Every finding on record at Otterbein at Granville

Based on medical record review, staff interview, and facility policy review, the facility failed to provide proper justification for the use of anti-psychotic medications. This affected one (Resident #7) of two residents reviewed for medication use. The census was 18.Findings Include:Resident #7 was admitted to the facility on [DATE]. Her diagnoses were Parkinson's disease, morbid obesity, hypertension, hyperlipidemia, major depressive disorder, insomnia, sleep apnea, anxiety disorder, delusional disorder, dementia, dysphagia, psychotic disorder, vitamin D deficiency, anemia, and Type II Diabetes. Review of his minimum data set (MDS) assessment, dated 03/12/26, revealed he had a mild cognitive impairment.Review of Resident #7's physician orders, dated 12/06/25, revealed he was prescribed Quetiapine (antipsychotic) 25 milligrams (mg) every morning for delusions, paranoia related to psychotic disorder with delusions due to known physiological condition. Also, he was prescribed Quetiapine 50 mg, 1.5 tablets at bed time for the same diagnosis as above on 02/10/26. Finally, he was prescribed Depakote Tablet (anticonvulsnt) 125 mg for unspecified dementia with mood disturbance, which was ordered on 02/17/26. Review of Resident #7's discontinued physician orders, revealed the following medications and diagnoses: Quetiapine 50 mg for delusions, paranoia related to psychotic disorder from 12/06/25 to 02/10/26; Quetiapine 25 mg, 0.5 tablets for the same diagnosis as above from 12/07/25 to 02/10/26; and Divalproex Sodium Tablet (Depakote) 125 mg three times daily for delusions, paranoia related to delusional disorders, dementia from 12/06/25 to 02/04/26. Review of Resident #7's psychiatry notes, dated 07/02/25, revealed there was no documentation of a past diagnosis of psychotic disorder. The chief complaint listed for this visit was for continual monitoring for depression, anxiety, and insomnia. In the psychiatric follow-up section, the notes reflected that the resident had a history of depression, anxiety, insomnia, Parkinson's disease with dementia, and recurrent urinary tract infections (UTI). There was no documentation reflecting he was diagnosed with psychotic disorder. Review of Resident #7's psychiatry notes, dated 08/13/25, revealed no diagnosis of psychotic disorder. But, the chief complaint listed for this visit was continual monitoring for depression, anxiety, insomnia, and Parkinson's disease with dementia and psychosis. Under the section that reviewed psychosis specifically, the notes reflected that he denies having hallucinations, delusions, or paranoia, but endorses frequent, extremely vivid, disturbing dreams. Review of Resident #7's behavioral logs, dated May 2025 to August 2025, revealed no behaviors for May 2025, June 2025, and July 2025. In August 2025, he had two documented behaviors, one for repeated movements and one for yelling/screaming. There were no documented behaviors leading up to the new documented diagnosis of psychotic disorder listed in August 2025. Review of Resident #7's psychiatry notes, dated 09/11/25, revealed his Melatonin (supplement sedative/hypnotic agent) dose was increased from six mg to ten mg after his last appointment on 08/27/25. Resident #7 reported during his appointment on 09/11/25 that he had better sleep with fewer vivid dreams. Interview with [NAME] President #500 on 04/28/26 at 10:55 A.M. confirmed that dementia is not a proper diagnosis for the use of Depakote, and confirmed that it was the listed diagnosis for Resident #7's use of Depakote. Interview with Director of Nursing (DON) on 04/28/26 at 1:15 P.M. confirmed there was no diagnosis of psychotic disorder for Resident #7 prior to August 2025. She confirmed there were signs and symptoms of delusions and paranoia, but there was no documentation to support he actually had the diagnosis of psychotic disorder.Review of facility Psychotropic Medication Management policy, dated 03/05/25, revealed it is the policy of the facility to ensure each resident's drug regimen is free from unnecessary psychotropic medications. When psychotropic medications are ordered, the facility will ensure a comprehensive assessment of the resident's physical, behavioral, mental, and psychosocial signs and symptoms have been completed to identify and rule out any underlying medical conditions and specific diagnosis is documented in the medical record.

Based on interview and record review the facility failed to ensure neurological assessments were completed after an unwitnessed fall. This affected one (Resident #6) out of one residents reviewed for falls. The facility census was 18.Findings include:Review of the medical record for Resident #6 revealed an admission date of 10/16/23 with diagnoses including history of transient ischemic attack, syncope and collapse, hypertension, dementia and atrial fibrillation.Review of the care plan dated 04/15/25 revealed the resident had a history of an actual fall with minor injury. Interventions included performing neurological checks after any falls and monitoring/reporting neurological deficits such as changes in level of consciousness, visual changes, aphasia, dizziness, weakness and restlessness.Review of the Fall Risk Screening Tool dated 10/27/25 revealed the resident was identified as being at risk for falls.Review of annual minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #6 was severely cognitively impaired, has not had any falls and required substantial/maximal assistance with chair to bed transfers. Review of the fall report dated 12/02/25 at 7:48 P.M. revealed the resident encountered an unwitnessed fall while attempting to exit a recliner. The resident was observed with bruising to the left side of the face, bruising on the left dorsal hand, and redness to the left collarbone. Neurological checks were initiated.Review of the hospice visit note dated 12/03/25 revealed scattered bruising to the right side, left eye, left collarbone, and left upper extremity from the elbow to the knuckles. The resident was noted to be taking Plavix and Eliquis (blood thinners), placing her at higher risk for bleeding and bruising.Review of the neurological check documentation revealed completed assessments on 12/02/25 at 6:30 P.M., 6:38 P.M., and 7:18 P.M.; on 12/03/25 at 5:02 A.M., 5:03 A.M., 7:39 A.M., 11:44 A.M., 3:00 P.M., and 7:00 P.M.; on 12/04/25 at 3:21 A.M., 7:51 A.M., 5:46 P.M., and 9:46 P.M.; on 12/05/25 at 5:44 A.M. and 5:40 P.M.; and on 12/06/25 at 9:40 A.M. Interview on 04/28/26 at 2:35 P.M. with the Director of Nursing (DON) confirmed required neurological assessments were missing following Resident #6's unwitnessed fall on 12/02/25.Review of the facility's Neurological Assessment Policy dated 03/19/21 revealed assessments should be initiated following any obvious head trauma, acute change in mental status, or unwitnessed fall. The policy requires neurological assessments every 15 minutes for four assessments, then every 30 minutes for two assessments, every hour for two assessments, every four hours for five assessments, and every eight hours for 24 hours.

Based on record review and interview, the facility failed to ensure physician ordered laboratory specimens were collected. This affected one resident (Resident #5) out of one resident reviewed for laboratory services. The facility census was 18.Findings include:Review of the medical record for Resident #5 revealed an admission date of 04/19/24 with diagnoses of major depressive disorder, Type II Diabetes Mellitus, chronic kidney disease, calculus of kidney and morbid obesity due to excess calories.Review of the care plan dated 05/23/25 revealed the resident had renal insufficiency with interventions to monitor laboratory reports as ordered and report results to the physician. The care plan also revealed the resident had Diabetes Mellitus Type II with an intervention to complete laboratory tests as ordered due to the risk of complications.Review of the physician visit dated 01/14/26 revealed the resident was seen for diabetes mellitus, hypertension, and chronic kidney disease follow up. The physician documented weight loss, improved blood sugars, and a plan to collect a glycated hemoglobin (A1C) in April 2026 for diabetes management. The note also documented a slight decrease in glomerular filtration rate (GFR) and a plan to recheck the basic metabolic panel (BMP) in three months.Review of the physician order dated 01/14/26 revealed an active order to collect a BMP and A1C on 04/15/26.Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively intact and exhibited no refusals of care.Interview on 04/28/26 at 10:23 A.M. with the Director of Nursing (DON) revealed the laboratory results ordered for 04/15/26 could not be located.Review of an updated physician order dated 04/28/26 at 10:45 A.M. again identified orders for a BMP and A1C.Interview on 04/28/26 at 12:09 P.M. with the DON confirmed the laboratory results ordered for 04/15/26 were not found, and the DON reported that new laboratory specimens had been drawn and were currently in process.

Based on medical record review, staff interview, and facility policy review, the facility failed to provide adequate monitoring for the long term use of antibiotics. This affected one (Resident #21) of one resident reviewed for antibiotic use. The census was 18.Findings Include: Resident #21 was admitted to the facility on [DATE]. Her diagnoses were senile degeneration of brain, adult failure to thrive, hypothyroidism, dysphagia, feeding difficulties, anemia, cognitive communication deficit, anxiety disorder, hypertension, major depressive disorder, cerebral atherosclerosis, abnormal weight loss, apraxia, polyosteoarthritis, vascular dementia, restlessness and agitation, vitamin D deficiency, Type II Diabetes, and somnolence. Review of her minimum data set (MDS) assessment, dated 01/27/26, revealed she had a severe cognitive impairment.Review of Resident #21's physician orders, dated 05/30/23, revealed she had an order for Macrodantin Oral Capsule (antibiotic) 50 milligram (mg) one time a day for urinary tract infection (UTI) prophylaxis. Review of Resident #21's medical diagnoses, dated June 2023 to April 2026, revealed no diagnoses of chronic UTIs or other urinary diagnoses to support the on-going need for a prophylactic antibiotic. Review of Resident #21's progress notes, dated May 2023 to April 2026, revealed she has not had a urinary tract infection since 05/18/23. Review of Resident #21's care conference notes, dated 02/04/26 and 10/22/25, revealed no discussion or review of her use of prophylactic antibiotics with the care team, which included Resident #21's family. Review of Resident #21's physician notes, dated 09/29/25, revealed she continues on Macrodantin 50 mg daily for for UTI prophylaxis due to history of recurrent UTIs. The note also confirmed she has not had an UTI in over a year. Review of the active medical problems section of the notes, there was no active diagnosis or problem listed regarding recurrent or chronic UTIs. Review of the Assessment and Plan section of the notes, it mentioned she had frequent UTIs but no recent UTIs. Continue Macrodantin. Finally, under the diagnoses section, there was no diagnoses of frequent/recurrent/chronic UTIs, but there was mention of long term (current) use of antibiotics. Interview with Registered Nurse (RN) #118 on 04/28/26 at 12:48 P.M. revealed the use of antibiotics long term and her frequent UTIs are discussed in care conferences with the family each time. She confirmed the last two care conferences do not have any mention of the antibiotic use or frequent/chronic UTIs. She stated they are monitoring the side effects of the medications, and if there was a change in condition, they would address it with the doctor. But, she stated they do not have any other type of monitor (lab work, periodic urology appointments, etc) to determine the effectiveness and needed use of long term use of the antibiotic. Review of facility Infection Prevention and Control Program policy, dated 11/05/21, revealed it is the facility's practice to prevent, recognize, and control, to the extent possible, the onset and spread of infection. This is accomplished by the development, implementation, and maintenance of an effective infection prevention and control program that achieves the following goals: perform surveillance and investigation that helps prevent, to the extent possible, the onset and the spread of infection.

Based on interview, observation, and record review, the facility failed to ensure a treatment was implemented when Resident #8 obtained a skin tear and the treatment was discontinued when the skin tear was resolved. This affected one resident (#8) of two residents reviewed for skin conditions. The facility census was 19. Findings include: Review of the medical record for Resident #8 revealed an admission date of 10/16/23. Diagnoses included but were not limited to hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side, personal history of transient ischemic attack, anxiety disorder, muscle weakness and depression. Review of the progress notes dated 04/26/25 at 1:06 P.M. revealed resident obtained a two (2) centimeter(cm) by (x) 2 cm skin tear to the back of the right hand. Review of the physician orders for Resident #8 from 04/26/25 through 04/29/25 at 11:08 A.M. revealed no treatment was ordered for the skin tear to the back of the resident's right hand. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 04 which indicated severe cognitive impairment. The resident was assessed to require substantial/maximum assistance with toilet hygiene, shower/bathe self, bed mobility and transfers. Review of the weekly skin observation tool dated 04/29/25 for Resident #8 revealed a skin tear to the back of the right hand that measured 2.0 cm x 2.0 cm x 0.1 cm. Review of the plan of care revised 04/29/25 revealed the resident had a skin tear to the right hand with an intervention including but not limited to treat per facility protocol. Review of the physician order dated 04/29/25 at 11:08 A.M. for Resident #8 revealed a treatment for the right-hand skin tear, to cleanse skin tear with soap and water, pay dry and apply a clean, dry dressing every evening shift. Review of the weekly skin observation tool dated 05/06/25 for Resident #8 revealed the skin tear to the back of the right hand to be measured at 1.0 cm x 1.0 cm x 0.1 cm. Further review of the weekly skin observation tools dated 05/13/25, 05/20/25 and 05/27/25 for this resident revealed no skin tear to the back of the right hand was observed and no wound measurements were noted. Review of the Treatment Administration Record (TAR) for 05/13/25 through 05/27/25 revealed Resident #8 received ordered treatments for the right back of the hand skin tear even after the weekly skin assessments were completed with no skin tear present. Observation on 05/28/25 at 2:34 P.M. of Resident #8's back of the right hand revealed no skin tear and no dressing. Interview on 05/28/25 at 3:05 P.M. with the Director of Nursing and the Assistant Director of Nursing verified there was no order for the skin tear to the back of the hand from 04/26/25 until 04/29/25 at 11:08 A.M. for Resident #8. Also verified this resident still had an active order for the treatment of the back of the right-hand skin tear as of 05/28/25 with documentation of the nursing staff providing the ordered treatment on the TAR for the dates of 05/06/25 through 05/28/25. The area was healed after the 05/06/25 weekly skin observation tool, but the ADON was not sure when as it was not documented.

Based on interview, record review and facility policy review, the facility failed to ensure comprehensive pressure wound assessments were completed weekly. This affected one resident (#17) of two residents reviewed for pressure ulcers. The census was 19. Findings include: Review of the medical record for Resident # 17 revealed an admission date of 03/15/25. Diagnoses included but were not limited to pressure ulcer to the sacral region stage II (partial-thickness skin loss, presenting as an open sore or blister with a red or pink wound bed), depression, anxiety disorder, moderate protein-calorie malnutrition, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side and acute chronic systolic heart failure. Review of the plan of care dated 03/15/25 for Resident #17 revealed her to have a stage II pressure ulcer area to the coccyx on admission and interventions including but not limited to assess/monitor the wound for healing. Assess and document the status of the wound perimeter, wound bed and healing process. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 13 which indicated the resident was cognitively intact. The resident was assessed to require supervision or touching assistance for showers/bathing self, partial/moderate assistance for toilet hygiene, roll left to right in bed transfers, substantial/maximum assistance with sit to lying and lying to sitting. This resident was also assessed to be at risk for developing pressure ulcers and to have a pressure ulcer on admission of a stage II. Review of the weekly skin observation tools dated 03/18/25, 03/25/25, 04/01/25 and 04/08/25 revealed no wound staging to the pressure ulcer on the resident's coccyx. Further review of the weekly skin observation tools for the pressure ulcer to the resident's coccyx, dated 03/25/25, 04/01/25, 04/22/25, 04/29/25, 05/06/25 and 05/20/25 revealed no assessment of the wound bed, wound edges or surrounding tissue was documented. Interview on 05/28/25 at 3:20 P.M. with the Assistant Director of Nursing verified no staging was documented for Resident #17's coccyx pressure ulcer on the weekly skin observation tools for the dates of 03/18/25, 03/25/25, 04/01/25, and 04/08/25. Interview on 05/29/25 at 9:27 A.M. with the Certified Nurse Practitioner #102 revealed it was the responsibility of the facility nurses to measure and document on the descriptions of pressure ulcers weekly as she does not always assess pressure ulcers at each visit and goes reviews their measurements for treatments. Interview on 05/29/25 at 9:40 A.M. with Regional Nurse (RN) #102 verified for the weekly skin observation tools dated for 03/25/25, 04/01/25, 04/22/25, 04/29/25, 05/06/25 and 05/20/25 did not include an assessment of the wound bed, wound edges or surrounding tissue. The RN verified this is part of the assessment and should have been included for Resident #17's coccyx pressure ulcer. Review of the facility policy titled Skin Care Management Procedure revised 12/09/22, revealed at least weekly at a minimum, documentation should include staging, wound bed which includes color and type of tissue/character including evidence of healing or necrosis and percent of tissue, and description of wound edges and surrounding tissue.

Based on record review and interview the facility failed to develop a comprehensive care plan for pain for Resident #11, who received pain medication. This affected one resident (#11) of six residents reviewed for unnecessary medication use. Findings include: Review of the medical record revealed Resident #11 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/04/21 revealed Resident #11 had impaired cognition. The resident received opioid medications seven days during the look back period. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's plan of care revealed no plan of care for pain had been developed for the resident. On 10/14/21 at 3:21 P.M. interview with Registered Nurse #204 confirmed the plan of care did not address the resident's pain or pain medications.

Based on record review and interview the facility failed to follow up on pharmacy recommendations in a timely manner for Resident #11 and Resident #12. This affected two residents (#11 and #12) of five reviewed for unnecessary medication use. Findings include: 1. Review of the medical record revealed Resident #11 was admitted to the facility on [DATE] with diagnoses including [CONDITION(S)] without behavioral disturbance, anxiety disorder, dysphagia, cognitive communication deficit, major depressive disorder, type two diabetes mellitus and depression. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/04/21 revealed the resident had impaired cognition. Review of the pharmacist recommendation, dated 08/03/21 revealed the pharmacist suggested adding a six month stop date to the as needed every eight hours [MEDICATION(S)] 0.25 milligram (mg) medication. The physician responded on 09/01/21 and indicated he disagreed with the recommendation. On 10/14/21 at 9:13 A.M. interview with the Director of Nursing (DON) confirmed there was a delay in the physician following up with the pharmacist's recommendation. She was unsure of the cause in the delay and revealed pharmacy recommendations were put in a book for the physician to review weekly. 2. Review of the medical record revealed Resident #12 was admitted to the facility on [DATE] with diagnoses including unspecified dementia with behavioral disturbance, alcohol dependence with unspecified alcohol-induced disorder, dysphagia, personal history of malignant neoplasm of prostate and major depressive disorder. Review of the quarterly MDS 3.0 assessment, dated 08/16/21 revealed the resident had impaired cognition. Review of the pharmacy recommendation dated 09/01/21 revealed the pharmacist recommended trying a reduction of [MEDICATION(S)] from 250 mg twice a day to 125 mg twice a day. The physician followed up on 09/29/21 and indicated he disagreed with the recommendation. On 10/14/21 at 3:21 P.M. interview with RN #204 confirmed the physician took 28 days to respond to the pharmacist's recommendation for Resident #12. RN #204 was unsure what caused the delay and reported the physician usually followed up on recommendations weekly.

Based on record review and staff interview the facility failed to ensure non pharmacological interventions were attempted prior to administering pain medication. This affected one resident (#10) of five residents reviewed for unnecessary medication use. Findings include: Review of Resident #10's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most recent quarterly Minimum Data Set (MDS) 3.0 assessment revealed the resident's cognition was intact, he required limited assistance from one staff member for bed mobility, transfers, dressing and personal hygiene and required extensive assistance from one staff member for toilet use. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MAR for 08/2021 revealed the resident received [MEDICATION(S)] 50 mg every four hours as needed for pain on 08/25/21 and 08/30/21 with no attempts of non pharmacological interventions prior to the medication administration. Review of the MAR for 09/2021 revealed the resident received [MEDICATION(S)] 50 mg on 09/01/21, 09/02/21, 09/03/21, 09/06/21, 09/07/21, 09/08/21, 09/10/21, 09/13/21, 09/14/21, 09/16/21, 09/17/21, 09/21/21, 09/22/21, 09/23/21, 09/24/21, 09/25/21, 09/26/21, 09/27/21, 09/28/21, 09/29/21 and 09/30/21 with no attempts of non pharmacological interventions prior to the medication administration. Review of the MAR for 10/2021 revealed the resident received [MEDICATION(S)] 50 mg on 10/05/21, 10/07/21, and 10/10/21 with no attempts of non pharmacological interventions prior to the medication administration. On 10/14/21 at 11:50 A.M. interview with Minimum Data Set (MDS) Coordinator #204 confirmed there was no evidence of non-pharmacological interventions on the dates noted above prior to administering the medication. MDS Coordinator #204 revealed she was aware of concerns with nursing documentation and indicated they had been reminding and educating the nurses to document thoroughly.

Based on record review and staff interview the facility failed to ensure non-pharmacological interventions were attempted prior to administering [CONDITION(S)] medications and/or failed to ensure appropriate diagnosis for use of [CONDITION(S)] medication. This affected three residents (#7, #10 and #12) of five residents reviewed for unnecessary medication use. Findings include: 1. Review of Resident #7's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including right sided [CONDITION(S)], ataxia, dysphagia, dementia, acute kidney failure, moderate protein calorie malnutrition and [CONDITION(S)]. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 09/15/21 revealed the resident was cognitively impaired, required extensive assistance from staff for bed mobility, transfers and toilet use and required extensive assistance from one person for dressing and personal hygiene. Review of the medication administration record (MAR) for 09/21 revealed the resident received Trazadone (antidepressant/sedative) 50 milligrams (mg) on 09/01/21, 09/02/21, 09/03/21, 09/06/21, 09/07/21, 09/08/21, 09/10/21, 09/13/21, 09/14/21, 09/15/21, 09/16/21, 09/17/21, 09/18/21, 09/19/21, 09/20/21, and 09/21/21 with no non-pharmacological interventions attempted prior to the medication administration. Review of the MAR for 09/2021 revealed the resident received [MEDICATION(S)] (antipsychotic) 0.5 mg on 09/04/21 with no non-pharmacological interventions attempted prior to the medication administration. Review of the MAR for 10/21/21 revealed the resident received [MEDICATION(S)] (antipsychotic) 25 mg on 10/01/21 with no documented reasoning or non pharmacological interventions attempted prior to the medication administration. On 10/14/21 at 11:50 A.M. interview with Minimum Data Set (MDS) Coordinator #204 confirmed there was no evidence of non-pharmacological interventions on the above dates prior to administering the medications. She stated she was aware of concerns with nursing documentation and revealed they had been reminding and educating the nurses to document thoroughly. 2. Review of Resident #10's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], chronic kidney disease, asthma, protein calorie malnutrition, [CONDITION(S)] and chronic respiratory failure. Review of the most recent MDS 3.0 assessment revealed the resident's cognition was intact, he required limited assistance from one staff member for bed mobility, transfers, dressing and personal hygiene and required extensive assistance from one staff member for toilet use. Review of the MAR for 08/2021 revealed the resident received Trazadone 50 milligrams (mg) on an as needed basis on 08/04/21, 08/05/21, 08/09/21, 08/10/21, 08/11/21, 08/12/21, 08/15/21, 08/16/21, 08/17/21, 08/19/21, 08/20/21, 08/23/21, 08/24/21, 08/25/21, 08/26/21, 08/27/21, 08/30/21, and 08/31/21 with no attempts of non pharmacological interventions attempted prior to the medication administration. On 10/14/21 at 11:50 A.M. interview with Minimum Data Set (MDS) Coordinator #204 confirmed there was no evidence of non-pharmacological interventions on the dates noted above prior to administering the medication. She stated she was aware of concerns with nursing documentation and revealed they had been reminding and educating the nurses to document thoroughly. 3. Review of the medical record revealed Resident #12 was admitted to the facility on [DATE] with diagnoses including unspecified dementia with behavioral disturbance, alcohol dependence with unspecified alcohol-induced disorder, dysphagia, personal history of malignant neoplasm of prostate and major depressive disorder. Review of the quarterly MDS 3.0 assessment, dated 08/16/21 revealed the resident had impaired cognition. The only behavior documented during the look back period was rejection of care which occurred four to six days. Review of the plan of care dated 08/24/21 revealed Resident #12 was receiving an antipsychotic drug for dementia with behavioral symptoms with the potential for adverse side effects. Interventions included administering medications as ordered by physician and monitoring for side effects, monitor and document resident's behavior for desired effects, obtain psychiatric and social service consultation for assessment, and anticipating needs. Review of the current physician's orders revealed Resident #12 had an order for [MEDICATION(S)] 250 milligram (mg) tablet to be administered twice a day for diagnoses of dementia with behavioral disturbance. The order was initiated on 05/04/21. Review of the Medication Administration Record (MAR) for 05/04/21 through 10/13/21 revealed the resident received the medication as ordered except when one dose was refused on 06/30/21, 07/31/21, 08/17/21, 09/13/21, 09/29/21, 10/01/21 and 10/04/21. Review of the [MEDICATION(S)] delayed-release tablets prescribing information (dated June 2021) revealed the indications for use were treatment of manic episodes associated with [CONDITION(S)] disorder, some [CONDITION(S)] types and prophylaxis of migraine headaches. On 10/14/21 at 11:55 A.M. interview with Registered Nurse (RN) #204 confirmed Resident #12 was on [MEDICATION(S)] related to dementia with behavioral disturbance. She additionally confirmed the prescribing information for [MEDICATION(S)] extended release did not include dementia as an indicated use.

Based on record review and staff interview the facility failed to ensure the bowel protocol was followed for Resident #9 as ordered. This affected one resident (Resident #9) of two residents reviewed for bowel and bladder incontinence. Findings include: Review of Resident #9's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 02/24/19 revealed the resident had severe cognitive impairment with a Brief Interview for Mental Status (BIMS) score of one. The MDS assessment revealed the resident required extensive assistance of two staff for toileting and was always incontinent of bowel and bladder. A plan of care dated 02/24/19 revealed Resident #9 had bowel incontinence and was at risk for constipation. Interventions included to follow the bowel protocol as indicated. Review of physician orders [REDACTED]. If there were no results after the administration of the enema, the physician was to be called. Review of resident's bowel movement documentation revealed Resident #9 did not have a BM from 03/05/19 to 03/09/19. Further review of the bowel movement documentation revealed Resident #9 had a BM on 03/12/19 but did not have another BM until 03/16/19. A nurse's note dated 03/17/19 at 1:28 P.M. revealed Resident #9 was incontinent of bowel and bladder. There was no documentation as to whether Resident #9 had a BM from 03/17/19 to 03/26/19. Interview on 03/26/19 at 2:24 P.M. with the Director of Nursing (DON) revealed Resident #9 did not follow the normal bowel protocol. The DON stated the resident did not have a BM daily and the staff may have waited five days before administering a laxative. DON verified Resident #9's orders revealed the resident was ordered laxatives as needed per the bowel protocol above. Interview on 03/27/19 at 1:08 P.M. with the DON verified Resident #9 went more than three days without the bowel protocol that was ordered for the resident being implemented and no as needed laxative medication was administered between 03/01/19 and 03/25/19. Interview on 03/27/19 at 2:12 P.M. with Registered Nurse (RN) #500 revealed the electronic documentation provided an alert each morning of residents who had not had a bowel movement in three days. RN #500 verified Resident #9 went more than three days without having a BM as noted above and indicated there would have been several alerts notifying the nurse the resident had not had a BM. RN #500 verified no as needed medication had been administered as ordered during the time periods noted above. Review of the Standing As Needed Orders for constipation (no BM within three days), and in the absence of significant [MEDICAL CONDITION], revealed to give [MEDICATION NAME] 30 ml by mouth one time. If no results in 24 hours, may insert one [MEDICATION NAME] suppository. If no BM within 24 hours after [MEDICATION NAME] suppository, may administer Fleet enema. Notify physician for further orders if no results.

Based on record review and interview the facility failed to ensure an accurate and complete pressure ulcer assessment, including Staging and measurements was completed upon admission for Resident #119. This affected one resident (Resident #119) of two residents reviewed for pressure ulcers. Findings include: Record review revealed Resident #119 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #119's admission skin assessment, dated 03/19/19 revealed the resident had areas to her lower back/spine area. However, there were no measurements or staging of the areas completed at the time of admission. On 03/26/19 a skin assessment was completed that determined the resident had one Stage II (partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister) pressure ulcer on the lower spine area that measured four centimeters (cm) in length by two cm width with 0.1 cm depth. Interview with the DON on 03/25/19 at 5:00 P.M. and 03/27/19 at 2:42 P.M. verified the skin assessment completed on 03/19/19 (admission) revealed the areas to Resident #119's lower back did not include any measurements or Staging. The DON revealed the normal facility procedure was to identify the areas (either upon admission or in-house acquired), follow the facility standing order treatments prior to calling the physician to ensure the wound was being treated, contact the physician about the areas, inform the DON, and then document everything in the electronic record accurately and thoroughly. Interview with Licensed Practical Nurse (LPN) #521 on 03/27/19 at 4:00 P.M. revealed she was the nurse who admitted Resident #119 on 03/19/19. She revealed she reviewed the hospital physician orders [REDACTED]. After getting the orders verified, she did a full assessment (including full skin assessment). She stated when she did the full skin assessment, she found three separate pressure ulcers, which in her opinion, she would have classified as Stage I (intact skin with a localized area of non-blanchable [DIAGNOSES REDACTED] (redness)) pressure areas on her spine/low back/coccyx area. The LPN verified she did not include any measurements or Staging of the areas in her admission skin assessment note. Review of facility Skin Assessment policy, dated 09/20/10 revealed, on admission, a full body skin assessment must be done on the shift that the resident was admitted to the health center.

Based on observation, record review and interview the facility failed to ensure Resident #7's oxygen tubing was intact and the humidifier had water in it. This affected one resident (Resident #7) of four residents who received oxygen. Findings include: Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The MDS 3.0 assessment also revealed Resident #7 had shortness of breath when lying flat. Review of the plan of care, dated 01/31/19 revealed Resident #7 required oxygen administration. Interventions included oxygen to be delivered at two liters per minute (2/min) nasal cannula as ordered. Review of the physician's orders [REDACTED].#7 was ordered oxygen at two liters per nasal cannula as needed to maintain oxygen saturation level greater than 90 percent. Observation on 03/25/19 at 8:43 A.M. revealed the oxygen concentrator was operating with oxygen tubing connected to the concentrator. Resident #7 had a nasal cannula in nares. However, the oxygen tubing was disconnected between the oxygen concentrator and the nasal cannula and laying directly on the floor. The observation also revealed the humidifier bottle on the oxygen concentrator did not have any water in it. Interview on 03/25/19 at 8:51 A.M. with Licensed Practical Nurse (LPN) #501 verified the oxygen tubing was disconnected and the humidifier bottle was empty. Review of the oxygen administration policy and procedure dated 01/08/13 revealed the humidifier was to be filled with distilled water and the cannula and tubing was to be connected to the humidifier.

Based on record review and staff interview the facility failed to ensure Resident #17's medical record was maintained in a complete and accurate manner related to the circumstances surrounding the residents transfer to the hospital. This affected one resident (Resident #17) of three residents reviewed for transfer/discharge. Findings include: Record review revealed Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 02/09/19 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13, which indicated she was cognitively intact. Review of Resident #17's medical record revealed the resident was discharged from the facility to the hospital on [DATE]. Record review revealed an electronic progress note, dated 02/09/19 at approximately 8:00 A.M. that stated the resident had no concerns or issues. An electronic progress note, dated 02/09/19 at approximately 3:00 P.M. revealed she was being transferred to the hospital. There was no other information in her medical record about why she was being transferred to the hospital. A separate record provided during the onsite survey, that was not independently available to the surveyors or part of the resident's medical record revealed the nurse on duty at the time of the transfer/discharge on 02/09/19 had contacted the on-call physician and reported Resident #17 was showing signs of altered mental status and [MEDICAL CONDITION] symptoms. There was no other description or information including vital signs, neurological checks or other assessments completed. Review of Resident #17's transfer packet that was sent to the hospital with her, the transfer/discharge form had the reason for discharge as being level of care change. There was nothing more specific documented than that. Interview with the Director of Nursing (DON) on 03/28/19 at 10:08 A.M. revealed she does not know the reason why Resident #17 was transferred to the hospital on [DATE] due to the lack of information in the resident's electronic medical record. She indicated it was the expectation that staff would document a description of the resident's condition or medical status when the resident had to be transferred to the hospital. Interview with Registered Nurse (RN) #26 on 03/28/19 at 10:14 A.M. revealed she was the nurse who transferred the resident to the hospital. the RN confirmed she did not put any information in Resident #17's medical record regarding the reason for her discharge. She stated she thought she did, but she must have forgot to do it. She confirmed it was the standard and expected that staff would put a description of why a resident was being discharged to the hospital in the resident's medical record.

Based on record review and interview the facility failed to adequately monitor significant weight loss for Resident #7. This affected one resident (Resident #7) of one resident reviewed for nutrition. Findings include: Resident #7 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 12/08/17 revealed the resident exhibited cognitive impairment and was not interviewable. Review of Resident #7's admission assessment, dated 11/27/17 revealed the resident was dependent on others for eating. Review of Resident #7's care plan for titled, swallowing and chewing difficulties related to dysphagia, revealed interventions that included to monitor weights and meal intakes intakes and notify medical director and Registered Dietitian (RD) of any significant weight changes. Review of Resident #7's documented weights revealed the following: On 12/05/17- 136.6 pounds, on 01/01/18- 129.3 pounds and on 01/03/18- 130 pounds. This reflected a 5.84% weight decrease from 12/05/17 to 01/01/18 and a 5.11% weight decrease from 12/05/17 to 01/03/18. Review of Resident #7's progress notes from admission through 01/30/18 revealed no progress notes or nutritional assessments completed by the RD. On 01/31/18, RD #91 entered the facility and reviewed Resident #7's chart. She wrote a nutritional progress note that stated, weight taken on 01/31/18: 129.8 (weight stable for 30 days). Nursing staff confirms meal intakes are 75-100%. Magic cup supplement offered during lunch and dinner as needed, and is well accepted. Recommendations: offer magic cup three times daily with meals due to slow weight decline despite adequate caloric intake, weight maintenance desired and will monitor and recommend additional changes as needed. Interview with Administrator on 01/31/18 at 9:17 A.M. confirmed the facility did not have evidence from the dietitian to support that she was notified when the significant weight occurred and if there was an assessment completed after the weight loss was discovered. She also confirmed there was no documentation of a nutritional assessment completed by the RD when the resident she was readmitted to the facility. Interview with Director of Nursing (DON) on 01/31/18 at 10:29 A.M. confirmed there were no dietary notes or assessments in Resident #7's medical record. Interview with RD #91 on 01/31/18 at 2:30 P.M. revealed she reviewed the resident's medical record on this day and added a recommendation of magic cup three times daily instead of the previous order of two times daily. She stated this was to be used for weight maintenance and stabilization. She stated she felt the resident would continue to lose weight because of her disease process, but indicated the magic cup should help stabilize it. Review of of facility Nutritional At Risk Notes revealed Resident #7's was listed on these notes as being someone who was reviewed for her nutritional and weight status by the dietitian on the following dates: 12/01/17, 12/15/17, 12/22/17, 01/12/18, and 01/26/18. There were no other notes written regarding her nutritional or weight status except on 12/01/17, which stated, resident needs re-admit weight, and on 12/22/17, which stated, stable. Review of facility Significant Weight Variance Report, dated January 2018 revealed three residents listed on the report for weight loss, but Resident #7 was not one of them. Review of the undated facility Nutrition At Risk (NAR) Program policy revealed, all residents identified to be at high nutritional risk shall be monitored in the nutrition at risk program. The committee shall be formed to include the dietary manager, dietary professional, nursing designee(s), social services, activities, and therapy staff shall attend as indicated. The committee will meet weekly. All new admissions and readmissions shall also be added to the NAR program. The dietary professional shall complete a nutrition at risk resident monitoring form for each resident added to the NAR program. Review of the facility Significant Weight Loss policy, dated 09/07/12 revealed, a significant weight change in the MDS will be completed for residents who have significant (unplanned) weight decline. Any weight change of four pounds or greater will require an automatic re-weight. If the weight loss of four pounds or greater is confirmed, the STNA will inform the charge nurse or director of nursing. The charge nurse or director of nursing will assess if the weight loss is significant. If significant, the charge nurse or DON will contact the RD or certified dietary manager.

Based on observation, record review and staff interview the facility failed to follow and maintain infection control standards to prevent infections when a Licensed Practical Nurse failed to wear adequate personal protective equipment when completing a dressing change for Resident #110 who was in contact isolation precautions for Methicillin-resistant Staphylococcus aureus (MRSA) in the urine. This affected one resident (Resident #110) and had the potential to affect all 30 residents residing in the facility. Findings include: Review of the medical record for Resident #110 revealed an admission date of [DATE] with a [DIAGNOSES REDACTED]. The resident was in isolation precautions due to the MRSA in the urine. Observation on 10/13/2016 at 10:16 A.M. of the dressing change for Resident #110 revealed Licensed Practical Nurse (LPN) #66, who was the facility wound nurse completed a dressing change procedure to a pressure ulcer to the resident's coccyx area. The Director of Nursing (DON) was present in the room during the procedure. The wound nurse was dressed in street clothes. She was not wearing a gown or any personal protective equipment (PPE) except gloves when the surveyor entered the room. The DON told the surveyor when asked, you don't need to wear any PPE unless you plan on touching something. The nurse stated she had cleansed the coccyx area with soap and water prior to the surveyor coming into the room. The resident had been incontinent of urine and was wearing an incontinent brief. The nurse wiped a second area with peri wipes and applied Sensicare (skin barrier) with a gloved hand. The nurse completed the dressing change procedure and repositioned the resident in the bed. LPN #66 was asked why she did not follow the isolation precautions and wear a gown during the procedure and she stated, I guess I just forgot. Review of the policy and procedure related to Contract Precautions dated 04/25/05, revised 06/29/08 revealed all personnel, including visitors, that have direct contact with a resident on contact precautions shall be required to follow all procedures as outlined within this policy in addition to standard precautions and general isolation precautions guidelines. Section 4 related to gown use revealed gowns were to be worn when it was anticipated that substantial contact with the infected part of the resident, environmental surfaces or items in the resident's room or if the resident was incontinent or had diarrhea, an ileostomy or wound drainage that was not contained by dressing.

Based on observation, record review and interview the facility failed to ensure adequate and timely pressure ulcer treatment and prevention for Resident #110, who was admitted to the facility with pressure ulcers present. This affected one resident (Resident #110) of one resident reviewed for pressure ulcers. The facility identified three residents with pressure ulcers. Findings include: Medical record review revealed Resident #110 was admitted to the facility on [DATE]. The resident had a [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident required extensive assistance with two person physical assistance by staff with transferring and bed mobility. The assessment revealed the resident was incontinent of bladder, had one Stage II pressure ulcer (partial-thickness skin loss with exposed dermis) and one unstageable pressure ulcer (obscured full-thickness skin and tissue loss). The assessment revealed both pressure ulcers were present upon admission. Review of the interdisciplinary notes dated 10/13/16 revealed the resident was receiving skilled therapy services. Review of the history and physical dated 09/27/16 revealed the resident was admitted with a Stage II pressure ulcer on the coccyx with a scab noted and a Stage I pressure ulcer on the back and buttocks. There were no physician orders to treat the pressure ulcers except to keep the wounds clean and dry until 09/30/16 (three days after admission). On 09/30/16, the physician ordered a treatment, using Sensicare cream to the coccyx twice a day. This physician order was not signed as being completed for the resident until 10/06/16 (six days later). Review of Certified Nurse Practitioner (CNP) #80's progress notes dated 10/07/16 revealed the resident had a dry unstageable pressure ulcer to the lower back and a small Stage II pressure ulcer to the the buttocks. There were no physician orders to treat the unstageable pressure ulcer to the lower back as of that time. On 10/13/16, the physician ordered to cleanse the unstageable pressure ulcer with normal saline, pat dry. Apply Allevyn to area every three days and as needed. Observation of wound on 10/13/16 at 10:16 A.M. revealed the unstageable wound appeared to have the first layer of skin off, with no scab noted. A pink wound base was visible and the area surrounding it was dry and scaly. There was no dressing in place at the time of the observation. Interview with the Director of Nursing (DON) on 10/12/16 at 2:50 P.M. revealed there were no treatment orders for the pressure ulcers until 09/30/16 and when implemented, the only treatment at that time was for the coccyx wound. The DON confirmed the treatment administration record (TAR) reflected no treatments being completed until 10/06/16. The DON also confirmed there were no treatment orders for the unstageable pressure ulcer and said CNP #80 was following him at a previous facility and he/she was trying to dry out the wound, which was why there was no treatment ordered. Interview with Certified Nurse Practitioner #80 on 10/13/16 at 9:30 A.M. confirmed she did not order a treatment to the unstageable pressure ulcer wound until today (10/13/16) because the wound used to be a scab and today the scab fell off. The CNP stated she was trying to keep the wound dry and since the scab fell off she ordered a treatment. She stated the Stage II pressure ulcer on the coccyx was hard to put a treatment on because of the location of the wound and felt that the use of Sensicare was the most appropriate treatment. The CNP said it was the facility protocol to use Sensicare treatment for [REDACTED]. Review of the facility's wound management protocol dated 04/08/05 revised 09/20/10 revealed for a Stage II pressure ulcer the procedure included to cleanse the wound with wound cleanser, pat dry the area around the wound. If applying a barrier, wipe with skin prep to intact surrounding skin. Remember to write order for treatment being given, and document treatment on the TAR. Sensicare was an approved protective ointment to use on the Stage two pressure ulcer. There was no procedure for unstageable pressure ulcers. Review of the product information for the Sensicare wound treatment revealed it temporarily protected and helped relieved chapped or cracked skin and lips. It helped treat and prevent diaper rash and protected minor skin irritation associated with diaper rash and helped seal out of wetness Review of the National Pressure UIcer Advisory Panel for Prevention and treatment of [REDACTED]. Cleansing should be done at each dressing change. General recommendations included to select a wound dressing based on the ability to keep the wound bed moist and need to address bacterial bioburden.

Based on observation, record review and interview the facility failed to ensure Resident #110, who was assessed to be at high risk for choking and aspiration received adequate supervision with meals. This affected one resident (Resident #110) of three residents reviewed for nutrition. The facility identified two residents who required supervision with meals who were at aspiration risk. Findings include: Medical record review revealed Resident #110 was admitted to the facility with a [DIAGNOSES REDACTED]. The assessment revealed the resident required supervision with set up assistance by staff for meals. Review of the speech therapist progress and discharge summary form dated 10/11/16 revealed the resident declined recommendation for nothing by mouth. The Speech Therapist (ST) recommended for the resident to receive a regular diet with thin liquids and to provide cues for the resident to implement recommended safe swallow strategies which included small bites and sips, slow rate, double swallow after every bite/sip, head turn to right and left following swallowing of solids. The ST also recommended supervision at meals, sit upright at 90 degrees during meal and remain upright for approximately 30 minutes following meals. Observation of the resident's room on 10/12/16 at 2:16 P.M. revealed there was a sign posted in his room stating to keep the head of bed at 90 degrees and no straws with all oral intake. There were no other safe swallow strategies listed. Further observation on 10/12/16 at 5:20 P.M. revealed a nurse provided the resident with his meal tray consisting of regular texture food items with thin liquids and then left the room. Continuous observation on 10/12/16 from 5:20 P.M. to 5:56 P.M. revealed at 5:23 P.M., the resident was observed feeding himself in his room without any staff in the room providing any supervision. On 10/12/16 at 5:56 P.M., a State tested nursing assistant (STNA) walked into the resident's room and asked the resident if he was still eating his meal and the resident replied yes. The STNA left the room and continued to leave the resident unsupervised during his meal. Interview with the Director of Nursing (DON) on 10/13/16 at 11:00 A.M. confirmed Resident #110 was not supervised with his dinner meal on 10/12/16 and confirmed she was not aware the resident should be supervised during meals. The DON also confirmed the ST progress and discharge summary form stated the resident was to receive supervision with meals and the safe swallow strategies which included small bites and sips, slow rate, double swallow after every bite/sip, and head turn to right and left following statuette. The DON confirmed these recommendations were not apart of the resident's care plan and these recommendations were not communicated to nursing. Interview with Rehabilitation Director #75 on 10/13/16 at 11:40 A.M. confirmed he was not aware of the speech therapy recommendations and verified the recommendations were not communicated to nursing. He said usually the ST would notify him of the recommendations and then he would notify nursing the following morning in their daily meetings.

Based on observation, record review and interview the facility failed to adequately assess and implement nutritional interventions to treat Resident #110. Resident #110 was assessed to sustain significant weight loss, was severely underweight with an unstageable pressure ulcer and had a [DIAGNOSES REDACTED].#110) of three residents reviewed for nutrition. The facility identified one resident with unplanned significant weight loss. Findings include: Medical record review revealed Resident #110 was admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident required supervision with set up assistance with meals, had moderate impaired cognition and had one Stage II pressure ulcer (partial-thickness skin loss with exposed dermis) and one unstageable pressure ulcer (obscured full-thickness skin and tissue loss). Both pressure ulcers were present upon admission. Review of the interdisciplinary notes dated 10/13/16 revealed the resident was receiving skilled therapy services. Review of the nutrition initial assessment dated [DATE] revealed the resident's admission weight was 140 pounds (#) and the resident's daughter had reported a 20# weight loss during his hospital stay. His body mass index was 20.2 and was a healthy weight for height. The resident's specific nutrition problem was the resident had increased nutrient needs (protein-energy) to rule out wound healing and acute medical status as evidence by reported weight decline prior to admission and impaired skin reported. The nutritional recommendations were to start a nutritional supplement, Boost 240 milliliters (ml.) twice daily which would provide additional 480 calories (kcals) and 20 grams (g.) protein and start a protein supplement, Prostat 30 ml. twice daily which would provide 200 kcals and 30 g. protein. The goal was for the resident to maintain his weight and wound healing. Review of the resident's nutrition plan of care revealed the resident had multiple [DIAGNOSES REDACTED]. The goal was for the resident to be without significant weight changes and accept and tolerate diet as ordered. Approaches included to provide supplements as ordered, notify the physician of any changes, and offer substitute if less than or equal to 75 percent consumed. Review of the nutrition progress note dated 10/07/16 revealed the resident weighed 120.7# on 10/03/16. The registered dietitian documented she questioned the accuracy of the weight as this was a significant decline of 19.3# and was a 13.8 percent (%) significant weight loss in the past week. Meal and intakes were noted to be 50-100%. The recommendation was to reweigh the resident for verification of current weight status. There was no change in the resident's plan of care. There was no evidence in the medical record the physician, resident and/or family was notified of the weight loss on 10/07/16. There was no follow up to the reweight until 10/13/16. Review of the nutrition progress note dated 10/13/16 revealed the resident's reweight on 10/07/16 was 122#. The reweigh confirmed severe 18# weight loss which indicated a 12.9% significant weight loss in less than one month. The resident's current body mass index was 17.4 which indicated the resident was underweight. The resident and physician were aware of the current weight loss at that time. The resident was encouraged good nutrient and fluid intake. The resident was agreeable to trying alternative nutrition supplements and flavors. The specific nutrition related problem was malnutrition related to varied oral intake in the setting of increased nutrient needs as evidenced by severe unintentional weight loss and underweight body mass index. The recommendations included to change Boost to Boost Plus twice daily to increase kcal and protein intake (720 kcals and 28 g. protein per day) and try Magic Cup (an ice cream high calorie supplement) twice daily to provide an additional 520 kcals and 19 g. protein per day to help stabilize weight and/or promote weight gain and promote wound healing since resident is below usual body weight, acceptable body mass index and has a pressure injury. Review of physician orders [REDACTED]. Observation of the resident on 10/12/16 at 2:16 P.M. revealed the resident had spilled some lunch items on his shirt. The resident said he spilled his juices. Further observation on 10/12/16 at 5:20 P.M. revealed a nurse brought in the resident's dinner to him in his room and left the room, leaving the resident unsupervised. Observation of the resident's meal on 10/12/16 at 5:23 P.M. revealed his meal was uncovered but his nutritional supplement and lemonade were covered and unopened for the resident to drink. Continuous observation on 10/12/16 from 5:23 P.M. to 5:56 P.M. revealed no staff supervised, cued, and/or encouraged the resident to eat and drink. A State tested nursing assistant (STNA) came into his room at 5:56 P.M. and asked the resident if he was still eating and the resident replied yes and the STNA left the room. Observation of the resident's beverages at this time revealed they were still covered and there was no evidence he consumed any of them. Interview with the Director of Nursing on 10/13/16 at 8:23 A.M. confirmed the family and physician were not notified of the resident's significant weight loss on 10/07/16. Interview with Registered Dietitian #85 on 10/13/16 at 9:15 A.M. confirmed there was no new nutrition interventions implemented on 10/07/16 and the reweigh was not addressed as of this date. (The registered dietitian (RD) completed her reassessment on 10/13/16 at 12:54 P.M.) The RD stated that she only comes in once a week and it was up to nursing to notify the family and physician of the weight loss and the RD confirmed she did not notify them herself. Interview with Certified Nurse Practitioner #80 on 10/13/16 at 9:30 A.M. confirmed she ordered nutrition related labs on this date and was aware of the weight loss.

Based on observations, clinical record review, staff, visitor, and resident interviews, review of the facility's Safe Smoking Policy, Oxygen Administration Policy and Procedure, Oxygen Therapy Safe Standard Policy, and review of Fire Safety Training and Staff Meeting notes and attendance sheets, the facility failed to provide adequate supervision and interventions related to smoking and failed to enforce smoking policy rules when Resident #41 was observed smoking unsupervised. This resulted in Immediate Jeopardy for one resident (Resident #41) reviewed for safe smoking and identified by the facility as the only resident who smokes. The census was 25. On 08/04/2015 at 1:57 P.M., the Director of Nursing (DON) was notified the Immediate Jeopardy began on 08/03/15 at 1:06 P.M. when Resident #41, who was assessed to require supervision while smoking, was observed smoking unsupervised in an undesignated smoking area with an oxygen tank attached to the back of the wheelchair. The Immediate Jeopardy was removed 08/05/15 at 6:00 P.M. when the facility took the following corrective actions: · On 08/04/15, the DON completed a new assessment of Resident #41. The assessment identified the resident was a long time smoker with poor safety awareness and was to be attended at all times by staff or caregivers or significant other who had been educated on turning the oxygen off, removing the oxygen canister, storage of the cigarette and lighter, and the designated smoking area. · On 08/04/15 the DON updated the Oxygen Administration Policy and Procedure, and presented a draft for an Oxygen Therapy: Safe Standard Policy. · On 08/04/15 at 2:20 P.M. and on 08/05/15 at 7:30 A.M., the DON provided education to staff regarding the revised Safe Smoking Policy. The three staff members on vacation will be in-serviced on their next working day. · On 08/05/15, the Safe Smoking Policy and Procedure was revised again to include oxygen was not permitted in the designated smoking area; a fire extinguisher was located in the Assisted Living (AL) hallway adjacent to the AL living room; and residents were not allowed to be left unsupervised by staff, caregiver, family and/or educated significant others while smoking. · On 08/05/15 at 12:15 P.M., the facility provided an updated Plan of Care for Resident #41. The plan of care addressed use of a smoking apron, that oxygen must be left at nursing station in exchange for cigarettes/lighter before going to the smoking area and may be picked up when finished smoking; smoking is only permitted in the designated smoking area outside the Assisted Living activity room area and with adult supervision by those trained on the safe smoking policy. Smoking assessments will be completed quarterly and with any significant change and training for staff, family, and others regarding the smoking policy. · On 08/05/15 at 10:51 A.M., LSW #23 provided education to Visitor #19 regarding Safe Smoking Policy and smoking procedures for Resident #41. · On 08/05/15 at 2:40 P.M., the DON provided the survey team a Safe Smoking Policy dated 08/04/15 stating that a nurse will distribute smoking materials to the residents. · On 08/05/15, an updated Oxygen Administration Policy and Procedure dated 08/05/15 included that families, visitors, significant others were not permitted to remove or turn on oxygen therapy, the nurse will turn on the oxygen flow meter and set the liter per minute as ordered by the physician, all smoking materials will be given to the resident or significant other by the nurse who will then turn off and remove the oxygen cylinder. The DON completed staff in-service on the Oxygen Therapy Administration Policy dated 08/05/15 to all staff but three who are on vacation. Staff on vacation will be in-serviced by the DON on their next working day. · On 08/05/15 at 2:45 P.M., the DON provided an updated policy entitled Oxygen Therapy: Safe Standards (draft dated 08/04/05) which addressed oxygen was a non-flammable gas; smoking is prohibited in areas where oxygen is being stored, transported, or used; residents, nursing personnel/caregivers and families must be educated regarding the safe us of oxygen use and must be informed of the hazards and all regulations associated with oxygen use. Although the Immediate Jeopardy was removed, the deficiency remained at a Severity level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of monitoring and evaluating the effectiveness of the Safe Smoking Policy and Procedure revisions; educating staff, resident and visitors; and completing the implementation of the Oxygen Therapy: Safe Standard Policy. Findings include: A review of the clinical record for Resident #41 revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #41's physician's order [REDACTED]. A review of a smoking assessment dated [DATE] revealed Resident #41 as an independent smoker. On 04/23/14 Licensed Social Worker (LSW) #7 reviewed the safe smoking policy with Resident #41 regarding smoking in designated areas only and oxygen sources not being permitted inside the smoking area. There was no plan of care available for review for 04/23/14 addressing residents smoking status. Review of the Minimum Data Set (MDS) for Resident #41 upon admission identified the resident with a Brief Interview for Mental Status (BIMS) score of 13. On 09/14/14 his BIMS score was 11 and on 12/02/14 his BIMS score was 9, both indicating moderate cognitive impairment. The quarterly assessment dated [DATE] revealed Resident #41's cognition was severely impaired with a BIMS of 4. The resident was identified at this time as needing extensive assistance with all activities of daily living with the exception of eating. Review of the Safe Smoking Policy (un-dated) in Resident #41's medical record indicated that LSW #7 informed the resident of the policy on 04/23/14 which included the resident must smoke outside on the Activity Room Patio; smoking is not permitted while oxygen is in use and oxygen sources are not permitted in the smoking areas. The policy also identified the resident's Plan of Care identified the resident as a smoker, the supervision that is necessary, and progress notes should document any non-compliance with the smoking policy. Any non-compliance is to be addressed with the resident and family members and the assessment is reviewed and updated with changes reflected in the Care Plan. The assessment completed 04/23/14 by the DON identified the resident as an independent smoker, to have no oxygen when smoking and that staff will observe the resident. Review of nursing progress notes dated 05/01/15 stated that Resident #41's family member reported the resident had her take him outside and he smoked a cigarette with his oxygen running per nasal cannula. Nursing notes indicated this would be reported to the DON and nurse manager by staff. The family member also stated that she would be addressing this in the care conference scheduled for 05/02/15. The nursing note also stated that a State tested Nursing Assistant (STNA) had witnessed Visitor #9 placing cigarettes in the dresser drawer in Resident #41's room before leaving. The nursing note stated the cigarettes were confiscated by staff. During an interview on 08/04/15 at 9:10 A.M. the DON confirmed there was no Plan of Care to review until 01/20/15 when she reported they had reassessed the resident due to a decline in his condition and determined that he was now a dependent smoker. The facility failed to provide a copy of this assessment for review. The Plan of Care initiated on 01/20/15 stated the resident was to ask the staff to assist him with his oxygen, smoking apron, lighter and cigarette. The plan of care also stated that he could request staff to allow Visitor #9 to supervise his smoking safety. Other interventions identified in the Care Plan included: oxygen must be turned off prior to leaving the nursing station to go to the smoking area. If possible, leave oxygen canister in nursing station as well, The resident is only permitted to smoke in the designated smoking area outside the Assisted Living activity room area. The facility had no documentation they provided training for Visitor #9 regarding the proper area to take the resident to smoke nor was the oxygen to be left at the nurses' station. The care plan indicated only to turn the oxygen off and if possible to leave the oxygen canister at the nurse ' s station. The Safe Smoking Policy that was undated stated no oxygen sources are allowed in the smoking area. Nursing notes on 04/10/15, 04/11/15, and 06/13/15 stated the oxygen had been turned off while Resident #41 smoked. On 08/03/15, at 1:06 P.M. Resident #41 was observed obtaining cigarettes, lighter and smoking apron from Unit Clerk #6 at the nursing station. The resident was accompanied by Visitor #19 to the patio outside the dining area (non-designated smoking area). Visitor #19 then applied the smoking apron to Resident #41, lit his cigarette and gave it to him. Visitor #19 stated that she came to visit frequently. She then stated the smoking area was across the courtyard but they just stayed and smoked in this area if no one else was sitting outside. A second Visitor #9 came outside and sat with the resident. She also confirmed that they smoked in this area frequently, and would also go to the other area where the ash tray was located if others were in the area outside the dining room. Visitor #19 and Visitor #9 stated the oxygen tank was left on the back of the wheelchair and they would turn the oxygen off when they took the nasal cannula off of Resident #41. During interview with the DON on 08/03/15 at 1:17 P.M., the DON was notified Resident #41 was smoking on the patio with the oxygen tank attached to the wheelchair. The DON stated the tank should have been removed when he went outside to smoke and that he should not be smoking in the non-designated smoking area. At this time, Licensed Practical Nurse (LPN) #13 went to the patio area, removed the tank from the wheelchair and asked Visitor #9 and Visitor #19 to go to the designated smoking area when smoking. During an interview with LPN #13 at this time, she stated Resident #41's friends normally take him out to smoke and they had both been informed of the location of the smoking area. LPN #13 verified the oxygen tank should be removed from the wheelchair before the resident was taken outside to smoke. On 08/03/15 at 2:59 P.M., STNA #4 stated during an interview Resident #41 normally had a friend or a family member take him outside to smoke. She stated she knew that he was to wear a fire apron and the oxygen was to be in the building before he went outside. During an interview with Resident #41 on 08/03/15 at 3:47 P.M., he stated that he has gotten inconsistent information about smoking. The resident stated that sometimes he smokes on the porch outside the dining area (non-designated smoking area) and nothing was said and other times he was told he had to go to the designated smoking area. The resident stated that he did not understand what the difference was regarding where he could smoke other than what staff members were working. Resident #41 stated that he did not remember the staff taking the oxygen cylinder from the chair before he goes outside to smoke. He confirmed that his visitors are normally the people who escort him outside to smoke. During an interview with LPN #16, on 08/03/15 at 4:08 P.M., she stated Resident #41's cigarettes and lighter were kept at the nurse's station. She stated that someone gives him a smoking apron and they make sure that his oxygen is turned off before he goes outside to smoke but does not remove the cylinder from the chair. During an interview with the DON on 08/03/15 at 4:44 P.M., she stated she had completed an updated assessment in January 2015 regarding Resident #41; however, she could not locate the assessment. She identified the resident is encouraged to smoke in the designated area; however, when his visitors take him to smoke, they do not always go to the designated area. The DON reported the staff very rarely takes him to smoke; however, it is the responsibility of the nursing staff to make sure the oxygen is not on his chair. She stated the oxygen canister should be exchanged for his cigarettes. During an interview with LPN #13 on 08/03/15 at 5:02 P.M., she stated that when the cigarettes are given to the resident, the oxygen cylinder should be placed in the holder in the nurse's station and when he comes back inside he would stop at the nurse ' s station to pick the oxygen up. She stated that Resident #41 is unable to turn his own oxygen tank off; however, the visitors turn it off on occasion when taking him to smoke. LPN #13 stated that she gave the cigarettes to Unit Clerk #6 to give to the resident. Interview on 08/03/15 at 5:19 P.M., Ward Clerk #6 stated that he was given the cigarettes, lighter, and apron by LPN #13 to give to Visitor #19 who was taking Resident #41 out to smoke after he had finished his lunch. Ward Clerk #6 stated that he did not know the oxygen needed to be turned off or removed from the wheelchair before the resident went outside to smoke. He reported that he gives the resident his cigarettes approximately two to three times per week. Interview on 08/04/15 at 9:10 A.M, with the DON reported that Resident #41 had a significant decline in his cognitive abilities and was reassessed in January, 2015. At this time the DON reported the Interdisciplinary Team met and concluded that he was no longer safe to smoke without supervision. She stated the team felt the resident needed to be observed at all times when he smoked and also felt the resident would benefit from the use of a smoking apron. The facility was unable to provide the surveyor the revised smoking assessment completed in January 2015 describing the decline in the resident ' s condition. Interview on 08/04/15 at 10:45 A.M. the DON stated that she did not have any information provided from the oxygen provider as to how the oxygen cylinders were to be stored, utilized or any cautions the facility should institute regarding the oxygen cylinders. She stated the oxygen supplier comes to the facility weekly and checks to assure the oxygen is stored properly; however, they do not follow up to assure the oxygen cylinders are properly utilized in the resident rooms. The DON denied having a policy and procedure regarding oxygen safety. Observation on 08/04/15 at 12:50 P.M., of Resident #41 revealed the resident was smoking in the designated smoking area with Visitor #9. The oxygen cylinder had been removed from the resident ' s wheelchair. A review of the Fire Safety Training conducted on 08/13/14 stated this was a general program which covered the common causes of fires and ways to prevent fires from happening in health care facilities. Staff was instructed on what to do should a fire happen. The facility provided documentation that 30 of 74 employees received this training. There was no specific training with staff regarding safety precautions during smoking. This was confirmed by the DON on 08/04/15 at 2:50 P.M. A staff meeting held on 08/21/14 and 08/22/14 addressed the location of the fire blanket, the designated smoking area as being located outside the Assisted Living activity room, the need to turn off oxygen and no oxygen tanks allowed in designated smoking areas. On 08/04/15, the DON provided the surveyors information from the supplier for their oxygen needs. The information stated that oxygen is to be kept away from radiators, heat ducts, stoves, or any other sources of heat.