Every finding on record at Oaks at Bethesda the

Based on record review, interview, facility investigation review and policy review, the facility failed to ensure a resident was not left in the shower alone, resulting in a fall with fracture. This affected one (Resident #2) of four residents reviewed for falls. The facility census was 49. Actual harm occurred on 04/04/26 when Resident #2, who required supervision and touching assistance with showering and bathing, was assisted into the bathroom to shower. Certified Resident Care Assistant (CRCA) exited the shower room leaving Resident #2 to shower herself. Resident #2 suffered a fall which resulted in a comminuted, intra-articular distal radius fracture on the right arm. Findings Include:Record review revealed Resident #2 was admitted on [DATE] with diagnoses includingType II Diabetes Mellitus with hyperglycemia, overactive bladder, pain, cognitivecommunication deficit, muscle weakness (generalized), difficulty in walking and Colles'fracture of right radius. Review of Resident #2's care plan, dated 10/14/24, revealed Resident #2 had impairment infunctional status related to impaired mobility, unsteady gait, impaired posture, generalizedweakness and dyspnea upon exertion. An intervention (dated 10/14/24) included in thecare plan was to provide assistance as needed with self-care and mobility functional tasks.Resident #2 was at risk for falling related to impaired mobility, generalized weakness,impaired posture, incontinence, dyspnea upon exertion, hypertension, Diabetes Mellitusand polypharmacy. An intervention (dated 10/14/24) included in the care plan indicatedstaff to assist Resident with transfers as needed and a new intervention dated 04/06/26 forstaff to assist resident with showers. Review of the profile care guide dated 10/01/24 documented Resident #2 needed theassistance of one person for transfers and the use of a platform walker.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealedResident #2 was alert and oriented and required supervision and touching assistance withtub/shower transfers, showering and bathing. Review of the facility investigation report, dated 04/04/26 at 9:15 P.M., revealed Resident #2was found on the floor in her bathroom. Resident #2 stated she was turning to put clothesdown in a dry place and fell. The root cause analysis documented that the resident did nothave staff assisting with getting ready or performing the shower as the aide did not staywith resident to assist with shower and the aide was outside the building when the falloccurred.Review of the witness statement dated 04/04/26 authored by CRCA #168 revealed she wascalled back to the unit, and resident was laying on the bathroom floor. Review of the witness statement dated 04/04/26 authored by Licensed Practical Nurse(LPN) #123 revealed the Resident #2's spouse stated, she left my wife in the bathroom andleft and did not come in to help. Review of the X-ray of right wrist dated 04/05/26 revealed a comminuted, intra-articulardistal radius fracture.During an interview on 05/27/26 at 3:00 P.M., Resident #2 stated prior to the fall she bathedherself, although it might not have been safe. She stated she was reaching for somethingand lost her balance.During an interview on 05/28/226 at 10:55 A.M., Therapy Director #190 stated Resident #2was independent and her assist level varied. Therapy kept her on a maintenance programto keep her moving. Resident #2 had a slow decline. She does not pay attention, whichaffects her safety awareness. Therapy Director #190 confirmed Resident #2 should havebeen supervised while bathing.Review of the facility policy titled Fall Management Program Guidelines dated 11/19/25,instructed to maintain a hazard free environment, mitigate fall risk factors and implementpreventative measures. Should the resident experience a fall the attending nurse shallcomplete an occurrence note. This includes an investigation of the circumstancessurrounding the fall to determine the cause of the episode, a reassessment to identifypossible contributing factors, interventions to reduce risk of repeat episode and a review bythe Interdisciplinary team (IDT) to evaluate thoroughness of the investigation andappropriateness of the interventions.

Based on observation, staff interview and review of facility policy, the facility failed to ensure medications were dated when opened and expired medications were disposed of timely. This affected three residents (Resident #48, #51 and #71) of three residents reviewed for medication storage. Facility census was 49.Findings include:1. Review of the medical record for Resident # 48 revealed an admission date of 05/08/26 with diagnoses including encounter for surgical aftercare following surgery on the digestive system status post (s/p) colostomy, sepsis, chronic obstructive pulmonary disease (COPD) and asthma.Review of the physician's orders for Resident # 48 revealed an order dated 05/08/26 for Ipratropium Bromide/Albuterol Sulfate 0.5mg/3mg per milliliter (ml) twice a day for COPD. Review of the Medication Administration Record (MAR) for Resident # 48 dated May 2026 revealed the resident received Ipratropium Bromide/Albuterol Sulfate twice daily from 05/08/26 to 05/27/26.Observation and interview on 05/27/26 at 4:56 P.M. with RN # 140 of the medication cart on 100 hall revealed one box of Ipratropium Bromide/Albuterol Sulfate 0.5mg/3mg per milliliter (ml) for Resident #48, there was a yellow sticker attached to the foil packaging to enter an open date and discard after 14 days. There was no open date on the package. RN #140 verified no open date on the medication.2. Review of the medical record for Resident # 51 revealed an admission date of 10/23/23 with diagnoses including Type II Diabetes Mellitus with diabetic chronic kidney disease, hypertension and hypertensive chronic kidney disease with stage I through stage IV chronic kidney disease.Review of the physician's orders for Resident # 51 revealed an order dated 05/12/26 and discontinued on 05/17/26 for insulin Lispro 100 unit/mL per sliding scale once daily.Observation and interview on 05/27/26 at 4:40 P.M. with Registered Nurse (RN) #128 during review of the medication cart for long 200 hall revealed, one vial of insulin Lispro with an open date of 04/11/26 and a yellow sticker that read expires after 28 days of opening. During concurrent interview with RN #128 it was verified the insulin Lispro was expired.3. Review of the medical record for Resident # 71 revealed an admission date of 05/15/26 with diagnoses including COPD and Diabetes Mellitus. Review of the physician's orders for Resident # 71 revealed an order dated 05/15/26 for Levalbuterol aerosol solution 1.25 milligrams (mg) every four hours as needed and an order dated 05/19/26 through 05/21/26 for Levalbuterol aerosol solution 1.25 milligrams (mg) three times a day for wheezing. Observation and interview on 05/27/26 at 4:40 P.M. with Registered Nurse (RN) #128 during review of the medication cart for long 200 hall, revealed one box of Levalbuterol aerosol solution 1.25 milligrams (mg) with no open date, there was a yellow sticker attached to the foil packaging to enter an open date and discard date after seven days , however the yellow sticker was blank. During concurrent interview with RN #128 it was verified the the medication was not labeled with the open date. Review of facility policy titled, Medication Storage, reviewed 11/01/22, revealed outdated or otherwise unusable medications must be immediately pulled from the active inventory and segregated to an area to prevent unintentional use.

Based on observation, medical record review, staff interview and review of facility policy, the facility failed to ensure staff donned personal protective equipment (PPE) prior to entering Resident # 66 room, who was on contact precautions. This had the potential to affect all residents on the long 200-hall. (Resident #2, #6, #7, #11, #15, #22, #23, #24, #46, #51 and #58). The facility census was 49.Findings include: Review of Resident #66 medical record revealed an admission date of 05/21/26 with diagnoses including sepsis due to Clostridioides difficile (C-diff). Review of Resident #66's physician orders revealed an order dated 05/21/26 for contact precautions. Review of the care plan dated 05/26/26 revealed resident had a need for contact isolation related to active infectious disease related to C-diff. Interventions included use principles of infection control and universal/standard precautions. Observation on 05/26/26 at 11:24 A.M. revealed Environmental Services Worker #154 entering contact isolation room for Resident #66 without donning proper PPE prior to entrance. A sign was posted outside of the room door to Resident #66's room indicated he was on contact precautions and a cart containing personal protective supplies was noted outside the resident's room door. Interview on 05/26/26 at 11:24 A.M. with the Environmental Services Worker #154 verified she did not follow the guidance for contact isolation and should have put PPE on prior to entering Resident #66's room due to contact precautions. Review of Center of Disease Control and Prevention (CDC) guidance for contact precautions, signage posted outside of Resident #66's room read Providers and Staff must also put on gloves before room entry. Put on gown before room entry. Review of facility policy titled Guidelines for Contact Precaution, reviewed 12/10/25 revealed wear a clean non-sterile, fluid resistant gown when entering the room if it is anticipated clothing will have substantial contact with the resident or environmental surface or when there is likelihood that organisms from blood, urine, stool, or wound drainage may be on surfaces or item's in the resident's rooms. Post a sign at the resident's door that is appropriate according to Center for Disease Control and Prevention (CDC) guidance.

Based on medical record review, staff interview, physician interview, and facility policy review, the facility failed to complete laboratory orders to ensure residents were able to attend medical appointments. This affected one (Resident #1) of four residents reviewed for condition change. Also, the facility failed to provide timely comfort care during a change in condition. This affected one (Resident #52) of four residents reviewed for a change of condition. The census was 49. Findings Include: 1.Resident #1 was admitted to the facility on [DATE]. Her diagnoses were osteomyelitis, sepsis, cellulitis of right/left lower limb, fibromyalgia, acute kidney failure, bacteremia, rheumatoid arthritis, nonrheumatic aortic valve stenosis, hypothyroidism, hyperlipidemia, atrial fibrillation, and hypertension. Review of her minimum data set (MDS) assessment, dated [DATE], revealed she was cognitively intact.Review of Resident #1's After Visit Summary (AVS), dated [DATE], revealed she had a nephrology consultation appointment scheduled for [DATE]. The AVS stated to please have testing done one week before your appointment. This allows the the results to be available for the provider to review with you at your appointment. Review of Resident #1's physician orders, dated [DATE] to [DATE], revealed no laboratory orders entered or completed related to the nephrology consultation appointment on [DATE]. Review of Resident #1's laboratory test results, dated [DATE] to [DATE], revealed no laboratory results completed that were related to her nephrology consults on [DATE]. Review of Resident #1's personal electronic medical records (EMR) access information, dated [DATE], revealed her nephrology appointment on that day had been cancelled. Notes in the record documented the appointment was cancelled by the resident. Review of Resident #1's progress notes, dated [DATE] to [DATE], revealed no progress notes related to laboratory testing ordered, completed, or information about the nephrology appointment being completed or reason it needed to be cancelled. Review of Resident #1's physician orders, dated [DATE], revealed new laboratory testing was to be completed on [DATE], which was one week prior to her rescheduled nephrology consultation appointment on [DATE]. Interview with Resident #1's representative on [DATE] at 1:28 P.M. confirmed that Resident #1's nephrology appointment was cancelled prior to her attending the appointment. She confirmed that she was upset because Resident #1 really needed this appointment. Interview with Resident #1 on [DATE] at 1:55 P.M. and 2:50 P.M. confirmed she did not attend her needed nephrology appointment on [DATE]. She stated she did not cancel the appointment; she was told by staff the morning of her appointment that it needed to be cancelled because they did not get the needed testing done prior to the appointment. Interview with Director of Nursing (DON) on [DATE] at 2:40 P.M., 3:04 P.M., and [DATE] at 8:40 A.M. and 10:46 A.M. confirmed Resident #1's nephrology appointment was not completed on [DATE] as scheduled. Initially, she stated Resident #1 cancelled the appointment and she did not know the reason why. the DON later confirmed there was an order for testing to be completed prior to her [DATE] and there was no evidence it was ever ordered or completed. The DON also confirmed there was no evidence the provider was contacted to clarify what orders needed to be completed prior to her [DATE] appointment. Interview with Nephrology Office Staff #300 on [DATE] at 11:16 A.M. confirmed Resident #1's nephrology consultation appointment that was scheduled for [DATE], was cancelled on [DATE] at 9:00 A.M. She confirmed their documentation has the reason for the cancellation as patient cancelled, but she also confirmed they will document that as the reason for cancelling, if the facility calls and cancels on behalf of the resident. She confirmed she has no other documentation or information to support the reason for the cancellation, other than it was cancelled the morning the appointment was supposed to occur. 2. Resident #52 was admitted to the facility on [DATE]. Her diagnoses were encephalopathy, chronic respiratory failure with hypoxia, urinary tract infection, atherosclerotic heart disease, non-rheumatic aortic valve insufficiency, pulmonary hypertension, interstitial pulmonary disease, edema, altered mental status, personal history of urinary tract infections, osteoarthritis, spinal stenosis, pyuria, hypo-osmolality and hyponatremia, nausea with vomiting, insomnia, depression, acute on chronic diastolic congestive heart failure, acute kidney failure, chronic pain syndrome, pleural effusion, obstructive sleep apnea, Type II Diabetes, fibromyalgia, hyperlipidemia, venous insufficiency, irritable bowel syndrome, and chronic obstructive pulmonary disease. Review of her MDS assessment, dated [DATE], revealed she had a severe cognitive impairment.Review of Resident #52's physician orders, dated [DATE] to [DATE], revealed she was prescribed Gabapentin (used for nerve pain) 200 milligrams (mg) twice daily for pain and Acetaminophen (analgesic) 650 mg every eight hours for pain. Review of Resident #52's progress notes, dated [DATE], revealed a new order from the provider to discontinue Gabapentin 200 mg twice daily scheduled and replace it with Percocet (Oxycodone-Acetaminophen) (opioid) 5-325 mg four times a day as needed. Review of Resident #52's progress notes, dated [DATE] to [DATE], revealed the following documentation about changes in condition and no notification to the provider about these changes: [DATE] at 12:31 A.M., Resident #52 was having difficulty sleeping, stated she doesn't want to be alone, telling staff Don't go, and staff providing one on one supervision; [DATE] at 1:03 A.M., Resident #52 was climbing out of bed and yelling when staff is out of the room; [DATE] at 4:21 A.M., Resident #52 was inconsolable at this time, resident noted to be crying and would scream out when staff left the room, was crying and noted to be tired and hurting; [DATE] at 5:42 P.M.; resident had a pain level of four to five with dull pain noted, non-verbal displays of pain were noted as well with resident complaining of pain; [DATE] at 10:20 P.M., noted Resident #52 had been restless, anxious, calling out for people who are not there and who are deceased ; and [DATE] at 2:43 A.M., Oxycodone-Acetaminophen 5-325 mg was administered for pain level seven out of ten, but Resident #52 spit some out, pain all over, resident was whining, crying, calling out, seeing and talking to people not in the room. Review of Resident #52's progress notes, dated [DATE], revealed at 8:36 A.M., the provider was finally notified of the changes and laboratory tests were ordered. At 12:27 P.M., the laboratory tests returned and based on the results (nothing of note was found to cause the changes in condition), the provider ordered that Percocet was to be discontinued and for the facility to discuss changing Resident #52's code status and hospice options with the family. Review of Resident #52's progress notes, dated [DATE], revealed the following: at 1:05 P.M., Resident #52 continued to cry and yell out for people, and at 5:46 P.M., Resident #52 continues with restlessness and tremors. Review of Resident #52's Medication Administration Records (MAR), dated [DATE] to [DATE], revealed she accepted and swallowed all other scheduled medication until [DATE]; her Percocet on [DATE] at 2:43 A.M. was the only medication documented as not being swallowed when offered/administered. Review of Resident #52's progress notes, dated [DATE], revealed the family decided not to move forward with hospice care at the facility due to financial reasons, so the facility sent Resident #52 to the emergency room for the following documented reasons: resident was unable to swallow, family's refusal for hospice services, and resident's continued decline. Review of Resident #52's Emergency Department provider notes, dated [DATE], revealed the family reported that she was in terrible pain, they can not get her to eat or drink anything, and wants her under hospice care. The report from the facility was, they are having difficulties doing anything due to the family not wanting to pay for anything. Resident #52 was given 50 micrograms (mcg) of Fentanyl (opioid) prior to arrival to the emergency room by EMS. While in the emergency room, she was administered Hydromorphone (opioid) injection 0.5 mg and Midazolam HCl (benzodiazepine) injection 0.5 mg. Her differential diagnosis in the emergency room was: evaluation for hospice, intractable pain, decline in mental status, and failure to thrive. Interview with Physician #301 on [DATE] at 3:20 P.M. confirmed she felt like she was kept up to date on the changes that Resident #52 was having during her stay in the facility. She confirmed she discontinued the order for as needed Percocet because they were not certain her changes in condition were caused by pain, and she was spitting the medication out; indicating she was having trouble swallowing. She confirmed there were no other tests or assessments completed (that she was aware of) to support that Resident #1 was not able to swallow. When asked why other pain medication or psychotropic medications were offered for the changes in condition to keep her comfortable, she stated, If she (Resident #52) was spitting out her Percocet, she would not swallow another type of medication. Physician #301 confirmed she was not told whether Resident #52 was swallowing her other scheduled medications during that time; she made the decision to stop the Percocet due to her swallowing difficulties. When asked if she could have ordered injectable medications (pain or psychotropics), she stated she would not take the responsibility of ordering those; she would rather send a resident to the emergency room for those to be administered. She is not comfortable ordering medications that are not swallowed for liability reasons. Interview with Regional Director #191 on [DATE] at 3:25 P.M. revealed from the time Percocet was discontinued ([DATE]) to the time the family made a decision to decline hospice services, the facility allowed the family to spend time with the resident at bedside. He confirmed there were no other medications ordered, such as psychotropics or injectable pain medications. He confirmed the facility was waiting for the family to make a decision on hospice services ([DATE] at 12:27 P.M. to [DATE] at 10:09 A.M.), so they did not put any other orders or interventions in place other than one on one staffing and allowing the family to sit with the resident at bedside. Review of facility Notification of Change in Condition policy, dated [DATE], revealed the following were sample reasons to notify the physician immediately for a change in condition: a deterioration in health, mental, or psychosocial status un either life-threatening conditions or clinical complications, need to alter treatment significantly, or clinical complications such as development of a pressure area, onset of delirium or recurrent urinary tract infections. Documentation of notification or notification attempts should be recorded in the electronic health record. Review of facility Guidelines for Pain Observation and Management policy, dated [DATE], revealed the purpose of the policy is to ensure each resident's pain, including it's origin, location, severity, alleviating and exacerbating factors, current treatment, and response to treatment will be observed and documented according to the needs of each individual. If there is a change in pain indicators or verbalizations from resident, a pain event form will be completed to indicate changes and care plan update.

Based on review of the medical record and interview with staff, the facility failed to ensure wound treatment orders were in place for Resident #56. This affected one resident (Resident #56) of three reviewed for wounds.Findings included:Review of the medial record revealed Resident #56 was admitted to the facility on [DATE]. Diagnoses included surgical aftercare, presence of an aortocoronary bypass graft, cardiogenic shock, atherosclerotic heart disease, respiratory failure, pulmonary fibrosis, chronic kidney disease, diabetes, tremor, macular degeneration, obstructive sleep apnea, chest pain, bipolar disorder, depression, diverticulosis, atelectasis and thrombocytopenia. He was discharged to the hospital on [DATE].Review of the progress note dated 04/17/25 at 5:41 P.M. revealed Resident #56 had a deep tissue injury to his bilateral buttocks. The right buttock measured 4.0 centimeters (cm) by 3.5 cm and was a dark reddish purple in color and hard. The left buttock measured 4.9 cm by 5.1 cm, was dark reddish purple in color and hard. Calazine was applied to both areas.Review of the Plan of Care dated 04/18/25 revealed Resident #56 had an approach under his Profile Care Guide on his care plan to apply barrier cream after each incontinent episode.Review of the physician's orders revealed Resident #56 had orders dated 04/17/25 to encourage the resident to float heels while in bed as tolerated, encourage turning and repositioning, a pressure reducing mattress to the bed, and a pressure reducing cushion in the wheelchair. Review of the Treatment Administration Record for Resident #56 from 04/17/25 to 04/20/25 revealed no documented evidence of protective cream to the resident's bilateral buttocks.Review of the occurrence note dated 04/21/25 at 12:15 P.M. revealed Resident #56 had Moisture Associated Skin Damage (MASD) (skin condition caused by prolonged exposure to moisture causing inflammation) to the buttocks. There were no measurements documented. Further review of the physician's order revealed Resident #56 had an order for protective cream to bilateral buttock twice daily and as needed, dated 04/21/25.Review of the Five-Day Minimum Data Set assessment dated [DATE] revealed Resident #56 had intact cognition. Resident #56 was dependent for toilet hygiene, required substantial assistance with rolling in bed, was occasionally incontinent for bladder and bowel, was at risk for pressure ulcers, and had two deep tissue injuries and surgical wounds.Interview on 07/12/25 at 9:55 A.M. with the Director of Nursing revealed the buttocks of Resident #56 were not open, they were just a Deep Tissue Injury (DTI) and would not require anything other than barrier cream and she had documented that she had put the barrier cream on him upon admission, however she did verify there was no other documentation of barrier cream being applied or an order for barrier cream until 04/21/25, after he was identified with MASD.Review of the facility policy titled, Guidelines for Pressure Prevention, dated 12/01/21 revealed the purpose was to maintain good skin integrity and avoid the development of pressure ulcers. This deficiency represents non-compliance investigated under Complaint Number OH00166207.

Based on review of the infection control logs, review Center of Disease Control and Prevention (CDC) guidelines, observation, interview, and policy review, the facility failed to ensure policy and procedures were in place for laundering isolation linens and clothing and failed to ensure staff were knowledgeable on the process to prevent infection transmission throughout the facility. This had the potential to affect all 52 resident residing in the facility. Findings include: Review of the infection control log dated 11/2024 to 01/09/24 revealed in November 2024 there were three cases of Clostridium difficile (C-diff, a highly contagious bacterium that causes diarrhea and colitis). In December 2024 there were four cases of C-diff, and in January 2025 (through 01/09/25) there was one case of C-diff recorded. Observation and interview on 01/08/24 at 11:30 A.M., with the Director of Environmental Service (DES) #149 revealed if a resident had C-diff infection, the floor staff would take the laundry from the resident's room to the soiled linen rooms on the hallway. The facility treats all laundry items as contaminated, so the staff don't label or place contaminated linens in any special bag or container. The laundry staff would then go to the soiled linen rooms with a barrel to collect the laundry to transport to the laundry room. The laundry staff would enter on the dirty side of the laundry room and apply gloves, gowns, and goggles and proceed to sort all the laundry. The staff do not separate the contaminated (C-diff) laundry from the non-contaminated laundry due to the facility washing machine being a high-temperature machine. DES #149 reported the hot water temperatures for the washer range from 140-145 and to her understanding the hot water would kill all organisms, including C-diff. DES #149 reported staff would use the wash cycle that was on a chart on the wall to wash the linens or clothing. DES #149 referenced the chart and stated #1 was a pre-set cycle for sheets, #2 was a pre-set cycle for towels, #3 was a pre-set cycle for incontinence pads, #4 was a pre-set cycle for residents' personal clothing items which did not contain bleach, and #5 was a pre-set cycle for blankets or bed sheets. DES #149 confirmed there was an isolation cycle, however it was not used as the hot water temperatures were effective and the isolation cycle contained bleach which would ruin colored items. DES #149 did not know what products or formula was used in which cycle and would have to call the supply company. Interview on 01/09/25 at 9:20 A.M., and 10:36 AM with DES #149 revealed the supply company came out last night to determine what products were used in each cycle. Cycle #1 was for sheets and contained 3.5 ounces of bleach, Cycle #2 was for towels and had 3.5 ounces of bleach. Cycle #3 was for incontinence pads and had 4.5 ounces of bleach. Cycle #4 was for personal items and had no bleach. Cycle #5 was for blankets/bedspreads and had no bleach. Cycle #11 was for isolation and had 4.5 ounces of bleach. DES #149 confirmed resident personal items, including residents infected with C-diff's personal items, would be washed in Cycle #4 with the formula which did not contain bleach. DES #149 confirmed the facility did not have a policy on washing isolation linen or clothing, however she was going to reach out to her corporate office. Interview on 01/09/25 at 10:53 A.M., with DES #149 revealed the only thing she could find regarding the laundry procedure dated 06/14/12 indicated infection linen would be double bag with two can liners. The procedure called for staff to bring the can liners to the central soiled utility room and place in a tub. The procedure recommended to wash personal laundry at the campus for infection control and not allow residents to take clothing or linens home to wash. Interview on 01/09/25 at 2:49 P.M., with Supplier #500 confirmed he had visited the facility last night to ensure which products were used in each formula/cycle. Supplier #500 reported destainer was the bleach, and if used would kill most of the common organisms. The supplier confirmed personal item cycle, and the blankets/bedspread formula/cycles do not contain bleach (destainer). Review of the facility policy Infection Prevention and Control Program (IPCP) revised 11/15/21 revealed the infection prevention and control program was designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The policy stated a member of the clinical team shall be designated to monitor the campus IPCP program to perform surveillance to identify, investigate, control, and prevent the spread of infection and reporting for the IPCP. The policy included responsibilities which included to review each department's policies and procedures annually for their adherence to infection control principles. The policy stated this included nursing, dietary, housekeeping, laundry, maintenance, and others as required. The policy additionally listed for a review of in-use disinfectants when evidence of continuing transmission of an infectious agent (such as rotavirus, C. diff, norovirus, etc) are reviewed and changed to a more effective disinfectant as indicated. Review of the CDC Guide to Preventing Clostridium difficile Infections dated 12/18/24 revealed although many EPA registered germicides kill the vegetative C. difficile, only chlorine-based disinfectants and high concentration hydrogen peroxide formulations kill spores. According to the CDC, the risk of disease transmission from soiled linen is negligible, and common-sense hygienic practices for processing and storage of linen are recommended. Policies and procedures should be in place to ensure that soiled linen is handled as little as possible to prevent microbial contamination of the air and of persons handling the linen. Soiled linen should be bagged or placed in containers at the location where it was used and should not be sorted or rinsed at that location. Heavily soiled or contaminated linen should be placed into containers that will prevent leakage. Soiled linen is usually sorted in the laundry before washing. Policies and procedures for appropriate protective apparel to be worn by laundry personnel should be in place and enforced at the laundering facility. The soiled textiles area must be functionally separated from the clean textiles processing area. Functional separation may be obtained by any one or more of the following methods: a physical barrier, negative air pressure in the soiled textiles area, and/or positive air flow from the clean textiles area through the soiled textiles area with venting directly to the outside. To remove significant quantities of microorganisms from grossly contaminated linen commercial laundry facilities, use water temperatures of at least 160 F, and may use 50 to 150 parts per million (ppm) of chlorine bleach as well. Satisfactory reduction of microbial contamination can be achieved at water temperatures lower than 160 degrees Fahrenheit (F) if chemicals suitable for low temperature washing are used. The facility was not able to provide evidence the hot water temperature in the facility's washing machine was greater than 160 degrees F by the conclusion of the survey on 01/09/25.

Based on record review, pharmacy recommendations, and staff interview, the facility failed to implement pharmacy recommendations in a timely manner for Resident #15. This affected one (Resident #15) out of five residents reviewed for unnecessary medications. The facility census was 52. Findings include: Review of the medical record revealed Resident #15 was admitted on [DATE] with diagnoses that included bipolar II, type 2 diabetes, anxiety disorder, and major depressive disorder. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #15 was cognitively intact. The MDS also revealed Resident #15 received antipsychotic and anticonvulsant medication. A pharmacy recommendation dated 10/10/24 revealed Resident #15 had an order for Estring (vaginal ring that reduces the symptoms of menopause) to be replaced every three months at the doctors office. A recommendation was made to add the month the Estring was to be replaced for better monitoring. The recommendation was marked as accepted. Review of the physician orders and Medication Administration Records (MAR) after the 10/10/24 recommendation revealed the month the Estring was to be replaced had not been added. A pharmacy recommendation dated 11/22/24 revealed Resident #15 was ordered Gabapentin (anticonvulsant and to treat nerve pain). A recommendation was made to consider adding a side effect monitoring order set for anticonvulsant's. On 12/19/24, monitoring for anticonvulsant medication was added to observe Resident #15 closely for significant side effects such as drowsiness, Ataxia, Nystagmus, dizziness, blurred vision, nausea, rash, gum enlargement, and jaundice. A pharmacy recommendation dated 12/30/24 revealed Resident #15 received aripiprazole (antipsychotic) medication. An abnormal involuntary movement (AIMS) assessment should be performed at baseline and at least every 6 months. The last AIMS assessment in the medical record was completed on 05/15/24. The pharmacy recommendation was marked as completed with a note the AIMS assessment was completed in October 2024. Review of the quarterly Observation and Data Collection form dated 10/05/24 revealed Resident #15 was not receiving an antipsychotic medication and the AIMS assessment did not need to be completed. Interview on 01/09/24 at 9:45 A.M. Director of Health Services (DHS) verified the recommendation to add the month Resident #15's Estring was to be replaced was not completed. DHS also verified the side effect monitoring for Gabapentin was not addressed until 27 days after the recommendation had been received. DHS verified the last AIMS assessment had been completed on 05/15/24 and an AIMS assessment for Resident #15 was not completed until 01/09/24 after being made aware pharmacy had made an AIMS assessment recommendation. Review of the policy Consultant Pharmacist Reports revised 11/18 revealed the medical regimen review (MRR) includes evaluating the residents response to medication therapy to determine that the resident maintains the highest practicable level of functioning and preventing or minimizing adverse consequences related to medication therapy. Recommendations are acted upon and documented by the facility personnel and/or the prescriber. The prescriber accepts and acts upon the suggestion or rejects and provides an explanation for disagreeing. The director of nursing or designated licensed nurse addresses and documents recommendations that do not require a physician intervention. Review of the Guidelines for: Abnormal Involuntary Movement Scale (AIMS) revised 05/22/18 revealed a licensed nurse will complete an AIMS assessment on all residents on antipsychotic medications and/or other medications know to cause tardive dyskinesia. The AIMS assessment will be completed if possible prior to the resident beginning this type of medication, or at the earliest possible time; either after admission, after medications are prescribed, and with dosage changes. The AIMS assessment will be repeated for every resident taking antipsychotic medications every six months or as needed for displaying symptoms of tardive dyskinesia.

Based on observation, interview, medical record review, and review of policies, the facility failed to notify the physician and address a change in Resident #11's ability to chew and swallow and failed to implement compression stockings or unna boot dressings per order for Resident #9. This affected two residents (#9 and #11) of 15 residents reviewed for quality of care and treatment. The facility census was 52. Findings include: 1. Review of Resident #11's medical record revealed an admitted [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, pulmonary fibrosis, heart failure, depression, anxiety disorder, hypotension, benign neoplasm of parotid gland, altered mental status, and age-related physical debility. Review of Resident #11's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she was cognitively intact. She had no chewing or swallowing concerns. Review of Resident #11's diet orders from 12/04/24 to 01/06/25 revealed an order for a regular texture diet. Review of Resident #11's plan of care dated 12/29/24 revealed the resident had no concerns related to chewing, swallowing, or dentition. Review of Resident #11's progress note dated 11/04/24 revealed the resident was holding pills in her mouth and not swallowing them. The note indicated Resident #11 also held pills crushed in pudding in her mouth. There was no indication the physician or family was notified. Review of Resident #11's Admission assessment dated [DATE] revealed the resident had no swallowing problems and no dental problems. Review of Resident #11's nutrition assessment dated [DATE] revealed no indication the resident had problems chewing or swallowing. Review of Resident #11's medical record from 11/05/24 to 12/29/24 revealed no further documentation related to Resident #11's difficulty swallowing. Review of Resident #11's progress note dated 12/30/24 revealed an unnamed Certified Nursing Assistant (CNA) had reported the resident was coughing and gagging with meals and drinks. The nurse noted the resident spit out the medication into her hand and rubbed them on the side of her face. Resident #11 also tried to hold medications in her mouth and then gagged and coughed. There was no indication the physician or family was notified. Review of Resident #11's progress note dated 12/31/24 revealed the resident was admitted to hospice related to physical debilities, and several of her routine medications and laboratory testing had been discontinued. The resident's daughter was in agreement with this. Review of Resident #11's nutrition assessment dated [DATE] revealed the resident had a recent episode of coughing and gagging with oral intake. There were no recommendations related to this and no indication the dietitian had discussed the concerns with the resident, family, or physician. Review of Resident #11's progress note dated 01/06/25 revealed the resident asked for a pureed diet after breakfast. She reported she could not chew her food well enough to swallow it. She received a puree diet for lunch and ate it well. Review of Resident #11's diet order dated 01/06/25 revealed an order for puree texture per the residents request as she could not chew the food well enough to swallow. Interview on 01/08/25 at 2:00 P.M. with Regional Dietitian #100 revealed the facility's dietitian was unavailable. He reported if he became aware of a resident having swallowing problems he would discuss it with nursing to ensure the proper steps were taken, whether that was downgrading a diet or referring a resident for a speech therapy evaluation. Interview on 01/08/25 at 4:01 P.M. with the Director of Nursing (DON) verified there was no evidence the physician or power of attorney (POA) was notified of Resident #11's swallowing problems on 12/30/24. She additionally verified there was no evidence this issue was followed up on or discussed with the resident. The DON reported she had discussed this concern with the resident today who reported that she only had a problem chewing due to poor dentition and she refused the dentist. Interview on 01/08/25 at 4:10 P.M. with Licensed Practical Nurse (LPN) #144 revealed she worked the morning of 12/31/24 and it had not been communicated to her that Resident #11 had problems swallowing and she had not notified the POA or physician. LPN #144 reported Resident #11 had always had problems chewing so she was sure the POA was aware. Interview on 01/09/25 at 7:51 A.M. and 8:25 A.M. with the DON verified prior to 12/30/24 the only indication Resident #11 had chewing or swallowing problems was the progress note on 11/04/24. The resident was not assessed or care planned to have problems chewing or swallowing. She additionally verified she would expect a nurse to notify appropriate parties of changes in a residents abilities to chew or swallow. The DON verified there was insufficient documentation to show anyone followed up or notified the physician or POA after Resident #11's 11/04/24 and 12/30/24 incident. Review of the policy 'Notification of Change of Condition' dated 12/17/24, revealed the facility must inform the resident, consult with the physician, and notify the resident's legal representative of an accident involving the resident and has the potential for requiring physician intervention, when there is a significant change in the resident's physical, mental, or psychosocial status, or a need to alter treatment significantly. 32801 2. Review of Resident #9's medical record revealed Record review revealed an admitted [DATE] with diagnoses including venous insufficiency, congestive heart failure, hypotension, dementia, diabetes (type 2), retention of urine, and cardiomyopathy. Resident #9 was hospitalized and readmitted to the facility on [DATE]. Review of Resident #9's peripheral vascular disease plan of care dated 12/06/24 revealed no evidence of compression stockings or unna boot treatments. Review of Resident #9's skin integrity plan of care dated 12/06/24 revealed treatments and preventative treatments were to be applied when ordered. Review of Resident #9's orders dated 12/09/24 and 12/27/24 (re-admission) revealed orders for compression socks to be applied in the morning and removed at night. Review of Resident #9's hospital discharge records dated 12/27/24 revealed orders for unna-flex elastic unna boot (compression gauze bandage impregnated with thick creamy mixture of zinc oxide and calamine used to treatment of venous insufficiencies of the leg and venous status ulcers) to be apply topically daily for three days and knee-high anti-embolism (compression) stockings with 20-30 millimeter of mercury (mm Hg) of compression to be worn daily. Review of Resident #9's orders dated 12/28/24 for the unna boot dressing application revealed to apply a unna boot daily for three days to right pretibial (shin area of the leg) area. Special instructions included to change as needed if the dressing becomes dislodged or soiled. On 12/30/24, the orders were changed to cleanse right lower extremity with normal saline or wound cleanser, apply an unna boot, and cover with kling wrap and tubigrip three times a week and as needed. On 12/31/24, the order was changed again to cleanse the wound with wound cleanser or normal saline, pat dry, apply unna wrap to right lower leg and cover with gauze wrap daily and as needed until healed. Review of Resident #9's progress note dated 12/31/24 revealed the resident had a peripheral vascular wound that was present on admission that measured 0.7 centimeters (cm) length by 1.8 cm width, by 0.1cm depth. The right lower leg was red/purple which was indicative of severe peripheral vascular disease (PVD). The listed treatment included cleansing the area with wound cleanser/normal saline. Apply unna wrap daily and cover with gauze wrap. The physician was recorded as being in agreement with the wound treatment, and the resident was informed of treatment orders and reported he would inform his spouse. Nursing would treat, monitor areas and notify the physician if the resident's condition worsened. Review of Resident #9's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for December 2024 revealed no evidence the unna boot was applied from 12/27/24 to 12/30/24 per orders. Observation of Resident #9 on 01/06/25 at 11:20 A.M., revealed the resident didn't have compression stocking or unna boot in-place. The resident had reported staff had been putting the compression hose/stocking on, but he didn't know where they went. Two surveyors looked around the room and was not able to locate the compression stockings. The resident had a piece of gauze wrapped around a small area below his knee, however most of his lower right leg was exposed. Both lower extremities were red and swollen. A subsequent observation on 01/08/25 at 8:02 A.M. revealed the resident was sitting up in his recliner. The resident did not have compression hose/stocking or an unna boot dressing in-place. The resident reported he still had not found his compression hose/stocking. The resident's lower extremities remained red and swollen. The resident has a gauze dressing in-tact to a small area below the right knee. Interview and observation of Resident #9 on 01/08/25 at 8:10 A.M., with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed the resident did not have compression hose/stocking or the unna boot in-place to the right lower leg per his current orders. The ADON removed the gauze dressing and there was an open area noted on the right lower leg below the knee. Interview on 01/09/25 at 7:47 A.M., with the DON and ADON confirmed the resident was ordered compression hose on 12/09/24 and the compression hose were re-ordered upon the resident's re-admission on 12/27/24. The DON confirmed the resident was ordered unna boots daily for three days when he returned from the hospital on 12/27/24, however the order was entered in the computer but for some reason did not transfer over the medication or treatment record. The DON confirmed there was no evidence the unna boot treatments were completed from 12/28/24 to 12/30/24. The DON reported she had started education with staff on how to correctly apply unna boots. Review of facility policy titled General Wound and Skin Care dated 05/10/17 and revised 12/17/24 revealed the facility provides measures that will promote and maintain good skin integrity.

Based on observation, interview, and medical record review, the facility failed to ensure an order was in place and care was documented for Resident #154 who had a catheter. This affected one resident (#154) of two residents reviewed for catheters. The facility identified four residents with indwelling urinary catheters. The facility census was 52. Findings include: Review of Resident #154's medical record revealed an admitted [DATE] with diagnoses including cerebral infarction due to embolism of cerebellar arteries, dysphagia, adult failure to thrive, severe protein-calorie malnutrition, depression, and gastro-esophageal reflux disease. Review of Resident #154's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he had moderately impaired cognition. Review of Resident #154's progress note dated 12/24/24 at 4:45 A.M. revealed the resident's abdomen was distended and a bladder scan showed urine present. He was unable to be straight cathed and he was sent to the emergency room to have a urinary catheter placed. Review of Resident #154's progress note dated 12/24/24 at 3:20 P.M. revealed the resident returned from the hospital with a new foley (indwelling urinary) catheter in place. Review of Resident #154's plan of care and physician orders on 01/07/25 at 8:30 A.M. revealed there was nothing related to a urinary catheter. Resident #154's record revealed no care was documented for Resident #154's catheter. Observation on 01/06/25 at 10:25 A.M. revealed Resident #154 had a urinary catheter in place. Interview on 01/07/25 at 8:32 A.M. with Registered Nurse #109 and and LPN #163 verified Resident #154 had a indwelling urinary catheter in place but had no orders or care plan for the catheter. Resident #154 went to the hospital and came back with the catheter. LPN #163 reported she would check the catheter size and put in the orders.

Based on medical record review, staff interview, and review of facility policy, the facility failed to have justification for prophylactic antibiotics for Resident #38. This affected one resident (#38) of two residents reviewed for antibiotic stewardship. The facility census was 52. Findings included: Review of the medical record for Resident #38 revealed an admitted [DATE]. Diagnoses included sepsis, acute cystitis with hematuria, polyneuropathy, and history of prostate cancer. Review of the physicians' orders dated 07/15/24 for Resident #38 revealed orders from a urologist for levofloxacin (an antibiotic) 500 milligrams (mg) by mouth daily for three days, prophylactic due to cystoscopy. On 07/15/24, macrobid (an antibiotic) 100 mg by mouth once daily was ordered prophylactic starting on 07/18/24, continuously for a year's duration. Review of the Plan of Care dated 08/22/24 revealed Resident #38 received long-term prophylactic antibiotic medication related to recurrent urinary tract infections. A listed goal included the resident will not exhibit signs of complications associated with prophylactic antibiotic use. Listed interventions included to encourage fluid intake, observe for signs and symptoms of adverse effects/complications associated with prophylactic antibiotic use and report to medical doctor (MD), observe for sign and symptoms antimicrobial resistant organisms and report to MD, and to obtain labs as/when ordered, reporting results to MD. Interview on 01/09/25 at 11:54 A.M. with Director of Health Service (DHS) and Infection Control Nurse #165 revealed that Resident #38's levofloxacin and macrobid did not meet the criteria for antibiotic use, and there is not a statement by the physician justifying the use of the prophylactic antibiotic and did not meet McGeer criteria for antibiotic use. Review of the policy Infection Prevention and Control Program (IPCP) revised 11/15/21 revealed the IPCP designee will work with campus pharmacy provider regarding an antibiotic stewardship program and campus Medical Director as needed. Outcome surveillance should be reviewed by the IPCP designee. Documentation shall be reviewed within the resident's Electronic Health Record (EHR) to assist in identify if the infection meets the McGeer Criteria.

Based on interview and record review the facility failed to monitor pain severity, location, and nonpharmacological interventions for Resident #37 who received as-needed pain medication. This affected one resident (#37) of two residents reviewed for pain management. The facility census was 52. Findings include: Review of Resident #37's medical record revealed an admitted [DATE] with diagnoses including unspecified dementia, chronic obstructive pulmonary disease, anxiety disorder, esophageal obstruction, depression, anxiety, dysphagia,and mixed receptive expressive language disorder. Review of Resident #37's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had moderately impaired cognition. Review of Resident #37's plan of care dated 11/13/24 revealed she was at risk for pain related to diagnoses and impaired mobility. Interventions included observing and recording verbal and nonverbal signs of pain, notifying the physician of increased pain, administering medications as ordered, and attempting non-pharmacological interventions. Review of Resident #37's physician order dated 12/19/24 revealed an order for Hydrocodone-Acetaminophen (narcotic pain medication) 5-325 milligrams (mg) every four hours as needed. Review of Resident #37's Medication Administration Record (MAR) from 12/19/24 to 01/06/25 revealed as-needed Hydrocodone was administered on 12/21/24 at 9:56 A.M. and 2:26 P.M., on 12/22/24 at 9:10 A.M. and 1:16 P.M., on 12/23/24 at 2:21 A.M. and 10:54 A.M., on 12/24/24 at 10:57 A.M. on 12/25/24 at 8:48 A.M., on 12/26/24 at 5:37 A.M., 9:43 A.M., 3:12 P.M., and 7:33 P.M., on 12/27/24 at 10:14 A.M. and 2:12 P.M., on 12/28/24 at 10:53 A.M., 12/30/24 at 3:42 P.M., and on 01/01/25 at 12:47 P.M. Review of the MAR notes revealed the medication was administered on 12/23/24 for knee pain of six out of 10. There were no additional notes or documentation related to the administration of the as-needed pain medication. There was no further rating of pain, description of pain, or indication of nonpharmacological interventions attempted. Review of Resident #37's progress notes from 12/19/24 to 01/06/25 revealed no further documentation related to the resident's reports of pain or the as-needed administration of Hydrocodone on the above days. Interview on 01/09/25 at 8:25 A.M. with the Director of Nursing (DON) verified there was no documentation of pain level, description of pain, or nonpharmacological interventions. Review of the policy 'Guidelines for pain observation and management' dated 12/17/24, revealed each resident's pain including its origin, location, severity, alleviating and exacerbating factors, current treatment and response to treatment will be observed and documented according to the needs of each individual.

Based on observation, record review, resident and staff interviews, and facility policy review, the facility failed to timely address or implement effective nutritional interventions for Resident #298 who experienced a significant weight loss. This affected one resident (#298) of three residents reviewed for nutrition. The facility census was 51. Actual Harm occurred on 01/05/24 when Resident #298's weight revealed a significant weight loss of 5% in less than 30 days. The Registered Dietitian (RD) was not notified and did not address the significant weight loss until 01/10/24 (five days later) to make nutritional recommendations. The facility did not implement the nutritional recommendations from the RD that were made on 01/10/24 until 01/12/24 (seven days after the significant weight loss was identified). The nutritional interventions were not properly monitored by the facility staff for effectiveness. Resident #298 was weighed again on 01/15/24 (ten days following the initial identification of a significant weight loss) which showed an additional 4% weight loss. Resident #298's total weight loss was 9% in less than 30 days. Findings Include: Review of the medical record for Resident #298 revealed an admitted on 12/22/23. Medical diagnoses included displaced intertrochanteric fracture of left femur, polymyalgia rheumatica, and Type II Diabetes mellitus without complications. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #298 had intact cognition and scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #298 had an impairment to her lower extremity and used a walker or wheelchair for mobility. Resident #298 required substantial/maximal assistance from staff to complete bed mobility and partial/moderate assistance with transfers. Resident #298 weighed 123 pounds (lbs) with no noted weight loss or gain in the last month or six months. Resident #298 was on a therapeutic diet. Resident #298 did not have any unhealed pressure ulcers or injuries. Review of weights dated from 12/22/23 to 01/15/24 revealed Resident #298 weighed 123 lbs on 12/22/23 at 10:15 P.M., 116 lbs on 01/05/24 at 3:53 P.M. (a seven lb weight loss), and 111 lbs on 01/15/24 at 9:57 A.M. (an additional five lb weight loss and a total weight loss of 12 lbs in less than 30 days). Review of meal intakes dated from 12/22/23 through 01/18/24 revealed Resident #298's intakes varied from 1-25% to 76-100%. From 12/22/23 to 01/05/23 (15 days), the resident's intake was documented as 50% or less 13 times. Review of the care plan dated 12/22/23 revealed Resident #298's Profile Care Guide included a regular diet, regular texture, thin liquids, and fortified foods. The care plan noted Resident #298 did not like cottage cheese. Review of the progress notes dated from 12/22/23 through 12/27/23 revealed on 12/22/23 at 5:37 P.M., Resident #298 was admitted to the facility. Vital signs were within normal limits. The resident had three surgical incisions to her lower left extremity from hip fracture surgery. Resident #298's abdomen was noted to be distended (bloating or swelling in the belly area) was noted. On 12/23/23 at 10:54 A.M., Resident #298 was noted to have non-pitting (does not indent when pressure is applied) swelling to her left lower leg as well as abdominal distension. On 12/24/23 at 11:54 P.M., 12/25/23 at 11:26 A.M., and 12/27/23 at 11:48 P.M., Resident #298 was noted without any swelling to either leg and abdominal distension was noted. Review of the Admission Nutrition assessment dated [DATE] at 8:13 A.M., revealed Resident #298's current body weight on 12/22/23 was 123 lbs. with a hospital weight of 124 lbs. The resident was noted for a risk of weight/fluid variances post surgery and post intravenous fluids (IVF) at hospital. Monitor weights as available. Increased metabolic demands related to hip fracture and surgery. Edema (swelling) noted per nursing masking actual weight and/or potential weight changes. Malnutrition risk related to edema masking actual weight and/or potential weight changes. Diet: Controlled Carbohydrate (CCHO). The diet was adequate to meet Resident #298's calculated needs. Intakes ranged from 26% to 100%. No dietary recommendations were made. Monitor weights, labs, physical parameters to evaluate diet and intakes meet actual needs with current interventions. Honor food preferences within ordered diet. Review of progress notes dated from 12/28/23 through 01/01/24, 01/03/24 through 01/05/24 through 01/09/24 revealed Resident #298 did not have any edema or abdominal distension noted. Review of the progress notes dated 01/02/24 at 7:35 A.M. and 01/09/24 at 7:10 A.M. by Medical Director (MD) #47 revealed there was no edema noted in the physician's assessments. Review of the progress note dated 01/05/24 at 10:25 P.M. revealed Licensed Practical Nurse (LPN) #61 identified a new dark, boggy intact area with no drainage measuring approximately 3.5 centimeters (cm) long by 2.5 cm wide to Resident #298's left heel. There was no documentation of the identified significant weight loss when Resident #298's weight was 116 lbs on 01/05/24. There was no documentation the Registered Dietitian (RD), physician, or resident representative were notified of the significant weight loss. There was no documentation a re-weight had been completed. Review of the Nutrition - Weight/Wound Note, dated 01/10/24 at 11:13 A.M. revealed Resident #298's current weight was 116 lbs taken on 01/05/24 (five days earlier). A significant weight loss of seven lbs or 5.7% in two weeks was noted. Recommended weekly weights for four weeks. Increased metabolic demands related to skin impairment. Loss may be related to recent acute care events. Consider diet liberalization to maximize nutritional support in advanced age setting. Intakes were 51-100%. Recommend changing diet to Fortified diet, regular texture, thin liquids to offer additional calories and protein. Monitor weights with nutritional interventions as recommended. Review of the Metabolic/Nutrition Event dated 01/10/24 and completed by Registered Dietitian (RD) #102 revealed the dietitian recommended to change diet to fortified diet, regular texture, thin liquids (discontinue controlled carbohydrate diet) and weekly weights for four weeks. The physician and resident representative were notified on 01/12/24 (seven days after a significant weight loss was identified). Review of the care plan for Resident #298 revealed the care plan had been revised on 01/10/24 and indicated the resident had experienced a significant weight loss within 30 days. Interventions included offer encouragement and assistance with eating as needed (PRN), provide diet, supplements, medications, adaptive equipment, and snacks as ordered, and weigh as ordered. Additionally, Resident #298 required increased caloric, protein, and/or nutrient needs related to presence of impaired skin integrity. Interventions included encourage fluids, obtain weight as ordered or as needed, provide diet as ordered, and provide supplements, vitamins, and/or minerals as ordered. Review of an Interdisciplinary Team Note (IDT) dated 01/12/24 at 4:51 P.M. (two days after recommendations were made and seven days after a significant weight loss was initially identified) revealed the dietitian recommends to add fortified foods to diet. MD #47 notified and agreed. Review of the physician's orders revealed Resident #298 had the following diet order: Controlled Carbohydrate, regular texture, fortified food, and thin liquids dated 01/12/23. An order for weekly weights had not been implemented as recommended. Review of the progress note dated 01/16/24 at 6:45 A.M. by MD #47 noted Resident #298's weight on 01/15/24 at 9:57 A.M. was 111 lbs (an additional five lb loss). Review of the Nutrition - Weight Note, dated 01/17/24 at 10:29 A.M., revealed Resident #298's current weight on 01/15/24 was 111 lbs. An additional weight loss of five lbs in ten days was noted and a significant weight loss of 12 lbs in 24 days or 9.5% weight loss was noted with decreased meal intakes. Monitor weights as available. Fortified diet as ordered. Recommend to discontinue CCHO diet in advanced age setting with poor meal intakes. Intakes ranged from 26-75%. May benefit from an appetite stimulant. Consider consulting with the physician for an appetite stimulant such as Remeron. Monitor oral intakes and weight trends with recommended interventions. Review of the Fortified Foods List revealed the options included: yogurt parfait, power shake, cheese and cracker plate, peanut butter crackers, and cottage cheese plate. Observation and interview on 01/17/24 at 1:00 P.M. with Resident #298 in her room revealed the resident had the lunch meal in front of her. The meal consisted of baked chicken, mashed potatoes, peas, Jello dessert, a chef's salad, and grapes. There was not a fortified food noted on the resident's meal tray. Interview on 01/17/24 at 2:41 P.M. with RD #102 revealed she was on-site at the facility one time per week to review resident weights. RD #102 stated if a resident was weighed after she was on-site that week and revealed a significant weight change, she would not know until the following week unless the facility staff notified her of the change. RD #102 confirmed she had not been notified of Resident #298's significant weight loss identified on 01/05/24 until 01/10/24 when she was on-site at the facility and reviewed the weights (five days later). RD #102 stated she made recommendations to add fortified foods and weekly weights as interventions on 01/10/24 and informed the staff. RD #102 stated a re-weight would be suggested when a significant weight loss or gain was indicated to confirm the weights are accurate. RD #102 confirmed the diet recommendation was not implemented until 01/12/24 (two days later and seven days following the identification of a significant weight loss). RD #102 confirmed an order for weekly weights had not been implemented by the facility. Resident #298 was weighed again on 01/15/24 and revealed an additional five lb weight loss. The most recent weight was just reviewed by RD #102 today, 01/17/24, with additional recommendations made. Observations and interviews on 01/17/24 at 5:10 P.M. and 5:25 P.M. with Resident #298 in her room. During the interview, discussion with the resident included the list of fortified foods. Resident #298 stated she did not like yogurt or cottage cheese. Observed the resident's dinner tray had been placed in front of her and included: a Ritz cracker and cottage cheese plate, turkey, dressing, green beans, mashed potatoes, and a piece of cake with fruit topping. Resident #298 stated she would not eat the cottage cheese. Review of the meal ticket for the dinner meal on 01/17/24 revealed the meal ticket stated fortified food, no sweets, wants small portions, and decaf coffee. There were not any dislikes listed. Interview on 01/17/24 at 5:45 P.M. and 5:57 P.M. with the Director of Food Services (DFS) #86 confirmed the fortified food offered with the dinner meal was a cracker and cottage cheese plate. DFS #86 stated the list of fortified foods was not reviewed with the residents for preferences. DFS #86 stated the kitchen staff picked a fortified food for the meal and if a resident requested another option, the kitchen would provide it. DFS #86 stated she was not aware Resident #298 did not like yogurt or cottage cheese. DFS #86 stated she did not know who was responsible for monitoring the acceptance of the fortified food. DFS #86 stated the kitchen staff did not provide education to the residents regarding the importance of eating the additional fortified food and did not explain to the resident why the additional fortified food was added to the meal trays. DFS #86 offered Resident #298 another fortified food option following surveyor intervention and the resident accepted peanut butter crackers. Interview on 01/17/24 at 6:20 P.M. with the Administrator and Assistant [NAME] President (AVP) #101 confirmed the facility had not been monitoring the acceptance of the fortified food options and had only been monitoring resident intakes of the whole meal tray. The Administrator and AVP #101 confirmed the fortified foods list did not meet the selection indicated in the facility's policy. The Administrator and AVP #101 confirmed resident preferences should have been addressed with the residents related to the fortified food options. Review of the facility policy, Nutrition Recommendation Guideline, reviewed 12/01/21, revealed the policy stated, the dietitian reviews recommendations with the Director of Health Services (DHS) and Director of Food Services (DFS) if possible or a copy of the recommendations is provided for the Executive Director (ED), DHS, and DFS to review. Suggested discipline follows up on recommendations in a timely manner. Review of the facility policy, Guidelines for Weight Tracking, reviewed on 12/31/22, revealed the policy stated, residents who have a weight that seem out of normal range shall be re-weighed to determine the accuracy of the original weight. The physician, resident representative, and dietitian shall be notified of a weight variance of 5% in 30 days. Review of the facility policy, Fortified Foods, reviewed 10/02/23, revealed the policy stated, The Fortified Foods program focuses on provided a greater variety of food choices to better meet the unique nutritional needs and preferences of each resident. The Fortified Foods selection includes shakes, desserts, breakfast items, soups, and savory foods. When placed on Fortified Foods, a resident will receive a fortified food item of choice in addition to the regular menu meal. The Director of Food Services (DFS) will talk with residents to decide on what fortified food is preferred. At least two fortified food options should be available per meal, with one option to always be a fortified shake.

Based on observation, record review, resident and staff interviews, review of skin assessments, and facility policy review, the facility failed to prevent, comprehensively assess and timely treat a pressure ulcer and failed to prevent the pressure ulcer from worsening for Resident #298. This affected one resident (#298) of three residents reviewed for skin impairments. The facility census was 51. Actual Harm occurred on 01/05/24 when a new, facility-acquired, skin area was identified on Resident #298's left heel that developed within 30 days of the resident's admission. The area was assessed as a purple-black bruise without swelling and measured 3.5 centimeters (cm) long by 2.5 cm wide. The facility failed to notify the physician or implement any treatment to the left heel until 01/09/24 (five days after the skin injury was identified) resulting in the wound worsening to an unstageable (full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough and/or eschar in the wound bed) deep tissue injury (purple or maroon localized area of discolored intact skin due to damage of underlying soft tissue from pressure and/or shear) measuring four cm long and three cm wide and covered by necrotic (dead) tissue. Findings Include: Review of the medical record for Resident #298 revealed an admitted on 12/22/23. Medical diagnoses included displaced intertrochanteric fracture of left femur, polymyalgia rheumatica, and Type II Diabetes mellitus without complications. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #298 had intact cognition and scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #298 had an impairment to her lower extremity and used a walker or wheelchair for mobility. Resident #298 required substantial/maximal assistance from staff to complete bed mobility and partial/moderate assistance with transfers. Resident #298 did not have any unhealed pressure ulcers or injuries. Skin treatments included a pressure reducing device for chair and bed. Review of the physician orders revealed Resident #298 had the following orders in place: Oxycodone 5 milligrams (mg) every six hours as needed (PRN) for pain dated 12/22/23 and a Wound Care (WC) order for left heel to cleanse wound with wound cleanser or normal saline, apply Betadine, and cover with foam (gentle or life) dressing every five days dated 01/09/24 (four days after the wound was identified). Review of progress notes dated from 12/22/23 through 01/18/24 revealed on 01/05/24 at 10:25 P.M., Licensed Practical Nurse (LPN) #61 noted the aide reported Resident #298 was requesting pain medication. LPN #61 spoke with Resident #298 who reported left heel pain rated a seven (out of ten) and stated, it usually only hurts at night. LPN #61 looked at bilateral heels and a dark, boggy, intact area with no drainage, approximately 3.5 cm long by 2.5 cm wide was noted to her left heel. LPN #61 assisted to reposition and elevated her feet on a pillow to help with reducing pressure. Resident #298 was educated on the importance of elevating her feet as much as possible. PRN pain medication was given. On 01/09/24 at 10:53 A.M. (four days later), the physician was notified of a left heel deep tissue injury (DTI) and new order was received to apply Betadine and cover with foam daily. Review of the Medication Administration Record (MAR) dated January 2024 revealed Resident #298 received PRN Oxycodone on 01/05/24 at 9:56 P.M. for pain to her left heel. The pain level was an eight out of ten where ten was the worst possible pain. Review of the Treatment Administration Record (TAR) dated January 2024 revealed Resident #298 received a weekly skin assessment on 01/02/24, 01/09/24, and 01/16/24. None of the assessments noted a 1 for a new impairment. Review of the care plan, dated 12/22/23, revealed Resident #298 had a pressure ulcer to left heel with a start date of 01/12/24. Interventions included assess and record the condition of the skin surrounding the pressure ulcer, observe for and report signs of pain related to the pressure ulcer, treatment per physician order and notify physician if treatment was not effective, and weekly skin assessment, measurement, and observation of the pressure ulcer and record. Review of the Skin Integrity Event - Bruise Event, created on 01/05/24 at 10:34 P.M. and completed at 10:36 P.M. by LPN #61 revealed Resident #298 had facility-acquired bruise on her left heel, approximately 3.5 cm long by 2.5 cm wide. The bruise was purple-black without swelling. Resident #298 reported a pain level of seven out of ten (where ten is the worse possible pain), and described as severe, horrible, intense pain. The immediate intervention was to make sure the resident had an appropriate treatment implemented. The physician and resident representative were notified. This event was invalidated by LPN #61 on 01/09/24 at 10:41 A.M. with a reason of incorrect data. However, the progress note was not invalid. Review of the Skin Integrity Event - Pressure, Stasis, Diabetic Wound Event, created on 01/05/24 at 10:25 P.M. (nine minutes prior to the Bruise Event was opened) but not completed until 01/09/24 at 10:43 A.M. (four days after the event was initially created) by LPN #61 revealed Resident #298 had a facility-acquired left heel wound measuring approximately 3.5 cm long by 2.5 cm wide. The wound was not staged and did not include a comprehensive assessment of the wound bed or the surrounding skin of the area. New interventions included to utilize transfer/draw sheets/trapeze to decrease friction and avoid positioning resident directly on skin breakdown. Treatment orders was marked yes. Physician and resident representative were noted to be notified on 01/09/24 at 10:44 A.M. Review of the Wound Management Detail Report dated 01/12/24 at 10:00 A.M. and completed by LPN #50 revealed Resident #298 had a facility acquired pressure ulcer to her left heel that measured four cm long by three cm wide. The wound was staged as an unstageable, deep tissue injury with necrotic tissue. The wound was 100% covered by eschar tissue (dead tissue that sheds or falls off from the skin, typically tan, brown, or black, and may be crusty. When a wound has eschar on top of it, the wound cannot be classified because it makes it difficult to see the wound underneath). The surrounding skin had redness and was blanchable (can make it go away by pressing on it). Interview on 01/17/24 at 5:10 P.M. with Resident #298 revealed the resident's left heel was still sore. Resident #298 stated she thought she caused the wound while trying to turn over in bed one night. The resident stated the wound was not seeping and she thought it was closed. Resident #298 stated the physician looked at the wound yesterday, 01/16/24. Resident #298 stated the wound was being covered with a dressing. A request to interview LPN #61 was made however according to the Administrator, the nurse was attending a funeral and unavailable to be interviewed. An interview with Medical Director (MD) #47 was attempted via telephone however no return contact was received. Interview on 01/18/24 at 9:08 A.M. with LPN #96 revealed she was not wound certified but based off of her nursing experience and education, if a wound had necrotic tissue, it would typically be staged at least as an unstageable pressure ulcer, not a deep tissue injury, because the professional would not be able to see the wound bed to determine an appropriate stage. Observation and interview on 01/18/24 at 9:12 A.M. of Resident #298 in her room with LPN #96 revealed the resident was laying in bed at the time of the observation with a blanket covering her. Resident #298 agreed to allow this surveyor and LPN #96 to look at her feet. LPN #96 raised the blanket and confirmed the resident's heels were not elevated off the mattress. Both heels were laying directly on the mattress. Resident #298's left heel was observed with a clean dressing in place dated 01/14/24. LPN #96 offered to place a pillow under the resident's heels. Resident #298 stated, there is supposed to be one under my heels but the aide had been busy and must have forgotten. Resident #298 was observed with facial grimacing when LPN #96 raised her left heel off the mattress and placed it on the pillow. Resident #298 confirmed her left heel hurts a little bit. Interview on 01/18/24 at 10:13 A.M. with Assistant [NAME] President (AVP) #101 confirmed a wound treatment for Resident #298's left heel wound that was identified on 01/05/24 was not initiated until 01/09/24 (four days later). AVP #101 confirmed a treatment should have been implemented immediately upon identification of a new skin area. AVP #101 stated the information included in the Bruise Event by LPN #61 was accurate as far as the description of the area. LPN #61 was not wound certified so she was unable to officially stage the area. Interview on 01/18/24 at 10:35 A.M. with LPN #50 revealed she had completed the wound assessment on 01/12/24 (seven days after the wound was first identified) for Resident #298 and had staged the wound as an unstageable, deep tissue injury. LPN #50 confirmed Resident #298's left heel wound had not been officially staged prior to 01/12/24. LPN #50 stated she did not know why the area was documented as a deep tissue injury on 01/09/24 because the area had not been officially staged yet. LPN #50 confirmed she was not wound certified but had some experience with wounds from a previous job. LPN #50 stated LPN #61 requested she look at the resident's left heel wound. LPN #50 stated the area was small and may heal fairly quickly if Resident #298's heels were off-loaded. Interviews on 01/18/24 at 10:43 A.M. and 11:37 A.M. with Assistant Director of Health Services (ADHS) #84 confirmed she was the facility's designated wound nurse and she completed wound rounds weekly. ADHS #84 stated Resident #289's left heel wound was identified while she was off from work due to COVID-19 on 01/05/24 but she was just informed of the wound yesterday, 01/17/24 (12 days after the wound was identified). ADHS #84 stated she returned to work on 01/11/24 and she did not know why she was not notified of the new wound area upon her return or why another nurse completed the wound assessment on 01/12/24. ADHS #84 stated she assessed Resident #289's left heel wound for the first time on 01/17/24 but had not entered the assessment into the resident's record yet. ADHS #84 confirmed the wound was unstageable because it was covered with necrotic tissue and she could not see the wound bed. ADHS #84 also stated it appeared to be a deep tissue injury, not a bruise. ADHS #84 confirmed the area should have been comprehensive assessed and staged by a wound certified nurse prior to 01/12/24 (seven days later). ADHS #84 stated the facility did not have a wound physician who made rounds on the resident and if a resident needed more extensive wound care the facility would need to refer them to a local wound clinic. Review of the facility policy, Guidelines for General Wound and Skin Care, date 05/10/17, revealed the policy stated, the following general wound and skin care guidelines should be followed for all residents with potential and/or actual impairment in skin integrity. Use pillows or wedges for positioning to avoid skin on skin contact. Evaluate the need for heel floats/boots. Document type of wound, location, stage (if applicable), length, width, depth in centimeters, base, drainage, periwound tissue, and treatment of the wound weekly using the wound/skin treatment flow sheet. Notify the wound care nurse/nurse supervisor for all new stage II-IV pressure ulcers or if you have any questions.

Based on observation, staff interview, and record review, the facility failed to properly store and date foods, dispose of expired foods, and complete proper hand hygiene during lunch meal service. This had the potential to affect 51 residents who received meals from the kitchen. The census was 51. Findings include: 1. The following concerns were noted during the main initial kitchen tour conducted on [DATE] between 9:38 A.M. and 10:07 A.M. Observation of the main fridge revealed 12 undated containers of moldy strawberries, 13 undated containers of moldy blackberries, an undated opened bag of fresh carrots and an opened large package of cream cheese with a use by date of [DATE]. Observation of main dry storage area revealed an open container of vinegar with an open date of [DATE] with a best by date of [DATE]. Interview on [DATE] between 9:42 A.M. and 9:48 A.M., Dietary Manager (DM) #86 verified there were 12 undated moldy containers of strawberries, 13 undated containers of moldy blackberries, an undated opened bag of fresh carrots and a large opened package of cream cheese with a use by date of [DATE] in the kitchens main refrigerator. Interview on [DATE] at 10:00 A.M., DM #86 confirmed an opened container of vinegar with an open date of [DATE] and a best by date of [DATE] was in the main kitchens' dry storage area. Review of the undated document titled Food labeling and Dating Policy states food removed from its original container, has a broken seal, has been processed in any way must have .Item Name, Date and Time the food was labeled, and Use by date. 2. The following observations were noted during meal service on [DATE] between 11:45 A.M. and 11:53 A.M. Observation of meal preparation on [DATE] at 11:45 A.M. revealed Cook #93 touched the outside of a plastic bag of hamburger buns with bare hands, then plated a hamburger for a resident. Cook #93 inserted their right hand under the chef's coat, walked around the kitchen, and then put on clean gloves without handwashing. Observation on [DATE] at 11:50 A.M. revealed Cook #93 exited the cooler with bare hands, carrying empty cardboard boxes and an unopened package of French fries; after laying them down, Cook #93 put on clean gloves without handwashing. Cook #93 walked to the fryer to plate meal items, touching fries with the contaminated gloved hands before placing the food on the plate. Observation on [DATE] at 11:53 A.M. revealed Cook #93 straightened their apron with bare hands before returning to the stove to check the soup's temperature with a thermometer. Cook #93 put on clean gloves without hand hygiene after taking food temperatures. Cook #93 walked to the grill to serve a hamburger, where staff handled a resident's bun with the contaminated gloved hands. Interview on [DATE] at 12:56 A.M. with DM #86 verified that staff are expected to wash their hands before putting on gloves. Interview on [DATE] at 1:00 P.M. with Executive Director #54 verified that staff are expected to wash their hands before putting on gloves. Interview on [DATE] at 1:10 P.M. with Cook #93 confirmed observations to be accurate, stated they forgot to wash hands before putting on gloves. Review of the Single- Use Gloves policy dated ,d+[DATE] revealed staff should wash hands before putting on gloves and after discarding gloves.

Based on record review, resident interview, staff interview, and policy review, the facility failed to ensure a resident received the type of bathing activity she preferred on her scheduled shower days. This affected one resident (#5) of one resident reviewed for choices. Findings include: A review of Resident #5's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included adult onset diabetes mellitus, congestive heart failure, chronic obstructive pulmonary disease, polyosteoarthritis, chronic pain in her bilateral shoulders, morbid obesity, lymphedema, syncope and collapse, repeated falls, muscle weakness, difficulty walking, unsteadiness on her feet, abnormalities of gait and mobility, lack of coordination, reduced mobility, and anxiety disorder. A review of Resident #5's Preferences for Everyday Living (PELI) assessment dated [DATE] revealed it was very important to the resident to be able to choose how often and the time she bathed. The resident preferred to be bathed in the evening and wanted to be bathed twice a week. It was also very important to the resident to choose the type of bathing activity she received. The resident specified that a shower was the type of bathing activity that she preferred. A review of Resident #5's annual minimum data set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues and was cognitively intact. She was not known to have any behaviors nor was she known to reject care. The resident indicated in the assessment that it was very important to the resident to choose the type of bathing activity she received. A review of Resident #5's care plans revealed they included a profile care guide that was initiated on 04/15/22. The interventions specified she was to receive showers Tuesdays and Fridays in the evening. Her activities of daily living (ADL's) care plan indicated the resident required staff assistance to complete ADL tasks completely and safely. That care plan originated on 03/22/21. The goal was for the resident to have ADL needs met safely by staff. Interventions included to encourage the resident to do as much as safely possible for herself. A review of Resident #5's physician's orders included the need for her to receive showers twice a week, but the days specified as her shower days was Mondays and Thursdays (which was different than the days specified on her PELI). That order had been in place since 02/03/23. A review of the facility's shower schedule for the hall Resident #5 resided on revealed revealed showers/ bathing activities were scheduled based on a resident's room number. Resident #5 was to be showered on the evening shift every Tuesday and Friday. A review of Resident #5's Point of Care History report from 12/12/23 to 01/18/23 revealed the resident's bathing activities were being documented when they occurred. It documented the date/ time the activity was provided and the type of bathing activity that was received. The resident was documented as not receiving any showers during the week of 12/17/23 through 12/23/23. Partial bed baths were provided daily with one complete bed bath being provided on 12/20/23. The week of 12/24/23 through 12/30/23 the resident was provided only one shower on 12/25/23. A complete bed bath was documented as having been provided on 12/28/23. They other bathing activities provided during that week were partial bed baths. The week of 01/07/24 through 01/13/24 revealed the resident was not documented as having received any showers during that week. There was one bathing activity marked as other bath that occurred on 01/09/24 and the others were partial bed baths. A review of Resident #5's nurses' progress notes did not reveal any evidence of the resident refusing to be showered on her scheduled shower days to explain when a shower had not been provided. There was also no explanations given as to why a complete bed bath or other bath were given in place of a shower. On 01/16/24 at 1:52 P.M., an initial interview with Resident #5 revealed she did not always get her showers twice a week as per her preference. She felt twice a week would be adequate for her if she received them. On 01/18/24 at 8:58 A.M., an interview with State tested Nursing Assistant (STNA) #73 revealed Resident #5 required total assistance with her ADL's and believed the resident's preference was to receive showers. She indicated the showers were done on the evening shift. She had not known the resident to refuse any showers when offered. On 01/18/24 at 12:42 P.M., further interview with Resident #5 confirmed it was her preference to get a shower on her scheduled shower days. She denied she had ever refused to be showered on her scheduled shower day or requested a different type of bathing activity to be provided on her scheduled shower days. She stated she liked to be showered and did not feel a complete or partial bed bath was enough. She indicated the staff would just come in and do a bed bath without offering her a shower on her scheduled shower days. On 01/18/24 at 1:05 P.M., findings were verified by the facility's Administrator. She was asked to provide any additional evidence to support Resident #5 was being provided two showers a week per her preference. No additional information was provided. A review of the facility's policy on Guidelines for Bathing Preference revised 05/11/16 revealed the purpose of the policy was to establish a personal preference bathing routine. The procedures included advising the resident of the facility's guidelines for them to self-determine their plan of care and schedule during their stay in the facility. The residents should determine their preference for bathing upon admission to include the day of the week, time of the day, and type of bathing (tub bath, bed bath, or shower). Bathing shall occur at least twice a week unless the resident's preference stated otherwise.

Based on record review, staff interviews, and facility policy review, the facility failed to timely notify the registered dietitian, physician, or resident representative of one resident's (#298) significant weight loss. The affected one resident (#298) of one resident reviewed for notification of change. The facility census was 51. Findings Include: Review of the medical record for Resident #298 revealed an admitted on 12/22/23. Medical diagnoses included displaced intertrochanteric fracture of right femur, polymyalgia rheumatica, and Type II Diabetes mellitus without complications. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #298 had intact cognition and scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #298 had an impairment to her lower extremity and used a walker or wheelchair for mobility. Resident #298 required substantial/maximal assistance from staff to complete bed mobility and partial/moderate assistance with transfers. Resident #298 weighed 123 pounds (lbs) with no noted weight loss or gain in the last month or six months. Resident #298 was on a therapeutic diet. Resident #298 did not have any unhealed pressure ulcers or injuries. Review of weights dated from 12/22/23 to 01/15/24 revealed Resident #298 weighed 123 lbs on 12/22/23 at 10:15 P.M., 116 lbs on 01/05/24 at 3:53 P.M. (a seven lb weight loss), and 111 lbs on 01/15/24 at 9:57 A.M. (an additional five lb weight loss and a total weight loss of 12 lbs in less than 30 days). Review of the Nutrition - Weight/Wound Note, dated 01/10/24 at 11:13 A.M. revealed Resident #298's current weight was 116 lbs taken on 01/05/24 (five days earlier). A significant weight loss of seven lbs or 5.7% in two weeks was noted. Recommended weekly weights for four weeks. Increased metabolic demands related to skin impairment. Loss may be related to recent acute care events. Consider diet liberalization to maximize nutritional support in advanced age setting. Intakes were 51-100%. Recommend changing diet to Fortified diet, regular texture, thin liquids to offer additional calories and protein. Monitor weights with nutritional interventions as recommended. There was no documentation the Registered Dietitian (RD), physician, or resident representative were notified of the significant weight loss. Interview on 01/17/24 at 2:41 P.M. with RD #102 revealed she was on-site at the facility one time per week to review resident weights. RD #102 stated if a resident was weighed after she was on-site that week and revealed a significant weight change, she would not know until the following week unless the facility staff notified her of the change. RD #102 confirmed she had not been notified of Resident #298's significant weight loss identified on 01/05/24 until 01/10/24 when she was on-site at the facility and reviewed the weights (five days later). Interview on 01/18/24 at 3:51 P.M. with the Administrator confirmed there was no evidence Resident #298's physician, registered dietitian, or resident representative were notified of the resident's significant weight loss when it was identified on 01/05/24. Review of the facility policy, Physician-Provider Notification Guidelines, reviewed 12/31/22, revealed the policy stated, The purpose of the policy was to ensure the resident's physician or practitioner is aware of a change in condition in a timely manner to evaluate condition for need of provision of appropriate interventions for care. Resident assessments for change in condition, suspected injury, event of unknown origin or ordered lab and/or other diagnostic tests should be completed in a timely manner. Review of the facility policy, Guidelines for Responsible Party Notification, reviewed 12/31/22, revealed the policy stated, the purpose of the policy was to ensure the resident's responsible party is aware of all diagnostic testing results or change in condition in a timely manner. The responsible party should be notified of change in condition or diagnostic testing results immediately. Documentation of notification attempts should be recorded in the Electronic Health Record (EHR). Review of the facility policy, Guidelines for Weight Tracking, reviewed 12/31/22, revealed the policy stated, the physician, resident representative and dietitian shall be notified of a weight variance of 5% in 30 days, 7.5% in 90 days, and 10% in 180 days.

Based on record review and staff interview, the facility failed to ensure a resident's oral hypoglycemic medication that was put on hold per physician's orders was evaluated or resumed timely, after the resident started eating, in accordance with the physician's orders. This affected one resident (#12) of five residents reviewed for unnecessary medications. Findings include: A review of Resident #12's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included Type 2 (adult onset) diabetes mellitus. A review of Resident #12's physician's orders revealed she had an order for the use of Metformin (an oral hypoglycemic used to lower blood glucose levels) 1,000 milligrams (mg) by mouth twice a day for diabetes mellitus. The order originated on 10/24/23. The physician's orders also included an order to hold the Metformin until the resident started eating. That order was given on 10/30/23 and was an open ended order. A review of Resident #12's medication administration record (MAR) for December 2023 and January 2024 revealed the nurses were holding the resident's Metformin 1,000 mg that was ordered by mouth twice a day. The MAR indicated the order remained on hold from 10/30/23. The MAR also included the order to hold the Metformin until the resident started eating. A review of Resident #12's laboratory test results in her electronic medical record (EMR) revealed she had not had a Hemoglobin A1C ( a blood test that calculates the average blood glucose level over a three month period) test performed since 08/31/23. That Hemoglobin A1C result was elevated at 7.4% (normal levels below 5.7%). A review of Resident #12's meal intakes for the past 30 days (12/17/23 to 01/17/24) revealed the resident had a fair appetite. She was noted to have only refused meals five times during that 30 day period. She ate between 1-25% 24 times, 26-50% 27 times, 51-75% 10 times, and 76-100% 20 times. Further review of Resident #12's EMR revealed it was absent for any documented evidence that the facility staff had followed up with Resident #12's physician regarding the order to hold her Metformin as previously ordered when Resident #12 was documented on the meal intake records as having consumed some of all of her meals. Furthermore, there was no evidence of the facility staff clarifying the previous order to hold the Metformin until the resident started eating to determine if there was any certain percentage amount the resident needed to consistently eat for the Metformin to be resumed. Findings were verified by the Director of Nursing (DON). On 01/17/24 at 3:40 P.M., an interview with the DON confirmed Resident #12's Metformin remained on hold, as per the physician's order given on 10/30/23. She acknowledged the order was to hold the Metformin until the resident was eating and her meal intakes for the past 30 days revealed she had been eating. She further acknowledged the order was not clear on how much the resident needed to be eating before the Metformin could be resumed. She confirmed the last time the resident had her Hemoglobin A1C checked was on 08/31/23 and her Hemoglobin A1C was elevated at that time. She stated the physician would be in the facility in the morning and she would clarify the order to hold the Metformin until the resident was eating to see if it should have been resumed when the resident had been known to be eating. Further review of Resident #12's nurses' progress notes revealed a nurse's note dated 01/17/24 at 4:05 P.M. that indicated the resident's physician was contacted and ordered for a complete metabolic panel (CMP) and a Hemoglobin A1C to be drawn. The lab tests were obtained and sent to the lab for processing. A review of the lab results for the CMP that had been collected on 01/17/24 at 6:02 P.M. and results reported on 01/17/24 at 7:06 P.M. revealed Resident #12's glucose level was elevated at 160 milligrams/ deciliter (mg/dl). The normal range for glucose was 65-100 mg/dl. The Hemoglobin A1C was still pending at that time. The physician was notified of the lab results when she visited the facility the morning of 01/18/24. The physician did not give any new orders at that time and was awaiting the results of the Hemoglobin A1C.

Based on record review, resident and staff interviews, review of the dialysis contract, and review of the facility policy, the facility failed to adequately communicate with the dialysis center to ensure proper coordination of care for one resident (#42). This affected one resident (#42) of one resident reviewed for dialysis services. The facility census was 51. Findings Include: Review of the medical record for Resident #42 revealed an admitted on 10/25/23. Medical diagnoses included chronic kidney disease-Stage 3, congestive heart failure, and cognitive communication deficit. Review of the physician orders revealed Resident #42 had the following orders: Dialysis port: monitor for signs and symptoms of infection dated 11/25/23 and To Davita dialysis on Monday, Wednesday, and Friday at 2:45 P.M. Complete Dialysis Center Communication Observation under Other Clinical Observation and send with resident dated 01/12/24. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #42 had intact cognition and scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #42 required set up or clean up assistance to supervision or touching assistance to complete Activities of Daily Living (ADLs). The resident did not have a significant weight loss or gain. Resident #42 received dialysis services. Review of the Dialysis Center Communication Forms dated from 11/27/23 to 01/15/24 revealed the communication forms were consistently not fully completed by either the facility, the dialysis center, or both providers. The communications from the dialysis center to the facility section was not completed. The facility did not monitor Resident #42's vital signs upon returning to the facility from the dialysis center. There were not any additional dialysis communications included in the resident's record. Review of the progress notes dated from 10/25/23 through 01/18/24 revealed on 01/17/24 at 8:04 A.M., Licensed Practical Nurse (LPN) #61 spoke with the dialysis center who stated a new order for Resident #42 to only go to dialysis twice a week and would not need to go today. On 01/17/24 at 2:23 P.M., Registered Dietitian (RD) #102 noted an attempt to contact the dialysis RD but was unavailable at the dialysis clinic. Requested lab work. Dialysis unit stated will send labs to the facility. Interventions included to coordinate with dialysis RD for nutritional interventions as needed. There was not an updated dialysis order for Resident #42 indicating the resident only needed to attend dialysis Mondays and Fridays. Observation and interview on Wednesday, 01/17/24 at 10:52 A.M. with Resident #42 in her room revealed she had a recent change in her dialysis schedule and only needed to go to dialysis on Mondays and Fridays from 10:30 A.M. to 2:15 P.M. now instead of Mondays, Wednesdays, and Fridays. Resident #42 stated she just started dialysis a couple of months ago. Resident #42 stated the facility sent a form with her to dialysis. The resident gave the form to the dialysis center and then the dialysis center sent the form back with her to the facility. Resident #42 then gave the forms to the nurse. Resident #42 stated, I don't know why they give it to me because it doesn't get filled out. Interview on 01/17/24 at 2:41 P.M. with Registered Dietitian (RD) #102 revealed she had not been able to reach the RD at the dialysis center yet to discuss Resident #42's nutritional status and any recommendations the dialysis dietitian may have. RD #102 stated she attempted to reach the RD at the dialysis today, 01/17/24, and was unsuccessful but the dialysis center had agreed to fax lab results to the facility. RD #102 stated she had not received any lab results for Resident #42 at all from the dialysis center since the resident started attending the dialysis center. Interview on 01/18/24 at 5:07 P.M. with Licensed Practical Nurse (LPN) #43 revealed the dialysis communication forms were documented under the observation tab in Resident #42's electronic health record. LPN #43 stated the forms were sent to the dialysis center via email, however, the facility did not usually receive the completed forms back from the dialysis center. LPN #43 was not aware of a change in Resident #42's dialysis schedule and would need to follow up with the dialysis center to confirm the change. LPN #43 confirmed the communication forms for Resident #42 were not completed and the resident's vital signs were not being documented upon returning to the facility from the dialysis center. Interview on 01/18/24 at 5:23 P.M. with LPN #50 revealed the dialysis center just faxed dialysis running sheets to the facility on [DATE]. The running sheets were dated from 12/18/23 to 01/15/24. LPN #50 confirmed none of the running sheets had been uploaded to the resident's medical record. Interview on 01/18/24 at 5:28 P.M. with the Administrator confirmed the facility and the dialysis center had not been in regular communication to coordinate Resident #42's care. The Administrator stated the dialysis center had not been responsive to the facility's attempted contacts. Review of the dialysis contract dated 10/29/13 revealed the contract stated, the dialysis center would provide to Care Facility from time to time all appropriate information and guidance regarding the renal condition of Residents who are patients of Dialysis Center, including administration of medications, directions for handling medical and nonmedical emergencies such as bleeding or hemorrhage, bacterial infection, and septic shock, and the care of shunts and fistulas. The Care Facility will provide to Dialysis Center, upon initial referral and from time to time thereafter, the same information relating to any Resident accepted for dialysis services which is necessary or useful in connection with the provision of dialysis services to such Resident. Review of the facility policy, Guidelines for Dialysis, reviewed 12/31/22, revealed the policy stated, the purpose of the policy was to provide communication to Dialysis Providers and monitoring of resident receiving dialysis. A report (may be written or verbal) shall be requested from the Dialysis that will alert the facility regarding: tolerance to procedure, vital signs, medications administered, and other information deemed necessary for the ongoing provision of care. Upon return from the Dialysis Provider the facility shall: provide ongoing monitoring of the shunt site for signs of complications and review the Dialysis Provider paperwork for any necessary follow up requirements. Notify attending physician, dialysis center and responsible party of adverse findings are noted. Document notifications in medical records.

Based on observations, resident and staff interviews, record review, and facility policy review, the facility failed to ensure a lunch meal was delivered timely to one resident (#42). This affected one resident (#42) of three residents reviewed for nutrition. The facility census was 51. Findings Include: Review of the medical record for Resident #42 revealed an admitted on 10/25/23. Medical diagnoses included chronic kidney disease-Stage 3, congestive heart failure, and cognitive communication deficit. Review of the physician orders revealed Resident #42 had the following order: To Davita dialysis on Monday, Wednesday, and Friday at 2:45 P.M. Review of the meal times revealed lunch meal was open dining in the dining room from 11:30 A.M. to 1:00 P.M. and the nursing facility hall trays were delivered starting at 12:00 P.M. Observation and interview on Wednesday, 01/17/24 at 10:52 A.M. with Resident #42 in her room revealed she had a recent change in her dialysis schedule and only needed to go to dialysis on Mondays and Fridays from 10:30 A.M. to 2:15 P.M. now instead of Mondays, Wednesdays, and Fridays. Resident #42 stated the facility usually provided a lunch to take with her to the dialysis center. Today, the kitchen staff provided chicken strips in a container for the resident to take with her this morning. Resident #42 stated she informed the dietary aide that she did not have to go to dialysis today because her schedule changed and requested chicken noodle soup for lunch instead. The dietary aide informed Resident #42 the kitchen staff were preparing the regular lunch meal for the day but would provide Resident #42 with chicken noodle soup as requested when the lunch meal was delivered in approximately an hour. The resident stated she spoke with the dietary aide at approximately 10:00 A.M. Interview on 01/17/24 at 12:45 P.M. and 1:49 P.M. with Resident #42 in her room revealed the resident stated she had not received any chicken noodle soup yet as requested. The resident could not recall the name of the dietary aide she spoke to this morning. Resident #42 stated she would still like to have chicken noodle soup because she was hungry. The resident stated she had not eaten anything since breakfast that morning. Interview on 01/17/24 at 1:53 P.M. with Cook #93 revealed she was aware Resident #42 requested chicken noodle soup but she thought the kitchen had followed up with her because the kitchen only had the kind of soup that had carrots in it and the resident typically did not like it. Cook #93 asked if Resident #42 had just returned from dialysis and was not aware of Resident #42's dialysis schedule change. Observation and interview on 01/17/24 at 1:55 P.M. with Resident #42 and Cook #93 in the resident's room revealed Cook #93 explained the kind of chicken noodle soup the kitchen had in stock to the resident and offered to make it for her if the resident still wanted it. Resident #42 accepted the chicken noodle soup and requested it be made for her again. Cook #93 informed the resident the soup was in small cans and offered two cans of the soup to the resident. Resident #42 agreed. Observation on 01/17/24 at 2:01 P.M. of Cook #93 with a meal tray and a bowl of soup walking towards Resident #42's room to deliver the soup to the resident (two hours after the regularly scheduled lunch meal time). Interview on 01/17/24 at 2:04 P.M. with Cook #93 confirmed she delivered the chicken noodle soup to the resident and the resident accepted it. Review of the facility policy, Meal Service, revised 01/2023, revealed the policy stated, meals will be served at the following hours Lunch Dining room [ROOM NUMBER]:30 A.M. and Tray Service after dining rooms have been served.

Based on observation, interview, record review and facility policy review the facility failed to have staff wear proper hair restraint, record food temperatures to conform safe serving temperatures, keep equipment clean, and keep prepared food covered and dated. This had the potential to all affect all 45 residents residing in the facility who were receiving food from the kitchen. Findings included: 1. a. Observation on 07/03/23 at 8:30 A.M. of Dining Services Assistant Director (DSAD) #159 walking through the kitchen past the yellow line on the floor requiring hair covering wearing a ball cap. His hair was extruding from the bottom of the ball cap approximately 3 inches over the collar of his shirt. He did not have a hair net covering or retaining the hair extruding from the bottom of the ball cap while reviewing the meal temperature log in the food preparation area. Observation on 07/03/23 at 9:30 A.M. of the DSAD #159 with the Licensed Nursing Home Administrator (LNHA) #159 wearing a hair net under his ball cap to retain the hair extruding from the bottom of the ball cap. An interview at the time with DSAD #159 revealed he was not wearing the hair net covering earlier and after reviewing the policy realized he should be. DSAD #159 removed his ball cap and hair net and replaced his ball cap. LNHA #159 verified DSAD #159's hair extruded from the bottom of the ball cap and down over the collar of his shirt. 1. b. Observation on 07/03/23 at 12:07 P.M. of State Testing Nursing Assistant (STNA) #131 walking into the kitchen past the yellow line on the floor requiring hair covering while lunch was being served. STNA #131 was directed to put on a hair net by another staff member. STNA #131 put on a hair net that only covered the top half of her head. Her hair was hanging out of the hair net on the back of her head from her ear level down. She entered the walk-in refrigerator where there was food on trays uncovered. An interview at the time with DSAD #159 verified she entered the kitchen without any covering and entered the walk-in refrigerator without her hair fully covered. Review of the facility policy titled, Hair Restraint, effective date 05/31/16, revealed the facility has chosen a baseball or beanie style cap for the restraint policy to meet the designed uniform code. This had will be worn to effectively keep hair from contacting exposed food. Those employees that have hair that extrudes out of the cap will be required to have hair wrapped into a bun style or tucked under the hat. Food Service employees will wear hair restraints while in all food preparation areas. 2. Review of food temperature logs for June 2023 revealed temperatures were not logged on 06/02/23 for dinner, 06/03/23 for dinner, and 06/26/23 for lunch to confirm food items were cooked to safe temperatures and held at appropriate minimum temperatures during service . Interview on 07/03/23 at 8:30 A.M. with DSAD #159 verified if the food temperatures were not documented and there was no way to confirm the food was cooked to a safe temperature for consumption and held at a safe temperature. Review of facility policy titled, Food Temp Serving Line, effective 03/30/18, revealed the standing operating procedure is to ensure the organization is providing quality food using safe food temperature guidelines. Further review revealed the temperatures of all foods on the serving line will be measured and record at every meal and at every service point. 3. Observation on 07/03/23 at 11:08 A.M. of the bench can opener (large can opener attached to table) blade with dark, crusted substance. An interview at the time with Dining Services Assistant #129 verified the can opener was dirty with dried black substance. She verified the can opener had been used earlier in the day and that the substance on the can opener blade appeared older than from use earlier in the day. Review of the facility policy titled, Manual Sanitation, revised 01/2023, revealed manual sanitation is the process where al microorganisms (bacteria, spores, fungi, viruses) contained in a liquid or solid or on equipment and utensils are completely destroyed. Further review revealed clean and sanitize food-contact surfaces anytime contamination as occurred. 4. Observation on 07/03/23 at 12:15 P.M. of the walk-in refrigerator revealed the following items on a tray not covered and no documentation to support preparation date: side salads (20), butterscotch brownie parfait (seven), strawberry cake (three pieces), baked apples (eight), and corn salad (twelve). The corn salad was noted to be very dry on the surface. An interview on 07/03/23 at 12:20 P.M. with DSAD #159 verified the items were in the refrigerator and not covered, labeled, or dated. He reported the cart usually had one large bag down over it for protection which was removed when lunch service started. He was not able to confirm when the items were prepared. Review of the facility policy titled, Food Labeling and Dating Policy, revised 04/26/22, revealed any food item must have a received-on label/received-on date, and or a label that indicates the production date and the use by date for the product. Further review revealed all food items must be properly covered (not exposed to air) prior to being labels and dated. This deficiency represents non-compliance investigated under Complaint Number OH00135648.

Based on record review and interview the facility failed to implement a comprehensive, individualized and effective pain management program for Resident #100 and Resident #202 at the time of admission. This affected two residents (#100 and #202) of two residents reviewed for pain management. Actual Harm occurred when the facility failed to provide physician ordered pain medication timely following Resident #202's admission to the facility on [DATE] resulting in the resident experiencing intolerable pain, urinary incontinence and increased anxiety/agitation affecting the residents daily activities. Findings include: 1. Medical record review revealed Resident #202 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident arrived to the facility on [DATE] at 4:38 P.M. Review of a baseline plan of care for pain revealed to administer medications per order. Interventions included to notify the physician if pain approaches were ineffective at maintaining pain at a tolerable level. Review of Resident #202's scanned prescription from the hospital dated 07/26/19 revealed an order for [REDACTED]. Review of Resident #202's admission assessment dated [DATE] revealed her pain was rated a five on a scale of one to ten (10) with 10 being the most severe pain. The pain location was not marked; however, the pain was described as sharp, throbbing, and aching. The resident was not assessed to be at risk for urinary incontinence. Interview on 07/29/19 at 11:14 A.M., with Resident #202 revealed she had concerns with pain medication not being administered timely. She stated she had been admitted on Friday 07/26/19 around 5:00 P.M. and did not receive her pain medication, [MEDICATION NAME] until 1:00 A.M. on 07/27/19. She reported she had hand delivered a prescription for her pain medications, both [MEDICATION NAME] and [MEDICATION NAME] at the time of her admission and stated she wanted to make sure she kept on a schedule with her pain medications as the schedule she had seemed to be working and controlling her pain. She reported she had to have bilateral knee surgery and was experiencing increased pain. She stated her last dose of pain medication at the hospital was at 4:00 P.M. Around 9:00 P.M., she inquired about receiving her pain medication. She stated she requested pain medication again at 10:00 P.M., 10:30 P.M., 11:18 P.M., and 11:42 P.M. She reported her pain started to become intolerable, she became sick to her stomach and was unable to move because the pain was so bad. At 12:05 A.M., she stated the the nurse told her the pharmacy had not received the orders for the pain medication. The resident explained to the nurse that was why she had hand delivered the orders so this would not happen. The nurse told her she found the order and faxed it to pharmacy and told the resident the medication would be available in about 15 minutes. At 12:35 A.M., Resident #202 stated she still had not received the pain medication. The resident stated at 1:00 A.M. she finally received her [MEDICATION NAME] 5/325 milligrams (mg), however the nurse documented she gave it at 2:34 A.M. She reported staff had obtained her vital signs and inquired why they were elevated, and she told them because she was in so much pain. The resident also reported she had been incontinent of urine because she was in such severe pain that she could not move her legs. She reported she had to use a bedpan and she had never had to use a bedpan in her life. She reported she was using a bedside commode right after her knee surgery in the hospital. The resident indicated she asked for another pain pill at 6:30 A.M. and 7:30 A.M. as her pain was still not controlled and finally had enough and called her daughter and told her to come and get her. She reported she could have taken better care of herself at home and had better pain relief. The resident indicated she was a nurse by profession. During the interview the resident reported staff wouldn't give her a bedside commode because they said it wasn't ordered and her bed did not have bed rails to assist her with turning and repositioning. Her daughter came right away after she had called her and spoke with administrative staff. The physician was notified and wrote orders for a one-time dose of [MEDICATION NAME] 5/325 mg two tablets now and [MEDICATION NAME] for anxiety due to the increased pain. The resident reported she received the [MEDICATION NAME]; however, the medication administration records did not indicate she received [MEDICATION NAME] on 07/27/19. She reported she had never taken anything for anxiety before, however her daughter suggested she take it. She reported the physician had to change her pain medication and she still must ask for it a couple of times before the nurse will administer it. On 08/01/19 at 9:00 A.M. during a follow up interview the resident reported she didn't think she was receiving her [MEDICATION NAME] per order either and last night the nurse gave her the wrong strength pain medication and they had to hold her next dose of pain medication as a result of the medication error. Interview on 07/31/19 at 4:22 P.M., with the Director of Nursing (DON) revealed the resident should have not waited four to five hours for pain medication following her admission. She stated if a resident was admitted with a prescription, the prescription should have been faxed to the pharmacy and the physician would need called to verify the orders. Once the pharmacist received the order, they would approve the removal of the medication. She confirmed the facility had the medication [MEDICATION NAME] 5/325 mg available onsite in the contingency (stock) box. The DON stated the process should take 20 minutes. The DON reported she was not sure why the pharmacy did not get the script, however, the nurse should have kept following up until the medication was approved. She confirmed the physician assistant (PA) was notified the next morning of the resident's pain and a pain event was initiated. The PA wrote an order for [REDACTED]. Review of Resident #202's pain event, dated 07/27/19 revealed the resident had incision pain. She described the pain as sharp, shooting, stabbing, throbbing pain. The pain was rated a ten (10) on a scale of one to 10 which indicated the pain was excruciating pain-worst possible and interfered with the resident's ability to carry on with daily routines, socialization or sleep. The pain was constant/persistent onset early morning, mid-morning afternoon, and evening. The resident's mental status changed and she had anxiety due to the pain. Review of Resident #202's progress notes, dated 07/27/19 revealed the PA had ordered one-time dose of [MEDICATION NAME] 5/325 mg now and then 1-2 tablets every four hours and [MEDICATION NAME] 0.25 mg due to resident being tearful and yelling at her daughter this morning. The resident requested bilateral grab bars to assist her with bed mobility. Resident #202 reported at 1:23 P.M., her pain was under control with the new medication change done this morning. She reported she was still slightly anxious, however felt it was related to not smoking. There were two late note entries, dated 07/29/19 at 3:58 P.M. and 4:04 P.M., for events that occurred on 07/27/19 that indicated the pharmacist had called the nurse regarding the high dose of [MEDICATION NAME] scheduled once daily. The resident confirmed she took one dose of 3,600 mg [MEDICATION NAME] daily. The resident reported she would try splitting the dose into two separate administrations. The PA was notified and gave new orders to change [MEDICATION NAME] to 1,800 mg twice daily. The second late entry revealed orders were clarified and PA stated it was ok to begin medication on 07/29/19 with new order, however the Medication Administration Records (MAR) revealed the resident received the new order of [MEDICATION NAME] 1,800 mg on 07/27/19 and 180 [MEDICATION NAME] 600 mg tablets were delivered on 07/27/19. Observation of Resident #202's [MEDICATION NAME] 600 mg blister packets on 08/01/19 at 9:30 A.M. with Licensed Practical Nurse (LPN) #10 and LPN #82 revealed there was six blister packets. Four of the blister packets were filled, one had three removed and one had 15 removed. There were 18 total tablets removed. There were originally 180 tablets of [MEDICATION NAME] 600 mg delivered on 07/27/19. On 08/01/19 at 2:07 P.M. review of Resident #202's medication administration records (MAR) dated 07/2019 with the Director of Nursing (DON) related to the administration of the resident's [MEDICATION NAME] and [MEDICATION NAME] revealed the following: a. The MAR indicated [REDACTED].M. on 07/27/19. The DON revealed a nurse, Registered Nurse (RN) #46) had pulled the [MEDICATION NAME] out of the contingency cart at 12:38 A.M. on 07/27/19. She had attempted to pull a [MEDICATION NAME] out at 12:31 A.M., however it was denied even though the control sheet indicated she removed one. The DON verified the MAR indicated [REDACTED].M., however indicated this was probably inaccurate, and the resident was probably correct when she reported it was administered at 1:00 A.M since it was pulled at 12:38 A.M. Further review of the MAR indicated [REDACTED].M. The order was rewritten to give one [MEDICATION NAME] 5/325 mg for mild pain and two for pain (no severity noted) every four hours as need until 07/29/19, then the order was changed again to give two 5/325 mg every four hours scheduled for pain. b. There was no evidence the resident received a [MEDICATION NAME] on 07/27/19. The DON reported there must have been miscommunication with staff and the resident because she did not receive a [MEDICATION NAME] on the 07/27/19, however the PA wrote an order that morning due to her increase anxiety. She had called the pharmacy and verified that a [MEDICATION NAME] had not been approved for removal. c. Further review revealed the resident received [MEDICATION NAME] 3,600 mg on the 07/27/19 between 6:00 A.M. and 10:00 A.M for chronic nerve pain, and received an additional 1,800 mg on 07/27/19 between 4:00 P.M. and 6:00 P.M. However, the order was only to administer 3,600 and it was documented the resident received 5,400 mg (on 07/27/19). On 07/28/19 the resident received [MEDICATION NAME] 1,800 mg twice daily. On 07/29/19 the resident only received one dose of 1,800 mg. She received two 1,800 mg doses on 07/30/19 and 07/31/19, and one dose thus far on 08/01/19. The DON reported the MAR indicated [REDACTED]. The inventory sheet indicating the 180 [MEDICATION NAME] 600 mg pills were not delivered until 07/27/19 at 11:12 P.M. The DON reported the nurses signed the medication off as administered in error. The DON confirmed the resident did not receive her [MEDICATION NAME] 5,400 mg on 07/27/19 as it was not available. The DON reported there were 100 mg [MEDICATION NAME] in the contingency box, however there was not enough to administer a complete dose. The MAR indicated [REDACTED]. The DON verified the resident did not receive [MEDICATION NAME] from another pharmacy. The DON confirmed the resident had not received her [MEDICATION NAME] as ordered since there were only 18 removed from the blister packet and she should have received 27 [MEDICATION NAME] total from 07/28/19 to 08/01/19. The DON confirmed the resident was admitted on [DATE] at 4:38 P.M., and most of her medications were not delivered until almost 31 hours later, which she stated was not unusual. The DON indicated there was a standing order to administer medication on the next delivery date due to the delivery timeframes and so staff were not constantly calling the physician. There was an order written [REDACTED]. Review of Resident #202's medication error event dated 07/31/19 revealed the resident received two [MEDICATION NAME] 10/325 mg and was only ordered two 5/325 mg [MEDICATION NAME]. The resident was notified and orders were received to hold the resident's 12:00 A.M. dose of [MEDICATION NAME] 5/325 mg. Interview on 08/01/19 at 11:49 A.M. with the DON verified the resident was out of [MEDICATION NAME] and the nurse had grabbed another resident's [MEDICATION NAME] in error and administered two 10/325 mg [MEDICATION NAME] tablets. The physician was notified and ordered to hold next dose of [MEDICATION NAME]. Review of the pharmacy first dose removal revealed on 07/27/19 the nurse removed one [MEDICATION NAME] 5/325 mg at 12:31 A.M., and 12:38 A.M. Review of Resident #202 pain monitoring dated 07/26/19 to 07/28/19 revealed the resident reported she had pain on 07/26/19 on the two to six P.M. shift, however there was no evidence of the numerical number. On the 10:00 P.M. to 6:00 A.M. shift the resident reported her pain was rated a nine out ten. On 07/27/19 the resident reported pain rated a nine out of 10 on the first two shifts. On 07/27/19 the resident reported her pain was rated eight of ten on the first two shifts. Review of Resident #202's bladder tracking, dated 07/26/19 to 08/01/19 revealed on 07/26/19 the bladder tracking was blank. Further review revealed the resident was continent of urine. Review of the facility pain policy dated 05/11/16 and revised on 05/23/19 revealed if there was a change in pain indicators or verbalization of pain from a resident, a pain event form would be completed to indicate changes and the care plan updated. The policy indicated to educate the resident/family/caregivers on the pain management interventions and importance of notifying staff of changes in pain status. Implement the care plan approaches to assist with pain management. 2. Review of Resident #100's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Observation and Data Collection assessment dated [DATE] at 6:33 P.M. and completed on 07/25/19 at 7:04 P.M. revealed the resident complained of pain rated a 5 on a 1-10 scale. The pain was described as a sharp pain with no location documented. Medication, rest and positioning were documented to help relieve the pain. Record review revealed the resident did not have an order for [REDACTED]. Review of the baseline plan of care implemented 07/26/19 revealed the resident's pain would be at a tolerable level. The resident was verbalizing or exhibiting signs of pain or was at risk for pain with interventions including to reposition for comfort, administer [MEDICATION NAME] per physician order [REDACTED]. On 07/30/19 at 2:00 P.M. interview with Resident #100 revealed she had intense, chronic pain that never went below a five on a 1-10 pain scale. The resident stated she recently had a broken wrist and numerous other surgical repairs including her knees and her shoulders. Resident #100 revealed she used the pain medication, [MEDICATION NAME] four times a day at home to help control her pain but there were issues getting pain medication when she was admitted to the facility. On 08/01/19 at 11:16 A.M. interview with LPN #44 revealed she was the nurse in charge of Resident #100's care when she was admitted to the facility. LPN #44 stated she and LPN #79 worked together on the admission. LPN #44 verified the resident complained of pain on admission but she did not provide the resident with pain relieving interventions including as needed Tylenol per the facility standing orders or repositioning. LPN #44 stated she did not follow-up with the resident after she completed admission paperwork because she had another admission to work on before the end of her shift at 10:00 P.M. On 08/01/19 at 11:42 A.M. interview with LPN #79 revealed the facility had standing orders for Tylenol to be used for pain. If the Tylenol did not relieve the resident's pain, the physician was to be notified for different orders. LPN #79 stated she was not in the room with the resident during her admission and was unaware the resident complained of pain. On 08/01/19 at 3:30 P.M. interview with the DON revealed it was the facility expectation that a resident's pain was to be addressed when it was reported to the nurse.

Based on medical record review, staff interviews, and policy review the facility failed to complete comprehensive bladder and bowel assessments and implement bladder and bowel training programs for a resident with noted decline in bladder and bowel functions. This affected one (Resident # 48) of one resident that experienced a decline in bladder and bowel status based on the Minimum Data Set (MDS) 3.0 assessment. Actual harm occurred when Resident #48 who was identified on admission to be always continent of bladder and bowel experienced declines and became frequently incontinent of bladder and occasionally incontinent of bowel without appropriate assessments/reassessments to determine the cause of the declines and the type of incontinence. The facility failed to implement any training programs or interventions to attempt to prevent further declines and/or improve his bladder and bowel function. Findings included: Record review for Resident #48 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #48's admission assessment dated [DATE] indicated Resident #48 was cognitively intact and alert and oriented. He was continent of bladder and bowel and was not at risk for incontinence of bladder. The resident's initial care plan for bladder was for staff to observe his urinary output. The care plan for bowel indicated staff were to aid Resident #48 as needed and monitor for changes in his bowel pattern. Resident #48 was ambulatory with full weight bearing with the assistance of one staff with a walker. He was noted to be independent for toilet transfers and hygiene. Review of Resident #48's MDS 3.0 assessments and bladder and bowel documentation indicated the following: -01/06/17- Resident #48 was noted not to have any evidence of rejection of care, was always continent of bladder and bowel, did not need a toileting program and required supervision of one staff with toileting. The resident's bladder and bowel documentation dated 12/31/16 to 01/06/17 confirmed the resident was continent of bowel and bladder. -01/27/17 - Resident #48 was noted to be occasionally incontinent of bladder and bowel without evidence of a toileting program. The resident's bladder and bowel documentation dated 01/21/17 to 01/27/17 indicated the resident had five episodes of bladder incontinence and one episode of bowel incontinence. There was no evidence the facility completed a comprehensive bladder and bowel assessment to attempt to determine the cause of Resident #48's incontinence and the type of incontinence. There were no interventions attempted to prevent further decline and/or improve his bladder and bowel function when these declines were identified. -02/24/17 - Resident #48 was noted to be frequently incontinent of bladder and bowel without evidence of a toileting program. The resident's bladder and bowel documentation dated 02/18/17 to 02/24/17 indicated the resident had seven episodes of bladder incontinence and four episodes of bowel incontinence. Resident #48's bladder and bowel function continued to decline and the facility failed to comprehensively assess him and attempt interventions to improve his bladder and bowel function. -03/27/17 - Resident #48 was noted to be frequently incontinent of bladder and occasionally incontinent of bowel without evidence of a toileting program. The resident's bladder and bowel documentation dated 03/21/17 to 03/27/17 indicated Resident #48 had 10 episodes of bladder incontinence and one episode of bowel incontinence. There was no evidence the facility completed a comprehensive assessment to attempt to determine the cause of Resident #48's incontinence or the type of incontinence. There was no evidence of any interventions implemented to prevent further decline and/or improve his bladder and bowel function. -04/18/17 - Resident #48 was noted to frequently incontinent of bladder and occasionally incontinent of bowel without evidence of a toileting program. The resident's bladder and bowel documentation dated 04/12/17 to 04/18/17 indicated Resident #48 had 20 episodes of bladder incontinence and one episode of bowel incontinence. There was no evidence the facility completed a comprehensive assessment to attempt to determine the cause of Resident #48's incontinence or the type of incontinence. There was no evidence of any interventions implemented to prevent further decline and/or improve his bladder and bowel function. Review of Resident #48's updated bladder and bowel care plan initiated on 01/12/17 revealed he was occasionally to frequently incontinent of bladder and bowels and had a history of [REDACTED].#48 was to have fewer episodes of urinary incontinence and to be free from signs and symptoms of constipation. The interventions indicated staff were to check Resident #48 frequently for incontinence, provide care, attempt to take him to the bathroom in advance of need to reduce the number of incontinent episode, and provide him with incontinence undergarments for dignity. Review of the bowel and bladder continence policy and procedure dated 05/10/16 revealed staff were to provide the resident who was incontinent appropriate treatment and services to prevent urinary tract infections and to restore as much normal bladder function as possible. Urinary incontinence is often a symptom of a condition and may be reversible. It is important to understand the cause and address incontinence to the extent possible. If the cause for incontinence is reversible or able to be partially mitigated a continence program should be established with routine toileting times as indicated by the patterns established in the elimination records or designated times such as upon rising, before/after meals and at bedtime. If a resident requires a structured continence program, they should be placed in a restorative nursing program with documentation completed per the program guideline. The elimination care plan should include individualized interventions to maintain or improve continence status of a clean, dry condition for those unable to re-establish continence. On 05/03/17 at 3:20 P.M., interview with Registered Nurse (RN) #8 confirmed Resident #48 had a decline in bladder and bowel function without evidence of a toileting program or an individualized toileting program. RN #8 was not aware of any bladder and bowel assessments completed to determine the type of incontinence Resident #48 experienced and confirmed the nurse aide documentation for him was not accurate. On 05/04/17 at 9:35 A.M., interview with RN #100 confirmed Resident #48 did not have a comprehensive bladder and bowel assessment, was not reassessed when declines were noted, was not on any type of toileting program, and reported staff were not documenting timely on the occurrence of each incontinent episodes.

Based on observation, record review and interview the facility failed to ensure adequate interventions were provided to prevent the development of a pressure ulcer to the left heel for for Resident #9. This affected one of two residents reviewed for pressure ulcers out of three residents in the facility identified with pressure ulcers. Harm resulted when the facility failed to ensure Resident #9's left heal was off loaded and pressure relief was provided to prevent the development of an unstageable pressure ulcer to the left heel. Findings include: Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician's admission orders [REDACTED]. The Nursing Admission Assessment and Data Collection dated 09/16/14 revealed a skin assessment that indicated no open [MEDICAL CONDITION] of the foot, no dressings, no history of skin impairment, compliant with turning/repositioning or treatment interventions and unable to change positions. The admission skin plan of care with check marks included turn and reposition for comfort with care and provide a pressure relieving device to the bed. The area that indicated to elevate heels off surface was not checked. Review of the pressure ulcer assessment dated [DATE] indicated the resident had pressure ulcers to the right lateral heel and right posterior heel that were both assessed as unstageable, due to suspected deep tissue injuries (SDTIs). The assessment indicated the pressure ulcers were both present on admission. The pressure ulcer to the right lateral heel measured 1.2 centimeters (cm) x 1.8 cm. The pressure ulcer to the right posterior heel measured 1.4 cm x 2.1 cm. Both were purple and black in color. The assessment indicated the current treatment was to pad and protect the right heel and to off-load heels. There was no evidence in the medical record or on the September 2014 treatment record that the right heel ulcers were padded and protected or that the heels were off-loaded in September 2014. There was a physician's telephone order dated 09/13/14 for a pressure reducing mattress. Review of the pressure ulcer assessment dated [DATE] indicated Resident #9 developed a pressure ulcer to the left heel that was assessed as unstageable, due to a SDTI. The pressure ulcer measured 4.0 cm x 3.5 cm and was purple and black in color. Review of the wound notes from the wound management certified nurse practitioner dated 09/29/14 revealed the left heel wound was a new pressure wound staged as a deep tissue injury measuring 4.0 cm x 3.5 cm. The wound was described as an intact blood filled blister. Review of the facility's Skin Impairment Circumstance, Assessment and Intervention dated 09/29/14 indicated a Skin Impairment Circumstance Investigation was completed. The investigation indicated the resident did not have pressure reducing or positioning devices and was compliant with care plan interventions. The Skin Risk Re-assessment indicated the resident was non-compliant with turning/repositioning and/or treatment interventions, was unable to change positions, had no history of skin impairment and had no foot problems present. The Prevention Update indicated to float heels per standing order and a treatment implemented. There was a physician's telephone order dated 09/29/14 to pad and protect the left and right heel wounds with abd (abdominal pads) and gauze wrap three times a week and as needed, off-loading boots to bilateral extremities, no shoes and a foam or gel wheelchair cushion. Review of the comprehensive skin care plan revealed review dates, but not consistent dates that interventions were initiated. Interview with registered nurse (RN ) #20 indicated the comprehensive skin care plan was initiated three months prior to the first review date. The skin care plan had a review date of 01/10/15. RN #20 verified the comprehensive skin care plan would have been initiated on 10/10/14. The pressure ulcer assessment dated [DATE] indicated the left pressure was a SDTI that measured 0.7 cm x 0.1 cm x 0.1 cm with visualized tissue at a stage III (full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscles not exposed. Slough may be present but does not obscure the depth of the tissue loss. May include undermining and tunneling). Slough is necrotic/avascular tissue in the process of separating from the viable portions of the body and is usually light colored, soft, moist, and stringy at times. On 02/11/15 at 10:23 A.M. observation of the dressing change to the left heel ulcer of Resident #9 was observed with licensed practical nurse (LPN) #34. The previous dressing was removed from the left heel. The wound bed was black and yellow with some slough. The ulcer was cleansed with normal saline and therahoney was applied to to the wound. A non-stick dressing and gauze wrap were applied. Interview with the director of health services (DHS) was conducted on 02/11/15 at 1:45 P.M. The DHS stated all residents have a pressure reducing mattress on the bed when admitted . She said Resident #9 was noncompliant with turns and pillows to elevate her heels. She said Resident #9 said heel boots would be too hot. Interview with the director of health services (DHS) and assistant director of health services (ADHS) on 02/11/15 at 3:15 P.M. was conducted. The DHS stated that Resident #9 had standing orders for a pressure reducing mattress, offload heels at all times when in bed and turn and reposition every two hours as needed. She said the facility did not always document the standing orders when done. The DHS stated Resident #9 was noncompliant with the interventions, but was unable to provide any documentation in the medical record or in the care plan of the non-compliance. The DHS verified that although she indicated the resident was noncompliant with the off-loading of the heels, there were no new interventions or changes to alleviate pressure to the heels until after the resident developed the SDTI to the left heel on 09/29/14. The DON provided a Pressure Ulcer Letter of Unavoidability, signed by the physician, dated 09/23/14 that stated "clinical conditions this resident exhibits that make the likelihood of this pressure ulcer unavoidable include, but are not limited to, resident immobility and noncompliance with care interventions of turning and repositioning and off-loading bilateral heels. The DHS verified on 09/23/15 the resident had the SDTIs to the right heel, that she was admitted with, but had not yet developed the SDTI to the left heel. She said the facility used the form when a resident was noncompliant with interventions to show that the facility had made the attempts to prevent pressure ulcers and due to noncompliance the resident still might develop a pressure ulcer. On 02/12/15 at 7:40 A.M. the DHS provided an undated form titled Letter of Unavoidability Guidelines. The form indicated the staff would identify residents at risk for skin impairment. Staff would make every effort to identify and implement care interventions to prevent skin breakdown. Should skin breakdown occur despite staff's best efforts at prevention, the physician would provide certification for reasons of unavoidability. Interview with the DHS on 02/12/15 at 7:50 A.M. verified the unavoidability form guidelines indicated the form would be used to show the unavoidability of a pressure ulcer that developed, not that future pressure ulcers for a resident would be unavoidable. She verified the pressure ulcer unavoidability form dated 09/23/14 for the resident indicated the current pressure ulcer was unavoidable, but Resident #9 did not develop the left heel pressure ulcer until 09/29/14.

Based on medical record review, clinical nutrition job description, policy review and staff interview, the facility failed to prevent an avoidable weight loss for Resident #93. This affected one of three residents reviewed for weight loss. The facility census was 26. Harm resulted when the facility failed to implement recommended nutritional supplements or other nutritional interventions for Resident #93 resulting in a significant weight loss of 6.4 percent (%) between 11/05/14 and 01/06/15, and a severe weight loss of 10.1% between 10/06/14 and 01/06/15. Findings include: Medical record review revealed Resident #93 was readmitted to the facility on 10/06/14 with [DIAGNOSES REDACTED]. Review of the [DIAGNOSES REDACTED].#93. Review of the 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #93 was severely impaired for daily decision-making, weighed 116 pounds, was 62 inches tall and had no significant weight loss. Review of the quarterly MDS assessment dated [DATE] revealed Resident #93 required extensive assist with eating, weighed 116 pounds, was 62 inches tall and had no significant weight loss. Review of the initial Nutrition assessment dated [DATE] revealed Resident #93's current body weight was 116 pounds, usual body weight was 118 pounds and body mass index (BMI) was 21.2. Review of Resident #93's Nutrition Progress Notes revealed the following. On 12/09/14, Resident #93's current body weight was 101 pounds with a BMI of 18.5, an eight pound weight loss was noted in 60 days. Registered Dietitian (RD) #71 recommended 120 milliliters of med pass (nutritional supplement) daily for additional 240 Kcal and 10 grams of protein. Review of the medical record revealed no documented evidence the recommended nutritional supplement was ordered or implemented for Resident #93. On 12/26/14, Resident #93's weekly weights 100 pounds with slight decline noted. Average meal intake 76%. Resident #93 started on fortified foods on 12/11/14. No evidence of new nutritional recommendations. Review of the Quarterly Nutrition Progress revealed the following. On 01/15/15, Resident #93 had a 15 pound weight loss since admission, low BMI indicated nutritional risk, healing skin area, discontinuation of [MEDICATION NAME] (antidepressant) with positive effects. RD #71 recommend adding one can of ensure daily for additional Kcal. Review of the medical record revealed no documented evidence the recommended nutritional supplement was ordered or implemented for Resident #93. On 01/16/15, weight loss of one pound in 30 days but stabilized at 99 pounds. Significant weight loss of 10 pounds in 90 days. Review of the quarterly note revealed no documented evidence of new nutritional recommendations or health shake three times with meals for Resident #93. Review of Resident #93's Weight Records revealed the following weights: -on 10/06/14, 109 pounds -on 11/05/14, 105 pounds -on 12/15/14, 100 pounds -on 12/22/14, 100 pounds -on 12/29/14, 99 pounds -on 01/06/15, 98 pounds -on 01/10/15, 99 pounds Review of Resident #93's Physician Orders revealed fortified foods with each meal was ordered on [DATE]. No other nutritional interventions were ordered between 10/06/14 and 02/09/15. Review of the Diet Order and Communication dated 01/14/15 revealed health shakes three times a day with meals. Review of the medical record revealed no physician order or documented evidence health shakes were administered. Review of the Medication Administration Record [REDACTED]. Review of Resident #93's Meals/Snacks/Fluids care plan dated 12/09/14 and revised 02/10/15 revealed resident with weight loss and meal intakes were not always good. Interventions added on 02/10/15 included to add fortified food at meals and 60 milliliters of nutritional supplement (med pass) twice a day. Review of the care plan revealed no documented evidence of measurable goals. Review of the Heights/Weights care plan dated 12/09/14 and revised 01/16/15 revealed Resident #93 had a significant weight loss in 30 and 90 days due to poor meal intake but weights had stabilized. Review of the care plan revealed no measurable goals. Review of the Clinical Nutrition (Dietitian) Job Description dated 06/08/12 revealed the dietitian was to ensure compliance with nutritional, dietary and regulatory standards. Review of the High Risk Nutrition procedure policy dated December 2007 revealed residents were to maintain acceptable parameters of nutritional status, taking into account the resident's clinical condition or other appropriate interventions when there was a nutritional problem. An aggressive nutritional program that provided interventions for those residents with established criteria defining them at high nutritional risk was to be initiated. Initial intervention included provision of fortified foods and resident preference of food choice. Two ounces of high caloric product was to be given to predetermined residents daily by the nurse during each routine medication pass. A high caloric product was to be used only at the recommendation of the dietitian and after fortified foods failed to achieve the desired results. Residents experiencing weight loss were to be assessed to determine possible causes. Residents were not to be added or removed without dietitian and physician approval. On 02/09/15 at 4:20 P.M., interview with Registered Nurse (RN) #52 verified Resident #93 was not receiving a nutritional supplement between or with meals. On 02/12/15 at 8:08 A.M., interview with Licensed Practical Nurse (LPN) #30 verified there was no documented evidence of nutritional interventions implemented for Resident #93's significant weight loss between October and November 2014. Dietitian #71 recommended 120 ml med pass once a day but stated the interdisciplinary team (IDT) determined not to initiate the nutritional supplement and initiated fortified foods instead. LPN #30 verified Dietitian #71 did not evaluate Resident #93 between 12/9/14 and 12/26/14 and the resident lost an additional two pounds. On 01/05/15 Dietitian #71 recommended ensure one can a day and the IDT determined that behavior stabilization set precedent over a stable weight. On 02/05/15 dietitian recommended 60 ml med pass twice a day; however, the IDT determined the dietitian reviewed inaccurate weights and did not initiate the recommendation. LPN #30 verified Resident #30 had a significant weight loss with no intervention or monitoring when on weekly weights in December 2014, the dietitian note of poor intake was inaccurate after review of meal percents documented and the facility was unable to determine the reason for the weight loss. LPN #30 also verified there were no nutritional labs ordered or obtained since admission, nutrition care plan did not have measurable goals and the MDS assessment dated [DATE] weight was inaccurately coded for 116 pounds and the resident actually weighed 98 pounds. On 02/12/15 at 9:04 A.M., interview with Registered Nurse (RN) #1 stated the resident weight loss was due to "scale" issues and inaccurate weights. RN #1 verified there was no documented evidence of any re-weights or information regarding inaccurate weights due to scales not being calibrated. Verified the inaccurate scales was not discovered until today after surveyor reviewing resident's weight loss and the scales were used for all residents. On 02/12/15 at 9:08 A.M., surveyor requested to speak to the dietitian and the dietitian did not respond to the surveyor request.