous 12 - 14 days, was totally dependant on staff for eating, and the resident's weight was 120# and had experienced no weight loss. A current physician's order for March 2011 documented the resident was to receive [MEDICATION NAME] 10, 325 mg tablet, 1 tab po tid for pain. The resident was observed on 03/15/11 during the lunch meal. The resident was very drowsy. CNA #8 was assisting the resident to eat. CNA #8 would call the resident's name and the resident would open her eyes and then close them again. The CNA kept calling the resident's name until she opened her eyes long enough to take a sip of the house supplement or water. Occasionally the resident would keep her eyes open long enough to take a bite of peaches. At 12:30 p.m., the CNA stopped feeding the resident and pushed her out of the assisted dining room to the lobby area. The resident had consumed 0% of the entree, 50% of the dessert, 50% of the house supplement, and 3 to 4 sips of water. The CNA was asked why the resident was so sleepy. She stated, "I don't know. She doesn't eat good. Sometimes it's hard to wake her up to eat." On 03/16/11, the resident was observed during the lunch meal. The resident was sleepy and kept closing her eyes during the meal. CNA #9 stated, "Wake up and try to eat." The resident opened her eyes and took several bites of food. The resident ate approximately 40% of her lunch. CNA #9 was asked how much of the meal did the resident consume. She stated 45% or so. The CNA stated that was the most she had seen her eat in over 2 weeks. The CNA stated the resident was drowsy at meals and when she turn to feed another resident, she would have to wake her up when she came back to her. On 03/17/11 at 6:27 a.m., resident #1 was observed asleep in her geriatric chair in the dining room. At 6:31 a.m., CNA #4 was observed sitting with resident #1. Resident #1 remained asleep. CNA #4 was holding the resident's head upright. At 6:33 a.m., resident #1's breakfast tray was delivered. CNA #4 continued to try to wake the resident. CNA #4 held the resident's head with her hand and attempted to give the resident a drink of water. The resident did not wake up. At 6:42 a.m., CNA #4 continued to attempt to wake up resident #1. She held the resident's head, rubbed her chest, and attempted to give her a drink of milk. At 6:43 a.m., the CDM asked CNA #4 if resident #1 was going to wake up. CNA #4 stated, "She'll get around." CNA #4 continued to attempt to wake the resident. She rubbed the resident's chest, tried to give her water, patted her chest, and talked with her, all while holding the resident's head upright. At 6:50 a.m., resident #1 remained asleep. She had not consumed any of her breakfast. At 7:01 a.m., resident #1 was asleep again. CNA #4 was asked if she was having difficulty getting the resident awake. She stated, "Yes." At 7:06 a.m., the CDM asked CNA #4 if resident #1 had woke up. CNA #4 stated, "No." At 7:15 a.m., resident #1 was leaning to the left in her geriatric chair. She remained asleep, and CNA #4 continued to attempt to wake her. The activities assistant stated, "She's really zonked out." At 7:19 a.m., CNA #4 continued to attempt to wake resident #1 and give her a drink of milk. CNA #4 stated, "Yes, she's not going to do it." LPN #1 stated, "In a couple of hours, make sure you go in her room and give her some water. I want her fluids taken care of." CNA #4 stated, "She'll be in the lobby for a little while." LPN #1 stated, "Make sure to do your rounds and give her water. She'd sleep til 10 o'clock in the morning." At 7:25 a.m., resident #1 was pushed from the dining room to the front sitting area. She was still asleep. At 5:40 p.m., the DON and RN #1 were asked how resident #1's continued weight loss was being addressed. They both stated it was addressed in the monthly weight meeting. The DON and RN #1 were asked who was responsible to follow up when a resident was identified with a severe weight loss. They both stated the DON should. They DON was asked if she had been following the severe weight loss of resident #1. She stated, "No." The DON and RN #1 were asked if the physician had been notified of the resident's continued weight loss and sleeping through the meals. The DON and RN #1 reviewed the clinical record. They both stated, "No."

Based on observations, interviews, and record reviews, it was determined the facility failed to prevent weight loss for three (#1, #5, and #7) of nine sampled residents reviewed for weight loss. The facility failed to prevent an actual harm of 10.4% severe weight loss in six months for resident #5, an 11.22% severe weight loss in three months and 5.61% severe weight loss in one month for resident #1, and a gradual weight loss of 8.9# (4.6%) in five months for resident #7. The resident's census and condition identified 3 residents with an unplanned significant weight loss. Findings: 1. Resident #5 was admitted to the facility with a [DIAGNOSES REDACTED]. A care plan, dated 09/17/08, documented, "Problem: Dietary Concern, Potential for Weight Loss r/t Altered Diet, DX Alzheimer's, HTN, Depression...Goal: Will show no weight loss over the next 90 days...Approaches: ...Monitor for food likes and dislikes...Monthly weights, report significant changes...My weight has been stable. I have a fair appetite...Regular Pureed...I need total assistance with eating d/t limited use of my hands...House supplements TID with meals and between meals...Multi mix added to pureed food for extra protein and calories..." The care plan was last updated on 08/25/10 with no changes documented. A facility weight record documented the following weights: 09/01/10 - 127.4#, 10/01/10 - 126.6#, 11/01/10 - 126#, 12/02/10 - 122.4#, 01/04/11 - 123#, 02/02/11 - 118.1#, and 03/01/11 - 114.1#. This constituted a severe weight loss of 13.3# (10.4%) weight loss in six months, 7.9# (6.2%) weight loss in three months, and a 5# (4%) weight loss in one month. A CDM dietary progress note, dated 10/12/10, documented, "Current weight 126.6 pounds weight has been in stable range...Multi-mix is added to pureed for extra calories and protein. Takes Theragram-M Multi vitamin as a nutritional supplement. Gets House supplement TID with meals." A quarterly assessment, dated 10/31/10, documented the resident was unable to complete the interviews to determine the cognitive skills for daily decision making, was totally dependent on staff for eating, and the resident's weight was 127# and had experienced no weight loss. A CDM dietary progress note, dated 12/23/10, documented, "Current Weight 122.4 pounds did lose 8.2 pounds in six months. Still needs total assistance in eating. Is given extra protein and calories is added to pureed." There were no new dietary interventions addressed regarding the resident's weight loss of 8.2# in six months. The care plan had not been updated to address the resident's weight loss of 8.2# in six months, the resident sleeping during meals and unable to arouse easily, or to address a new goal or new dietary interventions. A December 2010 weight alert meeting report failed to address the resident's gradual weight loss of 5# in three months and provide dietary interventions for the prevention of further weight loss. An RD nutritional risk assessment, dated 01/13/11, documented, "Gets Theragram-Mult Vitamin daily. Eats all meals in assist dining room and needs total assistance in eating." The RD assessment documented a score of 14 which indicated the resident was at high risk for weight loss. This was based on a scale of 0 to 10 with 10 or greater as high risk. The nutritional assessment failed to address the resident's gradual weight loss, the resident sleeping during meals, and new dietary interventions to prevent further weight loss. A quarterly assessment, dated 01/26/11, documented the resident was unable to complete the interviews to determine the cognitive skills for daily decision making, was totally dependent on staff for eating, and the resident's weight was 123# and had experienced no weight loss. A February 2011 weight alert meeting report failed to address the resident's continued weight loss of 9.3# in five months and provide dietary interventions for the prevention of further weight loss. The care plan had not been updated to address the resident's continued severe weight loss of 13.3# (10.4%) in six months, 7.9# (6.2%) weight loss in three months, and a 5# (4%) weight loss in one month. The care plan failed to address new nutritional interventions for the prevention of further weight loss. A current physician's order for March 2011 documented the resident was to receive a regular pureed diet and a house supplement with meals. There was no physician's order for the resident to receive the multi-mix protein powder for extra protein and calories. The resident was observed on 03/15/11 during the lunch meal. At 11:38 a.m. the resident was seated at a table in the assisted dining room. She received her house supplement and drank 100%. At 11:44 a.m., the resident received her lunch tray of pureed food, juice, tea, and 2% milk. The resident was asleep. At 11:54 a.m., CNA #6 called the resident's name and the resident would open her eyes and then close them again. The resident was unable to wake up. CNA #6 asked the resident if she was ready to eat. The resident nodded her head yes. The resident could not wake up and did not take any bites of food. At 12:03 p.m., the resident opened her eyes and the resident took a drink of milk. No bites of food were taken. At 12:17 p.m., CNA #6 was asked if the resident was always that sleepy during her meal times. She stated, "No, she's not. She drank her nutrition drink and milk. She always does." The CNA was asked why the resident was so sleepy that day. She stated, "Not for sure. She is more awake for breakfast." At 2:32 p.m., the DON and the Registered Dietitian were informed of the resident's severe weight loss. They were asked what new nutritional interventions had been implemented. Then RD stated, "She's getting the house supplement." She was asked what new interventions had been implemented. The DON stated, "I don't see anything on the chart." They were asked why the severe weight loss and new interventions had not been addressed on the care plan. No comment was made. The DON was asked if the physician had been notified of the resident's severe weight loss. She stated, "I don't know." She was asked who notified the physician of the weight loss. She stated, "She does (dietary manager)." The DON was asked if the physician's notification should be in the clinical record. She stated, "Yes." The resident's clinical records revealed the physician had not been notified of the severe weight loss. The DON was informed of the resident sleeping during the meal times and why it had not been addressed in relation to her severe weight loss. She stated, "I don't know." The RD was asked why the gradual weight loss which had resulted in a severe weight loss had not been addressed in the dietary notes. She stated, "She (CDM) has notes for the weight loss. I will see. I don't know if she fell through the cracks." The DON stated the weights weren't given to the dietitian until there was a significant or severe weight loss. The DON was informed the resident had experienced a severe weight loss. At 3:13 p.m., the dietary manager was informed cook #1 did not add the multi-mix powder to the pureed foods. The dietary manager stated, "She didn't do it today cause she was nervous." The resident was observed during the evening meal at 5:16 p.m. The resident received her dinner tray at 5:21 p.m. The resident was very sleepy. Her eyes were opening and closing. The dietary manager attempted to feed the resident a bite of food. The resident stated, "It's cold." The dietary manager stated, "It's supposed to be." The resident would not eat the bite of food. The dietary manager was asked if the pureed roast beef sandwich could not be heated. She stated, "It has mayo." She was asked if she could puree one without the mayo. A hot pureed sandwich was delivered to the resident and she took a few bites of the food. The resident was very sleepy. The resident was asked if she wanted a drink of water. The resident stated, "No. Milk." No milk was observed on the resident's tray. At 5:35 p.m., the resident took one bite of her dessert and at 5:44 p.m., the resident took one bite of her dessert. The resident was removed from the dining room. The resident was observed on 03/16/11 at 11:40 a.m. during the lunch meal. The resident was in the assisted dining room seated at a table asleep. The resident's meal consisted of pureed foods, 2% milk, juice and a supplement. CNA #6 asked the resident if she wanted a drink. The resident took a drink, took a bite, and fell back to sleep. At 11:46 a.m., the CNA asked the resident if she wanted a drink of milk. The resident did not wake up. At 11:59 a.m. and 12:01 p.m., the resident took a drink of her supplement but did not take any bites of food. The resident fell back to sleep. At 12:07 p.m., the CNA stated the resident didn't drink her milk that day and she didn't like juice. At 12:14 p.m., the resident was removed from the dining room. The resident remained asleep. On 03/16/11 at 4:20 p.m., CNA #7 was asked if the resident always slept like that during meals. She stated, "Yes." She was asked if it was difficult to feed her. She stated, "Yes it is." She was asked how she fed her. She stated, "I first try to encourage her to eat." The CNA was asked if the resident had always slept during meals. She stated, "As long as I've been here and I've been here 6 months." On 03/17/11 at 6:06 p.m., the DON was asked why the 13.3# severe weight loss in 6 months, the 7.9# weight loss in 3 months, and the 5# weight loss in one month had not been addressed on the care plan. She stated, "If it doesn't trigger we don't address it. If it isn't the 5%, 7.5%, or the 10%." The DON was asked whose responsibility it was to ensure weight loss was addressed. She stated, "The DON." She was asked if the weight loss should have been addressed on the care plan. She stated, "Yes." 2. Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. A facility weight record documented the following weights: 12/02/10 - 134.5#, 01/04/11 - 130.1#, 02/02/11 - 126.5#, and 03/16/11 - 119.4#. This constituted a severe weight loss of 15.5# (11.22%) weight loss in 3 months, and a 7.1# (5.61%) weight loss in one month. A CDM dietary progress note, dated 12/27/10, documented, "Still needs total assistance with meals. Consumes 50 to 75%. Yearly assessment done." The RD assessment documented a score of 14 which indicated the resident was at high risk for weight loss. This was based on a scale of 0 to 10 with 10 or greater as high risk. A CDM dietary progress note, dated 1/13/11, documented, "(name deleted) eats all meals in assist dining room, and consumes 25 to 50% of meals with house supplement Tid with meals and cranberry juice Bid with meals. Diet is regular mech soft (with) ground meat. Dr. Johnson was notified of weight loss." A CDM dietary progress note, dated 1/17/11, documented, "Will add to the diet plus program, which include super cereal, half and half." A January 2011 weight alert meeting report documented, "Current weight 130.1 pounds, loss 14.7 pounds in six months which is 10.15%. Diet (mechanical) soft with ground meat. According to charge nurse sleeps thru a lot of meals, d/t pain meds. At breakfast only meal she really care for. Will add to the diet plus program. Doctor Johnson was notified of weight loss." An RD nutritional progress note, dated 2/14/11, documented, "Boost (supplement) (with) meals - will be given ensure - meal intake - 60% breakfast - 25% lunch and 89% dinner - averaged - 58% or 1276 daily Calorie needed using 25/kg - 1436 - needed - refused supplement 14 times [DATE], - [DATE]. Will ask for clarification and if an appetite stimulant would be in order." No new dietary or nutritional notes were documented after 2/14/11. A nurse's note dated 2/24/11 at 4:00 p.m., documented, "Res resting in bed (with) eyes closed, Res responds slowly to verbal stimuli." A nurse's note, dated 02/25/11 at 9:00 a.m., documented, "...appears to be very tired..." A nurse's note, dated 02/25/11 at 9:00 p.m., documented, "...Refused to get up for supper..." A February 2011 weight alert meeting report failed to address the resident's continued weight loss of 3.6# in one month since the January 2011 weight alert meeting. A care plan, updated 3/9/11, documented, "Problem: Dietary Concern, Potential for weight loss r/t Dementia, [MEDICAL CONDITION], TIA's...Goal: Will continue to consume 75-100% of most meals over the next 90 days. Will show no significant weight loss over the next 90 days...Approaches: ...Monthly weights, report significant changes...Registered dietician consult as needed...I often eat in the assist D. R. and I need assist...Add to diet plus program...House supplements TID (with) meals..." A quarterly assessment, dated 03/07/11, documented the resident had severely impaired cognitive skills and short term memory problems, had a poor appetite the previous 12 - 14 days, was totally dependant on staff for eating, and the resident's weight was 120# and had experienced no weight loss. A current physician's order for March 2011 documented the resident was to receive [MEDICATION NAME] 10, 325 mg tablet, 1 tab po tid for pain. The resident was observed on 03/15/11 during the lunch meal. The resident was very drowsy. CNA #8 was assisting the resident to eat. CNA #8 would call the resident's name and the resident would open her eyes and then close them again. The CNA kept calling the resident's name until she opened her eyes long enough to take a sip of the house supplement or water. Occasionally the resident would keep her eyes open long enough to take a bite of peaches. At 12:30 p.m., the CNA stopped feeding the resident and pushed her out of the assisted dining room to the lobby area. The resident had consumed 0% of the entree, 50% of the dessert, 50% of the house supplement, and 3 to 4 sips of water. The CNA was asked why the resident was so sleepy. She stated, "I don't know. She doesn't eat good. Sometimes it's hard to wake her up to eat." On 03/16/11, the resident was observed during the lunch meal. The resident was sleepy and kept closing her eyes during the meal. CNA #9 stated, "Wake up and try to eat." The resident opened her eyes and took several bites of food. The resident ate approximately 40% of her lunch. CNA #9 was asked how much of the meal did the resident consume. She stated 45% or so. The CNA stated that was the most she had seen her eat in over 2 weeks. The CNA stated the resident was drowsy at meals and when she turn to feed another resident, she would have to wake her up when she came back to her. On 03/17/11 at 6:27 a.m., resident #1 was observed asleep in her geriatric chair in the dining room. At 6:31 a.m., CNA #4 was observed sitting with resident #1. Resident #1 remained asleep. CNA #4 was holding the resident's head upright. At 6:33 a.m., resident #1's breakfast tray was delivered. CNA #4 continued to try to wake the resident. CNA #4 held the resident's head with her hand and attempted to give the resident a drink of water. The resident did not wake up. At 6:42 a.m., CNA #4 continued to attempt to wake up resident #1. She held the resident's head, rubbed her chest, and attempted to give her a drink of milk. At 6:43 a.m., the CDM asked CNA #4 if resident #1 was going to wake up. CNA #4 stated, "She'll get around." CNA #4 continued to attempt to wake the resident. She rubbed the resident's chest, tried to give her water, patted her chest, and talked with her, all while holding the resident's head upright. At 6:50 a.m., resident #1 remained asleep. She had not consumed any of her breakfast. At 7:01 a.m., resident #1 was asleep again. CNA #4 was asked if she was having difficulty getting the resident awake. She stated, "Yes." At 7:06 a.m., the CDM asked CNA #4 if resident #1 had woke up. CNA #4 stated, "No." At 7:15 a.m., resident #1 was leaning to the left in her geriatric chair. She remained asleep, and CNA #4 continued to attempt to wake her. The activities assistant stated, "She's really zonked out." At 7:19 a.m., CNA #4 continued to attempt to wake resident #1 and give her a drink of milk. CNA #4 stated, "Yes, she's not going to do it." LPN #1 stated, "In a couple of hours, make sure you go in her room and give her some water. I want her fluids taken care of." CNA #4 stated, "She'll be in the lobby for a little while." LPN #1 stated, "Make sure to do your rounds and give her water. She'd sleep til 10 o'clock in the morning." At 7:25 a.m., resident #1 was pushed from the dining room to the front sitting area. She was still asleep. At 5:40 p.m., the DON and RN #1 were informed of the resident's continued weight loss and the resident sleeping through meals. The DON and RN #1 were asked how resident #1's continued weight loss was being addressed. They both stated it was addressed in the monthly weight meeting. They were asked who held the monthly weight meeting. The DON stated the dietary manager held the meeting. The DON and RN #1 were asked who was responsible to follow up when a resident was identified with a severe weight loss. They both stated the DON should. They DON was asked if she had been following the severe weight loss of resident #1. She stated, "No." The DON was asked if a nurse monitored the dining room during lunch. She stated, "The charge nurses should." She was asked who monitored the charge nurses. The DON stated, "The DON." She was asked if she made sure the charge nurses were monitoring the dining room. She stated, "No, I haven't been." The DON and RN #1 were asked if they were aware of or if any staff had told them about resident #1's sleeping during meals. They both stated, "No." The DON and RN #1 were asked if the physician had been notified of the resident's continued weight loss and sleeping through the meals. The DON and RN #1 reviewed the clinical record. They both stated, "No." 3. Resident #7 was admitted to the facility with a [DIAGNOSES REDACTED]. A dietary care plan, dated 09/16/09, documented, "Problem: Dietary concern, Potential for Weight Loss r/t Therapeutic diet and DX of Dementia...Goal: Will show no unplanned weight loss over the next 90 days...Approaches: ...Monthly weights, report significant changes...Serve Diet: Regular NAS as ordered...I need full assistance at meals..." A facility weight record documented the following weights: 10/04/10 - 192.6#, 11/02/10 - 191.1#, 12/03/10 - 188.3#, 01/03/11 - 187.3#, 02/03/11 - 184.5#, and 03/01/11 - 183.7#. This constituted a gradual weight loss of 8.9# (4.6%) in five months for resident #7. An annual assessment, dated 08/15/10, documented the resident had a short term and long term memory problem, moderately impaired in cognitive skills for daily decision making, required supervision with eating, and the resident's weight was 191# and had experienced no weight loss. The dietary care plan, updated 08/16/10, had not been changed to address the resident's diet change to mechanical soft with ground meats and nectar thickened liquids. A DM dietary progress note, dated 10/15/10, documented, "Wt. 192.6 (up) 3 lbs from last month. Consumes 75% of meals at times he will refuse. Diet is mch soft c gr meat nectar thick liquids. Will watch for changes..." A DM dietary progress note, dated 11/13/10, documented, "Current weight 191.1 (down) 1 lb. Eats 75% of most meals. Has refused some due to resident wouldn't wake up...No change in diet. Needs total assist eat. Will monitor." A DM dietary progress note, dated 12/23/10, documented, "Weight 188.3 (down) 3 lbs. from last month. Resident still above desired body wt (141). Eating 75% to 100% of meals. Diet is still mech soft c grnd meat. Nectar thick liquids." An RD nutritional risk assessment, dated 01/13/11, documented the resident was to receive a mechanical soft diet with ground meat, nectar thickened liquids, assistance with meals, and experienced problems with chewing and swallowing. The RD assessment documented a score of 14 which indicated the resident was at high risk for weight loss. This was based on a scale of 0 to 10 with 10 or greater as high risk. The nutritional assessment failed to address the resident's gradual weight loss and new dietary interventions to prevent further weight loss. A CDM dietary progress note, dated 01/21/11, documented, "Current weight 187.3 pounds. Diet Regular NAS Mech Soft with ground meat. With nectar thick liquids. Needs total assistance at meals." The dietary progress note failed to address the resident's gradual weight loss, the resident sleeping during meals, and new dietary interventions to prevent further weight loss. The dietary care plan had not been updated to address the resident's gradual weight loss, the diet order change to a regular NAS mechanical soft with ground meat and nectar thick liquids, the resident sleeping during meals and difficulty to arouse, and the resident required total assistance at meals. A quarterly assessment, dated 02/04/11, documented the resident was unable to complete the interviews to determine the cognitive skills for daily decision making, required supervision with meals, and the resident's weight was 187# and had experienced no weight loss. The dietary care plan had not been updated to address the resident's gradual weight loss of 8.9# in five months, the diet order change to a regular NAS mechanical soft with ground meat and nectar thick liquids, the resident sleeping during meals, the resident required total assistance at meals or to address a new goal or new dietary interventions to prevent further weight loss. On 03/15/11 at 11:35 a.m., the resident was observed during the lunch meal. The resident was seated at the dining room table. The resident was asleep and the CNA was attempting to wake the resident. At 11:48 a.m., the resident was aroused and took a few bites of okra and potatoes. The resident fell asleep and was then taken back to his room. LPN #3 was asked why the resident was so sleepy he couldn't wake up to eat. She stated, "He had lots of family in yesterday. He was up until 7:00 p.m. last nite when I left." On 03/17/11 at 6:13 p.m., the DON was informed of the resident's gradual weight loss of 8.9# in five months and why it had not been addressed. She stated, "I don't have an answer." The DON was asked if they had addressed the resident sleeping during meals and not being able to wake up. She stated, "I didn't know anything about it."