Every finding on record at River Grove Health and Rehabilitation

Based on facility policy review, observations, and interviews the facility failed to store frozen food items properly, failed to maintain kitchen equipment in a sanitary condition, and failed to discard undated cold food items, which had the potential to affect 95 of 97 residents residing in the facility. The findings include: Review of the facility's policy titled, Equipment Cleaning Procedures, dated 5/2018, revealed .all dietary equipment and the environment are cleaning and sanitized in a manner that meets .federal regulations .equipment .soiled between scheduled cleanings must be properly cleaned and sanitized .wash soil from equipment . Review of the facility's policy titled, Food Storage: Cold, dated 10/2019, revealed .frozen and refrigerated food items will be appropriately stored .Director insures [ensures] that all food items are stored properly in covered containers, labeled and dated .in a manner to prevent cross contamination . During an observation and interview with the Certified Dietary Manager (CDM) on 7/28/2025 at 11:36 AM, in the walk-in freezer area, revealed one 10-pound box of frozen [NAME] wedges, uncovered, which left the frozen food contents opened to air and potential contamination. Further observation revealed 2 of 8 [NAME] wedges had visible signs of discoloration on the food's surface from direct exposure to the air inside the freezer. The CDM confirmed the frozen [NAME] was available for resident use and was not sealed or stored properly. During an observation and interview with the CDM on 7/28/2025 at 11:41 AM, in the cooking and meal preparation area, revealed thick, brownish-yellow food debris present to 4 of 6 temperature dials (#1, #3, #4, and #6) located on the top and bottom convection ovens. Further observation revealed the lower convection oven had the presence of a thick, black, grease-like substance to the inner perimeter of the door handles. The CDM confirmed the temperature dials and door handles were not maintained in a sanitary condition and needed to be cleaned. During an observation and interview with the CDM on 7/28/2025 at 11:56 AM, of the reach-in refrigerator, revealed one 32-ounce (oz) container of nectar thick milk (1/4 full) with no open date present and directions written on the product's label to discard 7 days after opening, one 46-oz container of nectar thick water (1/2 full) with no open date present and directions written on the product's label to discard 7 days after opening, and one 46-oz nectar thick apple juice (1/2 full) with no open date present and directions written on the product's label to discard 7 days after opening. The CDM stated the nectar thick milk, nectar thick water, and nectar thick apple juice should be discarded 7 days after opening as directed on the product's label and stated she could not verify the opened dates. The CDM confirmed the thickened liquids were available for resident use, were not labeled appropriately, and should be discarded. During an observation and interview with the CDM on 7/29/2025 at 11:58 AM, revealed the can opener blade had a thick, black, sticky substance to the end of the blade. The CDM stated the thick, black, sticky substance was .probably the adhesive label from one of the cans . and confirmed the can opener blade needed to be cleaned and was not sanitary.

Based on review of the medical record and interview the facility failed to follow physician orders for 1 resident (Resident #72) of 25 residents reviewed for physician's orders.The findings include:Review of the medical record revealed Resident #72 was admitted to the facility on [DATE] with diagnoses including Pneumonia, Cerebral Infarction, Diabetes Mellitus, Severe Morbid Obesity, Dementia, Chronic Pain Syndrome, Dysphagia (difficulty or discomfort) in swallowing, Psychosis, and Adjustment Disorder with Anxiety.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #72 had a weight loss of 5% in the last month or loss of 10% or more in last 6 months and was not on a physician prescribed weight loss regimen.Review of the Registered Dietitian (RD) notes for Resident #72 dated 6/18/2025, revealed .RD Review Wt [weight] Loss: wt 271.5# 6/4 [6/4/2025], down from 312.6# x 1 mo [month] .signif [significant] wt loss 13%. Wt stable since 6/2 [6/2/2025]. BMI [body mass index] = 47, high .Will monitor weekly wts until stabilized.Review of the Physician Order Report for Resident #72 revealed an order dated 6/26/2025 for .Weekly weight Once A Day on Sun [Sunday] .Review of the Vitals Report for Resident #72 revealed weights for the resident were obtained as follows: 6/29/2025 - 273 lbs.; 7/2/2025 - 265.5 lbs.; 7/6/2025 - 265.0 lbs.; and 7/13/2025 - 258 lbs. Resident #72 refused to be weighed on 7/20/2025.Review of the Physician Order Report for Resident #72 revealed a Nurse Practitioner (NP) order dated 7/9/2025 for .Speech therapy [ST] evaluation for possible upgrade in diet . Further review revealed there was no order to discontinue the ST evaluation for Resident #72.Review of the ST notes for Resident #72 revealed an ST evaluation was not performed for the resident as ordered by the NP on 7/9/2025.Review of the physician order for Resident #72 dated 7/21/2025, revealed an order to discontinue weekly weights. Further review revealed .DC [discontinue reason] .Condition [weight loss] resolved . Further review revealed the order to discontinue weekly weights was initiated by the Director of Nursing (DON) and was not ordered to be discontinued by the physician or the NP.Review of the Vitals Report for Resident #72 revealed the resident was weighed on 7/31/2025 and was noted as 246.8 lbs. (2 weeks and 4 days since the previous weight on 7/13/2025).During a telephone interview on 7/31/2025 at 9:35 AM, ST C confirmed Resident #72 was not evaluated by ST according to the order on 7/9/2025, because the resident had recently been discharged from ST services on 6/24/2025. ST C stated she did not recommend upgrading the resident's diet because the resident was unable to safely consume a mechanical soft diet during the treatment sessions. During an interview on 7/31/2025 at 3:18 PM, the NP stated she was under the impression Resident #72 had been evaluated by ST as ordered. The NP stated she was not aware ST had not evaluated Resident #72 according to the order until 7/31/2025 (after identified by the Surveyor and 22 days after the order was written). The NP stated Resident #72 should have been on weekly weights, the weekly weights should not have been discontinued, and confirmed she had not written an order for the weekly weights to be discontinued. The NP stated she was not aware the weekly weights had been discontinued for the resident.During a telephone interview on 7/31/2025, the Medical Director stated increased weight monitoring should have been implemented at the point Resident #72 exhibited significant weight loss. The Medical Director stated she did not recall having a conversation regarding the resident's weekly weights and did not specifically recall giving the order to discontinue the resident's weekly weights. The Medical Director was not aware the ST evaluation ordered on 7/9/2025 for Resident #72 had not been done. The Medical Director stated she expected physician orders should be followed.During an interview on 7/31/2025 at 6:03 PM, the DON stated she discontinued Resident #72's weekly weights because the resident no longer flagged for significant weight loss. The DON stated weekly weights were discontinued if weights were stable for 4 consecutive weeks. Resident #72's weights were reviewed with the DON, who stated .looking at it now, weekly weights should not have been discontinued [for Resident #72]. I did not take into account, the weight refusal on 7/20/2025 . The DON confirmed Resident #72 should be on weekly weights and confirmed she had not discussed discontinuing the resident's weekly weights with the resident's physician.During an interview on 7/31/2025 at 6:45 PM, the Director of Therapy stated Resident #72 had been evaluated/treated by ST services. The resident was discharged from Speech Therapy services on 6/28/2025. The Director of Therapy stated an order was issued by the NP for a new ST evaluation for Resident #72 on 7/9/2025. The Director of Therapy stated she and the SLP (ST C) spoke with the Assistant Director of Nursing (ADON) by telephone. She stated the SLP explained the ST evaluation was not indicated due to the resident's recent discharge from ST, and the ST was not comfortable upgrading Resident #72's diet. The Director of Therapy stated she and the ADON spoke with the NP who was unaware the resident had recently been discharged from ST. The NP stated she understood and was going to address it (ST Order) accordingly. The Director of Therapy was under the impression the NP was going to cancel the order for the ST evaluation.

Based on facility policy review, observations, and interviews the facility failed to maintain a safe, clean, homelike environment for 1 resident (Residents #28) on 1 of 5 hallways observed. The findings include: Review of the facility's policy titled, Safe and Homelike Environment, revised 5/2025, revealed .In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment . Environment refers to any environment in the facility that is frequented by residents, including (but not limited to) the residents' rooms . A homelike environment is one that de-emphasizes the institutional character of the building .allows the resident to use personal belongings that support a homelike environment .determination of homelike should include the resident's opinion of the living environment .Housekeeping and maintenance services will be provided as necessary to maintain and sanitary, orderly and comfortable environment . Medical record review revealed Resident #28 was admitted to the facility on [DATE] with diagnoses including Unspecified Focal Traumatic Brain Injury, Hemiplegia, Dysarthria (slurred slowed or distorted speech), Anarthira (inability to articulate speech despite cognitive abilities), Epilepsy, Mood Disorder with Depressive Features, and Anxiety. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #28 scored a 10 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had moderate cognitive impairment. During an observation and interview in Resident #28's room on 7/28/2025 at 11:00 AM, revealed one missing tile pulled from the floor lying to the right side of the resident's bed and one loose tile under the resident's bed. Resident #28 shook his head no when asked if he recalled how long the floor tiles had been damaged. Resident #28 shook his head yes when asked if he like to have them repaired. During an observation in Resident #28's room on 7/29/2025 at 1:00 PM, revealed one missing tile pulled from the floor lying to the right side of the resident's bed and one loose tile under the resident's bed. During an observation and interview in Resident #28's room on 7/29/2025 at 3:00 PM, with the Administrator and Maintenance Director revealed one missing tile pulled from the floor lying to the right side of the resident's bed and one loose tile under the resident's bed. The Administrator and Maintenance Director confirmed Resident #28's room was not maintained in a safe, clean, homelike environment.

Based on Centers for Medicare & Medicaid Services (CMS) Minimum Data Set (MDS) Resident Assessment Instrument (RAI) 3.0 User's Manual, medical record review, and interview, the facility failed to accurately complete a MDS assessment for 1 resident (Resident #37) of 25 residents sampled. The findings include:Review of the CMS MDS RAI User's Manual with an effective date of 10/2024, revealed .SECTION L: ORAL/DENTAL STATUS .DEFINITIONS .CAVITY .A tooth with a discolored hole or area of decay that may have debris in it .Steps for Assessment .Conduct exam of the resident's lips and oral cavity .Visually observe and feel all oral surfaces .Check for abnormal mouth tissue, abnormal teeth, or inflamed or bleeding gums .Coding Instructions .obvious or likely cavity or broken natural teeth .if any cavity or broken tooth is seen . Review of the medical record revealed Resident #37 was admitted to the facility on [DATE] with diagnoses including Abdominal Aortic Aneurysm, Acute Kidney Failure, and Dementia. Review of the admission MDS assessment dated [DATE], revealed Resident #37 scored a 10 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had moderate cognitive impairment. Resident #37 had no dental problems including .Obvious or likely cavity or broken natural teeth . Review of the Nutritional assessment dated [DATE], revealed .Initial .Dental .Unable to examine .Review of the medical record revealed Resident #37 had no weight loss or oral pain.Review of the quarterly MDS assessment dated [DATE], revealed Resident #37 scored a 10 on the BIMS assessment which indicated the resident had moderate cognitive impairment. Resident #37 had no weight loss. During an observation on 7/28/2025 at 3:43 PM, Resident #37 had poor dentition with multiple missing top and bottom teeth with areas of decay/discoloration present to remaining teeth. Resident #37 denied any trouble chewing or mouth pain. Resident #37 stated his teeth had been missing and in poor condition prior to being admitted to the facility. During an observation on 7/29/2025 at 8:38 AM, Resident #37 was lying in bed watching TV. The resident's breakfast tray was on the bedside table. Resident #37 ate 100% of his breakfast meal. Resident #37 had poor dentition with multiple missing top and bottom teeth with decay/discoloration to remaining teeth. During an interview on 7/29/2025 at 4:19 PM, the MDS nurse stated MDS filled out section L of the MDS assessment. An oral examination was performed to complete the assessment. Resident #37's admission MDS assessment dated [DATE] stated Resident #37 had no broken or missing teeth. During an interview on 7/29/2025 at 4:28 PM, the MDS nurse and the Social Worker stated they had visited Resident #37 and performed an oral examination. The MDS nurse and the Social Worker confirmed Resident #37 had multiple missing, broken, and .rotted . teeth. Resident #37 confirmed his teeth had been missing prior to admission and stated they had been like that .for a long time . The MDS nurse confirmed Resident #37's admission MDS assessment was not accurate and the .Obvious or likely cavity or broken natural teeth . choices should have been marked on the MDS assessment. The MDS nurse confirmed the facility followed the RAI Manual to code MDS assessments. During an interview on 7/30/2025 at 9:55 AM, the Director of Nursing (DON) stated she observed Resident #37's teeth on 7/29/2025 and confirmed the resident had multiple missing teeth and poor dentition. The DON stated section L of the MDS was completed by the remote MDS Coordinator. The DON confirmed the resident's admission MDS assessment dated [DATE] that stated Resident #37 had no dental problems was not accurate. The DON stated it was the expectation that MDS assessments were accurate. The DON confirmed Resident #37 had no weight loss or mouth pain. During a telephone interview on 7/30/2025 at 10:31 AM, the remote MDS Coordinator stated she worked remote and was not onsite at the facility. The remote MDS Coordinator stated she reviewed resident observations and progress note documentation to complete section L since she was not onsite to complete the assessment. The admission MDS assessment dated [DATE] stated Resident #37 had no dental concerns. The remote MDS Coordinator stated she was unable to find any information in the medical record regarding the resident's oral/dental status and . I just put none of the above were present since nothing was documented .

Based on review of the facility policy, review of the medical record, observations, and interviews, the facility failed to revise the comprehensive care plan for 3 residents (Resident #21, #72, and #83) of 25 residents reviewed for care plans. Review of the facility’s policy titled, “Comprehensive Care Plans,” dated 3/3/2025, revealed “ .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, to meet a resident’s medical, physical, mental, and psychosocial needs .The comprehensive care plan will describe .The services that are to be furnished .Resident specific interventions that reflect the resident’s needs and preferences .The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment .” Review of the medical record revealed Resident #21 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Metabolic Encephalopathy, Chronic Obstructive Pulmonary Disease (COPD), Diabetes Mellitus, and Depression. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #21 required supervision or touching assistance for personal hygiene. Review of the quarterly MDS assessment dated [DATE], revealed Resident #21 was dependent on staff for personal hygiene. Review of the care plan for Resident #21 dated 6/13/2025, revealed “ .ADLs [Activities of Daily Living] Functional Status/Rehabilitation Potential .has an ADL self-care performance deficit r/t [related to] generalized weakness, oxygen dependence, and COPD .PERSONAL HYGIENE/ORAL CARE .requires supervision/touching assistance .for personal hygiene .” During a telephone interview on 7/30/2025 at 10:38 AM, the remote MDS Coordinator stated Resident #21’s quarterly MDS assessment dated [DATE] stated the resident was dependent on staff for personal hygiene. Resident #21’s current comprehensive care plan stated Resident #21 required supervision and touch assistance for personal hygiene. The remote MDS Coordinator stated “ .care plans are a work in progress right now .” The remote MDS Coordinator confirmed Resident #21’s care plan had not been revised to reflect that the resident was dependent on staff for personal hygiene. During a telephone interview on 7/31/2025 at 6:33 PM, the Regional Director of Clinical Reimbursement stated MDS staff were responsible to update the care plan after the MDS assessment. Review of the medical record revealed Resident #72 was admitted to the facility on [DATE] with diagnoses including Pneumonia, Cerebral Infarction, Type 2 Diabetes Mellitus, Severe Morbid Obesity, Dementia, Chronic Pain Syndrome, Dysphagia (difficulty or discomfort) in swallowing, Unspecified Psychosis, and Adjustment Disorder with Anxiety. Review of the care plan for Resident #72 dated 1/29/2025, revealed “ .[Resident #72] is a risk for alterations of nutritional status R/T [related to] DM [Diabetes Mellitus], mechanically altered diet, therapeutic diet .” Continued review revealed the care plan had not been revised after Resident #72's significant weight loss was identified. Review of the quarterly MDS assessment dated [DATE], revealed Resident #72 scored an 8 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had moderate cognitive impairment. Further review revealed Resident #72 required set up/clean up assistance with eating. Resident #72 had a weight loss of 5% in the last month or loss of 10% or more in last 6 months and was not on a physician prescribed weight loss regimen. During an interview on 7/31/2025 at 6:33 PM, the Director of Nursing (DON) confirmed Resident #72 had significant weight loss and confirmed the resident’s care plan had not been revised to reflect the resident’s actual weight loss. During a telephone interview on 7/31/2025 at 6:33 PM, the Regional Director of Clinical Reimbursement stated the quarterly MDS assessment dated [DATE] revealed the resident had a weight loss of 5% or more in the last month or a loss of 10% or more in the last 6 months and was not on physician prescribed weight loss regimen. The MDS Coordinator was responsible for updating the care plan after an MDS assessment. The Regional Director of Clinical Reimbursement confirmed the care plan had not been revised to reflect Resident #72’s weight loss. Review of the medical record revealed Resident #83 was admitted to the facility on [DATE] with diagnoses including Diabetes, Hemiplegia and Hemiparesis affecting the Right Side, and Acquired Absence of Toe(s). Review of a quarterly MDS assessment dated [DATE], revealed Resident #83 scored a 13 on the BIMS assessment which indicated the resident was cognitively intact. Further review revealed the resident was dependent upon staff assistance for personal hygiene and mobility. Review of a Physician’s Order for Resident #83 dated 7/1/2025, revealed “ .Off-loading [pressure reducing] boots to be worn while in bed .” Review of the comprehensive care plan for Resident #83 revised 7/2/2025, revealed “ .at risk for skin breakdown R/T [related to] immobility, impaired physical limitations .eliminate risk factors to extent possible .ADL [activities of daily living] self-care performance deficit .requires total assistance from staff member .” Further review revealed Resident #83’s order and use of the offloading-pressure reducing boots was not revised on the care plan. During an observation on 7/28/2025 at 1:00 PM, in Resident #83’s room, revealed Resident #83 was lying in bed with the bilateral offloading boots present to both heels. During an observation on 7/29/2025 at 3:55 PM, in in Resident #83’s room, revealed Resident #83 was lying in bed with the bilateral offloading boots present to both heels. During an interview on 7/30/2025 at 9:30 AM, Certified Nursing Assistant A stated Resident #83 required the use bilateral off-loading boots while in bed. During an interview on 7/30/2025 at 9:35 AM, the Wound Care Nurse stated Resident #83 wore the bilateral off-loading boots while in bed to offload pressure to the bilateral heels. During an interview on 7/30/2025 at 10:00 AM, Resident #83 stated he wore the offloading pressure boots to both of his heels and stated he “ .wears them all the time .” During an interview on 7/30/2025 at 11:00 AM, the MDS Nurse stated the care plan should be revised and updated when new care interventions are ordered for each resident. The MDS Nurse confirmed the facility failed to revise and update Resident # 83’s comprehensive care plan to reflect the required use of the off-loading boots to bilateral heels. During an interview on 7/30/2025 at 11:04 AM, the Assistant Director of Nursing (ADON) confirmed the facility failed to revise and update Resident # 83’s comprehensive care plan to reflect the resident’s required use of the off-loading boots to the bilateral heels.

Based on facility policy review, observations, and interviews, the facility failed to ensure the residents' health information remained private and confidential on 1 medication cart (Station 2 Cart 1) of 3 medication carts observed, which had the potential to allow unauthorized individuals access to the residents' private health information. The findings include:Review of the facility's policy titled, Confidentiality of Personal and Medical Records, dated 3/23/2022, revealed .'Keep confidential' is defined as safeguarding the content of information including written documentation .or other computer stored information from unauthorized disclosure without the consent of the individual and/or the individual's surrogate or representative .Paper notes or reminders with resident's personal or medical information shall not be left unattended or viewable by unauthorized persons .During an observation on 7/29/2025 at 8:10 AM, on the Station 2 hall, revealed there was a written shift-to-shift communication sheet which listed the residents' names and various medical conditions stored on top of the medication cart (Stations 2 Cart 1). Further observation revealed a medication card label which listed resident's name was stored above clean plastic drinking cups on the side of the medication cart. Continued observation revealed the residents' personal and confidential medical information was visible on the medication cart and was left unattended by Licensed Practical Nurse (LPN) D. During an observation and interview with LPN D on 7/29/2025 at 8:14 AM, on the 200 hall, revealed there was a written shift-to-shift communication sheet which listed the residents' names and various medical conditions stored on top of the medication cart (Stations 2 Cart 1) and a medication card label which listed resident's name was stored above clean plastic drinking cups on the side of the medication cart. LPN D stated she should have ensured the resident's personal and medical information was not visible prior to leaving the medication cart.During an interview on 7/30/2025 at 7:45 AM, the Director of Nursing (DON) stated staff were expected to ensure the residents' personal and confidential information was secured and covered prior to leaving the medication cart.

Based on review of the facility contract for nutrition services, review of the facility policy, review of the medical record, observation, and interview the facility failed to implement appropriate interventions to prevent weight loss for 1 resident (Resident #72) of 3 residents reviewed for weight loss. The findings include:Review of a facility document titled, Contract for Nutrition Services, dated 12/1/2023, revealed .Subcontractor Service Duties .provide one or all of the following services .Correlate and integrate the nutritional aspects of client care with other client care services to include directing the following .Reviewing the clients medical record history and assessing the client's nutritional status .Interviewing and counseling clients .Recording client information in the medical record .Assessing, planning, and implementing nutrition care for clients .Developing nutrition care goals .Completing nutrition assessment forms .Work as part of the medical team .Subcontractor Services shall include, but are not limited to .Visit FACILITY on days specified and agreed upon by both parties and assure that the professional dietary clinical needs of FACILITY are met .Complete monthly assessments on residents experiencing significant weight loss .Provide consultation to FACILITY employees regarding diet, nutritional problems and management including patient care plans and case review .Review resident care plans and participate in development of dietary policies .Provide FACILITY monthly written reports which shall be signed and dated and contain a summary of areas reviewed and recommendations .Chart nutritional information in accordance with the policies of FACILITY and accepted professional practice .RECORDS .FACILITY and Subcontractor shall prepare and maintain complete and detailed records concerning Facility's residents receiving Services under this Agreement, in accordance with prudent record-keeping procedures . Review of the facility's policy titled, Weight Assessment/Monitoring, dated 1/2025, revealed .The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents .Any weight change of 5% [percent] or more since the last weight assessment will be retaken for confirmation. If the weight is verified, nursing will notify the Dietitian .The Dietitian will review the unit Weight Record by the 15th of the month to follow individual weight trends over time. Negative trends will be evaluated by the treatment team whether or not the criteria for significant weight change has been met .The threshold for significant unplanned and undesired weight loss will be based on the following criteria .1 month - 5% weight loss is significant; greater than 5% is severe .3 month - 7.5% weight loss is significant; greater than 7.5% is severe .6 months - 10% weight loss is significant; greater than 10% is severe .Assessment information shall be analyzed by the multidisciplinary team and conclusions shall be made regarding the .Resident's target weight range (including rationale if different from ideal body weight) .Approximate calorie, protein, and other nutrient needs compared with the resident's current take .Whether and to what extent weight stabilization or improvement can be anticipated .The Physician and the multidisciplinary team will identify conditions and medications that may be causing .weight loss or increasing the risk of weight loss. For example .Cognitive or functional decline .Increased need for calories and/or protein .The Physician and the multidisciplinary team will identify conditions and medications that may be causing .weight loss .For example .Cognitive or functional decline .Chewing or swallowing abnormalities .Interventions for undesirable weight loss shall be based on careful consideration of the following .Resident choice and preferences .Nutrition and hydration needs .Functional factors that may inhibit independent eating .Chewing and swallowing abnormalities and the need for diet modifications .The use of supplementation and/or feeding tubes . Review of the medical record revealed Resident #72 was admitted to the facility on [DATE] with diagnoses including Pneumonia, Cerebral Infarction, Diabetes Mellitus, Severe Morbid Obesity, Dementia, Chronic Pain Syndrome, Dysphagia (difficulty or discomfort) in swallowing, Psychosis, and Adjustment Disorder with Anxiety. Review of the comprehensive care plan for Resident #72 dated 1/29/2025, revealed .[Resident #72] is a risk for alterations of nutritional status R/T [related to] DM [Diabetes Mellitus], mechanically altered diet, therapeutic diet . Review of the Physician Orders for Scope of Treatment (POST) form for Resident #72 dated 1/30/2025, revealed the box was checked for .Long-term artificial nutrition by tube [tube feeding] . Review of the Vitals Report for Resident #72 for 1/30/2025-7/31/2025 revealed the following weights:1/30/2025 - 323.6 pounds (lbs.)2/9/2025 - 315.5 lbs.2/17/2025 - 314.2 lbs.2/25/2025 - 314.2 lbs.3/8/2025 - 312.8 lbs.4/11/2025 - 312.8 lbs.4/15/2025 - 312.6 lbs.5/2/2025 - 312.6 lbs.6/2/2025 - 271.5 lbs. (13.15% weight loss in 1 month)6/4/2025 - 271.5 lbs. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #72 scored an 8 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had moderate cognitive impairment. Further review revealed Resident #72 required set up/clean up assistance with eating. Resident #72 had a weight loss of 5% in the last month or loss of 10% or more in last 6 months and was not on a physician prescribed weight loss regimen. Review of the Registered Dietitian (RD) notes for Resident #72 dated 6/6/2025, revealed the RD's quarterly review for Resident #72 revealed the resident was on a mechanical soft (diet which is easy to chew and swallow) Consistent Carbohydrate (CCHO-diet for managing blood sugar levels) diet. The resident's weight was 271.5 lbs., which was down from 312.6 lbs. for 1 month. The resident had a significant weight loss of 13% in 1 month. The plan was to continue to monitor, follow the resident as needed, and to continue the plan of care. Further review revealed no evidence the RD recommended interventions to prevent further weight loss for Resident #72. Review of the Speech Therapy (ST) notes for Resident #72 dated 6/16/2025, revealed the resident was evaluated by ST due to difficulty taking medications and decreased oral (by mouth) intake. The ST recommended a puree diet for Resident #72. Review of the physician orders for Resident #72 dated 6/16/2025, revealed an order for a CCHO, puree diet. Review of the RD notes for Resident #72 dated 6/18/2025, revealed .RD Review Wt] [weight Loss: wt 271.5# [pounds] 6/4 [6/4/2025], down from 312.6# x 1 mo [month] .signif [significant] wt loss 13%. Wt stable since 6/2 [6/2/2025] .Intakes good per nsg [nursing] doc. [documentation] Will monitor weekly wts until stabilized. Cont [continue] POC plan of care]. Continued review revealed the RD provided no recommendations to prevent further weight loss for Resident #72. Review of the nurse's notes for Resident #72 dated 6/23/2025 at 7:55 PM, revealed .Resident #72] dislikes pureed food and not eating as much as she normally does. Nurse crushes medications d/t recent choking episode on morning medications Review of the ST SLP (Speech-Language Pathologist) Discharge Summary for Resident #72 dated 6/24/2025, revealed .Assistance/Support to be Provided [with meals] .pt [patient] to be assisted by caregiver/staff .Progress & [and] Response to Treatment .At this time, pureed diet and thing liquids is the safest and most appropriate diet level .pt to discharge from therapy due to max potential achieved at this time .Prognosis to Maintain CLOF [continued level of functioning] .Good with consistent staff follow-through . Review of the Physician Order Report for Resident #72 revealed an order dated 6/26/2025 for .Weekly weight Once A Day on Sun [Sunday] . Review of the nurse's notes for Resident #72 dated 6/28/2025 at 1:13 PM, revealed .Patient [Resident #72] refuses to eat pureed food. Pudding offered and accepted. Patient's [Resident #72] food intake has decreased since the pureed diet was ordered . Review of the Vitals Report for Resident #72 for 1/30/2025-7/31/2025 revealed the following weights:6/29/2025 - 273.2 lbs.7/2/2025 - 265.5 lbs. (2.82% weight loss (6/29/2025; 2.21% from 6/2/2025, and 15.07% weight loss from 5/2/2025). Review of the Nurse Practitioner (NP) notes for Resident #72 dated 7/2/2025, revealed nursing staff reported Resident #72 had not been eating as well .since changing to a pureed diet, which was recommended by speech therapy . Continued review revealed no documentation of a plan to address the resident's refusal to eat and no documentation of the resident's significant weight loss. Review of the Vitals Report for Resident #72 for 1/30/2025-7/31/2025 revealed the following weights:7/6/2025 - 265.0 lbs. Review of the nurse's notes for Resident #72 dated 7/8/2025 at 6:13 PM, revealed the resident reported .she could not swallow. Continued to drink water and other drinks throughout shift. Refused to eat pureed food. NP notified . Review of the NP notes for Resident #72 dated 7/9/2025, revealed Resident #72 had a history of Dysphagia. The resident was being evaluated related to nursing staff concerns regarding Resident #72's refusal to eat and complaints of difficulty swallowing. Continued review revealed Resident #72 reported .ongoing swallowing difficulties, which have been previously evaluated by speech therapy. [Resident #72] is currently on a pureed diet but express dissatisfaction with it while simultaneously [at the same time] acknowledging her swallowing issues . The plan was to continue the pureed diet and refer the resident to speech therapy for diet upgrade evaluation. Review of the Physician Order Report for Resident #72 revealed an NP order dated 7/9/2025 for .Speech therapy evaluation for possible upgrade in diet . Review of the ST notes for Resident #72 revealed no evidence the ST evaluation was performed according to the order dated 7/9/2025. Review of the Vitals Report for Resident #72 for 1/30/2025-7/31/2025 revealed the following weights:7/13/2025 - 258.0 lbs. (17.47% weight loss from 5/2/2025-7/13/2025) Review of the RD notes for Resident #72 dated 7/16/2025, (44 days after Resident #72's significant weight loss of 13% had been identified on 6/2/2025), revealed wt 258# 7/13 [7/13/2025], down from 312.6# x 3 mo .signif wt loss 17.5% .Resident refusing to eat pureed diet [foods are blended or mashed to a smooth, pudding-like consistency and requiring no chewing] per nsg doc. ST reports resident was unable to chew mechanical soft diet when evaluated. Will provide Boost glucose control [nutritional drink designed to provide complete, balanced nutrition] BID [twice a day] between meals [ordered 2 months 2 weeks after Resident #72's significant weight loss of 13% had been identified] .Will cont to monitor and follow as needed, cont POC . Review of the physician order for Resident #72 dated 7/16/2025, revealed .Boost diabetic control .BID [two times a day] between meals Twice A Day . (44 days after Resident #72's significant weight loss had been identified on 6/2/2025). Review of the Medication Administration Record for 7/2025 for Resident #72 revealed the resident refused to be weighed on 7/20/2025. Review of the physician order for Resident #72 dated 7/21/2025, revealed an order to discontinue weekly weights. Further review revealed .DC [discontinue reason] .Condition [weight loss] resolved . Further review revealed the order was discontinued by the Director of Nursing (DON) and not by the physician or the NP. Review of the nurse's notes for Resident #72 on 7/21/2025 at 2:37 PM, revealed the resident refused to eat her pureed food. The NP was notified of the resident's refusal to eat the pureed diet. Review of the medical record for Resident #72 revealed no further documentation to show the RD had monitored/followed the resident's weight loss and had not made recommendations to prevent further weight loss since 7/16/2025. Review of the medical record revealed no Interdisciplinary Team (IDT- team of staff working together to coordinated patient care) meeting notes to address Resident #72's from 1/29/2025-7/31/2025. Review of the medical record revealed no lab tests had been performed since Resident #72's significant weight loss was identified on 6/2/2025. During an observation and interview on 7/28/2025 at 1:00 PM, of the lunch meal, revealed a Certified Nursing Assistant (CNA) brought Resident #72's tray into the resident's room, placed the tray on the overbed table in front of the resident, set up the resident's meal tray, and exited the room. Further observation revealed staff did not return to the resident's room to offer the resident assistance with eating. The resident at zero% of the lunch meal. When asked why she did not eat her lunch, Resident #72 stated .it's puree . She shook her head no, when asked if she did not like the pureed diet. During an observation on 7/29/2025 at 7:45 AM, revealed Resident #72 was in her room, lying in the bed, with her breakfast tray sitting on the overbed table in front of the resident. The resident ate zero % of the breakfast meal. Staff were not observed assisting the resident with her meal. During a telephone interview on 7/29/2025 11:09 AM, Resident #72's husband stated the resident had not been eating since her diet was changed to a pureed diet a couple of weeks ago. The resident's husband stated the resident was evaluated by speech who recommended she be on a pureed diet. During an observation on 7/30/2025 at 8:06 AM, revealed Resident #72 was in her room, lying in the bed, with her breakfast tray sitting on the overbed table in front of the resident. Continued observation revealed Resident #72 attempted to eat 2 or 3 bites of pureed scrambled eggs, but the eggs dropped off the spoon before she could eat it. Staff did not assist the resident with eating the breakfast meal. During a telephone interview on 7/30/2025 at 2:22 PM, the RD stated she had .not recently . observed Resident #72 eating meals. The RD was unable to say when she had observed the resident eating a meal. The RD stated residents with significant weight loss were discussed weekly with the IDT. The RD was unable to verbalize what the IDT had discussed regarding Resident #72's weight loss. The RD confirmed Resident #72's current meal intake and Boost twice a day was not sufficient to meet Resident #72's nutritional needs. Review of the nurse's notes for Resident #72 dated 7/30/2025 at 3:50 PM, revealed .This nurse [Assistant Director of Nursing-ADON] was present in the room while NP spoke with resident and husband about the risks associated with upgrading diet per resident and family request. Resident and husband in agreement with new diet order and both verbalized with this nurse present that they understand the risks associated with this change in diet. NP upgraded diet to mechanical soft with chopped meats, resident and husband aware . Review of the NP notes for Resident #72 dated 7/30/2025 at 7:28 PM, revealed .[Resident #72] has experienced weight loss due to refusing to eat pureed food. She was previously seen by speech therapy, who had not recommended an upgraded diet. A meeting was held with [Resident #72], her spouse, and the assistant director of nursing to discuss her request for a diet upgrade .[Resident #72] and her spouse have expressed a preference for quality of life over the current puree diet. They have requested an upgrade to a mechanical soft diet with chopped meats, despite understanding the associated risks including aspiration pneumonia, choking, and death. Both the patient [Resident #72] and her spouse acknowledged these risks but still wished to proceed with the diet upgrade, citing it as a quality of life issue . During a weight observation on 7/31/2025 with a surveyor present revealed the resident weighed 246.8 lbs. (21.05% weight loss from 5/2/2025-7/31/2025 and 23.73% weight loss for past 6 months). During a 2nd telephone interview on 7/30/2025 at 4:42 PM, the RD stated during ST treatment, Resident #72 told the ST she could not eat mechanical soft food, so the resident's diet could not be upgraded. The RD reported she ordered Boost 2 times per day and stated the resident should have been on weekly weights. When asked what the IDT plan was for the resident's weight loss, the RD responded .They upgraded her diet . The RD confirmed she had not recommended ordering laboratory values to check Resident #72's nutritional status or if the weight loss had impacted Resident #72's health. During an observation and interview on 7/30/2025 at 6:00 PM-6:45 PM, revealed Resident #72 was in her room, lying in the bed, with her dinner tray sitting on the overbed table in front of the resident. The meal consisted of a mechanical soft diet which included a ground turkey sandwich, diced beets, vegetable beef soup, and peach slices. Continued observation of the dinner meal revealed Resident #72, only ate 2 bites of a peach slice during the meal. Resident #72's husband stated the resident did not like the meal, stating .beets were not her favorite and the ground turkey was dry . Resident #72's husband stated they had not requested an alternative meal, as staff had not been back in the resident's room. Continued observation revealed staff did not check on the resident during the meal and did not offer to assist the resident with eating. During an observation on 7/31/2025 at 7:33 AM-8:10 AM, revealed Resident #72 was lying in the bed. A male CNA delivered the resident's breakfast tray and placed the tray on the resident's overbed table. The CNA set up the breakfast tray for the resident, added butter to the toast, and exited the room. Resident #72 picked up a piece of toast and took a small bite. At 7:40 AM, CNA B (a different CNA) entered Resident #72's room and offered to assist the resident with eating the breakfast meal, but the resident declined assistance. Resident #72 continued to attempt to eat independently. Resident #72 indicated she was finished eating at 8:10 AM. She consumed approximately 25% of the meal. During a telephone interview on 7/31/2025 at 9:35 AM, ST C stated Resident #72 had received speech therapy after the resident had experience a choking episode after taking medications and was discharged (6/24/2025). Resident #72 was unable to chew the mechanical soft diet and either refused the mechanical soft food, or spit out partially chewed food. ST C stated a mechanical soft diet was not in the best interest of Resident #72. ST C stated after the resident was discharged from ST, an unknown nurse approached her on an unknown date and asked if she had evaluated Resident #72. ST C informed the nurse she had evaluated and treated Resident #72, and had .just discharged the resident from services. I had just physically discharged her [Resident #72] .We [ST C and unknown nurse] talked about it, and they were going to discontinue the order [order for ST evaluation on 7/9/2025] . ST C confirmed Resident #72 was not re-evaluated by ST according to the order on 7/9/2025, because she did not feel an upgrade to a mechanical soft diet was safe for the resident, based on the previous evaluation and treatment. The ST was under the impression the order had been canceled. During an interview on 7/31/2025 at 10:30 AM, the DON stated she reviewed resident weights weekly and weights were followed by RD. The RD came to the facility weekly on Wednesdays. The DON stated if a resident was .on their [DON and RD] radar for weight loss . the DON and RD got together and discussed.We are following her [Resident #72] in risk [weekly IDT] . The DON stated the last IDT meeting was .last Wednesday [7/23/2025] .honestly don't remember if she was discussed in IDT last week or not . The DON was unable to verbalize why weekly weights were discontinued for Resident #72 on 7/21/2025, even though the resident continued to lose weight. The DON was unable to provide documentation Resident #72 was discussed during the weekly risk meetings. During an interview on 7/31/2025 at 3:18 PM, the NP stated she ordered an ST evaluation for Resident #72 related to the resident's decreased intake and weight loss (7/9/2025).I was seeing her because someone had notified me of [Resident #72's weight loss] .[Resident #72] had a history of Dysphagia. I referred her to speech therapy for an evaluation . When asked if previous diagnostic studies had been performed to determine the resident's ability to swallow, the NP responded .I don't know . The NP stated she became aware of residents' weight loss issues by reviewing 1-2 months of weights and/or the RD gave her a list of residents who had experienced weight loss. The NP reviewed Resident #72's weights stating weights as follows: 5/2/2025 - 312.5 lbs; 6/2/2025 - 271.5 lbs; 6/4/2025 - 271.5 lbs; 6/29/2025 - 273.2 lbs; 7/2/2025 - 265.5lbs; and 7/6/2025 - 265 lbs. The NP confirmed Resident #72 had experienced significant weight loss. The NP stated .My thought was to see if speech could evaluate her [Resident #72] to upgrade her diet since she wasn't eating the puree diet . The NP stated she was told by the ADON on an unknown date, Speech Therapy was not going to upgrade the resident's diet. The NP was under the impression Resident #72 had been evaluated as ordered on 7/9/2025, and did not want to upgrade the resident's diet. The NP was not aware ST had not evaluated Resident #72 according to the order until 7/31/2025 (after identification and notification by Surveyor). The NP stated Boost was ordered for the resident on 7/16/2025. The NP had discussed Resident #72 with the RD on 7/29/2025, with plan to discuss the risk of upgrading the resident's diet with the resident's husband. The resident's diet was upgraded to mechanical soft on 7/30/2025, after discussing the risks with the resident and the resident's husband, ensuring they understood the risks of upgrading the diet. The NP stated Resident #72 should have been on weekly weights to monitor weight loss and was unaware the resident's weekly weights had been discontinued. The NP confirmed weekly weights should not have been discontinued and she did not give an order to discontinue the weights. The NP stated Resident #72 had lost a significant amount of weight.she probably has lost muscle mass .Obviously, the Boost twice daily wasn't enough to sustain her weight .I think that I have put an intervention in place [upgrade to mechanical soft diet], although in my opinion I don't know that is going to be enough .I think when we follow up in 1-2 weeks it's going to have to be followed up on .It was my impression that dietary was following her and putting in interventions . The NP confirmed Resident #72's weight loss was unplanned. The NP confirmed no labs had been ordered to evaluate Resident #72's nutritional status. The NP confirmed the only interventions to address Resident #72's significant weight loss were ST evaluation ordered on 7/9/2025 (not completed) and Boost twice daily (7/16/2025). During an interview on 7/31/2025 at 5:07 PM, the ADON stated weekly at risk meetings (IDT) were held for residents with weight loss, with the RD, DON, MDS nurse, medical records, ADON, and Social Services in attendance. The ADON stated the NP ordered an ST evaluation for possible upgrade in diet for Resident #72 on 7/9/2025, but was unaware if the ST evaluation had been done. The ADON confirmed there was no documentation to reflect Resident #72 had been discussed in weight risk meetings. The ADON stated the IDT had discussed the resident did not like the puree diet, but was unable to verbalize the IDT plan to address Resident #72's significant weight loss. The ADON stated the IDT meeting notes should be in the medical record and confirmed there were no IDT notes to address Resident #72's significant weight loss in the medical record. The ADON stated Resident #72 was on a mechanical soft diet with CCHO until the diet was changed to puree diet on 6/16/2025. The ADON reviewed Resident #72's weights, stating the resident should have been weighed weekly if she was having significant weight loss. The ADON stated she was unaware why the resident had not been weighed from 7/13/2025 to 7/31/2025. The ADON stated, according to the order in the medical record, the order for weekly weights had been discontinued by the DON on 7/21/2025, with the reason for discontinuation documented as condition resolved. The ADON was unaware why the resident's weights were discontinued. During a telephone interview on 7/31/2025, the Medical Director stated she could not say she was specifically aware of Resident #72's weight loss. The Medical Director stated report of a significant weight loss (5%) would prompt a medical evaluation to establish if something medical was causing the weight loss. When a significant weight loss was identified, the Medical Director expected the RD to implement interventions, protein supplement .what would be appropriate for the resident . Increased weight monitoring should have been implemented at the point Resident #72 exhibited significant weight loss. The Medical Director stated .Some weight loss would be desirable [referring to Resident #72], but not at that rate .I would have expected we would have started Boost sooner . The Medical Director stated she did not recall having a conversation regarding the resident's weekly weights, and did not specifically recall giving the order to discontinue the resident's weekly weights. The resident needed to be re-evaluated, have a conversation by IDT with the resident or resident representative and determine the most reasonable interventions for the resident. The Medical Director stated she relied on the RD to assist with calculating caloric needs or to determine if the resident's diet was sufficient to maintain nutritional status.The fact that she [Resident #72] had weight loss would suggest it [diet and Boost] was not sufficient to maintain nutrition . The Medical Director stated .some weight loss is desirable, but again, not at that rate . The Medical Director was not aware the ordered ST evaluation had not been done and expected physician orders to be followed.During an interview on 7/31/2025 at 6:03 PM, the DON stated she discontinued Resident #72's weekly weights because the resident no longer flagged for significant weight loss. The DON stated weekly weights were discontinued if weights were stable for 4 consecutive weeks. Resident #72's weights were reviewed with the DON, who stated .looking at it now, weekly weights should not have been discontinued [for Resident #72]. I did not take into account, the weight refusal on 7/20/2025 . The DON confirmed Resident #72 should be on weekly weights. The DON confirmed she had not discussed discontinuing the resident's weekly weights with the resident's physician. The DON was unable to verbalize what had been discussed related to Resident #72's weight loss in the IDT meetings and confirmed IDT meeting documentation was not available in Resident #72's medical record. During a 3rd telephone interview on 7/31/2025 at 6:02 PM, the RD stated .When they [nursing staff] told me she [Resident #72] was not eating the pureed diet, I added the Boost . The RD confirmed the resident's significant weight loss occurred prior to initiating the pureed diet (6/16/2025). The RD stated she had spoken with the Director of Therapy about the ST evaluation which had been ordered on 7/9/2025.She was working on getting that [ST evaluation] done .It [ST evaluation] had been done before .I don't think they were going to upgrade the [resident's] diet . The RD confirmed the resident was not on a prescribed weight loss program. The RD confirmed the only interventions implemented to prevent further weight loss for Resident #72 was Boost twice a day (on 7/16/2025-44 days after Resident #72's significant weight loss was identified) and upgrading to a mechanical soft diet (7/30/2025-58 days after Resident #72's significant weight loss was identified on 6/2/2025). The RD confirmed labs to evaluate Resident #72's nutritional status had not been performed since the resident's significant weight loss. When asked what the goal for Resident #72, the RD responded .We were trying to get her diet upgraded so she would eat her meals . The RD confirmed she was aware ST's recommendation was a pureed diet for Resident #72's safety.

Based on facility contract for nutrition services review, facility policy review, medical record review, observation, and interview the facility failed to ensure adequate dietary services were provided to prevent weight loss for 1 resident (Resident #72) of 3 residents reviewed for weight loss. The findings include: Review of a facility document titled, Contract for Nutrition Services, dated 12/1/2023, revealed .Subcontractor Service Duties .provide one or all of the following services .Correlate and integrate the nutritional aspects of client care with other client care services to include directing the following .Reviewing the clients medical record history and assessing the client's nutritional status .Interviewing and counseling clients .Recording client information in the medical record .Assessing, planning, and implementing nutrition care for clients .Developing nutrition care goals .Completing nutrition assessment forms .Work as part of the medical team .Subcontractor Services shall include, but are not limited to .Visit FACILITY on days specified and agreed upon by both parties and assure that the professional dietary clinical needs of FACILITY are met .Complete monthly assessments on residents experiencing significant weight loss .Provide consultation to FACILITY employees regarding diet, nutritional problems and management including patient care plans and case review .Review resident care plans and participate in development of dietary policies .Provide FACILITY monthly written reports which shall be signed and dated and contain a summary of areas reviewed and recommendations .Chart nutritional information in accordance with the policies of FACILITY and accepted professional practice .RECORDS .FACILITY and Subcontractor shall prepare and maintain complete and detailed records concerning Facility's residents receiving Services under this Agreement, in accordance with prudent record-keeping procedures . Review of the facility's policy titled, Weight Assessment/Monitoring, dated 1/2025, revealed .Any weight change of 5% [percent] or more since the last weight assessment will be retaken for confirmation. If the weight is verified, nursing will notify the Dietitian .Negative trends will be evaluated by the treatment team whether or not the criteria for significant weight change has been met .The threshold for significant unplanned and undesired weight loss will be based on the following criteria .1 month - 5% weight loss is significant; greater than 5% is severe .3 month - 7.5% weight loss is significant; greater than 7.5% is severe .6 months - 10% weight loss is significant; greater than 10% is severe .Assessment information shall be analyzed by the multidisciplinary team and conclusions shall be made regarding the .Approximate calorie, protein, and other nutrient needs compared with the resident's current take .Whether and to what extent weight stabilization or improvement can be anticipated .The Physician and the multidisciplinary team will identify conditions and medications that may be causing .weight loss or increasing the risk of weight loss. For example .Cognitive or functional decline .Increased need for calories and/or protein . Review of the medical record revealed Resident #72 was admitted to the facility on [DATE] with diagnoses including Pneumonia, Cerebral Infarction, Diabetes Mellitus, Severe Morbid Obesity, Dementia, Chronic Pain Syndrome, Dysphagia (difficulty or discomfort) in swallowing, Psychosis, and Adjustment Disorder with Anxiety. Review of the comprehensive care plan for Resident #72 dated 1/29/2025, revealed .[Resident #72] is a risk for alterations of nutritional status R/T [related to] DM [Diabetes Mellitus], mechanically altered diet, therapeutic diet . Review of the Physician Orders for Scope of Treatment (POST) form for Resident #72 dated 1/30/2025, revealed the resident desired full treatment including artificial treatment with a feeding tube. Review of the Vitals Report for Resident #72 for 1/30/2025-7/31/2025 revealed the following weights:1/30/2025 - 323.6 pounds (lbs.)2/9/2025 - 315.5 lbs.2/17/2025 - 314.2 lbs.2/25/2025 - 314.2 lbs.3/8/2025 - 312.8 lbs.4/11/2025 - 312.8 lbs.4/15/2025 - 312.6 lbs.5/2/2025 - 312.6 lbs.6/2/2025 - 271.5 lbs. (13.15% weight loss in 1 month)6/4/2025 - 271.5 lbs. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #72 scored an 8 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had moderate cognitive impairment. Further review revealed Resident #72 required set up/clean up assistance with eating. Resident #72 had a weight loss of 5% in the last month or loss of 10% or more in last 6 months and was not on a physician prescribed weight loss regimen. Review of the Registered Dietitian (RD) notes for Resident #72 dated 6/6/2025, revealed .Quarterly Review: Diet: CCHO [Consistent Carbohydrate-diet of managing blood sugar levels], Mechanical soft [diet which is easy to chew and swallow]. Intakes good per nsg [nursing] doc [documentation]. wt [weight] 271.5# [pounds], down from 312.6# x [times] 1 mo [month] .signif [significant] wt loss 13%, likely R/T fluid shifts .Will cont [continue] to monitor and follow as needed, cont POC [plan of care] . No further nutritional interventions were recommended or implemented and there was no documentation of the resident's weight loss being a desired or planned weight loss. Review of the Speech Therapy (ST) notes for Resident #72 dated 6/16/2025, revealed the resident was evaluated by ST due to difficulty taking medications and decreased oral (by mouth) intake. The ST recommended a puree diet for Resident #72. Review of the physician orders for Resident #72 dated 6/16/2025, revealed an order for a CCHO, puree diet (foods are blended or mashed to a smooth, pudding-like consistency and requiring no chewing). Review of the Registered Dietitian (RD) notes for Resident #72 dated 6/18/2025, revealed .RD Review Wt Loss: wt 271.5# 6/4 [6/4/2025], down from 312.6# x 1 mo .signif wt loss 13%. Wt stable since 6/2 [6/2/2025] .Intakes good per nsg doc. Will monitor weekly wts until stabilized. Cont POC. Continued review revealed the RD provided no recommendations to prevent further weight loss for Resident #72. Continued review revealed no documentation of the resident's weight loss being desired or a planned weight loss. Review of the nurse's notes for Resident #72 dated 6/23/2025 at 7:55 PM, revealed Resident #72's meal intake had decreased because the resident did not like the puree diet. Review of the ST SLP (Speech-Language Pathologist) Discharge Summary for Resident #72 dated 6/24/2025, revealed the resident required assistance/support with meals. ST recommended pureed diet and thin liquids as the safest and most appropriate diet for the resident. Resident #72 was discharge from ST services due to maximum potential had been achieved. Further review revealed .Prognosis to Maintain CLOF [continued level of functioning] .Good with consistent staff follow-through . Review of the nurse's notes for Resident #72 dated 6/28/2025 at 1:13 PM, revealed Resident #72 refused to eat pureed food. The resident's food intake had decreased since the pureed diet was ordered. Review of the Vitals Report for Resident #72 for 6/29/2025-7/31/2025 revealed the following weights:6/29/2025 - 273.2 lbs.7/2/2025 - 265.5 lbs. (2.82% weight loss (6/29/2025; 2.21% from 6/2/2025, and 15.07% weight loss from 5/2/2025).7/6/2025 - 265.0 lbs. Review of the nurse's notes for Resident #72 dated 7/8/2025 at 6:13 PM, revealed Resident #72 drank water and other drinks throughout the shift but refused to eat pureed food. The NP was notified of the resident's refusal to eat. Review of the Vitals Report for Resident #72 for 7/6/2025-7/31/2025 revealed the following weights:7/13/2025 - 258.0 lbs. (17.47% weight loss from 5/2/2025-7/13/2025) Review of the RD notes for Resident #72 dated 7/16/2025, (44 days after Resident #72's significant weight loss of 13% had been identified on 6/2/2025), revealed wt 258# 7/13 [7/13/2025], down from 312.6# x 3 mo .signif wt loss 17.5% .Resident refusing to eat pureed diet per nsg doc. ST reports resident was unable to chew mechanical soft diet when evaluated. Will provide Boost glucose control [nutritional drink designed to provide complete, balanced nutrition] BID [twice a day] between meals [ordered 2 months 2 weeks after Resident #72's significant weight loss of 13% had been identified] .Will cont to monitor and follow as needed, cont POC . Review of the physician order for Resident #72 dated 7/16/2025, revealed .Boost diabetic control .BID between meals . (44 days Resident #72's significant weight loss of 13% had been identified on 6/2/2025). Review of the medical record for Resident #72 revealed no further documentation to show the RD had monitored/followed the resident's weight loss and had not made recommendations to prevent further weight loss since 7/16/2025. Review of the nurse's notes for Resident #72 on 7/21/2025 at 2:37 PM, revealed the resident refused to eat her pureed food. The NP was notified of the resident's refusal to eat the pureed diet. Review of the nurse's notes for Resident #72 dated 7/30/2025 at 3:50 PM, revealed the Assistant Director of Nursing (ADON) and NP spoke with Resident #72 and her husband regarding the risks of upgrading the resident's diet to mechanical soft. The resident and resident's husband verbalized understanding and wanted to proceed with an upgraded diet. The resident's diet was upgraded to mechanical soft with chopped meats. Review of the medical record for Resident #72 revealed no further documentation to show the RD had monitored/followed the resident's weight loss and had not made recommendations to prevent further weight loss since 7/16/2025. Review of the medical record revealed no laboratory tests had been performed since Resident #72's significant weight loss was identified on 6/2/2025. During an observation and interview on 7/28/2025 at 1:00 PM, of the lunch meal, revealed Resident #72 ate zero% of the lunch meal. During an observation on 7/29/2025 at 7:45 AM, revealed Resident #72 ate zero % of the breakfast meal. During a telephone interview on 7/29/2025 at 11:09 AM, Resident #72's husband stated the resident had not been eating since her diet was changed to a pureed diet a couple of weeks ago. The resident's husband stated the resident was evaluated by speech who recommended she be on a pureed diet. During a telephone interview on 7/30/2025 at 2:22 PM, the RD stated she had .not recently . observed Resident #72 eating meals. The RD was unable to say when she had last observed the resident eating a meal. The RD stated residents with significant weight loss were discussed weekly with the IDT. The RD was unable to verbalize what the IDT had discussed regarding Resident #72's weight loss and was unable to provide documentation the resident was discussed during the IDT meetings. The RD confirmed Resident #72's current meal intake and Boost twice a day was not sufficient enough to meet or sustain Resident #72's nutritional needs. During a weight observation on 7/31/2025 with a surveyor present revealed the resident weighed 246.8 lbs. (21.05% weight loss from 5/2/2025-7/31/2025 and 23.73% weight loss for past 6 months). (The last recorded weight was on 7/13/2025 of 258 lbs.) During a 2nd telephone interview on 7/30/2025 at 4:42 PM, the RD stated she ordered Boost 2 times per day for Resident #72 and stated the resident should have been on weekly weights. When asked what the IDdT plan was for the resident's weight loss, the RD responded .They upgraded her diet . The RD confirmed she had not recommended ordering laboratory values to check Resident #72's nutritional status. During an interview on 7/31/2025 at 10:30 AM, the DON stated she reviewed resident weights weekly and weights were followed by RD. The RD came to the facility weekly on Wednesdays. The DON stated if a resident was .on their [DON and RD] radar for weight loss . the DON and RD got together and discussed.We are following her [Resident #72] in risk [weekly IDT] . The DON stated the last IDT meeting was .last Wednesday [7/23/2025] .honestly don't remember if she was discussed in IDT last week or not . The DON was unable to verbalize why weekly weights were discontinued for Resident #72 on 7/21/2025, even though the resident continued to lose weight. During an interview on 7/31/2025 at 3:18 PM, the NP stated she had seen Resident #72 because someone had notified her of the resident's weight loss . The NP reviewed Resident #72's weights and confirmed the resident had experienced significant weight loss. The NP reported the RD ordered Boost for the resident on 7/16/2025 (44 days after Resident #72's significant weight loss was identified on 6/2/2025). The NP stated she and the RD had not discussed Resident #72's weight loss until 7/29/2025. The NP confirmed Resident #72 had lost a significant amount of weight.I'm not going to say the word harm, but she probably has lost muscle mass .Obviously, the Boost twice daily wasn't enough to sustain her weight . It was my impression that dietary was following her and putting in interventions . The NP confirmed Resident #72's weight loss was unplanned and significant. The NP confirmed no labs had been ordered to evaluate Resident #72's nutritional status. The NP confirmed the only interventions which addressed Resident #72's significant weight loss were the ST evaluation ordered on 7/9/2025 (which was not completed) and the Boost ordered twice daily on 7/16/2025. During a telephone interview on 7/31/2025, the Medical Director stated she could not say she was specifically aware of Resident #72's weight loss. The Medical Director stated reports of a significant weight loss (5%) would prompt a medical evaluation to establish if something medical was causing the weight loss. When a significant weight loss was identified, the Medical Director expected the RD to implement interventions, protein supplement .what would be appropriate for the resident . Increased weight monitoring should have been implemented at the point Resident #72 exhibited significant weight loss. The Medical Director stated .Some weight loss would be desirable [referring to Resident #72], but not at that rate .I would have expected we would have started Boost sooner . The resident needed to be re-evaluated, have a conversation by IDT with the resident or resident representative and determine the most reasonable interventions for the resident. The Medical Director stated she relied on the RD to assist with calculating caloric needs or to determine if the resident's diet was sufficient to maintain nutritional status.The fact that she [Resident #72] had weight loss would suggest it [diet] was not sufficient to maintain nutrition . The Medical Director stated .some weight loss is desirable, but again, not at that rate . During a 3rd telephone interview on 7/31/2025 at 6:02 PM, the RD stated .When they [nursing staff] told me she [Resident #72] was not eating the pureed diet, I added the Boost . The RD confirmed the resident's significant weight loss occurred prior to initiating the pureed diet on 6/16/2025. The RD stated she had spoken with the Director of Therapy about the ST evaluation which had been ordered on 7/9/2025.She was working on getting that [ST evaluation] done .It [ST evaluation] had been done before .I don't think they were going to upgrade the [resident's] diet . The RD confirmed the resident was not on a prescribed weight loss program. The RD confirmed the only interventions implemented to prevent further weight loss for Resident #72 was Boost twice a day (on 7/16/2025-44 days after Resident #72's significant weight loss was identified) and upgrading to a mechanical soft diet (7/30/2025-58 days after Resident #72's significant weight loss was identified on 6/2/2025). The RD confirmed labs to evaluate Resident #72's nutritional status had not been performed since the resident's significant weight loss. When asked about the goal for Resident #72, the RD responded .We were trying to get her diet upgraded so she would eat her meals . The RD confirmed she was aware ST's recommendation was a pureed diet for Resident #72's safety.

Based on facility policy review, observations, and interviews, the facility failed to ensure garbage and refuse were properly contained and failed to ensure the outside dumpster area was maintained in a sanitary and orderly condition. he findings include: Review of the facility's policy titled, Dispose of Garbage and Refuse, dated 10/2019, revealed .it is the center policy all garbage and refuse will be collected and disposed of in a safe and efficient manner .Director coordinates .to insure [ensure] that the area surrounding the exterior dumpster area is maintained in a manner free of rubbish and other debris .lids are provided for all containers . During an observation of the outside dumpster area on 7/28/2025 at 12:36 PM, with the Certified Dietary Manager (CDM), revealed 4 dumpsters for waste disposal. Further observation revealed there were 2 alternate trash receptables present to the right side of the main dumpster area. Continued observation revealed the 2 alternate trash receptacles had the lids propped open which exposed both trash receptacles' contents to the elements and potential pests. Observation of the area adjacent to dumpster A revealed one broken bedside table, one broken wooden shelf, one broken office desk, and one broken wooden table. Observation of the area adjacent to dumpster D revealed one broken over-the-bed table, multiple broken wooden pallets, and one blue barrel with various pieces of rusted metal, broken wooden planks, and unidentified trash items observed floating in approximately 12 inches of brown, turbid water in the bottom of the blue barrel. During an interview on 7/28/2025 at 12:40 PM, the CDM confirmed the 2 alternate trash receptacles' contents were not properly contained and the outside dumpster area was not maintained in a sanitary or orderly condition.

Based on facility policy review, medical record review, observation, and interview the facility failed to ensure appropriate Personal Protective Equipment (PPE) was worn for 1 resident (Resident #96) of 5 residents reviewed for Enhanced Barrier Precautions (used to reduce the transmission of multidrug-resistant organisms-MDRO).The findings include:Review of the facility's policy titled, Enhanced Barrier Precautions, dated 1/2025, revealed .'Enhanced barrier precautions' (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities .Enhanced barrier precautions will be utilized for residents with .indwelling medical devices .urinary catheters .even if the resident is not known to be infected or colonized with a MDRO .Review of the medical record revealed Resident #96 was admitted to the facility on [DATE] with diagnoses including Congestive Heart Failure, Urinary Tract Infection, and Hypertension.Review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #96 had an indwelling catheter and required moderate to partial assistance with rolling from left to right.Review of the physician orders for Resident #96 revealed an order dated 7/10/2025 for 4% (percent) Lidocaine patch (topical pain reliever) to be applied to the resident's left hamstring (back of thigh) .on for 12 hours off for 12 hours . Continued review revealed an order for EBP related to urinary catheter.During an observation on 7/29/2025 at 8:00 AM, of Resident #96's room door, revealed signage indicating the resident was on EBP. Continued observation revealed PPE was readily available for use.During an observation on 7/29/2025 at 8:04 AM, of Resident #96, revealed the resident had an indwelling urinary catheter.During an observation on 7/29/2025 at 8:22 AM, of medication administration, revealed Licensed Practical Nurse (LPN) D entered Resident #96's room, donned gloves, leaned over the resident and assisted the resident to turn on his right side. Continued observation revealed LPN D's top touched the resident's blanket while assisting with turning the resident. Further observation revealed LPN D's top continued to touch the resident's blanket while LPN D applied a Lidocaine patch to the resident's left hamstring area.During an interview on 7/29/2025 at 8:27 AM, LPN D confirmed Resident #96 was on EBP and confirmed she did not wear appropriate PPE (gown and gloves) while repositioning the resident. LPN D stated she should have worn a gown in addition to gloves while applying Resident #96's Lidocaine patch.During an interview on 7/30/2025 at 7:48 AM, the Director of Nursing (DON) confirmed staff were expected to wear appropriate PPE, including gown and gloves, when providing care and/or repositioning residents on EBP.

Based on observation and interview the facility failed to properly store a nebulizer mask for 1 resident [Resident #72] of 3 residents observed on nebulizer treatments. The findings include:Review of the medical record revealed Resident #72 was admitted to the facility on [DATE] with diagnoses including Pneumonia, Cerebral Infarction, Obstructive Sleep Apnea, and Dementia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #72 scored an 8 on the Brief Interview for Mental Status (BIMS) assessment, which indicated the resident had moderate cognitive impairment. Review of a physician's order dated 1/29/2025, revealed an order for Ipratropium-Albuterol [a medication used to open up the airway] solution for nebulizer. Review of the Medication Administration Record (MAR) dated 7/1/2025 - 7/31/2025, revealed Resident #72 received inhalation treatment on 7/28/2025 during the 7:00 PM-11:00 PM medication administration. During an observation on 7/28/2025 at 11:30 AM, in Resident #72's room revealed the nebulizer mask was laying on the bedside table, uncovered and open to air. During an observation on 7/29/2025 at 7:45 AM, in Resident #72's room revealed the nebulizer mask was laying on the bedside table, uncovered and open to air.During an observation on 7/29/2025 at 2:00 PM, in Resident #72's room revealed the nebulizer mask was laying on the bedside table, uncovered and open to air. During an observation and interview on 7/29/2025 at 3:00 PM, with the Wound Care Nurse, in Resident #72's room, revealed Resident #72's nebulizer mask was laying on the bedside table, uncovered and open to air. The Wound Care Nurse confirmed Resident #72's nebulizer mask was uncovered and should have been stored in a plastic bag.During an interview on 7/29/2025 at 3:05 PM, the Director of Nursing (DON) confirmed nebulizer masks were to be stored in a plastic bag and labeled with the resident's name.

Based on facility policy review, observations, and interview the facility failed to ensure food items were sealed properly, failed to keep cleaning products away from open food containers, failed to ensure cooking equipment was maintained in a sanitary condition, and failed to ensure expired food items were not available for resident use which had the potential to effect 87 of 91 residents. The findings include: Review of the facility policy titled, Food Safety and Foodborne Illness Prevention, dated [DATE], revealed .Facility staff shall inspect all food, food products, and beverages .and ensure timely and proper storage .Dry food storage .in a clean, dry area, off the floor and clear of ceiling sprinkler, sewer/waste disposal pipes and vents .Refrigerated storage .Labeling, dating, and monitoring refrigerated foods, including, but not limited to leftovers, so it is used by its use-by-date, or frozen (where applicable)/discarded .Keeping foods covered or in tight containers . During an observation of the kitchen on [DATE] at 10:35 AM, with the Certified Dietary Manager (CDM) revealed the following food items were not sealed and left open to air: One 28-ounce (oz) bottle of lemon pepper seasoning One 18-oz bottle of paprika One 5-oz bottle of basil leaves One 20-oz bottle of chili powder One 16-oz bottle of celery seed One 20-oz bottle of 17-Seasoning. During an observation on [DATE] at 10:40 AM, with the CDM, revealed on the shelf where the spice containers were stored was an unmarked and unlabeled red bucket which contained a cloth and a semi-clear liquid. The CDM stated the bucket contained sanitizing cleaner solution used for cleaning, and it was supposed to be on the second shelf not the top shelf near the spice containers. During an observation of the clean dish storage area on [DATE] at 10:55 AM, with the CDM, revealed the following: 4 of 4 muffin pans had a copper/brown colored substance on the front and back of each pan. 28 of 28 baking sheet pans had a caked on black substance around the outside edges and brown substance on the front and back of the pans. During an observation of the E-F hall refrigerator on [DATE] at 11:15 AM, with the CDM, revealed 3 sandwiches were stored in the refrigerator with a use by date of [DATE] and available for resident consumption. During an interview on [DATE] at 11:25 AM, the CDM confirmed spice containers were to be fully sealed after each use, the sanitizing cleaner should not have been placed near the spice containers, and the cooking equipment was not maintained in a sanitary condition. The CDM confirmed the sandwiches stored in the E-F hall refigerator were past the use by date of [DATE] and were available for resident consumption. During an interview [DATE] 4:00 PM the Administrator stated the expectation was for the kitchen to be maintained in a sanitary condition, food items be sealed properly, and food items be discarded if expired.

Based on facility policy review, medical record review, observations, and interviews the facility failed to ensure an oxygen tank was stored in a secure location for 1 resident (Resident #38) and failed to obtain an order for oxygen administration for 1 resident (Resident #386) of 3 residents reviewed for oxygen storage and oxygen administration. The findings include: Review of the facility's undated policy titled, Oxygen Safety, revealed, .Handling Oxygen Cylinders . Protect cylinders from damage by not storing .where objects may strike them or fall . Review of the facility policy titled, Oxygen Administration, dated 3/24/2024 revealed, .oxygen is administered under orders of a physician . Medical record review revealed Resident #38 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease and Atherosclerotic Heart Disease. Medical record review of the Physician's Orders for Resident #38 dated 3/25/2024, revealed, .Oxygen 2 L [liters]/ [per] min [minute] via [by] NC [nasal cannula]. May remove for personal hygiene, ADLs [activities of daily living], and/or transport . Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #38 received oxygen therapy at the facility. During an observation on 4/29/2024 at 12:32 PM, in Resident #38's room, revealed Resident #38 was lying in bed resting. Resident #38 received 2 liters oxygen (O2) via nasal cannula that was delivered from an oxygen concentrator. There was a 2000 pound per square inch (psi) O2 tank that was approximately 3/4 full leaning against the wall of the resident's room unsecured and not in use. During an observation on 4/30/2024 at 7:59 AM, in Resident #38's room, revealed Resident #38 was lying in bed resting. Resident #38 received 2 liters O2 via nasal cannula that was delivered from an oxygen concentrator. There was a 2000 pound per square inch (psi) O2 tank that was approximately 3/4 full leaning against the wall of the resident's room unsecured and was not in use. During an observation on 4/30/2024 at 11:00 AM, in Resident #38's room, revealed Resident #38 was lying in bed resting. Resident #38 received 2 liters O2 via nasal cannula that was delivered from an oxygen concentrator. There was a 2000 pound per square inch (psi) O2 tank that was approximately 3/4 full leaning against the wall of the resident's room unsecured and was not in use. During an interview on 5/1/2024 at 5:15 PM, the Director of Nursing (DON) stated her expectation was for oxygen tanks to be stored in a secured location and not in a resident's room without a secured canister. 49568 Medical record review revealed Resident #386 was admitted to the facility on [DATE] with diagnoses including Pneumonia, Major Depressive Disorder, and Chronic Kidney Disease. Medical record review of a comprehensive care plan dated 4/24/2024, revealed Resident #386 had .Respiratory/Pulmonary .has altered respiratory status/difficulty breathing related to utilizes O2, acute respiratory failure .Administer oxygen as ordered . Medical record review of a current Physician's Order dated 4/2024, revealed Resident #386 did not have an order for use (or administration) of Oxygen. During an observation and interview on 4/29/2024 at 11:00 AM, in the resident's room, Resident #386 was lying in bed with eyes closed and oxygen was infusing at 2 liters per minute (LPM). Resident #386 stated she had been using oxygen since admission to facility. During an observation on 4/30/2024 at 7:20 AM, Resident #386 was lying in bed with oxygen infusing at 2 LPM via nasal cannula. During an observation on 5/1/2024 at 8:15 AM, Resident #386 was lying in bed with oxygen infusing at 2 LPM via nasal cannula. During an observation and interview on 5/1/2024 at 10:40 AM, in Resident #386's room, the Assistant Director of Nursing (ADON) confirmed Resident #386 had oxygen infusing at 2 LPM via nasal cannula. The ADON confirmed Resident #386 did not have a physician's order for oxygen administration and it was her expectation anyone receiving oxygen had a physican's order.

Based on facility policy review, medical record review and interviews, the facility failed to develop a comprehenisve care plan to address hospice services for 1 resident (Resident # 16) and failed to involve the resident and/or resident representative in the care planning process for 1 resident (Resident #72) of 27 residents reviewed for care plans. The findings include: Review of the facility policy titled, Comprehensive Care Plans, revised 2/2024, revealed .The comprehensive care plan will be prepared by an interdisciplinary team, that includes, but is not limited to .Family members .others desired by the resident .The comprehensive care plan will be .revised by the interdisciplinary team . Medical record review revealed Resident #16 was admitted to the facility on [DATE] with diagnoses including Dementia, Muscle Weakness, Chronic Kidney Disease, Myocardial Infarction, Congestive Heart Failure, and Cerebrovascular Accident. Medical record review of a Physician's Order for Resident #16 dated 12/19/2023, revealed .Hospice . Medical record review of the comprehensive care plan for Resident #16 revealed a care plan had not been developed to reflect hospice services. During an interview on 5/1/2024 at 5:15 PM, Minimum Data Set (MDS) Coordinator A stated Resident #16 received hospice services and confirmed a comprehensive care plan had not been developed to reflect hospice services. 50216 Medical record review revealed Resident #72 was admitted to the facility on [DATE] with diagnoses including Diabetes and Vascular Dementia. Review of an admission MDS assessment dated [DATE], revealed Resident #72 scored a 1 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment. During an interview on 4/30/2024 at 10:27 AM, Resident #72's resident representative stated they had not been invited or participated in an initial care plan conference. During an interview on 5/1/2024 at 1:00 PM, the Social Service Assistant and Regional Licensed Social Worker (RLSW) stated residents and resident representatives were invited to the care planning conference. The RLSW stated the facility did not have any documentation to verify Resident #72 or the resident's representative had been invited or attended the initial care conference.

Based on facility policy review, review of Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual, medical record review, and interviews, the facility failed to accurately complete a [NAME] Data Set (MDS) assessment for 3 residents (Resident #16, #8, and #20) of 27 residents reviewed. The findings include: Review of the facility policy titled, RAI Assessment - MDS 3.0 Completion, dated 3/23/2022, revealed, .Residents are assessed, using a comprehensive assessment process, in order to identify care needs .According to federal regulations, the facility conducts .a comprehensive, accurate and standardized assessment of each resident's functional capacity, using the RAI specified by the State . Review of the Centers for Medicare & Medicaid Services Long-Term Care Facility RAI 3.0 User's Manual dated 10/2023, revealed, .Code .renal dialysis which occurs at the nursing home or at another facility .Code residents identified as being in a hospice program for terminally ill persons where .services is provided for .terminal illnesses . Medical record review revealed Resident #16 was admitted to the facility on [DATE] with diagnoses including Dementia, Muscle Weakness, Chronic Kidney Disease, Myocardial Infarction, Congestive Heart Failure, and Cerebrovascular Accident. Review of a quarterly MDS assessment dated [DATE], revealed Resident #16 scored an 11 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had moderate cognitive impairment and the resident did not receive hospice services. Medical record review of a Physician's Order for Resident #16 dated 12/19/2023, revealed .Hospice . Review of a hospice note for Resident #16 dated 4/24/2024, revealed .[named hospice company] .Plan of Care .Diagnosis .CVA [stroke] . During an interview on 5/1/2024 at 5:15 PM, MDS Coordinator A stated Resident #16 received hospice services and confirmed the MDS assessment dated [DATE] was inaccurate. 49568 Medical record review revealed Resident #8 was admitted to the facility on [DATE] with diagnoses including Diabetes, End Stage Renal Disease, and Dependence on Renal Dialysis. Review of a quarterly MDS assessment dated [DATE], revealed Resident #8 scored a 10 on the BIMS assessment which indicated the resident had moderative cognitive impairment. Continued review revealed Dialysis was documented on Resident #8's MDS assessment. Medical record review of a comprehensive care plan dated 3/6/2024, revealed Resident #8 .has renal failure Stage 5 chronic kidney disease and requires Dialysis 3 times a week . During an interview on 4/29/2024 at 11:30 AM, Resident #8 stated he received dialysis three times weekly. During an interview on 5/1/2024 at 4:10 PM, MDS Coordinator A confirmed Resident #8 received dialysis and the quarterly MDS assessment dated [DATE] was inaccurate. 41782 Medical record review revealed Resident #20 was admitted to the facility on [DATE] with diagnoses including Diabetes, Asthma, Morbid Obesity, Sleep Apnea, Atrial Fibrillation, and Chronic Kidney Disease. Medical record review of a Physician's Order for Resident #20 dated 11/30/2022, revealed .Hospice . Continued review revealed the hospice order was discontinued on 7/13/2023 .Reason .Condition resolved . Review of a quarterly MDS assessment dated [DATE], revealed Resident #20 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact and received hospice care. During an interview on 5/1/2024 at 10:10 AM, Resident #20 stated she was receiving hospice, but it was discontinued .6 months to a year ago .because they said I wasn't dying . During an interview on 5/1/2024 at 10:13 AM, the Director of Nursing (DON) confirmed Resident #20's hospice services was discontinued on 7/13/2023 and the quarterly MDS dated [DATE] was inaccurate. During an interview on 5/1/2024 at 10:18 AM, MDS Coordinator A confirmed Resident #20 no longer received hospice services and the quarterly MDS assessment dated [DATE] was inaccurate.

Based on facility policy review, medical record review, observations, and interviews, the facility failed to follow a physician's order for 1 resident (Resident #59) related to tube feeding and water flush rates of 3 residents reviewed for tube feeding. The findings include: Review of the facility policy titled, Care and Treatment of Feeding Tube, dated 5/31/2023, revealed .it is the policy of this facility to utilize feeding tubes in accordance with current clinical standards of practice .to prevent complications .feeding tubes will be utilized according to physician orders .periodic evaluation of the amount of feeding being administered for consistency with practitioner's orders . Medical record review revealed Resident #59 was admitted to the facility on [DATE] with diagnoses including Cerebral Palsy, Epilepsy, and Autistic Disorder. Medical record review of the Physician's Order for Resident #59 dated 5/3/2023, revealed .Enteral Feeding [medical device/tube used to provide nutrition to people who cannot obtain nutrition by mouth] .Administer .Jevity 1.2 .at Rate 45ml [milliliters]/hr [hour] for 22hrs [hours]/day . Medical record review of a comprehensive care plan dated 5/30/2023, revealed Resident #59 .has . peg tube [percutaneous endoscopic gastrostomy- a tube surgically placed in the abdomen for feeding] . Medical record review of the Physician's Order for Resident #59 dated 7/20/2023, revealed .Hydration .Provide 25/ml/hour via [by] PEG tube . Medical record review of the Registered Dietician's note for Resident #59 dated 4/17/2024, revealed .currently receiving Jevity 1.2 @ [at] 45 ml/hour x 22 hours per day with a 25 ml water flush every hour . During an observation on 4/30/2024 at 9:40 AM, Resident #59 was observed lying in the bed with Jevity 1.2 infusing at 60ml/hr and a water flush was infusing at 45ml/hr via peg tube. During an observation and interview on 5/1/2024 at 8:22 AM, in Resident #59's room, Registered Nurse (RN) A confirmed Jevity 1.2 was infusing at 60ml/hr with water flush infusing at 45ml/hr. RN A confirmed the physician's order was for Jevity 1.2 at 45 ml/hr with a water flush at 25 ml/hr. RN A stated she worked on 4/28/2024 and the tube feeding was infusing at the correct rate of 45 ml/hr with a water flush at 25 ml/hr. During an interview on 5/1/2024 at 10:18 AM, Nurse Pracitioner A stated Resident #59's Jevity 1.2 infusing at a rate of 60ml/hr and a water flush infusing at a rate of 45 ml/hr for a short time did not cause the resident any complications. During an interview on 5/1/2024 at 5:15 PM, the Director of Nursing confirmed the facility failed to follow Physician Orders related to tube feeding and water flush rates for Resident #59.

Based on facility policy review, medical record review, observation, and interview, the facility failed to maintain resident's dignity during meal assistance for 1 resident (Resident #5) of 4 residents observed for meals. The findings include: Review of the facility policy titled, Resident Rights, dated 3/22/2022, revealed, .The resident has a right to be treated with respect and dignity . Medical record review revealed Resident #5 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Traumatic Brain Injury, Hemiplegia Affecting Right Dominant Side, Cognitive Communication Deficit, Muscle Wasting and Atrophy, and Altered Mental Status. Medical record review of a comprehensive care plan dated 5/17/2023, revealed Resident #5 had .ADL [Activities of Daily Living] self-care performance deficit r/t [related to] Hemiplegia, TBI [Traumatic Brain Injury], contractures, impaired mobility, cognitive deficit .EATING: The resident requires extensive assist from staff to eat . Medical record review of the physician's orders for Resident #5 dated 3/7/2024, revealed, .Dietary .Regular, Nectar [a liquid that is slightly thicker than water], Puree [modified food that has been ground to a pudding like consistency] . Medical record review of the physician's orders for Resident #5 dated 3/19/2024, revealed, .Assist with meals/meal supervision . Review of a significant change Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #5 had severe cognitive impairment, impaired range of motion to the bilateral upper and lower extremities, and was dependent on staff for eating. During an observation in Resident #5's room on 4/30/2024 at 7:55 AM, Resident #5 was being fed the breakfast meal by Certified Nursing Assistant (CNA) B. CNA B stood over the resident, beside the bed, to feed Resident #5 the breakfast meal. CNA B removed the bedside table from the resident's reach and exited the room to obtain additional silverware. During an interview outside Resident #5's room on 4/30/2024 at 7:58 AM, CNA B stated staff that fed residents were to be seated in a chair beside the resident's bed to maintain positioning at the resident's eye level. CNA B confirmed she was not seated at the resident's eye leveal and further stated she should have been seated in a chair next to Resident #5's bed while feeding the resident. CNA B returned to Resident #5's room after the interview to continue assisting Resident #5 with the breakfast meal. During a second observation in Resident #5's room on 4/30/2024 at 8:02 AM, CNA B fed the resident oatmeal. CNA B continued to stand over the resident, beside the bed, while feeding the resident. During an interview on 4/30/2024 at 10:00 AM, the Director of Nursing confirmed it was her expectation that staff were seated and at eye level with the resident during feeding to maintain the resident's dignity.

Based on facility policy review, observation, and interview, the facility failed to ensure expired medications were not available for resident use in 1of 4 medication carts observed. The findings include: Review of the facility's policy titled, Destruction of Unused Drugs, revised 4/24/2024, revealed .all .expired drugs shall be disposed of . During an observation and interview of the unit 2 hall medication cart on 4/30/2024 at 8:40 AM, with Licensed Practical Nurse (LPN) A, revealed 1 box of Ferrous Gluconate (medication used to treat iron deficiency anemia) 324 mg (milligram) which contained 87 tablets with an expiration date of 1/2024. LPN A confirmed the medication was expired and was available for resident use. During an interview on 5/1/2024 at 5:15 PM, the Director of Nursing (DON) confirmed expired medications were to be removed from the medication cart and discarded.

Based on review of facility policy, medical record review and interview, the facility failed to provide pressure ulcer care in accordance with the care plan for 1 resident (Resident #1) of 3 residents reviewed for pressure ulcers. The facility failure resulted in missed treatments of a stage 2 sacral pressure ulcer for 5 days, 6/2/2023-6/7/2023. The findings included: Review of the facility policy Pressure Injury Prevention and Management, revised 8/30/2022, showed .the facility shall establish and utilize a systematic approach for pressure injury prevention and management .including prompt assessment and treatment .Licensed Nurses will conduct pressure injury risk assessment .upon admission/readmission .or whenever the resident's condition changes .findings will be documented in the medical record .staging of pressure injuries will be clearly identified . Resident #1 was admitted to the nursing home under Medicare Hospice Services for 10 days of respite care on 5/31/23 with diagnoses including End Stage Hypertensive Heart, Chronic Kidney Disease, Ischemic Heart Disease, Congestive Heart Failure, Encounter for Palliative Care, Squamous Cell Carcinoma of Multiple Skin Sites, and Polycythemia Vera (a rare blood disorder which causes increased levels of all blood cell types which causes the blood to thicken, often associated with widespread tissue and organ damage, heart attacks, strokes, and is frequently related to pre-existing chronic renal disease states or some cancerous tumors). Review of the Discharge MDS, dated [DATE], showed Resident #1 had moderately cognitive impairment with a brief interview of mental status (BIMS) score of 9 out of 15, was incontinent of urine and stool, had limited mobility, and required assistance of one or two persons for activities of daily living (ADLs) Review of the Initial Nursing Evaluation, dated 5/31/2023, showed Resident #1 was admitted to the facility with a pre-existing pressure ulcer stage 2 of the sacrum and vascular ulcers to the right foot. Review of the Initial Weekly Skin Assessment, dated 6/1/2023, showed the facility wound nurse Licensed Practical Nurse (LPN) #1 documented the presence of vascular ulcers on Resident #1's right foot and the care provided them, but did not document the presence of the sacral pressure ulcer or care provided to treat the sacral ulcer. Review of the Care Plan, dated 6/1/2023, showed Resident #1 was considered at risk for skin breakdown, was noted to have a sacral pressure ulcer present on admission, with orders to apply moisture barrier cream (A zinc-based cream or ointment used to reduce tissue maceration and skin breakdown) to the perineum, boney prominences and areas of skin breakdown with incontinence care and as needed (PRN). Review of the Physician Orders Summary showed no orders for the use of barrier creams or ointments were documented or transcribed to the corresponding Treatment Administration Records (TAR) or medication administration records (MAR) despite inclusion of the intervention on the care plan. Review of corresponding ADLs documentation and narrative nursing notes made no references to use of barrier ointments to treat Resident #1's sacral pressure ulcer or it's status. Review of Physician Verbal Orders and the corresponding entry on the TAR, dated 6/1/2023, showed wound care orders for Resident #1's sacral pressure ulcer as follows: .wound on coccyx (includes sacral area) .clean wound with N/S (normal saline) pat dry, apply Hydrofera Blue (a silicone impregnated antimicrobial dressing) cover with .dressing .change PRN (as needed) . Continued review showed the TAR entry dated 6/1/2023, was left empty. Continued review of the narrative nursing notes and TAR entries, dated between 6/2/2023 and 6/7/2023, showed no references or evidence to Resident #1's sacral ulcer nor treatments administered. The TAR was updated on 6/8/2023 with corresponding Physician orders to increase the frequency of sacral ulcer dressing changes to three times weekly on Mondays, Wednesdays and Fridays. Continued review of the TAR showed a dressing change was performed on Friday 6/9/2023, in accordance with the new orders and care plan. During an interview with LPN #1, the facility wound care nurse, on 9/27/2023 at 2:45 PM, the LPN reported on 6/1/2023 she assessed Resident #1's sacral wound and wrote the corresponding orders on the TAR. LPN #1 acknowledged she did not document the treatment as completed on the TAR in accordance with facility policy and confirmed she had failed to document all pertinent clinical findings related to the sacral pressure ulcer on the Initial Skin Assessment or in narrative nursing notes as required by facility policy and could not offer any proof the care was provided, in accordance with the physician orders. During an interview with the Director of Nursing (DON) on 9/28/2023 at 1:08 PM, the DON confirmed the facility did not document care of Resident #1's sacral pressure ulcer, in accordance with physician orders and the care plan from 6/2/2023-6/7/2023. The DON confirmed the facility medical records showed no evidence the barrier cream care planned intervention, dated 5/31/2023, had been performed and confirmed there was no evidence in the medical record the use of barrier ointments for Resident #1 had been ordered by the Physician or Nurse Practitioner.

Based on review of facility policies, medical record review and interview, the facility failed to document pre-existing pressure ulcers on the Resident Assessment Instrument (RAI) and Weekly Skin Assessments for 1 resident (Resident #1) of 3 residents reviewed for pressure ulcers. The facility's failure resulted in inaccurate documentation of pressure ulcer status in the medical record/Minimum Data Set (MDS) for Resident #1. The findings included: Review of the facility Policy Wound Care Pressure Injuries Overview, revised 3/24/2022, showed .Staging pressure injuries for purposes of the MDS Assessments will reference current definitions in the Resident Assessment Instrument User's Manual . Review of the facility policy Pressure Injury Prevention and Management, revised 8/30/2022, showed .the facility shall establish and utilize a systematic approach for pressure injury prevention and management .including prompt assessment and treatment .Licensed Nurses will conduct pressure injury risk assessment .upon admission/readmission .or whenever the resident's condition changes .findings will be documented in the medical record .staging of pressure injuries will be clearly identified to ensure correct coding on the MDS . Resident #1 was admitted to the nursing home under Medicare Hospice Services for 10 days of Respite Care on 5/31/23, with diagnoses including End Stage Hypertensive Heart Disease, Chronic Kidney Disease, Ischemic Heart Disease, Congestive Heart Failure, Encounter for Palliative Care, Squamous Cell Carcinoma of Multiple Skin Sites and Polycythemia Vera (a rare blood disorder which causes increased levels of all blood cell types which causes the blood to thicken, often associated with widespread tissue and organ damage, heart attacks, strokes, and is frequently related to pre-existing chronic renal disease states or some cancerous tumors). Review of the Discharge MDS, dated [DATE], showed Resident #1 had moderate cognitive impairment, with a brief interview of mental status (BIMS) score of 9 out of 15, was incontinent of urine and stool, had limited mobility and required assistance of one or two persons for activities of daily living (ADLs). Review of the Initial Nursing Evaluation, dated 5/31/2023, showed Resident #1 was admitted to the facility with a pre-existing pressure ulcer, stage 2 of the sacrum and vascular ulcers of the right foot. Review of the Initial Weekly Skin Assessment, dated 6/1/2023, showed the facility's wound nurse, Licensed Practical Nurse (LPN) #1 documented vascular ulcers on Resident #1's right foot and the care provided for them, but did not document the presence of the sacral pressure ulcer or the care ordered to treat the ulcer. Review of Resident #1's Care Plan, dated 6/1/2023, showed the resident was considered at risk for skin breakdown, noted a sacral pressure ulcer present on admission, and multiple interventions were developed to prevent or treat pressure ulcers. Review of the Treatment Administration Records and Corresponding Physician Orders, dated 6/1/23 to 6/11/2023, showed Resident #1 had treatments ordered for the stage 2 pressure ulcer of the sacrum. Review of the Discharge Minimum Data Set, dated dated [DATE] (look back period 6/4/23 to 6/11/2023) showed section M (Skin Conditions) Questions M100 and M210 marked as 0 (no pressure ulcers). Review of hospital records, dated 6/11/2023, showed Resident #1 presented to a local hospital emergency room , approximately 2 hours after discharge from the nursing home, for evaluation of deconditioning, difficulty speaking and weakness. Review of the emergency room Physician Assessment showed Resident #1 with a superficial, noninfected, stage 2 pressure ulcer of the sacrum. During interview with the Director of Nursing (DON) on 9/28/2023 at 1:08 PM, in the conference room, the DON confirmed the facility had failed to properly document Resident #1's sacral ulcer on the Initial Skin Assessment performed 6/1/2023 and as a result the discharge MDS failed to capture and document Resident #1's sacral pressure ulcer in violation of facility policies.

Based on medical record review, review of a facility investigation, review of facility policy, and interview, the facility failed to check skin integrity after the application of an ace bandage resulting in the development of Stage II and Stage III pressure ulcers (Harm) for one resident (#5) of three residents reviewed. The findings included: Resident #5 was admitted to the facility on [DATE], and readmitted [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Patient Nursing Evaluation dated December 26, 2012, revealed "...Braden Scale for Predicting Pressure Sore Risk...At Risk...Mobility...very limited..." Medical record review of the annual Minimum Data Set (MDS) dated [DATE], revealed the resident was cognitively intact, required extensive assistance with all Activities of Daily Living (ADL's), and no skin conditions or pressure ulcers. Medical record review of the Care Plan dated January 14, 2013, revealed the resident had impaired breathing problems, potential for dehydration, impaired physical mobility, potential for impaired skin integrity, self care deficit, and potential for falls. Medical record review of a Resident Weekly Skin Check Sheet dated March 1, 2013, revealed "...no open areas to note..." Medical record review of a Post Fall Evaluation dated March 5, 2013, revealed "...slid out of chair..." Medical record review of a Nurse's Note dated March 5, 2013, revealed "...No fx (fracture) or dislocation..." Medical record review of a Condition Change Form dated March 7, 2013, revealed "...C/O (complain) r (right) ankle pain s/p (status [REDACTED]. Medical record review of a Physician's Telephone order dated March 7, 2013, revealed "...R (right) ankle pain...diffic (difficulty) with bed mob (mobility) and T/f's (transfers)...PT to evaluate and treat for pain on R ankle..." Medical record review of a Physical Therapy Evaluation dated March 7, 2013, revealed "...Pt (patient) referred to PT...R ankle pain/swelling s/p fall...hx (history)[MEDICAL CONDITION] R [MEDICAL CONDITION] swelling on R ankle lateral aspect pain to palpation over anterior area of lat (lateral) maleoli (protrusion of ankle)...bruised area noted below r lat maleoli..." Medical record review of a Resident Weekly Skin Check Sheet dated March 8, 2013, revealed "...dark discoloration bilateral lower extremities skin dry and flaky lotion applied..." Medical record review of a Nurse's Note dated March 8, 2013, revealed alert and oriented...OOB (out of bed) daily in w/c (wheelchair)..." Medical record review of a Daily Interaction Form dated March 8, 2013, revealed the resident was treated by PT from 1:54 p.m. through 2:55 p.m. Medical record review of a Nurse's Note dated March 11, 2013, revealed "...received BNP (blood test to detect heart failure) (changed) from 3/8/13...new orders received send to (hospital) to eval (evaluate) and tx (treat)..." Medical record review of a hospital History and Physical dated March 11, 2013, revealed "...patient had a recent fall...from a wheelchair for which...complained of leg pain and on my examination of the patient in regards to...leg pain...large indurated area on the medial aspect of...right foot with a yellow flocculent (shreds of mucus)-looking strip of skin running along the instep to...heel...other large pale areas with red borders...family unaware of the changes to...right foot...Physical Examination...flaccid right lower extremity...multiple ulcerative [MEDICAL CONDITION] on...right foot particularly along the lateral instep border and the anterior shin above at the ankle joint...Impression...foot ulcer unclear etiology but appears to be very painful and relatively new to the patient...general surgeon to evaluate ulcer to give further advice on management...foot ulcer appears to be stage II to III...cellulitic event...patient is high risk for further decompensation given...advanced age...foot ulcer...unclear etiology..." Medical record review of a Rehab (rehabilitation) Addendum Note dated March 20, 2013, revealed "...Asked by nurse about applying ace bandage on R ankle. Told nurse this PT would do it on next visit which was 3/8/13. This PT applied ace bandage on R ankle..." Medical record review of a Physical Therapy Discharge Summary dated March 20, 2013, revealed "...Facility D/C (discharge) date 3/11/12...applied ace bandage on R ankle to provide support when t/f..." Medical record review revealed no physician order for [REDACTED]. Medical record review of the hospital Discharge Orders dated March 21, 2013, revealed "...Discharge [DIAGNOSES REDACTED]. Medical record review of a hospital Discharge Summary dated March 21, 2013, revealed "...Stage 2 decubitus right foot-present on admission...Stage 3 decubitus right heel-present on admission...had an ace wrap...upon admission...had a large area of nonblanching pale skin over the dorsum of the right foot and over the next several days the skin sloughed and now...has a stage 2 wound covering the dorsum of most of the foot...stage 3 decubitus of the right heel present on admission which progressed during hospitalization to hard eschar (slough) over the proximal part of the decubitus but remaining boggy toward the mid foot...may require surgical debridement...wound care assistant thinks with care the dorsal right foot decubitus will heal...doubts about the right heel..." Medical record review of a Patient Nursing Evaluation (on readmission) dated March 21, 2013, revealed "...Braden Scale for Predicting Pressure Sore Risk...High Risk...Skin Inspection...Pressure Ulcer Location R heel...Activity...Bedfast..." Medical record review of a Weekly Pressure Ulcer Report dated March 21, 2013, first observation revealed "...location top of foot...Unstageable/Deep Tissue Injury (DTI)...size 6 cm (centimeter) x 7.5 cm...obscured by necrosis...no granulation tissue present...right heel...Unstageable/DTI...size 15.5 cm x 9 cm...obscured by necrosis...White/Grey non-viable tissue...no granulation tissue present...right lateral ankle...Unstageable/DTI...size 1.5 cm x 2 cm...obscured by necrosis...no granulation tissue present...right lateral foot...Stage I 2.5 cm x 1.5 cm...non-blanchable...partial thickness wound..." Review of facility policy, Ace Bandage Application, dated September 26, 2013, revealed "...observe bandage frequently for wrinkles and uneven pressure...at least every 8 hours or as ordered remove the bandage by rolling smoothly over the skin and check circulation...Documentation Guidelines...date, time, and reason for application...circulation, [MEDICAL CONDITION], pulse and temperature...date and time of physician notification, physician orders..." Interview with Licensed Practical Nurse (LPN) #1 on December 9, 2013, at 2:25 p.m., at the Nurse's Station revealed the nurse had taken care of the resident on March 8 and 10, 2013, and was aware of the ace bandage on the right lower extremity. Continued interview revealed the nurse was unaware of who was responsible for the application or monitoring of the ace bandage. Further interview confirmed the LPN did not monitor, remove, and/or complete a skin assessment of the right lower extremity on March 8 and 10, 2013. Interview with Physical Therapist (PT) #1 on December 9, 2013, at 2:45 p.m., in the PT office revealed the PT had applied the ace bandage to the residents RLE to alleviate pain on March 8, 2013, no therapy was performed on March 9-11, and the resident was transferred to the hospital on March 11, 2013. Continued interview confirmed the PT had failed to obtain a physician's order, observe the bandage after application and document the date, time, reason for the application, circulation, [MEDICAL CONDITION], pulse, temperature. Interview with LPN #2 on December 9, 2013, at 4:30 p.m., by telephone revealed the LPN had been the resident's nurse on March 8, 2013. Continued interview revealed a skin assessment was completed on March 8, 2013, (no time documented), and no alteration in skin integrity was documented. Further interview revealed the nurse had no knowledge of the ace bandage. Interview with the Therapy Program Director on December 9, 2013, at 5:40 p.m., in the conference room revealed when the PT staff applied ace bandages they are to obtain a physician's order, check the skin integrity every 15-30 minutes, and then every hour when first applied. Interview with the Director of Nursing on December 9, 2013, at 6:15 p.m., in the conference room revealed the facility had failed to obtain a physician's order for an ace bandage applied to the resident with swelling to the right lower extremity. The ace bandage was applied on March 8, 2013, sometime between 1:54 p.m. and 2:55 p.m., by PT #1, the resident was transferred to the hospital on March 11, 2013, at 11:00 a.m. (three days later). Continued interview confirmed the facility had failed to assess the resident's right lower extremity for adverse effects of the ace bandage since application. The hospital removed the ace bandage on arrival to the hospital on March 11, 2013, and the resident had developed a Stage II and Stage III decubitus ulcer to the right foot, heel, and right lateral aspect of the foot. Further interview confirmed the facility had failed to assess the resident's ankle after the application of an ace bandage for three days and the resident developed a Stage II and Stage III decubitus ulcers (Harm) to the right foot. C/O #

Based on medical record review, review of facility policy, and interview, the facility failed to notify the physician of the application of an ace bandage resulting in the development of pressure ulcers (Harm) for one resident (#5) of three residents reviewed. The findings included: Resident #5 was admitted [DATE], and readmitted [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Condition Change Form dated March 7, 2013, revealed " ...C/O (complain) r (right) ankle pain s/p (status [REDACTED]. Medical record review of a Physician's Telephone order dated March 7, 2013, revealed "...R ankle pain...diffic (difficult) with bed mob (mobility) and T/f's (transfers)...PT to evaluate and treat for pain on R ankle..." Medical record review of a Physical Therapy Evaluation dated March 7, 2013, revealed "...Pt (patient) referred to PT...R ankle pain/swelling s/p fall...hx (history)[MEDICAL CONDITION] R [MEDICAL CONDITION] swelling on R ankle lateral aspect pain to palpation over anterior area of lat (lateral) maleoli (protrusion of ankle)...bruised area noted below r lat maleoli..." Medical record review of a Rehab (rehabilitation) Addendum Note dated March 20, 2013, revealed "...Asked by nurse about applying ace bandage on R ankle. Told nurse this PT would do it on next visit which was 3/8/13. This PT applied ace bandage on R ankle..." Medical record review of a Physical Therapy Discharge Summary dated March 20, 2013, revealed "...Facility D/C (discharge) date 3/11/12...applied ace bandage on R ankle to provide support when t/f (transfer)..." Medical record review revealed no physician order for [REDACTED]. Review of facility policy, Ace Bandage Application, dated September 26, 2013, revealed "...date and time of physician notification, physician orders..." Interview with Physical Therapist (PT) #1 on December 9, 2013, at 2:45 p.m., in the PT office revealed the PT had applied the ace bandage to the residents RLE (right lower extremity) to alleviate pain on March 8, 2013. Continued interview confirmed the PT had failed to obtain a physician's order to apply the ace bandage. Interview with the Therapy Program Director on December 9, 2013, at 5:40 p.m., in the conference room revealed when the PT staff applied ace bandages they are to obtain a physician's order. Interview with the Director of Nursing on December 9, 2013, at 6:15 p.m., in the conference room revealed the facility had failed to obtain a physician's order for the application of an ace bandage to the resident's RLE resulting in Stage II and Stage III pressure ulcers to the RLE (Harm). C/O #