Every finding on record at Pleasant Valley Manor

The facility reported a census of 40 residents. Based on observation, interviewed and record review, the facility failed to maintain an effective pest control program to ensure the facility remained free of pests, specifically cockroaches, and affected all residents in the facility. Findings included: - During an initial tour of the kitchenette area between the dining room and kitchen on 01/29/25 at 10:47 AM, the following areas of concern were noted: 1. The pop machine had standing liquid in the spill tray. 2. A trash can was over-flowing with trash and had dried-on liquid and food debris on the top and sides of the trash can. 3. The bags of syrup for the pop machine were kept in a cabinet underneath the pop machine. The bags had spilled syrup which had dried on several areas of the shelfs on which they rested. 4. The cabinet and drawer doors had multiple areas of dried-on food and fluids. During an initial tour of the kitchen on 01/29/25 at 10:47 AM, the following areas of concern were noted: 1. The two-door reach-in refrigerator had dried-on food on the front of the doors, the inside of the doors, the vents of the machine and in the handles of the doors. 2. The counter which held the coffee maker had multiple areas of dried-on coffee. 3. The bottom shelves of two food prep tables had food debris. 4. A covered trash can in the dish washing area had dried on food and liquids on all sides as well as the lid to the trash can. 5. Five plastic containers holding cold cereal had a dried-on, sticky food substance on the lids. 6. A three-tiered plastic cart used to stack clean dishes had food debris on all three tiers. 7. The trash can by the oven was overflowing and had dried-on food and liquid on all sides and the lid of the trash can. 8. The wire carts holding clean pots and pans had a build-up of food debris. 9. The bread shelf had a sticky build-up on all shelves. On 01/29/25 at 09:57 AM, Resident (R) 41 stated the facility had roaches in the kitchen and the dining room. The residents were able to see them crawling on the walls in the dining room. The facility has someone come out every month and spray for the bugs. On 01/29/25 at 11:13 AM, R14 stated there were roaches in the kitchen and dining room. On 01/29/25 at 01:13 PM, R37 stated there had been roaches in the dining room for quite a while and he could see them crawling on the walls. On 01/29/25 at 12:43 PM, Certified Medication Aide (CMA) R stated the facility had a problem with roaches in the kitchen. On 01/30/25 at 09:00 AM, Certified Nurse Aide (CNA) N, stated there had been roaches in the dining room and kitchen. CNA N stated when you go into the kitchen you could see them around the dish washer area. On 01/30/25 at 01:14 PM, CNA M stated the kitchen and dining room had roaches. The CNA said you could see them on the walls in the dining room. On 02/03/25 at 07:31 AM, CNA P stated the facility had roaches in the kitchen. On 02/03/25 at 11:41 AM, Consultant HH stated the facility was sprayed monthly for roaches. It would be difficult to get rid of roaches when there was a food supply within easy access to the roaches. On 02/03/25 at 12:05 PM, Administrative Staff A stated the facility was having problems with roaches in the kitchen and dining room. Administrative Staff A stated the facility had a contract with pest control company since, February 2014, and they would come in to spray monthly. Administrative Staff A stated they were unsure how the facility developed a roach problem when the facility was sprayed every month. The facility policy for Pest Control Program, undated, included: It was the policy of the facility to maintain an effective pest control program which eradicated and contained common household pests and rodents. The facility failed to maintain an effective pest control program to ensure the facility was free of pests, specifically roaches, and affected all residents in the facility.

The facility reported a census of 40 residents. Based on observation, record review and interview, the facility failed to prepare and serve food to the residents, under sanitary conditions, to prevent the potential for food borne bacteria. Findings included: - During an initial tour of the kitchenette area between the dining room and kitchen on 01/29/25 at 10:47 AM, the following areas of concern were noted: 1. The pop machine had standing liquid in the spill tray. 2. A trash can was over-flowing with trash and had dried-on liquid and food debris on the top and sides of the trash can. 3. The bags of syrup for the pop machine were kept in a cabinet underneath the pop machine. The bags had spilled syrup which had dried on several areas of the shelfs on which they rested. 4. The cabinet and drawer doors had multiple areas of dried-on food and fluids. During an initial tour of the dining room on 01/29/25 at 10:47 AM, the following areas of concern were noted: 1. The inside of microwave had a heavy build-up of dried on food on the top and all sides of the microwave oven. 2. The juice machine had dried-on juice on the back splash of the machine and in the spill tray. 3. There were several areas of dried-on food on the counter. During an initial tour of the kitchen on 01/29/25 at 10:47 AM, the following areas of concern were noted: 1. The two-door reach-in refrigerator had dried-on food on the front of the doors, the inside of the doors, the vents of the machine and in the handles of the doors. 2. The bottom of the reach-in had dried-on spilled liquid and food debris. 3. Four open gallons of milk lacked open dates. 4. A gallon pitcher of a vanilla supplement lacked a date. 5. The three-door reach-in refrigerator had a sandwich bag with half of a red bell pepper, an open bottle of an orange salad dressing, an open gallon of milk, a partially uncovered container of fruit cocktail, an open quart bottle of BBQ sauce and an open gallon of dill pickle slices, all lacking open dates. 6. A one-gallon container of a white salad dressing lacked an open date and had a large glob of dressing, which had turned into a brownish color, dried to the side of the container. 7. The bottom of the reach-in had a heavy build-up of food debris. 8. The front left corner of the bottom of the reach-in had an area of dried blood. 9. The counter which held the coffee maker had multiple areas of dried-on coffee. 10. The bottom shelves of two food prep tables had food debris. 11. A covered trash can in the dish washing area had dried on food and liquids on all sides as well as the lid to the trash can. 12. Five plastic containers holding cold cereal had a dried-on, sticky food substance on the lids. 13. A three-tiered plastic cart used to stack clean dishes had food debris on all three tiers. 14. A plastic container holding sharp knives had a build-up of dust and debris on the top. 15. The trash can by the oven was overflowing and had dried-on food and liquid on all sides and the lid of the trash can. 16. The wire carts holding clean pots and pans had a build-up of food debris. 17. The dry storage room had three open bags of chips lacking an open date. 18. The three-doored freezer had a build-up of food debris on the bottom. 19. The bread shelf had a sticky build-up on all shelves. On 01/30/25 at 01:30 PM, Administrative Staff A stated the above issues needed to be taken care of immediately. The facility policy for Dietary Cleaning Procedures, undated, included: The facility will store, prepare, distribute, and serve food under sanitary conditions to ensure proper sanitation and food handling practices to prevent the outbreak of foodborne illnesses was attained continuously. The dietitian and/or the dietary manager would review documentation of cleaning tasks and perform quality assurance process tracking and trending with team members at least once a month. The facility failed to prepare and serve food under sanitary conditions for the residents of the facility appropriately to prevent the potential for food borne bacterial.

The resident reported a census of 40 residents. Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for all residents and staff. Findings included: - During the initial tour of the kitchen areas on 01/29/25 at 10:27 AM, the following area of concern was noted: The floor throughout the kitchen had a heavy build-up of a blackish substance at the end of all table legs and legs of the kitchen equipment. The floor in the kitchenette area had a dried-on red liquid. The floor of the dry storage room had a sticky substance throughout. On 01/30/25 at 01:30 PM, Administrative Staff A stated it was the expectation for the floors to be kept mopped and cleaned at least daily. The facility policy for Dietary Cleaning Procedures, undated, included: The dietary staff will keep the kitchen floor clean and free of debris. The facility failed to provide a safe, functional, sanitary, and comfortable environment for all residents and staff.

The facility reported a census of 40 residents Based on observation, interview, and record review the facility failed to maintain an effective infection control program related to the failure of staff to sanitize the glucometer between use and the failure to perform proper hand hygiene. This deficient practice had the potential to spread possible infections to the residents in the facility. Findings included: - During an observation on 01/30/25 at 10:30 AM Certified Medication Aide (CMA) S gathered supplies to complete a glucose check. CMA S went to the therapy room to find R1 and completed a glucose check. CMA S then removed her gloves without preforming hand hygiene, she opened a door and walked to the nurses' station and threw away her gloves and retrieved other gloves, without performing hand hygiene. CMA S also did not sanitize the glucometer (instrument used to calculate blood glucose). CMA S walked through another hallway to R37's room, knocked on the door, performed hand hygiene, applied gloves, and checked R37's blood sugar. She removed her gloves and walked to the nurses' station to report the blood sugar reading. During an interview on 01/30/25 at 10:30 AM, CMA S reported she was not aware that the glucometers needed to be sanitized after use and prior to using on another resident. CMA S also verified she should perform hand hygiene after removing her gloves. During an interview on 02/03/25 at 09:05 AM, Administrative Nurse D expected staff to sanitize the glucometer with sanitizing wipes after every use. Administrative Nurse D expected staff to preform hand hygiene before gloves were applied and after staff removed gloves when glucose checks were completed. During an interview on 02/03/25 at 11:05 AM, ADON Administrative Nurse E reported she expected staff to sanitize the glucometer after each use. She stated she planned to reeducate. Also expected staff to preform hand hygiene before and after glucose checks were preformed after removal of gloves. Also, before the gloves were put on and right after they were taken off, before doing anything else. The facility's Infection Control Policy reviewed 12//2024 revealed hand hygiene was to be performed before and after contact with a resident, immediately after removing gloves, after touching objects and medical equipment in immediate resident care areas. The facility's Glucometer Disinfection policy dated 10/2022 revealed the glucometer was to be cleaned and disinfected after each use. The process for using the glucometer included wash hands, apply gloves, obtain the sample according to the facility policy, remove and discard gloves and preform hand hygiene prior to leaving the room, reapply gloves if there was visible signs of blood or if the resident had HIV, Hepatitis (inflammatory condition of the liver) B or C. Use two disinfectant wipes, the first to clean, the second to disinfect. The facility failed to maintain an effective infection control program related to the failure of staff to sanitize the glucometer between use and the failure to perform proper hand hygiene. This deficient practice had the potential to spread possible infections to the residents in the facility.

The facility reported a census of 40 residents with 12 residents selected for review, including three residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to safely transfer Resident (R)8. Findings included: - Review of Resident (R)8's Electronic Medical Record (EMR) revealed a diagnosis of Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of four, indicating severe cognitive impairment. She had functional limitation in range of motion (ROM) on both sides of her lower extremity and required substantial to maximal staff assistance for chair-to-bed-to-chair transfers. The Functional Abilities Care Area Assessment (CAA), dated 01/20/25, did not trigger. The Quarterly MDS, dated [DATE], documented the resident had a BIMS score of nine, indicating she had moderately impaired cognition. She had limited ROM on both sides of her lower extremity and was dependent on staff for chair-to-bed-to-chair transfers. The Care Plan, revised 11/29/24, instructed staff the resident required two staff and the use of a gait belt when transferred. Review of the resident's EMR, from 01/01/25 through 01/29/25, revealed the resident required substantial/maximal assistance to dependent with all transfers. On 01/30/25 at 09:00 AM, Certified Nurse Aide (CNA) N and Administrative Nurse D transferred the resident from her wheelchair to her recliner in her room. The resident, wearing appropriate footwear, was only able to bear minimal weight during the transfer. On 01/30/25 at 01:14 PM, CNA N and CNA O transferred the resident from her wheelchair to her recliner in her room. The resident, wearing appropriate footwear, was unable to bear weight during the transfer. On 01/30/25 at 09:00 AM, CNA N stated some days the resident could bear weight during transfers and other days she could not, it depended on the day. When the resident did bear weight, it was on her tip toes as she was not able to put her foot down flat on the floor due to the contractures in both of her legs. On 01/30/25 at 01:14 PM, CNA O stated the resident was not usually able to bear her full weight during transfers. On 02/03/25 at 07:31 AM, CNA P stated the resident required extensive assistance of two staff and the gait belt for transfers. CNA P stated the resident was not always able to bear her full weight. On 02/03/25 at 11:03 AM, Consultant Staff GG stated he would not consider a transfer to be safe if the resident could only bear minimal weight. On 02/03/25 at 09:07 AM, Administrative Nurse E stated staff would use a gait belt and two staff assist when transferring the resident. The resident was not always able to bear her weight during transfers. On 01/30/25 at 09:00 AM, Administrative Nurse D stated the resident was not always able to bear weight during transfers. On 01/30/25 at 09:00 AM, Administrative Nurse D stated the resident will bear weight at times on her [NAME] toes but was not always able to bear her full weight during transfers. The facility policy for Safe Resident Handling/Transfers, undated, included: The facility shall ensure residents are handled and transferred safely to prevent or minimize risks for injury and provide a safe, secure, and comfortable experience for the resident. The facility failed to safely transfer this dependent resident.

The facility reported a census of 40 residents with 12 residents sampled, including 2 residents reviewed for Activities of Daily Living (ADLS). Based on observation, interview, and record review, the facility failed to ensure two Residents (R)8, regarding staff not dressing the resident in clean clothing and R 13, regarding not assisting the resident at meal times, as care planned. Findings included: - Review of Resident (R)8's electronic medical record (EMR) revealed a diagnosis of Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interviewf or Mental Status (BIMS) score of four, indicating severe cognitive impairment. She required substantial/maximal staff assistance for dressing her upper portion. The Functional Abilities Care Area Assessment, (CAA), dated 01/20/25, did not trigger. The Quarterly MDS, dated [DATE], documented the resident had a BIMS score of nine, indicating moderately impaired cognition. She was dependent on staff for dressing of her upper portion. The care plan for Activities of Daily Living (ADL), revised 11/19/24, instructed staff the resident required one staff assistance with dressing. Review of the resident's EMR, from 01/01/25 through 01/29/25, revealed the resident required substantial/maximal to dependent staff assistance with dressing. On 01/29/25 at 10:17 AM, the resident sat in her recliner in her room. The resident wore a blue sweatshirt which had dried liquid and food on the front. On 01/29/25 at 12:37 PM, the resident sat at the dining room table with her peers. The resident continued to wear the dirty sweatshirt. On 01/29/25 at 03:13 PM, the resident sat in her recliner in her room and continued to wear the dirty sweatshirt. On 01/30/25 at 09:00 AM, Certified Nurse Aide (CNA) N stated staff should change resident's clothing when they are dirty. On 01/30/25 at 01:14 PM, CNA M stated the resident's should have clean clothing on at all times. On 02/03/25 at 09:43 AM, Administrative Nurse D stated it was the expectation for staff to ensure resisdent's were always dressed in clean clothing. The facility policy for Quality of Life--Dignity, undated, included: Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. The facility failed to ensure this dependent resident was dressed in clean clothing at all times. - Review of Resident (R)13's electronic medical record (EMR) revealed a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of three, indicating severe cognitive impairment. She had no swallowing disorder and was independent with eating. The Nutritional Care Area Assessment (CAA), dated 07/21/24, documented the resident had a history of malnutrition (lack of proper nutrition) and a poor appetite. The Functional Abilities CAA, dated 07/21/24, did not trigger. The Quarterly MDS, dated [DATE], documented the resident had a BIMS score of three, indicating severe cognitive impairment. She had no swallowing disorders and required setup or clean-up assistance with eating. The nutrition care plan, revised 01/15/25, instructed staff the resident required staff to feed her at mealtimes. Review of the resident's EMR, from 01/06/25 through 02/03/25, revealed the resident required setup to dependent assistance with eating. Review of the resident's EMR, revealed the following physician's order: Regular diet, pureed texture, regular liquids, ordered 01/08/25. On 01/30/25 at 12:25 PM, staff served lunch to the resident which consisted of pureed beef stew, pureed biscuit, and pureed peas. The resident made no attempt to feed herself. At 12:29 PM, Administrative Nurse D placed a spoon in the resident's hand and encouraged her to feed herself. The resident made multiple attempts to feed herself but was unable to get the food from her plate to her mouth with the spoon. At 12:32 PM, Certified Nurse Aide (CNA) N asked the resident to try the beef stew, but CNA N did not offer assistance to the resident. At 12:37 PM, Consultant staff II asked Administrative Nurse D to assist the resident with eating. Administrative Nurse D fed the resident, and the resident ate well with no difficulty swallowing. The resident consumed approximately 75% of her meal. On 02/03/25 at 07:29 AM, CNA P stated the resident will eat well when staff feed her. On 01/30/25 at 01:43 PM, Licensed Nurse (LN) H stated the resident required assistance from staff to feed her since her recent decline. On 01/30/25 at 12:37 PM, Administrative Nurse D stated the resident would usually feed herself and was unsure of why the resident required staff assistance for the noon meal. The facility policy for Quality of Life--Dignity, undated, included: Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. The facility failed to feed this dependent resident who required staff assistance at mealtimes.

The facility reported a census of 40 residents with 12 residents sampled, including three residents reviewed for dignity. Based on observation, interview and record review, the facility failed to show respect and dignity to one Resident (R)13, regarding staff dressing her in tops which were to large for her and hung on her, exposing her bare skin. Findings included: - Review of Resident (R)13's electronic medical record (EMR) revealed a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of three, indicating severe cognitive impairment. She required substantial/maximal staff assistance with upper body dressing. The Functional Abilities Care Area Assessment (CAA), dated 07/21/24, did not trigger. The Quarterly MDS, dated [DATE], documented the resident had a BIMS score of three, indicating severe cognitive impairment. She required substantial/maximal staff assistance with upper body dressing. The Care Plan for Activities of Daily Living (ADL), revised 10/22/24, instructed staff the resident required assistance with dressing. Review of the resident's EMR, from 01/01/25 through 01/29/25, revealed the resident required substantial/maximal to dependent staff assistance with dressing. On 01/29/25 at 02:55 PM, the resident sat at the dining room table with two male peers. Her improperly fitting dress fell off of the left shoulder, exposing bare skin. On 01/29/25 at 03:45 PM, the resident continued to sit in the dining room with her bare left shoulder exposed. On 01/30/25 at 08:57 AM, the resident sat in her wheelchair in the therapy room with several other peers. The collar of her t-shirt hung down low, exposing much of the resident's bare chest. On 01/30/25 at 11:51 AM, the resident sat in the dining room awaiting lunch. Her t-shirt collar continued to hang low, exposing much of her bare chest. On 01/30/25 at 01:33 PM, Certified Nurse Aide (CNA) M confirmed the resident's clothing was too large and would sag down exposing her bare skin. On 02/03/25 at 07:29 AM, CNA P stated the resident had lost weight and her clothes no longer fit her properly and would, at times, slide down and expose her skin. On 01/30/25 at 01:43 PM, Licensed Nurse (LN) H stated the resident had lost weight and her clothing did not fit her well. On 02/03/25 at 09:43 AM, Administrative Nurse D stated it was the expectation for resident's clothing to fit them properly and not expose too much of their skin. Administrative Nurse D stated the facility will look into getting the resident clothing that fit properly. The facility policy for Quality of Life--Dignity, undated, included: Staff will promote, maintain and protect the bodily privacy of all residents. The facility failed to dress this dependent resident in well-fitted clothing, instead of too large of clothing which was sliding down and exposing the resident's bare skin.

The facility reported a census of 38 residents with 14 selected for review. The sample included four residents for skin conditions. Based on observation, interview, and record review, the facility failed to ensure Resident (R)4, one of the four sampled residents, received wound treatment and care in accordance with professional standards of practice, with the failure to report a skin tear timely to the nurse for adequate treatment, for the nurse to timely assess the wound/skin tear, and failure to implement immediate intervention implementation to prevent further skin tears for this dependent resident with a history of skin tears. Findings included: - Review of the resident (R)4's, Physician Orders, dated 01/15/23, revealed diagnoses which included, displaced intertrochanteric fracture of right femur (leg bone broken at joint), Alzheimer's Disease (progressive mental deterioration characterized by confusion and memory failure), Parkinson's Disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), epilepsy (seizures), chronic pain, and anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The Annual Minimum Data Set (MDS) dated [DATE], documented, the Brief Interview for Mental Status (BIMS) score of 04, which indicated severe cognitive impairment. She exhibited inattention, disorganized thinking, trouble concentrating, and restlessness (such as moving around a lot more than usual). She directed physical behaviors towards others (e.g., hitting, kicking, pushing, scratching, grabbing). The resident rejected evaluation or care during one to three days of the look back period, which significantly interfered with the resident's care. The resident required extensive assistance of staff for bed mobility, dressing, and toilet use. She required limited assistance of staff for transfer, locomotion, and personal hygiene. She did not walk. Her balance during transition was not steady and was only able to stabilize with staff assistance. The resident had no functional limitation in her range of motion for the upper nor lower extremities. She used a wheelchair (w/c) as a mobility device. The formal clinical skin assessment revealed the resident was at risk for pressure ulcer injury. She received application of dressings to her feet. The Quarterly MDS, dated [DATE], documented the following changes from the above which included she required extensive assist for transfers. The resident was without any current skin treatments. The Delirium Care Area Assessment (CAA), dated 06/09/22, documentation included the resident spent the late afternoon and evenings looking for her family members and became distressed and agitated. The Care Plan Meeting Notes, (CP), dated 02/22/23 at 01:53 PM, documentation included the resident representatives expressed concerns due to the resident's skin tears. The Care Plan, dated 2/22/23, documentation included: 1. Staff will need to observe for and report any skin issues noted while assisting the resident with her care, initiated 08/05/2014. 2. The staff added padding to the front of the resident's w/c due to the resident's history of skin tears, initiated 08/24/2017. 3. The resident preferred to be close to other residents when sitting in the wheelchair while in the living room of the facility. She understands that this could cause an accident, initiated 01/09/2018. 4. Staff apply noodle coverings to her assist bars on her bed to prevent bruises to hands and arms in case she bumps them during the night, initiated: 01/28/2022. 5. Staff should check placement of foam wrapped around the w/c frame at the junction of the foot pedals, initiated 06/28/2022. 6. Staff instructed to offer assistance to the bathroom after eating, then assist her to her recliner to watch television, initiated on 09/25/2022. 7. The resident had a skin tear to her right lower leg, follow the treatment plan in her orders, initiated 01/07/23. 8. When the resident sits in the recliner, place a folded-up pillow on the metal part of the recliner to remind her not to put feet through the footrest between the chair to help prevent skin injury, initiated on 01/07/2023. The Physician Orders, dated 01/15/23, included orders for: 1. Apply tubi-grips to bilateral lower extremities when the resident gets out of bed, if her pants do not cover her legs and remove at bedtime, to prevent skin impairment. 01/08/23. 2. Clean the right lower leg with wound cleaner, apply skin prep and allow to dry. Apply steri strips as needed until closed, cover with bordered dressing one time a day, ordered on 01/08/2023. 3. Apply lotion to bilateral lower extremities every shift for skin integrity, ordered 02/20/23. 4. Monitor steri strips on skin tear to shin, apply steri-strips as needed. Monitor for signs and symptoms of infection until resolved, ordered on 02/23/23. Review of Nurses Progress Notes, (NPN), documentation dated 1/7/2023 at 3:48 PM revealed at approximately 08:00 AM, the nurse was performing a skin assessment and noticed a bandage on the resident's right lower leg on the front. She removed the soiled bandage measured both skin tears, Skin Tear #1 measured 4.0 centimeters (CM) by 1.0 CM by no depth and was dried and crusted over. Skin tear #2 measured 2.0 CM by 1.0 CM. by no depth, with bloody drainage. The nurse cleaned the skin tears with wound cleaner, applied skin prep and allowed them to dry, applied steri-strips, and covered with bordered dressing. She applied tubi- grips on the resident's bilateral legs. Review of the Incident Investigation Report, dated 01/07/23, documented the noted skin tears on the skin assessment, on 01/07/23 at 03:24 PM, by the nurse had a dressing in place. The nurse was not aware of the existence of the skin tears/injury prior to the routine skin assessment and discovery of the bandage. The staff identified the skin tear as an injury of unknown origin at that time. Review of a Witness Statement, dated 01/9/23, by CNA Q (the CNA responsible for the resident's care the evening of 01/06/23), included CNA Q reported at approximately 10:00 PM, she found the resident attempting to get out of her recliner by swinging her legs to the side of the recliner. The resident said ouch. CNA Q observed blood on the resident's right outer shin, she cleaned the blood and placed a dry bandage on it. The resident wanted to go to bed, and the CNA assisted the resident to her bed. She stated she forgot to tell the nurse about the skin tear. Review of the Electronic Medical Record (EMR) revealed the nurse did not assess the resident's skin tear when it occurred on 01/06/23 to determine the extent of injury and necessary treatment/care it needed. On 02/23/23 at 02:24 PM, a family member reported that the resident had a lot of skin tears. The facility reported that the skin tears may be related to her scratching herself, but they are unsure. On 02/26/23 at 11:04 AM, tour of the resident's room revealed the resident's bed with foam covering on the turn bar upper left side of the bed. The bathroom call light chain had a foam covering, also on the grab bar beside the toilet. On 02/27/23 at 09:07 AM, the resident sat at the dining table in the wheelchair. The wheelchair's brake handle and metal end caps, and foot pedal [NAME] contained covering with a pink foam and tape. On 02/27/23 at 09:10 AM, Certified Medication Aide (CMA) T applied the wheelchair foot pedals to the wheelchair and positioned the resident's feet. The resident had on tubi-grips (padding protection) on her bilateral legs. On 02/27/23 at 09:30 AM, CMA T applied a gait belt to transfer the resident to the recliner in the living room. The resident stood with extensive assistance of staff and pivoted to the recliner to a seated position. The CMA elevated the recliner footrest and placed a folded pillow beneath the resident's calf. On 02/27/23 at 03:36 PM, CNA T reported the staff member that first sees a resident with a skin injury should notify the nurse immediately. The nurse should follow-up on the report by assessing the resident to determine the source of the injury to put an immediate intervention in place to prevent further injury. The resident should not be moved until the nurse directs the staff to move the resident. The Nurse will notify the physician and family and obtain orders to treat/dress the wound. The CNAs should not bandage wounds. The resident gets skin tears from time to time. She has a skin tear on each shin with interventions to wear tubi-grips. On 02/28/23 at 10:12 AM, Licensed Nurse (LN) G stated when staff identify skin tears or injury, they should immediately notify the nurse. The nurse will assess the resident to determine the extent of the injury and contact the physician for orders to treat. Immediate interventions are put in place to prevent further injury and the care plan should be updated to communicate the interventions to all care givers. The CNAs fill out witness statements as part of the investigation to determine contributing factors. CNAs should not put a dressing on a skin tear. The resident should not be moved prior to the assessment. On 02/28/23 at 11:11 AM, Administrative Nurse D, confirmed the above findings. She stated staff should report any injury or change of condition immediately to the nurse and the CNAs should not apply any bandages. The facility policy Incidents and Accidents, dated 2022, documentation included Assuring that appropriate and immediate interventions are implemented and corrective actions are taken to prevent reoccurrences and improve the management of resident care. Any injury will be assessed by the licensed nurse or practitioner and the affected individual will not be moved until safe to do so. The facility failed to ensure Resident (R)4 received treatment and care in accordance with professional standards of practice when the staff failed to immediately report the resident's skin tear to the nurse, the nurse did not get to assess the wound and obtain an appropriate treatment for the wound timely. Furthermore, the facility failed to implement an intervention to prevent further skin wounds following this incident of injury/skin tear for this dependent resident, with history of multiple skin tears.

The facility reported a census of 38 residents with 14 residents sampled, including six residents reviewed for accidents. Based on observation, interview and record review, the facility failed to provide safe transfers for Resident (R)10, one of the six sampled residents. Findings included: - The Physician Order Sheet (POS), dated 01/23/23, documented Resident (R)10 had a diagnosis of Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness). The significant change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of ten, indicating moderately impaired cognition. She required extensive assistance of two staff for transfers and had limited range of motion (ROM) in her upper and lower extremities. The Activities of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 01/30/23, documented the resident had a diagnosis of Parkinson's and required assistance with all ADLs. The quarterly MDS, dated [DATE], documented the resident had a BIMS score of four, indicating severe cognitive impairment. She required extensive assistance of one staff for transfers and had an impairment in ROM on both sides of her upper and lower extremities. The care plan for ADLs, revised 01/30/23, instructed staff the resident required assistance with all her ADLs. The resident was unable to transfer herself and required assistance of one staff. Review of the resident's electronic medical record EMR, revealed the staff transferred the resident using extensive assistance of one to two staff. On 02/27/23 at 10:52 AM, Certified Nurse Aide (CNA) M and CNA N entered the resident's room to provide cares. Staff set the resident up to the side of the bed and transferred her using total assistance of two staff from the side of the bed to the wheelchair. The resident's socked feet skimmed the floor, and she was unable to bear weight on her legs during the transfer. The staff put their arms under R10's upper arms and grabbed the back of her pants to lift the resident. The staff failed to use a gait belt. On 02/27/23 at 03:28 PM, Certified Medication Aide (CMA) R and CNA O entered the resident's room to transfer the resident from her bed to the wheelchair. Staff put the gait belt on the resident and transferred her from the bed to the wheelchair. During the transfer the resident's socked feet skimmed the floor and she was unable to bear full weight on her legs. On 02/27/23 at 10:52 AM CNA M stated she failed to use the gait belt during the transfer and should have. The resident was unable to bear full weight due to the contractures in her lower extremities. CNA M stated staff mostly lift and transfer the resident. On 02/27/23 at 10:52 AM, CNA N stated the resident was not able to bear weight during her transfer. CNA N confirmed the resident had contractures to her lower extremities. On 02/27/23 at 04:16 PM, CMA R stated the resident was unable to bear full weight on her legs during transfers. On 02/28/23 at 09:18 AM, Licensed Nurse (LN) G stated the resident required staff assistance for transfers. On 02/28/23 at 09:36 AM, Administrative Nurse D stated the staff should always use a gait belt when transferring residents. Residents should be able to bear some weight during a transfer for it to be considered a safe transfer. The facility policy for Safe Transfers, undated, included: Staff members are expected to maintain compliance with safe transfer practices. The facility failed to provide a safe transfer for this dependent resident with contractures to her lower extremities, who could not stand on her legs.

The facility reported a census of 38 residents with 14 residents sampled, including five residents reviewed for unnecessary medications. Based on observation, interview and record review, the facility failed to ensure one Resident (R)10 was kept free from unnecessary medications regarding the failure to administer as needed (PRN) bowel medication for constipation. Findings included: - The Physician Order Sheet (POS), dated 01/23/23, documented Resident (R)10 had a diagnosis of constipation (difficulty passing stool). The significant change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 10, indicating moderately impaired cognition. She required extensive assistance of two staff for toileting and was always incontinent of bowel and bladder. The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 01/30/23, documented the resident was dependent on staff for toileting needs. The quarterly MDS, dated [DATE], documented the resident had a BIMS score of four, indicating severe cognitive impairment. She required extensive assistance of one staff for toileting and was frequently incontinent of bowel. The care plan for bowel management, revised 01/30/23, instructed staff the resident had as needed (PRN) medications to help prevent and treat constipation. Staff were to monitor the resident's bowel movements (BM) closely and inform the nurse if the resident went three days without a BM. Review of the resident's electronic medical record (EMR), from 01/29/23 through 02/26/23, revealed the resident did not have a BM every three days, without PRN medications to stimulate a BM, on the following dates: No BM from 02/14/23 through 02/18/23, for a total of five days. No BM from 02/24/23 through 02/27/23, for a total of four days. Review of the resident's physician orders for PRN medications for bowels, revealed the following: Biscolax suppository (a stimulant laxative that works by increasing the fluid/salts in the intestines), 10 milligrams (mg) rectally every (Q) 24 hours, PRN, for constipation, ordered 11/24/21. Disposable enema (a procedure in which liquid or gas is injected into the rectum, typically to expel its contents), rectally, Q 24 hours, PRN, for constipation, ordered 12/12/21. Milk of Magnesia (MOM-laxative), 30 milliliters (ml), by mouth (po), Q 24 hours, PRN, for constipation, ordered 12/03/21. Miralax (laxative), 17 grams (gm), Q 24 hours, po, PRN, for constipation, ordered 11/24/21. On 02/28/23 at 09:23 AM, Certified Medication Aide (CMA) S stated the nurse will give her a list of residents who need something (medication) PRN for bowels at the beginning of every shift. The resident's name was on the list that morning, but CMA S stated she had not given the PRN medication to the resident yet. On 02/28/23 at 09:18 AM, Licensed Nurse (LN) G stated she will get a report each morning of residents who had not had a BM for three days or more. LN G stated she will give the list to the CMA who will give the resident a PRN medication to assist the resident to have a BM. On 02/28/23 at 09:36 AM, Administrative Nurse D stated it was the expectation for staff to administer PRN medications to residents who had not had a BM for three days or more. The resident had a history of constipation. The facility's standing orders for Bowel Protocol, undated, included: The staff were to follow the physician's orders for constipation. The facility failed to keep this dependent resident free from unnecessary medications by failing to provide PRN medications for constipation when the resident went four and five days without a BM.

The facility reported a census of 45 residents, including three residents reviewed for accidents. Based on observation, interview, and record review the facility failed to ensure Resident (R) 1 remained free from accident hazards when Certified Nurse Aide (CNA) M failed to safely transport R1 in a shower chair from her room to the shower room on 01/25/22. During transport, the wheel of the shower chair caught in a loose drain cover in the hallway outside of the resident's room, throwing the resident forward out of the chair and onto the floor, causing R1 to sustain a right [CONDITION(S)]. Findings included: - The Physician Order Sheet (POS), dated 01/02/22, documented R1 with diagnoses of Alzheimer's disease (a type of progressive brain disorder that causes problems with memory, thinking and behaviors) and [CONDITION(S)] disease (a progressive nervous system disorder that affects movement). The Annual Minimum Data Set (MDS), dated [DATE], documented R1 with a Brief Interview for Mental Status (BIMS) score of three, indicating severely impaired cognition. The resident required extensive assistance of one staff member for transfers and used a wheelchair for mobility. The resident was totally dependent on one staff member for bathing. The Falls Care Area Assessment (CAA), dated 06/04/21, documented the resident had a history of falls. R1 had diagnoses of [CONDITION(S)] disease and Meniere's disease (a rare disorder of the inner ear that causes [CONDITION(S)], the sensation of spinning), which affected the resident's balance. The PPS 5-day MDS, dated [DATE], documented the resident with a BIMS score of five, indicating severely impaired cognition. She required extensive assistance of two staff members for transfers and was totally dependent on one staff member for bathing. The resident sustained a fall with fracture and required surgical repair of the hip. The Falls Care Plan, updated 01/28/22, documented all hallway drain covers in the facility were secured to cover the entire drain and maintenance would check routinely. Staff were to transport R1 to the shower room with her wheelchair and then transfer her into the shower chair. A Post Fall Evaluation Note, dated 01/25/22 at 08:00 AM, by Licensed Nurse (LN) G revealed a witnessed fall in the facility hallway as CNA M transported R1 via the shower chair to the shower room. The wheel of the shower chair dipped into the drain in the floor, which was lower than floor level and caused the chair to tip over, tossing the unsecured resident out of the chair. The resident complained of severe pain to the left hip and transferred to the hospital for imaging. A Nurse's Note, dated 01/25/22 at 10:52 AM, by LN G revealed the facility fixed the drain hole this AM. Staff were advised that residents were not to be transported via the shower chair and were to be taken in wheelchairs to the bath house and transferred there. A Witness Statement, dated 01/25/22, by CNA M revealed she transferred R1 to the shower chair in her bathroom and then pushed her out of her room into the hallway towards the shower room. The shower chair wheel hit a hole in the hallway floor and tipped. Staff M tried to keep R1 from falling out of the chair, but she was unable to catch her quickly enough to stop the fall. The resident landed on the hallway floor. She called for LN G who assessed R1. Three staff transferred the resident to her bed. A statement, dated 01/25/22, by Maintenance Staff U revealed he was informed that the sewer plate cover on R1's hallway on the west end needed repair due to being damaged and dislodged at 08:45 AM. He repaired the plate by 09:00 AM. He checked all the other sewer plates and they were secure. Staff U would check them weekly from that day forward. Observation on 02/07/22 at 01:48 PM with Administrative Staff A, revealed a silver metal type cover approximately eight inches (in) in diameter lying on the floor next to R1's room. During observation, Maintenance Staff U loosened the screw in the middle of the plate to allow Surveyor GG to look beneath. Staff U stated it was a way to get to the plumbing in the facility. Staff U replaced the plate and screwed it back onto the floor. Approximately 2 minutes later, as Surveyor GG talked with Administrative Staff A, Surveyor GG nudged the plate with her foot and the plate immediately dislodged and became loose again. Interview on 02/07/22 at 02:06 PM CNA N reported the resident fell out of the chair during transport to the shower room by CNA M when the wheel of the shower chair hit the drain cover and caused it to move because it was loose. The wheel became caught in the cover and caused the resident to tumble forward out of the shower chair onto the hallway floor. CNA N stated she noticed the cover being loose at other times when she rolled the resident's wheelchair over the cover and could hear it rattle. She stated she has not had any problems with the loose cover. Interview on 02/07/22 at 02:33 PM LN G stated she was preparing medications at the time CNA M hollered down the hallway for her help. She found R1 and CNA M on the ground in the hallway outside of R1's room. R1 was on the floor hollering it hurts and rubbing her hips. Administrative Nurse D came to assist and help evaluate the resident. R1 kept trying to get up off the floor and the staff were trying to keep her still. R1 kept rocking on the floor and LN G and Administrative Nurse D were afraid it was making her injury worse, so they stabilized R1 and all three staff members picked the resident up off of the floor and assisted her to bed. R1 kept trying to climb out of her bed, so Administrative Nurse D sat with the resident while LN G went to notify the nurse practitioner to get orders to send her to the emergency room . The staff also notified the resident's family. LN G stated the fall was caused by the shower chair hitting the drain cover, which was loose, the plate then shifted and caught the wheel of the chair. It caused the resident to fall forward out of the chair onto the floor. LN G stated that there had been no other problems with the drain covers, but she had caught the toe of her shoe in the cover in the past when she was hurrying down the hallway. Interview, on 02/07/22 at 03:44 PM, Maintenance Staff U revealed there was damage to the threads in the plastic plug under the drain cover. The screw would not stay tight. When staff rolled the wheelchairs over the plate four or five times, the plate would come loose again. He verified that he tightened up the plate after the resident's fall but did not check for thread damage. At this time, he was checking the drains once a week, but had no documentation showing he checked the plates. If anything was broken in the facility, the staff filled out a form to notify him of the issue. He stated if the plate needed to be tightened frequently, the plug should be replaced. The facility policy Abuse, Neglect and Exploitation Policy and Procedure, updated March 31, 2020, documented .Neglect means the failure of this facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress . The facility failed to provide safe transport in a shower chair and ensure necessary maintenance services when the wheel of a shower chair transporting R1 became lodged in a loose drain cover in the hallway floor outside of R1's room, which caused the resident to tumble forward out of the chair and fall on the floor. The fall caused R1 to sustain a right [CONDITION(S)], which required surgical repair.

The facility reported a census of 45 residents with three residents sampled for accidents. Based on record review and interview, the facility failed to report to the State Agency, as required, a fall sustained by Resident (R) 1, when the staff transported the resident from her room to the hallway in a shower chair, hit a loose drain plate in the floor, caught the wheel in the plate, and caused the resident to tumble forward out of the chair onto the floor, resulting in a right [CONDITION(S)] (neglect). Findings included: - The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS), dated [DATE], documented R1 with a Brief Interview for Mental Status (BIMS) score of three, indicating severely impaired cognition. The resident required extensive assistance of one staff member for transfer and used a wheelchair for mobility. The resident was totally dependent on one staff member for bathing. The Falls Care Area Assessment (CAA), dated 06/04/21, documented the resident with a history of falls. R1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The PPS 5-day MDS, dated [DATE], documented the resident with a BIMS score of five, indicating severely impaired cognition. She required extensive assistance of two staff members for transfer and totally dependent on one staff member for bathing. The resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . The Falls Care Plan, updated 01/28/22, documented all hallway drain covers in the facility are secured to cover the entire drain. Maintenance will check routinely. Staff are to transport R1 to the shower room with her wheelchair and then transferred her into the shower chair. A Post Fall Evaluation Note, dated 01/25/22 at 08:00 AM, by Licensed Nurse (LN) G revealed a witnessed fall in the facility hallway as R1 was being transported via the shower chair by CNA M to the shower room. The wheel dipped into the drain in the floor, which was lower than floor level, and caused the chair to tip over, tossing the resident out of the chair. The resident complained of severe pain to the left hip. The resident was transferred to the hospital for imaging. A Witness Statement, dated 01/25/22, by CNA M revealed she transferred R1 to the shower chair in her bathroom and then pushed her out of her room into the hallway towards the shower room. The shower chair wheel hit a hole in the hallway floor and tipped. Staff M tried to keep R1 from falling out of the chair but was unable to catch her quickly enough to stop the fall. The resident landed on the hallway floor. She called for LN G who assessed R1. The resident was transferred to her bed with assistance of three staff. A statement, dated 01/25/22, by Maintenance Staff U revealed he was informed that the sewer plate cover on R1's hallway on the west end needed repair due to being damaged and dislodged at 08:45 AM. He repaired the plate by 09:00 AM. He checked all the other sewer plates and they were secure. Staff U would be checking them weekly from that day forward. Observation, on 02/07/22 at 01:48 PM, with Administrative Staff A, revealed a silver metal type cover approximately eight inches (in) in diameter lying on the floor next to R1's room. During observation, Maintenance Staff U loosened the screw in the middle of the plate to allow Surveyor GG to look beneath. Staff U stated it was a way to get to the plumbing in the facility. Staff U replaced the plate and screwed it back onto the floor. Approximately 2 minutes later, as Surveyor GG was talking with Administrative Staff A, Surveyor GG nudged the plate with her foot and the plate immediately dislodged and became loose again. This was 13 days after the fall. Interview, on 02/07/22 at 01:48 PM, with Administrative Staff A, revealed she did not report the fall to the State. She stated their investigation found no evidence of abuse or neglect, so the fall was not reported. Interview, on 02/07/22 at 02:06 PM, CNA N reported the resident fell out of the chair during transport to the shower room by CNA M when the wheel of the shower chair hit the drain cover and caused it to move because it was loose. The wheel became caught in the cover and caused the resident to tumble forward out of the shower chair onto the hallway floor. CNA N stated she noticed the cover being loose at other times when she rolled the resident's wheelchair over the cover and could hear it rattle. She stated she has not had any problems with the loose cover. Interview, on 02/07/22 at 02:33 PM, LN G stated she was preparing medications at the time CNA M hollered down the hallway for her help. She found R1 and staff M on the ground in the hallway outside R1's room. R1 was on the floor hollering it hurts and rubbing her hips. Administrative Nurse D came to assist and help evaluate the resident. R1 kept trying to get up off the floor and the staff were trying to keep her still. R1 kept rocking on the floor and LN G and Administrative Nurse D were afraid it was making her injury worse, so they stabilized R1 and all three staff members picked the resident up off the floor and assisted her to bed. R1 kept trying to climb out of her bed, so Administrative Nurse D sat with the resident while LN G went to notify the nurse practitioner to get orders to send her to the emergency room . The staff also notified the resident's family. LN G stated the fall was caused by the shower chair hitting the drain cover, which was loose, the plate then shifted and caught the wheel of the chair. It caused the resident to fall forward out of the chair onto the floor. LN G stated that there had been no other problems with the drain covers, but she had caught the toe of her shoe in the cover in the past when she was hurrying down the hallway. Interview, on 02/07/22 at 03:44 PM, Maintenance Staff U revealed there was damage to the threads in the plastic plug under the drain cover. The screw would not stay tight. When staff rolled the wheelchairs over the plate four or five times, the plate would come loose again. He verified that he tightened up the plate after the resident's fall but didn't check for thread damage. At this time, he was checking the drains once a week, but had no documentation showing he checked the plates. If anything was broken in the facility, the staff fill out a form to notify him of the issue. He stated if the plate needed to be tightened frequently, the plug should be replaced. The facility policy Abuse, Neglect and Exploitation Policy and Procedure, updated March 31, 2020, documented .VII. Reporting/Response .O. The Administrator, DON or designee will notify the State Agency within 24 hours of incident . The facility failed to report to the State Agency, as required, a fall sustained by Resident (R) 1, which resulted in a right [CONDITION(S)] (neglect), when the staff transported the resident from her room into the hallway in a shower chair, hit a loose drain plate in the floor, caught the wheel in the plate, and caused the resident to tumble forward out of the chair onto the floor.

The facility reported a census of 45 residents with five of those residents that received a pureed diet. Based on observation, interview, and record review, the facility failed to serve the bread item planned on the menu to meet the nutritional needs of the residents. Findings included: - The facility Diet Spreadsheet, for week two, day 11, revealed the pureed menu included the following items: pureed chicken Jambalaya, pureed carrots, pureed dessert/fruit, and pureed buttered dinner roll. On 08/11/21 at 12:15 PM, Dietary staff DD served a pureed diet in the dining room to R15, who was sitting next to R6, who also had a pureed diet. The meal lacked the pureed buttered dinner roll. On 08/11/21 at 12:16 PM, Dietary staff DD confirmed that she served R15 pureed chicken Jambalaya, pureed carrots, and pureed brownie. Dietary staff DD stated he did not get any bread because he was on a pureed diet and those residents do not get bread served to them. On 08/11/21 at 12:19 PM, Dietary staff BB stated that the pureed menu did include bread verified residents on a pureed diet did not receive the bread. The facility policy Menus, dated 10/2008, indicated that menus shall meet the nutritional needs of the residents, be prepared in advance, and be followed. The facility failed to follow the menu and provide the pureed bread item to the five residents with a pureed diet, to meet the nutritional needs of the residents that reside in the facility.

The facility reported a census of 45 residents. Based on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions for the residents in the facility. Findings included: - Observation of the kitchen area, on 08/17/21 at 10:30 AM, with Dietary staff BB, revealed the following areas/items of concern: 1. The four vents on the outside of the stove hood contained dust and lint. Below one of the vents, above the oven, had rust spots and the bottom edge of the hood above the oven had an area of rust. 2. There was a broken tile by the freezer, missing tile by the bread storage rack, and cracked floor tile by the dishwashing area. 3. The ceiling contained five vents that had mildew spots and the vent above the dishwasher had lint and dirt present. 4. The light cover above the steam table had a crack approximately three feet in length. The cover had debris settled inside of the cover. 5. The ice machine vent was dirty. The machine sat on a wood platform. The wood platform had water present to the back side with mildew present at one of the back corners. A soiled towel was present on the floor between the platform and the wall, and a cup was under the ice machine. The pipe from the ice machine had a layer of brown substance on the top and appeared moist. 6. A refrigerator, located in proximity to the ice machine, had water on the floor behind the refrigerator as well as two water pitcher lids, and several small items, unable to be determined. 7. A storage rack, next to the dishwashing area, contained several plastic cups stored on a solid flat surface that were not dry. 8. A stack of steam table pans, on the storage shelf, included two pans that were not dry. 9. Two toasters both contained crumbs to the top and large number of crumbs in the trays. The Environmental Report, dated 07/07/21, had been answered yes that the hood vents were cleaned monthly and the heat vents were cleaned monthly. The Ice Machines Service/Cleaning Log, dated 2021, indicated that maintenance service the kitchen ice machine and cleaned the ice machine filters on 08/06/21. On 08/17/21 at 10:40 AM, Dietary Staff BB stated that maintenance should clean the stove vent hood every couple of months. She was not aware of the ceiling vents with mildew or the vent above the dishwashing station with dirt and lint. Dietary Staff BB stated she was not aware of the crack in the light cover or the water and towel behind the ice machine. She stated that maintenance cleaned the vent on the ice machine once a month when the filters were cleaned. Dietary Staff BB stated there was a list of duties to be completed on each shift and those duties are covered upon hire, they do not keep a cleaning log. Dietary Staff BB verified the above concerns. On 08/17/21 at 02:06 PM, Maintenance Staff U stated he cleaned the inside vents of the stove hood and thought the company that it contracted to come would clean the outside of the stove and the ice machine vent. Maintenance Staff U stated he removes the white vents on the ceiling and washes them off and that he repairs items in the kitchen when he was made aware. The environmental rounds for August had not been completed. The facility policy Sanitization, dated 10/2008, revealed that the food service area shall be maintained in a clean and sanitary manner. The Food Services Manager will be responsible for scheduling staff for regular cleaning of kitchen and dining areas. Food service staff would be trained to maintain cleanliness throughout their work areas during all tasks, and to clean after each task before proceeding to the next assignment. The facility failed to store, prepare, and serve food under sanitary conditions for the residents in the facility.

The facility reported a census of 45 residents including eight residents that ate their meals in their room. Based on observation, interviews, and record review, the facility failed to serve food that was palatable and at safe and appetizing temperature to eight residents (R) of the facility that eat their meals in their room, that included (R) 11, R 12, R17, R 20, R 35, R 36, R 40, and R 43 of the facility. Findings included: - During interviews, four residents voiced concerns with the facility food as follows: On 08/11/21 at 10:03 AM, Resident (R)11, stated the food was usually cold when she got her room tray. On 08/11/21 at 10:36 AM, R 20, described the food at the facility as low quality and often overcooked. He stated he usually ate burritos from his stock he kept in his refrigerator instead of the facility food because the food was not good. On 08/11/21 at 02:58 PM, R 12, stated he previously ate his breakfast in the dining room but did not do that anymore. The food was sometimes cold and did not taste good. His wife brought him a meal every day and kept his refrigerator stocked with snacks and food that he could eat in his room. On 08/11/21 at 02:28 PM, R 17, reported the facility had an alternate menu that the residents could select food items from, but often ran out of those foods. On 08/11/21 at 09:04 AM, during the initial tour, Dietary Staff BB reported the facility had an always available menu and the residents could order items from it if they did not like the food they were served. On 08/12/21 at 12:57 PM, during the food prep observation, it was noted the hall/room trays were covered with a lid but lacked a plate warmer beneath when placed on the open cart. On 08/12/21 at 01:05 PM, upon request, dietary staff BB checked the temperature of the last tray served and noted the following concerns: 1. A meatball sub on a bun- the meatball temperature was 120 degrees Fahrenheit (F). 2. Macaroni and cheese was 90 degrees F. 3. Cucumber and tomato salad was 60 degrees F (served as a cold item). 4. Peach cobbler temperature was 80 degrees F. On 08/12/21 01:17 PM, dietary Staff BB verified the cold food items should be at least 40 -degree F or lower and the warm food items should be 140 -degree F or higher. Additionally, the peach cobbler should be a warm/hot food item. On 08/16/21 at 12:15 PM, observed Dietary Staff CC, prepared plates of food without checking the food temperatures. Menu items included: 1. Beef and cheese baked spaghetti. 2. Buttered Italian blend vegetables. 3. Garlic bread. 4. Assorted/desserts/fruit, 5. Gravy. 6. Creamed corn. On 08/16/21 12:27 PM, observed Dietary Staff CC, prepared pureed plates of food without checking the food temperatures for food items that included: 1. Beef and cheese baked spaghetti. 2. Buttered Italian blend vegetables. 3. Garlic bread. 4. Assorted/desserts/fruit. 5. Gravy. 6. Creamed corn. On 08/16/21 at 12:32 PM, Dietary Staff BB stated staff should check the temps before serving food. On 08/16/21 at 01:28 PM, Dietary Staff CC checked the temperature of a requested test tray and noted the following temperatures outside of the acceptable food temperature parameters: 1. Spaghetti at 130 degrees F. 2. Italian veggies at 120 degrees F. 3. Puree vegetables at 130 degrees F. On 08/16/21 at 01:30 PM, Dietary Staff CC confirmed the food temperatures as noted above and stated staff should check the food on the steam table prior to serving the food. Additionally, the canned pears should be refrigerated after opening, placed on ice after removal from the refrigerator, and temperature maintained below 42- degrees F at the time of serving to the residents. On 08/17/21 at 08:37 AM, Certified Nurse Aide (CNA) M, stated residents complain about the food sometimes. They may not like what they have, or it may not be cooked to their specifications. For example, residents complain about the food being cold when they get it. The residents usually have several choices from the alternate menu, sometimes two or three of those items are not available. Sometimes that resident can only eat the food they are out of. On 08/17/21 11:39 AM, Administrative Staff A made aware of kitchen findings mentioned above. On 8/18/21 at 02:36 PM, Dietary Staff BB, identified (R) 11, R 12, R17, R 20, R 35, R 36, R 40, and R 43 as residents who choose to eat their meals in their room. The facility policy for Serving Temperatures for Hot and Cold Foods, dated 2020, documentation included foods would be served at the following temperatures to ensure a safe and appetizing dining experience. Meats and casseroles, vegetables, potatoes, desserts, and gravy should be maintained at 135-170 degrees (F). Cold foods such as dairy products, desserts, and salads should be maintained at 41 degrees (F)or below. The cook would take the temperatures of hot and cold food items using approved thermometers prior to each meal service. The facility failed to serve food that was palatable and at safe and appetizing temperature for the facility residents to eight residents (R) of the facility.

The facility reported a census of 45 residents with 15 selected for review. Based on observation, interview, and record review, the facility failed to revise Resident (R)7's care plan following falls. Findings included: - The Order Review History Report, dated 07/13/21, for Resident (R)7, included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS), dated [DATE], assessed R7 with a Brief Interview of Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. He required supervision and assistance of two or more staff for bed mobility, extensive assistance of two or more staff for transfers and toilet use, limited assistance of one staff for dressing and personal hygiene, and supervision and one staff for assistance with locomotion on and off the unit. He ambulated in the room and corridor one or two times and required assistance of one staff. R7 used a wheelchair for mobility. His balance was not steady and required staff assistance when moving from a seated to standing position, moving on and off the toilet, and transferring from surface to surface. R7 fell in the past two to six months prior to admission and had one non-injury fall since admission. The Falls Care Area Assessment' (CAA), dated 05/21/21, revealed R7 required staff assistance of two for transfers, he had one fall since admission, and the staff would continue to assist him and keep him as safe as possible. The Baseline Care Plan, dated 05/14/21, located in the paper chart, indicated the R7 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan revealed that R7 was independent in bed mobility, required staff assistance of two for transfers, walking, and toileting, and required assistance of one for locomotion on and off the unit. R7 used a manual wheelchair. Included in the care plan tab in the paper chart was an intervention dated 05/16/21 that revealed staff placed R7's low bed against the wall and a floor mat was in place to prevent injury if he fell out of bed. Additionally, an intervention, dated 06/06/21, revealed the staff applied padding to the legs of the overbed table at his bedside for his safety. The Care Plan, revised 06/15/21, located in the electronic medical record (EMR), revealed R7 was a high risk for falls. The staff were to keep a fall mat at the bedside due to noncompliance with calling for staff assistance, Anti roll backs on the wheelchair due to the resident often forgot to lock his wheelchair brakes, and standby to touching assistance with staff for resident transfers. The Care Plan, dated 08/13/21, located in the paper chart under the care plan tab, included additional interventions with the following dates: 1. On 07/11/21, R7 required his bed to be locked in low position. 2. On 08/13/21, R7 would become impatient and try to transfer himself which would increase his fall risk. If R7 fell , the staff should assess for the cause of the fall and correct if able. A record should be kept of his fall and patterns evaluated, and the staff were to review his medications for possible contributory factors. 3. A handwritten intervention, undated, instructed to keep his room close to the nurses' station. The Progress Notes, located in the EMR, revealed that R7 fell on the following dates: 05/16/21, 05/26/21, 06/03/21, 06/06/21, 06/15/21, 07/01/21, and 08/09/21. The Progress Note, dated 07/01/21, revealed R7 fell and was found on the floor mat at his bedside and stated he was getting up to the toilet and fell . The resident received an abrasion above his left knee, his left nonskid sock in place and the right nonskid sock was on the floor. The note indicated the intervention To be determined. The care plan lacked an intervention until 07/11/21, 10 days following the fall. The Progress Note, dated 08/09/21, the resident fell in his room. The head of his bed was stuck in high Fowler's (upright) position. and the activity at the time of the fall was unknown. The care plan did not include a new intervention. On 08/12/21 at 09:42 AM, R7 was on his bed with his eyes closed, the bed was in low position, positioned against the fall, a fall mat beside the bed, and the call light was within his reach. He had nonskid socks in place and the staff parked the wheelchair near the head of his bed with anti-tip bars in place. The wheelchair was in a locked position. The overbed table had padding to the legs. On 08/17/21 at 08:37 AM, Certified Nurse Aide (CNA) M stated that he is told about new interventions in report and that the care plan has new interventions when a resident had a fall. On 08/17/21 at 01:48 PM, Licensed Nurse (LN) G, stated when a resident had a fall, a new intervention should be put into place, added to the fall report, and written on the care plan. On 08/17/21 at 04:05 PM, Administrative Nurse D stated that an immediate intervention should be put in place after each resident fall and that after the fall on 08/09/21 the bed was switched out so maintenance could repair the bed, however the intervention was not placed in the care plan. The fall on 07/01/21 was to keep the bed in a locked position and a sticker placed on the wall for staff to know the bed should be below that level. Administrative Nurse D confirmed that the care plan lacked the interventions for the two falls. The facility policy Resident Centered Care Plan Process, dated 03/28/18, indicated that at 90-day intervals, or more frequently based on response to the resident's condition, the interdisciplinary team would revise the plan for care, treatment, and services. In addition, the facility's policy Accident/Incident Committee, dated 11/20/17, indicated the purpose was to review post incident documentation to ensure adequate interventions had been put into place to reduce the risk of future occurrences. The committee would review the care plan to ensure immediate interventions were put into place after the incident. The facility failed to revise R7's care plan following falls, for staff guidance, for this resident with multiple falls.

The facility reported a census of 45 residents with 15 selected for review including four residents reviewed for falls. Based on observation, interview, and record review, the facility failed to implement new interventions following falls for Resident (R)7, who had multiple falls, to prevent further falls. Findings included: - The Order Review History Report, dated 07/13/21, for Resident (R)7, included diagnoses of history of falling, muscle weakness, age-related physical debility, and dementia (progressive mental disorder characterized by failing memory, confusion). The Admission Minimum Data Set (MDS), dated [DATE], assessed R7 with a Brief Interview of Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. He required supervision and assistance of two or more staff for bed mobility, extensive assistance of two or more staff for transfers and toilet use, limited assistance of one staff for dressing and personal hygiene, and supervision and one staff for assistance with locomotion on and off the unit. He ambulated in the room and corridor one or two times and required assistance of one staff. R7 used a wheelchair for mobility. His balance was not steady and required staff assistance when moving from a seated to standing position, moving on and off the toilet, and transferring from surface to surface. R7 fell in the past two to six months prior to admission and had one non-injury fall since admission. The Falls Care Area Assessment' (CAA), dated 05/21/21, revealed R7 required staff assistance of two for transfers, he had one fall since admission, and the staff would continue to assist him and keep him as safe as possible. The Baseline Care Plan, dated 05/14/21, located in the paper chart, indicated the R7 had a history of falls. An intervention, dated 06/03/21, revealed R7 would put himself on the floor mat at his bedside with the bed at the lowest position. The care plan revealed that R7 was independent in bed mobility, required staff assistance of two for transfers, walking, and toileting, and required assistance of one for locomotion on and off the unit. R7 used a manual wheelchair. Included in the care plan tab in the paper chart was an intervention dated 05/16/21 that revealed staff placed R7's low bed against the wall and a floor mat was in place to prevent injury if he fell out of bed. Additionally, an intervention, dated 06/06/21, revealed the staff applied padding to the legs of the overbed table at his bedside for his safety. The Care Plan, revised 06/15/21, located in the electronic medical record (EMR), revealed R7 was a high risk for falls. The staff were to keep a fall mat at the bedside due to noncompliance with calling for staff assistance, Anti roll backs on the wheelchair due to the resident often forgot to lock his wheelchair brakes, and standby to touching assistance with staff for resident transfers. The Care Plan, dated 08/13/21, located in the paper chart under the care plan tab, included additional interventions with the following dates: 1. On 07/11/21, R7 required his bed to be locked in low position. 2. On 08/13/21, R7 would become impatient and try to transfer himself which would increase his fall risk. If R7 fell , the staff should assess for the cause of the fall and correct if able. A record should be kept of his fall and patterns evaluated, and the staff were to review his medications for possible contributory factors. 3. A handwritten intervention, undated, instructed to keep his room close to the nurses' station. The Progress Notes, located in the EMR, revealed that R7 fell on the following dates: 05/16/21, 05/26/21, 06/03/21, 06/06/21, 06/15/21, 07/01/21, and 08/09/21. The Progress Note, dated 06/03/21, revealed R7 fell and was found sitting on the floor mat beside the bed with nonskid socks in place and the wheelchair locked and beside the bed. The Staff believed he slid out of the bed and to continue the safety interventions with the floor mat and the low bed. The facility failed to implement a new intervention to prevent further falls. The Progress Note, dated 06/06/21, revealed R7 fell and was found lying partially on the floor mat at his bedside. The resident received an abrasion (scraping or rubbing away of a surface, such as skin, by friction) above his left knee. A nonskid sock was on his right foot and his left foot was bare, and R7 stated that he needed to Pee. Staff determined the cause of the fall was R7 was attempting to toilet himself. The staff added padding to the legs of the overbed table. The facility failed to implement a new intervention to prevent further falls. The Progress Note, dated 07/01/21, revealed R7 fell and was found on the floor mat at his bedside and stated he was getting up to the toilet and fell . The resident received an abrasion above his left knee, his left nonskid sock in place and the right nonskid sock was on the floor. The note indicated the intervention To be determined. The care plan lacked an intervention until 07/11/21, 10 days following the fall. The facility failed to put an immediate intervention in place to prevent further falls. The Progress Note, dated 08/09/21, the resident fell in his room. The head of his bed was stuck in high Fowler's (upright) position. and the activity at the time of the fall was unknown. The fall lacked a new intervention to prevent further falls and the care plan did not include a new intervention. The facility failed to implement a new intervention following the fall. On 08/12/21 at 09:42 AM, R7 was on his bed with his eyes closed, the bed was in low position, positioned against the fall, a fall mat beside the bed, and the call light was within his reach. He had nonskid socks in place and the staff parked the wheelchair near the head of his bed with anti-tip bars in place. The wheelchair was in a locked position. The overbed table had padding to the legs. On 08/16/21 at 09:51 AM, R7 observed to be sitting on the side of the bed in his room. On 08/16/21 at 01:40 PM, R7 observed to move from lying to sitting position on the side of the bed without difficulty. He had nonskid socks in place, a fall mat by his bed, and the bed in low position. On 08/17/21 at 01:48 PM, Licensed Nurse (LN) G, stated that when a resident had a fall, a new intervention should be put into place, added to the fall report, and written on the care plan. On 08/17/21 at 04:05 PM, Administrative Nurse D stated that an immediate intervention should be put in place after each resident fall and that after the fall on 08/09/21 the bed was switched out so maintenance could repair the bed. The fall on 07/01/21 was to keep the bed in a locked position and a sticker placed on the wall for staff to know the bed should be below that level. Administrative Nurse D confirmed that the other falls lacked immediate interventions. The facility's policy Accident/Incident Committee, dated 11/20/17, indicated the purpose was to review post incident documentation to ensure adequate interventions had been put into place to reduce the risk of future occurrences. The committee would review the care plan to ensure immediate interventions were put into place after the incident. The facility failed to implement immediate interventions following falls for this resident with frequent falls, to prevent further falls.

The facility reported a census of 45 residents. Based on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions for the residents in the facility. Findings included: - Observation of the kitchen area, on 11/26/19 at 08:26 AM, revealed the following areas/items of concern: 1. The refrigerator with three doors, contained two pitchers of white gravy, a container of creamed corn, and a container of green beans that lacked a date. 2. The refrigerator with two doors, contained a plate with two dried out sandwiches, uncovered and undated. Interview, on 11/26/19 at 08:32 AM, with Dietary staff CC, confirmed the items lacked a date, and reported she made the gravy, creamed corn, and green beans yesterday and forgot to date them. Observation, on 11/26/19 at 08:49 AM, revealed a beverage station off of the main dining room that had three containers with liquids in it for dispensing. The containers were dated 11/22/19. The microwave in the main dining room had yellow splatters on the top of the inside. Observation, on 11/26/19 at 12:38 PM, of social services staff X, assisting to serve lunch plates to the dining area on Sunflower Lane, washed her hands, shut the faucet off, picked up silverware rolled in a cloth napkin, and placed it on a table for a resident, then went back to the sink and washed her hands, shut off the faucet, dried her hands with a paper towel and exited the area. She returned later to deliver another resident meal. Observation, on 11/26/19 at 12:44 PM, revealed social services staff X, shut off the faucet of the sink without drying her hands first, then exited the area. Interview, on 11/26/19 at 12:48 PM, with social services staff X, revealed that hands should be dried before shutting off the faucet and a dry paper towel should be used to do so. Observation, on 12/02/19 at 03:24 PM, of the kitchen area, revealed the following areas/items of concern: 1. The containers in the steam table that hold the water, had food debris in the water, grime built up, and one of the containers also had rust colored substance on the inside. 2. The stove hood had a grease build up on the inside and the outside vents had cobwebs. 3. The drawer that contained the food scoops, had food debris in the bottom of the drawer with the utensils. 4. A cake pan that was stored with the clean items, had a brown substance on the inside edges that rubbed off easily. 5. The hot air oven, had a build up of grime on the inside, black substances to the bottom and crumb debris to the inside lower edge visible when the doors opened. The top of the oven had a greasy grime coating. 6. Above a storage area that contained pitchers, lids, water cups, and serving trays had peeling paint to the ceiling above it. 7. The ceiling around the vent, above the steam table, had brown dust areas attached to the ceiling and around the vent near the refrigerator with two doors, that was above the location of the ice cart. 8. The microwave in the dining room had brown splatters to the inside top. Interview, on 12/02/19 at 3:58 PM, with Dietary staff B, confirmed that staff empty and sanitize the steam table containers holding the water at night, and that the containers had a grime build up and one container had rust on the inside. Furthermore, she reported that the outside vents to the range hood as cleaned monthly and may need to be cleaned more often. The hood was last cleaned by the cleaning company on 6/20/19 and the company was due back on 12/20/19. The drawer where the food scoops were cleaned weekly. There were no routine cleaning logs for all areas of the kitchen. Observation, on 12/02/19 at 04:13 PM, revealed the microwave oven in the kitchenette of Sunflower Lane, had brown splatters to the inside top of it. Interview, on 12/03/19 at 03:21 PM, with Dietary staff BB, confirmed that the fluids in the beverage serving containers, located off the main dining room, should be changed daily. The facility policy Handwashing/Hand Hygiene, undated, directed the staff to vigorously lather hands with soap and rub them together, creating friction to all surfaces, for a minimum of 20 seconds (or longer) under a moderate stream of running water, at a comfortable temperature. Rinse hands thoroughly under running water. Dry hands thoroughly with paper towels and then turn off faucets with a clean, dry paper towel. The facility policy Food Receiving and Storage, undated, identified that all foods stored in the refrigerator or freezer would be covered, labeled and dated (use by date). Beverages must be dated when opened and discarded after 24 hours. The facility policy Sanitization, undated, identified that it is the policy that the food service area shall be maintained in a clean and sanitary manner. All kitchens, kitchen areas and dining area shall be kept clean. All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions. Kitchen and dining room surfaces not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent accumulation of grime. The facility failed to store, prepare, and serve food under sanitary conditions for the residents in the facility.

The facility reported a census of 45 residents. Based on observation, interview, and record review, the facility failed to serve all bread items planned on the menus to meet the nutritional needs of the residents. Findings included: - Observation, on 11/26/19 at 01:00 PM, revealed the staff failed to serve any of the residents the dinner rolls with the meal, as planned on the menu. Interview, on 11/26/19 At 01:00 PM, with Certified Nurse Aide N, confirmed that the staff did not serve any dinner rolls with lunch. Interview, on 11/26/19 at 01:04 PM, with Dietary staff BB, revealed that there was bread available and the residents knew that the kitchen staff have it. Whenever there are rolls on the menu the kitchen staff serve bread. Furthermore, she confirmed that no residents asked for bread and that the menu board inside of the main dining room did not include it. Observation, on 11/26/19 at 01:07 PM, revealed the menu board hanging in the main dining room listed roast beef, scalloped potatoes, spinach and mushrooms, and party cookie or pears. The menu board did not list dinner roll or that bread was available. Record review, of the Diet Spreadsheet for week four day 24, Tuesday, for a regular diet listed for lunch: roast beef with gravy, scalloped potatoes, spinach and mushrooms, assorted desserts/fruit, dinner roll/margarine, and beverage. Interview, during Resident Council meeting, on 11/27/19 at 11:15 AM, revealed that occasionally the kitchen staff served dinner rolls but not often. The staff serve bread if you want it at breakfast, but bread was not typically served with lunch or supper. Observation, on 11/27/19 at 12:14 PM, revealed the menu posted in the main dining room included: oven fried chicken, red skin mashed potatoes, peas and carrots, spice cake or cinnamon apples, and that bread and butter were available. Record review, of the Diet Spreadsheet for week four day 25, Wednesday, listed for a regular diet for lunch: Smokey mountain chicken, smashed red potatoes, buttered peas and carrots, assorted desserts/fruit, Texas toast, and beverage. Interviews, in the dining room with various residents, on 11/27/19 beginning at 12:18 PM, revealed the following comments: 1) After confirming that the resident did not receive Texas toast or any bread with lunch reported, I would eat it if it was there. 2) After confirming that the resident did not receive Texas toast or any bread with lunch reported, I don't see anyone with bread so they must not have any. Interview, on 11/27/19 at 12:19 PM, with Certified Nurse Aide M, confirmed that the four residents at the table she was sitting with did not receive bread with lunch. Observation, on 12/02/19 at 12:00 PM, revealed the menu posted in the dining room included: deviled pork, mashed sweet potatoes, Brussel sprouts, cookie or pears, and that bread and butter were available. Record review, of the Diet Spreadsheet for week one day two, Monday, listed for a regular diet for lunch: deviled pork, mashed sweet potatoes, roasted Brussel sprouts, assorted desserts/fruit, cornbread/margarine, and beverage. Interview, on 12/02/19 at 12:56 PM, with Dietary staff BB, confirmed the kitchen staff did not serve cornbread today and that today was a bread and butter day. We serve cornbread with ham and beans and garlic bread with spaghetti. We serve bread and butter Monday thru Friday and rolls on Sunday. The Registered Dietician was aware that the bread was not being offered and she sees that when she is in the facility. On 12/03/19 at 02:18 PM, a phone attempt to reach the Registered Dietician for interview was not successful. Record review, of the Week At a Glance for week one through week four, revealed the signature of the Registered Dietician and no changes made to the menu for items to be served at mealtimes. The facility policy, Menus, undated, directed that it was the policy that menus shall meet the nutritional needs of the residents, be prepared in advance, and be followed. Furthermore, the policy included that menus would provide a variety of foods from the basic daily food groups and would indicate standard portions at each meal. If a food group was missing from a resident's daily diet, the resident would be provided an alternate means of meeting the resident's nutritional needs. The facility failed to serve bread items from the menus to meet the nutritional needs of the residents of the facility.

The facility reported a census of 45 residents. Based on interview the facility failed to employ a certified dietary manager to serve as the director of food and nutrition services, for the residents of the facility. Findings included: - Interview , on 12/02/19 at 11:54 AM, with Dietary staff BB, confirmed a Registered Dietician came to the facility on ce a month. Interview, on 12/02/19 at 04:26 PM, with Dietary staff BB, confirmed that she was not a certified dietary manager. Interview, on 12/03/19 at 03:21 PM, with Dietary staff BB, revealed that she worked in the dietary manager position for two years and started the certification course at that time. Furthermore, she reported that it was a year long course, she had two extensions to the course added, and she would take her state test on 12/04/19. Interview, on 12/03/19 at 04:30 PM, with Administrative Staff A, confirmed the hire date of Dietary staff BB, was on 08/01/17. The facility failed to employ a certified dietary manager to serve as the director of food and nutrition services, for the residents of the facility.

The facility reported a census of 58 residents, with 5 residents reviewed. Based on observation, interview, and record review the facility failed to ensure the safety for 1 of the 5 sampled residents. Resident #1 (assessed at risk for elopement) eloped from the facility without staff knowledge. The resident left the facility unattended through a door which did not alarm, after multiple attempts to elope from the facility. Staff found the resident behind the facility in the alley approximately 10 feet from the street. This deficient practice placed the resident in immediate jeopardy. The facility also failed to provide adequate supervision for 1 sampled resident (#1) regarding safety with smoking. Staff found resident #1 smoking in his/her room, on two different occasions, both times he/she had a lighter in his/her possessions, although the facility previously identified the resident's need for the facility to store his/her cigarettes/lighter for safety. Findings included: - The medical record of resident #1, revealed admission to the facility on [DATE], with [DIAGNOSES REDACTED]. [REDACTED]. The 2/10/17 admission MDS (minimum data set), identified the resident had a BIMS(brief interview for mental status) score of 3, which indicated severely impaired cognition. The assessment documented no behaviors, including wandering, and documented the resident used tobacco products. The 3/15/17 quarterly MDS, documented no change in cognition, behaviors, wandering, or the use of tobacco products. The 2/10/17 CAA (care area assessment) for behaviors did not trigger for further review. The 2/1/17 admission care plan lacked identification or interventions related to elopement. The 2/7/17 care plan documented he/she used a wheelchair for mobility and propelled self. An addition, dated 3/23/17, included instructions that the resident at times becomes frustrated when not able to do things when he/she wants to. Please redirect him/her as needed. Please help with the purchase of cigarettes. The resident worries and becomes upset when he/she runs short on cigarettes. Smoking is a big part of the resident's day. The resident likes to go outside and smoke at times and knows the door codes. If the resident is upset with staff, sometimes he/she goes outside and it helps to take his/her mind off why he/she is upset. Another update to the resident's care plan, on 4/12/17, instructed that a camera was on the unit hallway, to monitor the resident's location. On 4/15/17, the resident will leave the building at times by him/herself. Please make sure the alarms are hooked up, so if the resident forgets to tell staff when leaving they will sound. Please take the resident outside when he/she wants to go. Monitor the resident's location. Because the resident does not always want to stay in the patio area, he/she does like to wheel around. Assist the resident back to the facility when he/she goes outside. Addition, on 5/10/17, the dietary exit has an alarm and key pad in place. The unit kitchen door and the southwest hall exit door have door alarms. The 2/1/17 admission assessment included an elopement risk assessment, which documented a score of 3, and identified the resident as low risk for elopement. The clinical record lacked any further elopement risk assessment until after the 5/10/17 occurrence. Nurses' notes documented the resident exited the building or attempted to exit the building on 6 occasions, between admission on 2/1/17 and 5/6/17, as follows; 1.) On 3/4/17 at 4:31 PM, documented the resident was outside in the parking lot trying to pick up cigarette butts long enough to smoke. 2.) On 3/5/17 at 1:07 AM, documented the resident went to the front of the building and attempted to go outside to look for cigarette butts, since he/she was out of cigarettes. 3.) On 3/25/17 at 5:15 AM, documented staff heard the east door alarm and saw the resident attempting to get out of the south door, by the therapy room. Staff escorted the resident back inside. The resident wanted a cigarette, and was informed the smoke room opened at 6:00 AM. Staff educated the resident related to safety, and the resident agreed not to do it again. 4.) On 4/25/17 at 2:14 PM, documented the resident went outside in his/her wheelchair, with staff following behind to the parking lot. The staff brought the resident back into the building. 5.) On 4/28/17 at 5:34 PM, documented the resident attempted to go out the front door, and was brought back to the smoke room and received a cigarette 35 minutes ahead of the scheduled time. 6.) On 5/6/17 at 2:28 PM, documented the resident went to the southwest exit door, took the stop sign down, and opened the door, which set off the alarm. Staff immediately went after him/her and explained not to go out the door at any time without staff direction, due to the door being an exit used in case of fire. The resident nodded his/her head in acknowledgement. 7.) On 5/10/17 without a time, documented staff saw the resident in the dining room at 7:45 AM., and when the housekeeper went to get the resident's breakfast order, he/she was no longer there. Staff looked for the resident on the North and South hall, then went outside the facility and found the resident by a trailer park. He/she wore a jacket and was fully dressed and the outside temperature was 66 degrees. The resident was brought back into the building. The resident does know the alarm codes for the outside doors. On 5/16/17 at 10:00 AM, administrative staff A reported the facility had not had any residents elope, only residents that went out with the staff following, and the facility had not done investigations for any of those situations. On 5/16/17 at 10:30 AM, licensed nursing staff G demonstrated the route the resident took (on 5/10/17) when leaving the building. The resident went approximately 69 feet inside the building, to the outside exit door, and went approximately 30 feet on the sidewalk outside of the building to the alley. The resident then started down the alley approximately 100 yards, getting to within 10 feet of the street, before staff reached him/her. The route had uneven surfaces, from the concrete sidewalk, through a grassy area, and then through gravel. It also had an area with 2 cables stretched across the entry into the actual alley. One of the cables rested approximately an inch above the ground and the second one hung very loose, and was easily able to be moved up and down. On 5/16/17 at 11:48 AM, therapy staff J reported he/she entered the building the morning of 5/10/17, when licensed nursing staff G met staff J in the hallway and asked if a resident was outside when he/she entered the building. Staff J reported he/she did not see a resident. The exit door alarm was sounding for the exit door by the therapy room, and staff J verified he/she must have neglected to put in the door code when he/she entered the building. On 5/16/17 at 12:02 PM, licensed nursing staff E reported the resident frequently went outside, but was not sure what the resident's elopement risk assessment scored. Licensed nursing staff E added he/she witnessed the resident going to the doors, and the resident always had a staff member bring him/her back into the building. Staff E was not aware of any elopement interventions added to the resident's care plan, following times the resident exited the building unassisted. On 5/17/17 at 12:29 PM, consultant nursing staff D verified the only elopement assessments completed for the resident were on 2/1/17 and 5/17/17. The elopement assessment completed on 5/17/17 (7 days after the resident eloped), which documented a score of 17.5 which indicated the resident at high risk for elopement. Staff D verified the resident's record lacked any elopement risk assessments, following the resident's 6 documented attempts to exit the building. Consultant nursing staff D reported staff should complete a new elopement assessment, with each attempt to leave the building, and reported the resident should not go out of the building without staff. On 5/16/17 at 12:40 PM, licensed nursing staff G reported he/she worked on 5/10/17, when the resident exited the building, and saw the resident sitting in the hall around 7:45 AM. At 8:00 AM, staff G went into an office, and when he/she left the office around 8:10 AM., he/she became aware the other staff were looking for the resident. Licensed nursing staff G reported he/she heard an alarm sounding, checked the panel, saw a lit exit light for the southeast hall, and saw a therapy staff. Staff G asked the therapy staff if he/she just entered through the southeast exit door, and was assured he/she had, but did not see any residents outside. Staff G then went outside and walked around the building, while direct care staff I went around the building a different way. Staff G saw the resident in the wheelchair behind the building in the alley. The resident was propelling his/herself in the graveled alleyway, and when staff G called out, the resident began to go faster. Licensed nursing staff G ran to the resident and reached him/her just before the resident reached the road. Licensed nursing staff G pushed the resident's wheelchair, across the road and called the facility to pick them up. On 5/16/17 at 1:30 PM, the resident sat in the wheelchair at the dining room table with an I-pad. When questioned if the resident remembered leaving the building a few days before, the resident nodded his/her head, yes and said a few words, Far away, money, and then used his/her fingers as if smoking. On 5/16/17 at 3:45 PM, administrative nursing staff C reported the intervention put in place after the resident left the building without staff knowledge included placing an additional pull type alarm on the door the resident used to exit the building on 5/10/17, but was not added to the resident's plan of care until 5/17/17 (7 days after the resident's elopement). The facility also had the alarm company scheduled to come to the facility on [DATE] to change the exit door alarm codes. On 5/17/17 at 5:00 PM, administrative nursing staff C reported the care plan lacked interventions when the resident went outside, and added the resident had the code to exit the building from admission, and he/she had went outside to smoke since that time. On 5/17/17 at 6:00 PM, direct care staff I reported assisting licensed nursing staff G, when the resident left the building on 5/10/17. Staff I reported seeing the resident in his/her wheelchair about ½ way down the alley. Staff I stated, he/she began running after the resident, and when he/she called the resident's name, the resident began to go faster. The resident got to about 10 feet from the road, when licensed nursing staff G ran between the end of the road and the resident. Staff I explained the resident told them he/she had money for cigarettes and pointed toward the grocery store. Staff I gave the resident a cigarette to calm him/her, and talked to him/her until the facility van arrived to take them back to the facility. The 10/15/12 facility policy for a missing resident documented staff would revise the resident's care plan to reflect the elopement and a plan developed or revised, and staff would conduct a thorough investigation of the elopement needs as soon as possible to prevent other occurrences, as well as to protect other residents. The facility failed to ensure adequate supervision and/or assistive devices to prevent this resident from leaving the facility without staff knowledge, following 6 attempts and then eloped when the exit door alarm did not sound and the resident in a wheelchair, went through uneven surfaces and then an alleyway, and almost to the street before the staff intervened. This deficient practice placed this resident in immediate jeopardy. The facility abated the immediate jeopardy, on 5/18/17 at 6:05 PM, as follows: 1.) On 5/10/17, the facility added an additional alarm on the back door through which the resident exited. 2.) Staff monitored the resident the remainder of the day for exit seeking behaviors, with none noted. 3.) Staff updated the resident's care plan to include the need for staff escort when the resident went outside to smoke. Also to include weekly shopping trips in which the resident will have the opportunity to purchase his/her own cigarettes. 4.) All staff received in-service education on missing residents, which completed on 5/10/17. 5.) On 5/17/17, all exit door codes were changed and staff posted the door codes in Roman numerals. 6.) All staff received in-service education on the facility elopement policy, completed on 5/18/17 at 6:05 PM. The facility will monitor for compliance one time a week when going outside, the resident will be allowed to enter the access code for exit to the building, if the resident is able to enter the access code correctly the code will be immediately changed. The facility QAPI (quality assurance performance initiative) team will re-assess and provide direction for additional interventions/monitoring as indicated and update the care plan as needed. This deficiency remained at a scope/severity of a D. - The medical record of resident #1, revealed admission to the facility on [DATE], with [DIAGNOSES REDACTED]. [REDACTED]. The 2/10/17 admission MDS (minimum data set), identified the resident had a BIMS(brief interview for mental status) score of 3, which indicated severely impaired cognition. The assessment documented no behaviors and documented the resident used tobacco products. The 3/15/17 quarterly MDS, documented no change in cognition, behaviors, or the use of tobacco products. Furthermore, the resident's 2/1/17 admission care plan, contained the following interventions related to the resident smoking. It instructed the staff the resident was a smoker and to reassure the resident he/she was safe. The resident would follow rules for the facility smoking and be free of injury from smoking. A smoking assessment would be completed. The resident would be assessed for safety concerns, and the facility would provide interventions as needed. The resident's 2/7/17 care plan, documented he/she used a wheelchair for mobility and propelled self. An addition, dated 3/23/17, included instructions that the resident at times becomes frustrated when not able to do things when he/she wants to. Please redirect him/her as needed. Please help with the purchase of cigarettes. The resident worries and becomes upset when he/she runs short on cigarettes. Smoking is a big part of the resident's day. The resident likes to go outside and smoke at times and did know the door codes. The resident also goes through the cigarettes that other residents leave, and if he/she is upset with staff, sometimes goes outside and it helps to take his/her mind off why he/she is upset. Update, dated 3/31/17, instructed the staff to please keep the ashtrays emptied on a routine basis so the resident would not be tempted to search ashtrays for cigarette butts to smoke. The resident is aware that in order to make his/her cigarettes last, he/she can smoke about 1 per hour. Usually the resident goes to the medication aide or the nurse about every 40 to 45 minutes and tries to ask for a cigarette, and is reminded to make the cigarettes last all month with the routine. The resident requires a smoking assessment, to be completed on a quarterly or on an as needed basis to determine his/her safety, regarding smoking. The resident understands he/she is unable to carry a lighter and will need assistance on lighting his/her cigarette. Remind the resident routinely of the smoking policy. The 2/18/17 Smoking Assessment, identified smoking as a high risk activity and documented the resident had no cognitive loss, or varying cognition, no visual deficit, and no dexterity problem. The assessment identified the resident smoked 10 plus times per day, and liked to smoke morning, afternoon, and evenings. He/she was able to light his/her own cigarette, and had no need for adaptive equipment. The resident required no smoking apron, or cigarette holder, and did not need supervision or one to one assistance. The assessment documented he/she did need the facility to store his/her lighter and cigarettes. The assessment further documented, No, when it asked if the resident's plan of care is used to assure the resident was safe while smoking. Further review of the resident's nurses' notes, revealed the resident was not safe and was found smoking in his/her room as follows; 1.) On 2/4/17 at 3:16 PM, the resident had expressive aphasia (difficulty verbally expressing needs/thoughts) and needed to be asked yes and no questions. The resident continued to request to go to smoke room frequently. For safety, staff should accompany him/her. He/she tends to smoke cigarettes to the butt and loses the cherry, burning his/her clothes. Smoking apron utilized when he/she smokes. 2.) On 2/18/17 at 9:18 AM, the facility stored the residents' cigarettes and lighters in the nurses station for all of the smokers for safety reasons. The resident gets up early and starts smoking from the time he/she gets up till he/she has a cigarette after supper and then goes to bed. 3.) On 3/18/17 at 5:05 AM, a resident reported resident #1 to be smoking in his/her room. The direct care staff saw the resident smoking a butt in his/her room (that he/she got out of an ashtray). The nurse went to talk with the resident. The resident had a lighter and a whole cigarette (not his/her brand) in his/her bra. The resident very unwillingly gave them up. 4.) On 3/26/17 at 4:10 AM, staff reported to the nurse the smell of cigarette smoke coming from resident #1's room. Investigation revealed that the resident had a lighter hidden in his/her bra and the room did smell like smoke. The resident finally admitted to smoking in the bathroom by nodding yes when questioned about it. No cigarette could be found but the resident pointed to the toilet, so it was probably flushed. The nurse explained the seriousness of smoking inside the room and a fire could start or oxygen could blow up and people could be seriously hurt or killed. The nurse also reminded the resident that it was against the rules. On 5/16/17 at 12:20 PM, administrative licensed nurse staff B reported being unaware of how the resident got the lighters to smoke in his/her room, and the resident would not tell staff B where he/she got them from. Staff B verified the resident did not use a smoking apron when smoking. The facility smoking policy, dated 8/23/12, documented the purpose was to promote/maintain/increase safety when residents choose to smoke. 1.) Residents shall smoke in the designated smoking areas outside the facility. (Designated areas: front area, courtyard, area located behind therapy and designated smoking room). 2.) All residents who smoke will have a smoking risk assessment performed upon admission by the admitting nurse. The SSD (social service designee) shall ensure a smoking assessment is performed upon any significant changes or upon re-admission, and then annually thereafter. 3.) Only residents who have had a smoking risk assessment performed may smoke. The facility failed to ensure the resident remained safe during smoking, when the resident was found in his/her room smoking a cigarette on 2 occasions with a lighter/cigarette in his/her possession.

The facility reported a census of 61 residents with 20 selected for review. Based on observation, record review and interview, the facility failed to acknowledge and provide to the resident recommendations from the registered dietician for weight loss of one (#81) of the 3 sampled residents reviewed for nutrition. Resident # 81, sustained a significant weight loss of 7.85% in 33 days. Findings included: - The facility face sheet revealed resident #81, admitted to the facility on [DATE], with the following diagnoses; nutritional marasmus (inadequate energy intake including protein), dysphagia (difficulty in swallowing), and emaciation (a leanness caused by disease or lack of nutrition). The admission MDS (minimum data set), dated 6/21/13, revealed the resident had a BIMS (brief interview for mental status) score of 3, indicating severely impaired cognition. The MDS documented the resident had [MEDICAL CONDITION]; inattention and disorganized thinking, which fluctuated. The resident required for ADL's (activities of daily living) for eating, limited staff assistance of 1; for locomotion, total dependence of 1 staff; and transfers, extensive staff assistance of 2. The resident's mobility per wheelchair. The resident was frequently incontinent of bladder, occasionally incontinent of bowel, and with constipation present. The resident received PRN (as needed) pain medication, and rated his/her pain level at a 5 on scale of 0-10. The resident was without swallowing difficulties, weighed 121 pounds, and received a mechanically altered and therapeutic diet. The resident had broken or loosely fitting full/partial denture. The CAAS (care area assessment summary), dated 7/2/13, revealed the following: "Cognitive Loss: The resident had BIMS score of 3. (He/she) has significantly impaired cognition. The family reports that this is a decline from resident's usual state of function. Resident had previously been living at home alone for the past 7-8 years. The resident is able to make choices and staff allow and encourage (him/her) to make as many choices as possible..." "ADL's:...(He/she) needs assistance from staff for safe transfers, bed mobility, dressing and all other ADL's except for eating which (he/she) requires set up assistance...." "Nutrition: The resident is provided with LCS (low concentrated sweets), pureed diet with thin liquids. (He/she) admitted to the facility with a [DIAGNOSES REDACTED]. The resident's admit weight was 121 pounds initially on 6/14/13, and on 6/18/13, the resident's weight has increased to 125 pounds. The resident was moved to the supervised area of the dining room for staff to monitor and cue (him/her) if needed. Staff will monitor (his/her) weight routinely for gains/losses. The resident has been feeding self with set-up assistance and cueing. They (the staff) also provide supervision to ensure adequate nutritional intake. The resident denies having any difficulty chewing or swallowing ..." "Dental: The resident has upper dentures and lower partials, the lower partials do to fit well. (He/she) denies having any difficulty with chewing or swallowing at this time and is on a pureed diet with thin liquids. The resident admitted with [DIAGNOSES REDACTED]. Resident currently does not want to have dentures worked on or re-aligned. Staff will continue to observe resident for difficulties with oral care, meal intake or swallowing difficulties..." The 30 day MDS 3.0 dated 7/12/13, revealed the resident had a BIMS score of 3, and [MEDICAL CONDITION]. The only change in ADL's is in eating, required supervision and set-up assistance. Mobility is unchanged. The resident continued to not have any swallowing difficulties, weighed 117 pounds, and required a mechanically altered/therapeutic diet. No change in dental." The care plan reviewed on 7/2/13, documented the following: Nutrition/Hydration: --I am on a LCS (low concentrated sweets) pureed diet with thin liquids. I get double portions of pureed food. --I eat in the small dining room for cueing/supervision and assistance to ensure my intake. --I have upper dentures and they fit well but my bottom has a partial that doesn't fit well my family has taken them home as I no longer wear them. Staff will need to provide me with reminders and assistance with oral care. --Offer fluids every 2 hours with cares, in addition to my meals and medications due to my cognition impairment. The Nutrition/Hydration care plan lacked instructions for the resident to receive House Shakes (supplement) BID (twice daily) as recommended by the registered dietician. The nutrition assessment dated [DATE], completed by the registered dietician, documented the following: New admit: Weighed past 30 days: 121 pounds on 6/14/13, 87% of desirable resident weight. Supplement: Recommend House shake BID plus start skin protocol. Patient goals: patient to gain 1-2 pounds week to within DW. (desired weight) The physician orders, dated 6/14/13, documented diet: LCS pureed. The resident's weight as follows per facility weight log: 6/14/13-121 pounds (Admission weight). 6/21/13-125 pounds. 6/27/13-127 pounds. 7/5/13-122 pounds. The physician orders, dated 7/10/13, instructed staff to give resident double portions of pureed food. 7/12/13-117 pounds. The resident with a 10 pound weight loss or a 7.87 % weight loss in 17 days, from 6/27/13 to 7/12/13. The physician orders, dated 7/15/13, documented, "...resident to continue on double portions on puree diet but may request mechanical soft at his/her will. (He/she) is safe to eat mechanical soft but (he/she) prefers puree." 7/15/13-117 pounds. 7/22/13-116 pounds. 7/29/13-117 pounds. The resident experienced a ten pound weight loss or a 7.87% significant weight loss from 6/27/13 through 7/29/13 (33 days). 8/5/13-119 pounds. The facility Meal Intake record documented the following: June 2013: The resident ate an average of 75% of breakfast, and averaged 360 cc (cubic centimeters) of fluids, and staff documented an N, indicating supplement not offered. For lunch, the resident ate and average of 50% of meal, averaged 360 cc of fluids, and staff documented an N, indicating the supplement not offered. For dinner, the resident ate an average of 75% of meal, averaged 240 cc of fluids, and staff documented an N, indicating the supplement not offered. July 2013: The resident ate 75 to 100% of breakfast, lacked documentation for the 8th, and the 12th. The resident averaged 360 cc of fluid for breakfast, and staff documented an N, indicating the supplement not offered. For lunch the resident ate 75% of the meal. The record lacked documentation for 11 days. The resident averaged 360 cc for fluid intake, and lacked documentation for 11 days, and staff documented an N, indicating the supplement not offered. For dinner the resident ate 75% of meal. The record lacked documentation for 7 days for meal intake. The resident's fluid intake averaged 360 cc, and lacked documentation for 7 days, and staff documented an N, indicating the supplement not offered. August 2013 (1-6): The resident averaged 100-75% of breakfast, 360 cc of fluids, and staff documented an N, indicating the supplement not offered. The resident averaged for lunch, 75-100%, averaged 360 cc of fluids, and staff documented an N, indicating the supplement not offered. The resident averaged for dinner 75-100%, averaged 360 cc of fluids, and staff documented an N, indicating the supplement not offered. The nurses notes, dated 6/21/13, documented the following: "SNAR (skin, nutrition and at risk) IDT (interdisciplinary team) reviewed; Resident is new admit on 6/14/13. Current weight is 125 pounds... Admit [DIAGNOSES REDACTED]. Loves milk and to give at all 3 meals, also loves eggs. CDM (certified dietary manager) to notify dietary staff, floor staff informed. Resident eats approx 75% of (his/her) meals." The nurses notes, dated 7/5/13 documented the following at 11:15 AM, "SNAR meets to Review status, weight down 4.8 pounds, since last meeting (1 week). Continue to have admit pressure area to left ankle, gets Prostat (protein supplement) 60 cc TID (three times a day), continue to work with resident increasing caloric output. Will notify physician." The Physician weight change notification form, dated 7/5/13, documented: "The above resident had a 4.8 pounds weight loss over the past 7 days. Current weight 122 pounds. The following interventions are currently in place: Supplement 2 times per day. Cues/Supervision, assistance with eating. Prostat 60 cc TID. Signed (by the physician) on 7/8/13." The Physician weight change notification form, dated 7/12/13, documented: "The above resident has had a 5 pound weight loss over the past 7 days. Current weight 117 pounds. The following interventions are currently in place: Supplement, 2 times per day, whole milk. The resident on pureed, LCS diet. Likes pureed foods, started on house supplement BID and milk all 3 meals. Patient is to have dentures checked." Signed 7/16/13. The RD Recommendations, dated 7/12/13, documented, "Noted a significant weight loss in 2 weeks. Current diet is pureed, portions were just doubled this week. Requested he/she also be put on house supplement BID between meals for additional calorie/protein to prevent further weight loss." The nurses notes, dated 7/18/13, documented, "SNAR/IDT recommendations from PCP (primary care (physician) was to have dentures checked. "Family chose not to have dentures done. Resident tried pureed food and liked it. Current PO (oral) intake, Breakfast, 75%, Lunch,75%, Dinner, 75%.Wants to continue (his/her) diet as written. Current weight 117 pounds, down 0.2 pounds over the past seven days. Flagged at 5% over 30 days (significant weight loss)." The nurses notes, dated 7/26/13 at 12:00 PM, documented "SNAR Review current weight 116 pounds, 1 pound down past seven days, and weight loss slowed. Will contact PCP about reviews next week. Continue dietary recommendations at this time. Continue with current diet but up grade to regular textures when able to tolerate. Start on House supplement BID." Observation, on 8/5/13 at 8:39 AM, revealed the resident sitting in the wheelchair in the lounge area. The resident reported he/she "had a good breakfast." Observation, on 8/5/13 at 8:30 AM, revealed the resident ate pureed sausage, eggs, cereal, juice, and milk, without any supplement noted. The resident ate 100% of meal. On 8/5/13 at 10:15 AM, the resident resting in the recliner in the lounge area, with eyes closed. No supplement offered to the resident On 8/5/13 at 11:15 AM, direct care staff Q weighed the resident, using the floor scale. The resident weighed 119 pounds. On 8/5/13 at 12:15 PM, the resident in the assisted dining room. The resident fed him/herself pureed meat loaf, mashed potatoes and gravy, broccoli with cheese sauce and banana cream pie. The resident also had a 240 cc glass of milk and water. Stff did not offer the resident a supplement at this time. On 8/5/13, at 1:00 PM, the resident completed eating of meal, at approximately 75% of meal, and no house supplement noted. On 8/5/13 at 2:10 PM, the resident rested in the recliner in the lounge area, with eyes closed. Staff did not offer the resident a supplement at this time. On 8/5/13 at 5:15 PM, the resident was sat in the assisted dining room. The resident fed him/herself pureed diet, milk and juice. No house supplement noted. On 8/5/13 at 3:44 PM, direct care staff R reported, "Dietary staff puts out that the resident is on a pureed diet. The resident is not on power milk, (he/she) has regular drinks. Does not receive house shakes that I am aware. The resident eats very well, and feeds self." On 8/5/13 at 4:02 PM, direct care staff S reported, "(He/she) eats well, is on a pureed diet, eats 100%, does not receive double portions, or house shakes." On 8/5/13 at 4:25 PM, licensed nursing staff R reported, "(He/she) did lose weight initially. I think (he/she) has pretty much stabilized. A lot of times when they first admit from the hospital, the resident will lose weight the first week. (The resident) is on a low concentrated sweet diet pureed." Staff R reviewed the chart, and reported, "To be given double portions. Dietary is to have a card that says the resident is on double portion. They do a SNAR every week. And I know the doctor and PA (physician assistant) know (of the weight loss), and we are given a 'early warning tool'. The doctor does not come in weekly. PA are in here weekly." The nurse was not aware the resident was to receive a House Shake. On 8/5/13 at 5:13 PM, consultant staff J reported, "The resident had been started on the wound protocol (Vitamin C and multivitamin). When I came back, 2-3 weeks later, I found out (he/she) did not progress on (his/her) meal to increase to mechanical soft. I recommended the supplement when (he/she) first came here." On 8/5/13 at 5:20 PM, dietary staff CC reported, "I don't see the resident's name on the house supplement list." Staff verified the resident did not receive a supplement/shake during snack time and meal time. The staff lacked knowledge of the shake/supplement, and lacked documentation resident received supplement/shake during snack time and meal times. On 8/5/13 at 5:45 PM, administrative staff A reported the resident has stabilized. Staff A was unable to explain why the resident did not receive the house supplement from the time when the the the RD first recommended. On 8/5/13 at 6:00 PM, consultant staff J reported, "The resident came here after being at home by self, for approximately 2 days without food or water when (he/she) fell and fractured (his/her) hip. The resident was not eating well at home. I do not know (the resident's) life time weight." On 8/5/13 at 6:30 PM, administrative nursing staff B reported, "I know you won't believe this, but the resident has been receiving the supplement all along, the staff just has not been documenting it. This is why I do not like supplements. The resident will fill up on fluids and not eat their meal." On 8/7/13 at 1:20 PM, physician assistant U reported, "I was aware the resident had lost weight. The last notification I have at this time with me, is dated 7/12/13. I recommended the resident receive house supplement BID, and have (his/her) dentures checked. Not aware the resident not receiving house supplement as documented." The facility SNAR Policy and Procedure, policy revised on 10/12, documented, "6.) If weight loss/gain of 2% in 30 days, 6% in 90 days, and 8% in 180 days is noted on monthly weights, the resident then will be added to the weekly SNAR meeting for review... 13.) The physician will be notified of recommendations made by the Registered Dietician or observations from the inter-disciplinary team and then the inter-disciplinary team will note any new orders received from the physician." The facility failed to acknowledge and follow the recommendations by the Registered Dietician, and PA orders to provide this resident with house supplements twice a day. The resident sustained [REDACTED].