Every finding on record at Riverwalk Post Acute

Based on observation, interview and record review, the facility failed to maintain a clean, and sanitary environment for resident use for three of four communal shower rooms (shower rooms [ROOM NUMBER]).This failure had the potential to result in cross-contamination, increasing the spread of infection to vulnerable population of residents in the facility.Findings:On July 21, 2026, at 12:40 p.m., Resident 2 was observed sitting in her bed, awake and alert. In a concurrent interview with Resident 2, she stated she just finished her shower. She stated the shower room was dirty and needs to be cleaned. She stated somebody needs to clean the shower room after each use.On July 21, 2026, at 12:50 p.m., during an inspection of the shower rooms with the Assistant Director of Staff Development (ADSD), the following were observed:- shower room [ROOM NUMBER]: used gloves on the shower floor;- shower room [ROOM NUMBER]: used towels on the shower floor; and- shower room [ROOM NUMBER] (Bariatric shower room): a trash can without a plastic liner with used gloves hanging on the rim of the trash can, one large trash barrel without a cover with used gloves hanging on the rim of the barrel, a large rectangular container for soiled linens without a cover containing soiled linens not in plastic bag, and a piece of gauze on the floor of the shower stall.A sign was posted on the wall of shower room [ROOM NUMBER] which indicated, .PLEASE LEAVE SHOWER FLOOR CLEAN WHEN YOU LEAVE.NO LINEN.NO FECES.NO DIRTY DIAPERS.In a concurrent interview with the ADSD, she stated the housekeepers were assigned to clean the shower rooms everyday but the Certified Nursing Assistants (CNAs) were expected to keep the shower rooms clean after each use.On July 21, 2026, at 1:03 p.m., Resident 3 was observed lying in bed awake and alert. She stated the shower room was not clean. Resident 3 stated sometimes the shower room had feces.On July 21, 2026, at 1:35 p.m., CNA 1 was interviewed. She stated the CNAs should clean up the shower room after each use. She stated the CNA should pick up wound dressings and soiled linens should be in a plastic bag and placed in the soiled linen container provided in the shower room. She also stated the CNA should clean up if there were feces on the shower floor and call the housekeeper to disinfect the shower room. She stated the CNAs were expected to keep the shower rooms clean with no linen or trash on the floor.On July 21, 2026, at 2:12 p.m., CNA 2 was interviewed. She stated the shower rooms should be kept clean and sanitary. She stated the soiled linens should be in a plastic bag and placed in a covered soiled linen container. She stated large trash cans should have a cover, there should be no trash on the shower floor, and used gloves should be in the trash can and not hanging on the rim.Resident 2's record was reviewed. Resident 2 was admitted to the facility on [DATE], with diagnoses which included shortness of breath.Resident 3's record was reviewed. Resident 3 was admitted to the facility on [DATE], with diagnoses which included diabetes (high blood sugar).On July 21, 2026, at 3:29 p.m., the housekeeper was interviewed. She stated she would perform her first cleaning of the shower rooms at 9 a.m. She stated at around 2 p.m., she would clean and disinfect the shower rooms. The housekeeper stated CNAs were expected to clean up feces on the floor and call her to disinfect. She stated CNAs were to pick up trash on the floor and all soiled linens should be in a plastic bag and placed in the soiled linen container provided in the shower room. She stated the trash cans should have a liner and the large trash bin should be covered.On July 21, 2026, at 5:08 p.m., the Director of Nursing (DON) was interviewed. She stated the should rooms should be kept clean and sanitary for infection control. She stated she expected the CNAs to keep the shower areas clean.The undated facility policy and procedure titled, Routine Bathroom Cleaning, indicated, .It is the policy of this facility.to provide a clean and sanitary environment for residents, staff and visitors in order to prevent cross contamination and transmission of healthcare-associated infection.

Based on observation, interview, and record review, the facility failed to provide the necessary care and services for one of seven residents reviewed (Resident 1) when Resident 1 did not receive her showers or bed baths on June 22, July 6, 9, and 20, 2026.This failure had the potential for Resident 1 to have unpleasant odors, develop skin irritations, and bacterial growth that could lead to infection.Findings:On July 21, 2026, at 11:33 a.m., Resident 1 was observed, lying in bed, awake and alert. A wound vac (a medical device that uses suction to help complex, chronic, or slow-healing wounds to close faster) canister was observed on the bed next to Resident 1. In a concurrent interview with Resident 1, she stated she preferred to have bed baths instead of showers.The facility shower schedule indicated Resident 1 should receive showers every Monday and Thursday.Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which included End Stage Renal Disease (ESRD - a complete loss of kidney function). The history and physical dated June 27, 2026, indicated Resident 1 was able to make her own decisions.Resident 1's shower/bath records indicated Resident 1 did not receive her shower or bath on the following days:- June 22, 2026 (Monday)- July 6, 2026 (Monday)- July 9, 2026 (Thursday; and- July 20, 2026 (Monday).On July 21, 2026, at 1:35 p.m., Certified Nursing Assistant (CNA) 1 was interviewed. CNA 1 stated the CNAs should provide showers to the residents twice a week. She stated if a resident refused to shower, the CNA should come back later and ask the resident again if the resident would like to shower. CNA 1 stated they should offer the resident a bed bath if the resident refused to shower. CNA 1 stated showers should be documented in the resident's medical records under the task or on the shower sheets if the resident refused.On July 21, 2026, at 2:48 p.m., the Assistant Director for Staff Development (ADSD) was interviewed. She stated all residents have a scheduled shower twice a week. She stated if the resident refused to shower, the CNA should offer three times and if the resident still refused on the third time, the CNA should inform the Licensed Vocational Nurse (LVN). She stated the LVN should speak to the residents and explain the benefits of taking a shower. If the resident still refused, the refusal to shower should be documented on the shower sheets and signed by the LVN. A concurrent record review of Resident 1's shower sheets and shower/bath records on the CNA task was conducted with the ADSD. The ADSD stated there was no documented evidence that Resident 1 received showers or bed baths on June 22, July 6, 9, and 20, 2026.On July 21, 2026, at 5:08 p.m., the Director of Nursing (DON) was interviewed. She stated the facility had a schedule for the residents to have a shower. She stated the CNA should offer the resident to shower three times and if the resident refused, the LVN should be notified to explain to the resident the benefits of taking a shower. She stated it is important for the residents to take their shower regularly for personal hygiene, relaxation and skin assessment.The facility policy and procedure titled, Shower/Tub Bath, revised October 2020, indicated, .The purpose of this procedure is to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin.The following information should be recorded on the resident's ADL (activities of daily living) record.The date and time of the shower/tub bath was performed.The name and title of the individual(s) who assisted the resident with the shower/tub bath.If the resident refused the shower/tub bath, the reason(s) why and the interventions taken.The signature and title of the person recording the data.Notify the supervisor if the resident refuses the shower/tub bath.

Based on interview and record review, the facility failed to provide care and treatment for one of three residents reviewed (Resident 1) according to the physician's orders and the resident care plan when the Licensed Vocational Nurse (LVN) did not administer insulin as ordered when the resident experienced hyperglycemia (elevated blood sugar).This failure had the potential to cause fluctuations in Resident 1's blood sugar (BS) levels that could lead to serious illness and life threatening conditions.Findings:On June 16, 2026, Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses of diabetes mellitus (a chronic condition characterized by high blood sugar). Resident 1's history and physical, dated January 6, 2026, indicated Resident 1 did not have the capacity to understand and make decisions.The physician's order dated October 13, 2025, indicated, .HumaLOG Solution (a type of insulin) 100 UNIT/ML (unit per milliliter - a unit of measurement) Inject per sliding scale (method where the insulin dose is determined by the current blood sugar level).if 151-200 = 2 units; 201-250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units; BS =/> (equal to or greater than) 401 give 12 units and call MD (medical doctor) subcutaneously (under the skin) before meals and at bedtime for diabetes.The care plan revised April 28, 2025, indicated, .Resident has a diagnosis of diabetes and is at risk for complications manifested by history of hypo/hyperglycemia (low/high BS).neuropathy (a condition that damaged the nerves outside the brain and spinal cord), peripheral vascular disease (a blood vessel disorder), skin breakdown.Interventions.Administer medications as ordered.The progress notes indicated a late entry was entered by LVN 1 initiated on May 26, 2026, at 7 p.m., and completed on May 30, 2026, at 6:43 p.m., which read .Resident had a BGL (blood glucose level - same as blood sugar) of 400.administered approximately 10 units of insulin based on the sliding scale.A review of the Medication Administration Record for May 25, 2026, did not indicated a BS level of 400 and 10 units of Humalog was administered to Resident 1.On June 24, 2026, at 4:29 p.m., LVN 1 was interviewed. She stated that on June 25, 2026, at 4:30 p.m., she checked Resident 1's blood sugar and it was 486. LVN 1 stated she did not document Resident 1's BS of 486. She also stated she administered 10 units of HumaLOG to Resident 1. A concurrent record review was conducted with LVN 1. Resident 1's insulin order indicated for BS of =/> 401 to give 12 units of HumaLOG. LVN 1 stated she did not see the order to give 12 units of Humalog, if the BS is =/> 401. She stated she must have overlooked it. LVN 1 stated she should have given Resident 1 12 units of HumaLOG for BS of 486.On June 24, 2026, at 9:54 a.m., the Director of Nursing was interviewed. The DON stated that when she talked to LVN1, she stated Resident 1's BS on May 25, 2026, at 5 p.m., was 400. She stated LVN 1 gave Resident 1 10 units of Humalog for a BS of 400. The DON stated she was not aware that Resident 1's BS was 486. She stated LVN 1 should have followed the physician's order and should have administered 12 units of Humalog to Resident 1.A review of the facility policy and procedure titled, Administering Medications, revised April 2019, indicated, .Medications are administered in a safe and timely manner and as prescribed.Medications are administered in accordance with prescriber orders .

Based on interview and record review, the facility failed to maintain and complete accurate clinical records in accordance with accepted professional standards and practices for one of three residents reviewed (Resident 1) when the Licensed Vocational Nurse (LVN):- did not document Resident 1's blood sugar (BS) readings of 486 and 71 on May 25, 2025; and- did not document Resident 1's blood sugar while monitoring for the effectiveness of the interventions. These failures had the potential to compromise Resident 1's diabetic management and overall health.Findings:On June 16, 2026, Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses of diabetes mellitus (a chronic condition characterized by high blood sugar). Resident 1's history and physical, dated January 6, 2026, indicated Resident 1 did not have the capacity to understand and make decisions.The progress notes indicated a late entry was entered by LVN 1 initiated on May 26, 2026, at 7 p.m., and completed on May 30, 2026, at 6:43 p.m., which read, .Resident had a BGL (blood glucose level - same as blood sugar) of 400.administered approximately 10 units of insulin based on the sliding scale.Resident was closely monitored following insulin administration, blood glucose gradually stabilized in the low 80's md/dL (milligrams per deciliter - a unit of measurement). LVN was called into the room about an hour after glucose incident and the resident's family member stated that the resident appeared to be confused and had removed her clothing. Resident was reassessed and found to be exhexhibiting (sic) s/s (signs and symptoms) consistent with hypoglycemia (low blood sugar).Resident was closely monitored.A review of the Medication Administration Record (MAR) for May 25, 2026, for Resident 1 did not indicate a BS level of 400 and 10 units of Humalog was administered to Resident 1.A review of the MAR for May 25, 2026, for Resident 1 did not indicate a BS level of 71.A review of the Resident 1's MAR for May 2026, did not indicate the BS level checks were conducted every 15 minutes for 1 hour during Resident 1's hyperglycemic and hypoglycemic episodes on May 25, 2026. On June 24, 2026, at 2:02 p.m., LVN 2 was interviewed. LVN 2 stated if a resident's BS level was below 80 or 400 and above, after her interventions, she would recheck the resident's BS within 30 minutes. She stated she would document all the BS readings and all her interventions in the resident's MAR or progress notes.On June 24, 2026, at 3:28 p.m., LVN 3 was interviewed. He stated BS checks and interventions should be documented in the resident's MAR or progress notes.On June 24, 2025, at 3:52 p.m., LVN 4 was interviewed. She stated the licensed nurse should document in the medical record the exact BS level, the medications administered and the dose given in the Medication Administration Record (MAR). She also stated the licensed nurse should document in the resident's progress notes the interventions performed including repeated BS checks. In a concurrent record review with LVN 4, she stated there was no documented evidence LVN 1 documented Resident 1's BS of 400 and/or low 80's in the MAR. In addition, LVN 4 stated there was no documented evidence of BS monitoring during Resident 1's hyper/hypoglycemia episodes on May 25, 2026.On June 24, 2026, at 4:29 p.m., a concurrent interview and record review was conducted with LVN 1. She stated that on June 25, 2026, at 4:30 p.m., she checked Resident 1's blood sugar and it was 486. LVN 1 stated she did not document Resident 1's BS of 486. LVN 1 did not provide an answer when asked why she did not document Resident 1's BS of 486. She stated she administered 10 units of Humalog (a type of insulin). She stated she monitored Resident 1 and rechecked the BS every 15 minutes and did not document. LVN 1 stated that approximately after an hour, Resident 1's family member approached her, and she was informed that Resident 1 was restless and was removing her clothes. She stated she rechecked Resident 1's BS and it was on the low 80's. She stated she could no longer remember the exact BS level. LVN 1 stated she gave Resident 1 a cup of orange juice with 10 packets of sugar and rechecked Resident 1's BS level every 15 minutes for one hour. She stated she did not document the BS levels during that hour. She stated she should have documented the BS level in the MAR and the times of the BS checks. On June 25, 2026, at 9:54 a.m., the Director of Nursing (DON) was interviewed. She stated LVN 1 told her that on May 25, 2026, at around 5 p.m., Resident 1's BS was 400 and LVN 1 administered 10 units of insulin according to the physician's order. The DON stated she was not aware the BS was 486. She stated Resident 1's BS went down to 71 and the resident became confused and was removing her clothes. She also stated LVN 1 told her that she monitored Resident 1 for the hypoglycemic episode and checked the BS every 15 mins for 1 hour. She stated she was not aware LVN 1 did not document Resident 1's BS of 71 and all her interventions. The DON Stated the licensed staff were aware of the importance of documentation to ensure proper medical, psychosocial, physical and emotional management of the residents. She also stated the accurate documentation provided information to the Interdisciplinary Team (IDT - a group healthcare professional who work together to create, implement, and manage a comprehensive plan for every resident) for an appropriate treatment plan for the residents.The facility policy and procedure titled, Charting and Documentation, revised April 2008, indicated, .All services provided to the resident, or any changes in the resident's medical or mental conditions, shall be documented in the resident's medical record.All observations, medications administered, services performed.must be documented in the resident's clinical records.Documentation of procedures and treatments shall include care-specific details and shall include at a minimum.The date and time the procedure/treatment was provided.

Based on interview and record review, the facility failed to ensure the family member was notified, for one of three residents (Resident 1), when Resident 1 eloped (when a resident leaves the facility without the knowledge of the staff) from the facility.This failure had the potential to result in Resident 1's family member to not being aware of Resident 1's condition.Findings:A review of Resident 1's admission Record indicated he was admitted to the facility on [DATE], with diagnoses which included Wernicke's encephalopathy (a brain injury caused by lack of thiamine [vitamin]) and his family member was listed as emergency contact # 1.A review of Resident 1's Elopement and Wandering Risk Observation/Assessment dated February 14, 2026, indicated the resident is alert and oriented x 3 (name, place and time) and can follow instructions.A review of Resident 1's Nurse's Note dated February 15, 2026, at 11:00 p.m., created by Registered (RN) 1, indicated Resident 1 was alert, oriented x 2, follows command and ambulatory using a cane. Resident 1 came to the nurse station at 6:30 p.m., asked for a pen then sat in the lobby and did word search puzzles. At 8:50 p.m., RN 1 was notified that Resident 1 was not in his room and the staff searched for the resident in the facility. When he was not found a (code used by the facility for missing resident) was activated for resident search. Resident 1 was searched for outside the facility in proximity, but the resident was not around. The notes indicated the charge nurse (Licensed Vocational Nurse [LVN] 1) notified the family, called law enforcement and the medical doctor.A review of Resident 1's Social Service Note dated February 16, 2026, at 11:45 a.m., (nearly 15 hours after the staff first noticed Resident 1 was missing) indicated a late entry that the Social Service Director (SSD) was informed Resident 1 left the facility last night (February 15, 2026). The SSD attempted to contact Resident 1's family members but was initially unsuccessful. The SSD eventually spoke with Resident 1's family member, who stated Resident 1 was at (name of general acute care hospital).On March 3, 2026, at 1:10 p.m., during an interview with LVN 1 and a record review of Resident 1's medical record, LVN 1 stated she was familiar with Resident 1. LVN 1 stated Resident 1 was alert and oriented to name and place. LVN 1 stated Resident 1 was confused a few times. LVN 1 stated Resident 1 did not want to be in one place, he stayed in his room for a few hours then he would go to the activity room and to the patio. LVN 1 stated Resident 1 did not seem to be at risk of eloping.During the same interview, LVN 1 stated on February 15, 2026, she was the charge nurse for Resident 1, and she gave him his medications at 4:00 p.m., in the lobby, then Resident 1 ate his dinner between 4:30 to 5:00 p.m., in his room. LVN 1 stated when she made her rounds (routine checks) between 6:00 p.m. to 6:30 p.m., when she noticed Resident 1 was not in his room, and she notified RN 1, the CNA and announced their code for missing resident. LVN 1 stated she did not notify the family member because they were still looking for Resident 1. LVN 1 stated Resident 1's family member should have been notified.On March 4, 2026, at 9:26 a.m., during an interview, RN 1 stated she asked LVN 1 to call Resident 1's family member that he was not found. RN 1 stated family members should be notified as soon as the resident was not found.On March 4, 2026, at 1:59 p.m., during an interview, the Director of Nursing stated the RN or LVN are supposed to notify the resident's family member and document it in the medical record.A review of the facility's policy and procedure titled, Emergency Procedure - Missing Resident dated August 2018 indicated, .Resident elopement resulting in missing resident is considered a facility emergency .Notify the family/responsible party and attending physician if the resident is not found in the facility or the grounds .Emergency Job Tasks .Nursing Staff .Notify the family/responsible person and inform him of his/her status .ensure the incident and events are documented objectively in the resident record including .notification of .family .

Based on interview and record review, the facility failed to ensure a safe environment was provided for one of two residents, Resident 1, when Resident 1 exited the facility through the front door without the staff knowledge. Resident 1 was found wandering on the grounds of a college campus and was transported to a general acute care hospital (GACH) by emergency medical services.This failure had the potential to result in Resident 1 to sustain serious injury such as being struck by a vehicle or death.Findings:A review of Resident 1's admission Record indicated he was admitted to the facility on [DATE], with diagnoses which included Wernicke's encephalopathy (a brain injury caused by lack of thiamine [vitamin]).A review of Resident 1's Nursing Admission/re-admission Evaluation/Assessment dated, February 13, 2026, indicated the resident is alert and oriented to name and place, forgetful and follows direction at times.A review of Resident 1's Elopement and Wandering Risk Observation/Assessment dated February 14, 2026, indicated the resident is alert and oriented x 3 (name, place and time) and can follow instructions and expressed being unhappy or not accepting with placement at the facility.A review of Resident 1's Nurse's Note dated, February 15, 2026, at 11:00 p.m., created by Registered (RN) 1 indicated Resident 1 was alert, oriented x 2, follows command and ambulatory using a cane. Resident 1 was in his room at 3:15 p.m. Resident 1 came to the nurse station at 6:30 p.m., asked for a pen then sat in the lobby and did word search puzzles. At 8:50 p.m., RN 1 was notified that Resident 1 was not in his room and the staff searched for the resident in the facility and he was not found. A (code used by this facility for missing person) was activated for resident search. Resident 1 was searched for outside the facility in proximity, but resident was not around. A review of Resident 1's Nurses Note dated February 16, 2026, at 4:02 a.m., indicated a late entry that at approximately 3:52 a.m., an RN from (name of GACH) reported to the facility that Resident 1 was found by law enforcement on February 15, 2026, at 10:10 p.m., at (name of college campus) wandering (moving around with no purpose). On March 3, 2026, at 1:10 p.m., during an interview with Licensed Vocational Nurse (LVN) 1 and a review of Resident 1's medical record, LVN 1 stated she was familiar with Resident 1. LVN 1 stated Resident 1 was alert and oriented to name and place. LVN 1 stated Resident 1 was confused a few times. LVN 1 stated Resident 1 did not want to be in one place, he stayed in his room for a few hours then he would go to the activity room and to the patio. LVN 1 stated Resident 1 did not seem to be at risk of eloping (a resident leaving the facility without staff knowledge).During the same interview, LVN 1 stated on February 15, 2026, she was the charge nurse for Resident 1, and she gave his medications at 4:00 p.m. in the lobby, then Resident 1 ate his dinner between 4:30 to 5:00 p.m., in his room. LVN 1 stated when she made her rounds (routine checks) between 6:00 p.m. to 6:30 p.m., she noticed Resident 1 was not in his room, and she notified RN 1, the CNA, and announced their code for a missing resident. On March 4, 2026, at 9:26 a.m., during an interview, RN 1 stated she was familiar with Resident 1. RN 1 stated she was the RN supervisor on February 15, 2026, for the 3pm-11pm shift. RN 1 stated at 3:00 p.m., Resident 1 was in his room, at 5:40 p.m., Resident 1 was in the lobby with puzzles and books, and she approached him because it was dinner time. RN 1 stated Resident 1 was able to walk to his room, she helped him with his dinner tray, and she left the resident's room. A few minutes later, Resident 1 went back to the front nurses' station (Station 1), asked for a pen and sat down in the lobby. RN 1 stated between 10:00 to 11:00 p.m., she was notified that Resident 1 was not in his room and they searched everywhere for him.During the same interview, RN 1 stated there are six exit doors in the facility with alarms. RN 1 stated the front door has an alarm now and it didn't have an alarm before. RN 1 stated she cannot remember when the alarm was placed but it was due to something that happened recently.On March 4, 2026, at 10:52 a.m., during an interview, CNA 1 stated on February 15, 2026, he last saw Resident 1 at 5:50 p.m., when he picked up his dinner tray. CNA 1 stated he did not really check on Resident 1 because he was independent. CNA 1 stated he found out that Resident 1 was missing on February 16, 2026, when the Director of Staff Development called him.On March 4, 2026, at 11:14 a.m., during a concurrent interview and review of the facility's surveillance camera with the Maintenance Director (MTD) and Assistant Maintenance (AMT), the AMT stated Resident 1 left the facility through the front door. The surveillance camera showed Resident 1 dressed in regular clothes and exited the front door of the facility on February 15, 2026, at 6:59 p.m. The MTD stated the front door is locked at 8:00 p.m.On March 4, 2026, at 1:31 p.m., during an interview, LVN 2 stated no one is responsible for monitoring the front door after the receptionist leaves. LVN 2 stated there are nurses at Station 1 to keep an eye on the front door.On March 4, 2026, at 1:48 p.m., during an interview, RN 1 stated she stayed at Station 1 if there is nothing to do. RN 1 stated the LVNs monitor the front door after the receptionist leaves. RN 1 stated there is always an LVN at Station 1 or she would call a CNA to stay there to make sure no resident goes out. RN 1 stated there should always be someone at Station 1 but sometimes they get busy, especially the hours between 6:00 to 9:00 p.m. RN 1 stated it was not a guarantee there is always someone sitting at Station 1.On March 4, 2026, at 1:59 p.m., during an interview, the Director of Nursing (DON) stated the desk nurse, charge nurse and the RN keeps an eye on the front door after the receptionist leaves. The DON stated there is always somebody watching the front door. The DON stated a resident leaving through the front door can happen if the nurses bent down or are on the phone. A review of the facility's policy and procedure titled, Safety and Supervision of Residents dated July 2017, indicated, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities .

Based on interview and record review, the facility failed to ensure, for one of one resident, Resident 1, the baseline care plan (BCP- initial, person-centered care guide developed within 48 hours of a resident's admission) included interventions to prevent and/or minimize falls.This failure had the potential to result in Resident 1 to have repeated falls and fall related injury. Findings:A review of Resident 1's admission Record dated January 2, 2026, indicated he was admitted the facility on April 30, 2025, with diagnoses which included repeated falls.A review of Resident 1's Admission/readmission Evaluation Assessment dated April 30, 2025, indicated the reason for Resident 1's admission to the facility included status post fall (experienced a fall previously), the resident had left sided weakness, was non-ambulatory and required assistance with transfer and dressing.A review of Resident 1's Fall Risk Observation/Assessment dated April 30, 2025, indicated the resident was a high risk for falls.A review of Resident 1's Baseline Care Plan Person-Centered Care Planning dated April 30, 2025, did not indicate that the resident had a history of falls and did not include any intervention for falls.A review of Resident 1's Nurse's Note dated May 3, 2025, indicated the resident was found on the floor at 10:00 p.m., and the resident reported he was trying to reach for his clothes by himself, he hit his shoulder and his head. Resident 1 was transferred to the general acute hospital at 10:45 p.m.Further review of Resident 1's medical record indicated the resident did not return to the facility.On January 2, 2026, at 2:17 p.m., during a concurrent interview with Licensed Vocational Nurse (LVN) 1 and record review of Resident 1's medical record, LVN 1 stated a BCP is initiated as soon as a resident is admitted to the facility so the staff will know what they have to do to care for the resident. If a resident had a history of falls, she would include interventions such as placing call right within reach and bed in low position. LVN 1 stated Resident 1's BCP did not indicate any interventions to address falls.On January 2, 2026, at 3:14 pm., during an interview with the Director of Nursing (DON) and Assistant Director of Nursing (ADON), the DON stated a BCP is initiated so that the staff would know how to care for a resident. The ADON reviewed Resident 1's BCP and stated the BCP did not indicate that the resident had a history of falls and did not indicate any interventions to prevent the resident from falling, and it should have been added to make the staff aware that the resident is at risk for falling.A review of the facility's policy and procedure titled, Care Plans - Baseline dated March 2022, indicated, A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission .The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality of care and must include the minimum healthcare information necessary to properly care for the resident .

Based on interview and record review, the facility failed to review and update its facility assessment to accurately reflect the current resident census (official count or survey of a population) and the sufficient staffing levels required to meet residents' needs.This failure resulted in an inaccurate evaluation of the staffing necessary to provide appropriate care and support for the residents. Findings:On December 11, 2025, at 3:42 p.m., a concurrent interview and record review was conducted with the Administrator (ADM). The ADM stated he was responsible for conducting the facility assessment. The ADM stated the last facility assessment was updated on November 11, 2025. During a review of the facility assessment dated [DATE], the ADM stated the facility assessment should reflect the accurate census of the facility and sufficient staffing needs. The ADM stated the general staffing plan of the facility assessment indicated the facility census was between 20-41, requiring an average of two charge nurses and six CNAs per shift.The ADM stated that section of the facility assessment was inaccurate and probably came from from another sister facility's assessment. The ADM stated the facility has always had a maximum census of 146. The ADM stated the facility assessment dated [DATE], did not accurately reflect the facility census and sufficient staffing needs of the residents.A review of the facility policy and procedures titled Facility Assessment, revised October 2018, indicated .Once a year, and as needed, a designated team conducts a facility-wide assessment to ensure that the resources are available to meet the specific needs of our residents.The facility assessment also includes a detailed review of the resources available to meet the needs of the resident population. This part of the assessment includes.all personnel including.regular employees (full and part time).The facility assessment is intended to help our facility plan for and respond to changes in the needs of our resident population and helps to determine budget, staffing, training, equipment and supplies needed.

Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented for four out of five residents reviewed for infection control practices (Residents 66, 2, 94, and 57) when: 1.For Resident 66, nursing staff did not clean and disinfect a shared blood pressure (BP) machine with an attached BP Cuff, after use, in accordance with the facility's infection control policy; 2.For Resident 2, a disconnected foley catheter insertion tubing was observed at bedside on the floor readily and available to use;3.For Resident 94, the respiratory tubing was not changed in accordance with the facility's prevention of infection respiratory equipment policy; and4.For Resident 57 the facility did not implement Enhanced Barrier Precaution (EBP - an infection control guideline indicating the use of gowns, gloves, during high-contact resident care activities {e.g. bathing, hygiene care, and wound care} to prevent the spread of multi-drug resistant organisms and other infections) related to foley catheter (flexible tube inserted into the bladder to drain urine) since admitted to the facility in November 11, 2025. These failures had the potential to expose residents to infection and compromise residents' health and safety in the facility.Findings: 1.During a medication administration observation on December 9, 2025 at 8:28 a.m., Licensed Vocational Nurse (LVN) 5 was observed using a shared blood pressure machine with an attached BP Cuff to obtain Resident 66's blood pressure in the resident's room. On December 9, 2025, at 8:40 a.m., LVN 5 was observed returning the used BP machine and cuff to the medication cart drawer without cleaning or disinfecting the equipment. During an interview with LVN 5 on December 9, 2025 at 11:56 a.m., LVN 5 acknowledged the BP machine with cuff was returned to the medication cart drawer without being cleaned or disinfected after use. LVN 5 stated the BP machine is shared equipment and should have been cleaned and disinfected after use with a MicroKill bleach (Environmental Protection Agency, a government agency [EPA]-registered one-step cleaning and disinfectant wipes approved to kill germs on hard, non-porous surfaces) wipes available in the medication cart for infection control. During an interview with LVN 2 on December 11, 2025, at 10:40 a.m., LVN 2 stated BP machine and cuff are shared medical equipment and should be cleaned with disinfectant wipes before and after each use to prevent the transmission of infection. During an interview with the Director of Nursing (DON) on December 11, 3:15 p.m., the DON stated any shared medical equipment including BP machine and cuff should be cleaned with disinfecting wipes before and after use. A review of the facility's policies and procedures, titled Cleaning and Disinfecting of Resident-Care Items and Equipment, dated September 2022, indicated, .Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC (Centers for Disease Control and Prevention - a nationally recognized disease control and prevention organization) recommendations for disinfection and the OSHA (Occupational Safety and Health Administration – a government agency for workplace safety) Bloodborne Pathogens (disease-causing germs, like viruses or bacteria in human blood and other body fluids that can cause disease in people) Standard.Non-critical items are those that come in contact with intact skin.Non-critical resident-care items include.blood pressure cuffs.Non-critical items require cleaning followed by either low- or intermediate-level disinfection following manufacturers' instructions. Disinfection is performed with an EPA-registered disinfectant labeled for use in healthcare settings.Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment) .Durable medical equipment (DME) is cleaned and disinfected before reuse by another resident. 2.On December 8, 2025, at 11:26 a.m., Resident 2 was observed seating in his motorized wheelchair, well groomed, alert and interviewable. Resident 2's indwelling foley catheter bag insertion connection (tube inserted into the bladder to drain urine into a 1,000 milliliter bag- ml unit of measurement) was observed at bedside on the floor readily available for use by Resident 2. Resident 2 stated he disconnect himself from the foley catheter bag to the leg foley catheter bag (small wearable urine collection bag) twice daily. Resident 2 stated he only uses the foley catheter bag during the evening time and the leg bag during the day. Resident 2 further stated nursing does not disconnect him from the foley bag to the leg foley bag. On December 8, 2025, at 2:44 p.m., a concurrent observation and interview was conducted with the licensed vocational nurse (LVN 7). LVN 7 stated the foley catheter bag insertion tubing should not be on the floor. A concurrent record review was conducted with LVN 7. LVN 7 stated Resident 2 has not been cared planned for self-care of the foley catheter bag. LVN 7 stated nursing should be disconnecting Resident 2 from the foley catheter bag to the leg foley catheter bag and not Resident 2. On December 9, 2025, Resident 2's medical record was reviewed. Resident 2 was admitted to the facility on [DATE], with diagnoses which included chronic kidney disease (kidneys are damaged and can not filter waste and extra fluid from the blood), immunodeficiency (immune system can not fight infections), and benign prostatic hyperplasia (prostate gland grows larger in a non-cancerous way squeezing the urethra causing urinary problems). The history and physical completed November 13, 2025, indicated Resident 2 had the capacity to make decisions. The physician order dated November 13, 2025, indicated .indwelling urinary (foley) catheter.for obstructive uropathy (blockage in the urinary tract that slows or prevents urine flow). The care plan dated November 12, 2025, indicated .focus.the resident has immunodeficiency due to benign prostatic hyperplasia with lower urinary tract symptoms.intervention.the resident is at risk for contracting infections due to impaired immune status.keep the environment clean and people with infections away. There was no documented evidence of a care plan for Resident 2 to perform self-care for the foley catheter. On December 10, 2025, at 11:30 a.m., a concurrent interview and record review was conducted with the Director of Nursing (DON). The DON stated the facility process is to care plan for independent resident for their foley catheter care. The DON stated Resident 2 had not been care planned on how to self-detach from the foley bag to the foley leg bag. The DON further stated Resident 2 should not have been disconnecting himself from the foley bag to the leg foley bag nursing should have been disconnecting Resident 2 from the foley catheter bag to the leg foley catheter bag. A review of the facility policy and procedure titled Indwelling Catheter Care, Urinary, revised September 2014, indicated .use standard precautions when handling or manipulating the drainage system.maintain clean technique when handling or manipulating the catheter, tubing, or drainage bag.be sure the catheter tubing and drainage bag are kept off the floor. 3.On December 8, 2025, at 11:11 a.m., Resident 94 was observed upright in bed, well groomed, alert and interviewable with nasal cannula tubing (lightweight flexible plastic tube with two prongs that fit into each nostril to deliver oxygen) connected to an oxygen concentrator (medical device that pulls in air and purifies the air to oxygen). Resident 94 stated she had been using the oxygen concentrator since admission for shortness of breath. The nasal cannula tubing was observed dated November 30, 2025. On December 8, 2025, at 11:17 a.m., a concurrent observation and interview was conducted with LVN 7. LVN 7 stated the facility process is to change respiratory tubing every seven days. LVN 7 further stated Resident 94's nasal cannula tubing should have been changed Sunday, December 7, 2025. Resident 94's medical record was reviewed. Resident 94 was admitted to the facility on [DATE], with diagnoses which included asthma (chronic lung disease), orthopnea (shortness of breath when lying flat), and immunodeficiency (immune system can not fight infections). The history and physical dated November 3, 2025, indicated Resident 94 had decision making capacity. The physician order summary dated December 5, 2025, indicated .oxygen therapy via nasal cannula @ 2-5 liter per minute as necessary for changes in episodes of respiratory distress (difficulty breathing) . The care plan dated November 4, 2025, indicated .focus.the resident has immunodeficiency.intervention.the resident is at risk for contracting infections due to impaired immune status.keep the environment clean and people with infections away. On December 10, 2025, a concurrent interview and record review was conducted with the DON. The DON stated the facility process is to change the respiratory tubing (nasal cannula tubing) weekly every Sunday. The DON further stated Resident 94's respiratory tubing should have been changed Sunday, December 7, 2025. A review of the facility policy and procedures titled Prevention of Infection Respiratory Equipment (equipment used for breathing), revised November 2011, indicated .change pre-filled humidifier when the water level becomes low.change the oxygen cannula and tubing every (7) days, or as needed.keep the oxygen cannula and tubing used prn (as necessary) in a plastic bag when not in use. 4. On December 8, 2025, an observation with a concurrent interview was conducted with Resident 57. Resident 57 was in bed, alert and interviewable. Resident 57 was observed to have a foley catheter with a covered urine drainage bag hanging by the bed and off the floor. In a concurrent interview, Resident 57 stated she had been using the foley catheter since she was admitted to the facility in November 2025. On December 8, 2025, at 9:46 a.m., an observation was conducted outside Resident 57's room. There was no EBP set up (gowns, gloves, mask available for staff to use upon entering the resident's room) and EBP sign in place outside Resident 57's room. On December 8, 2025, at 10:38 a.m., a second observation was conducted outside of Resident 57's room. An EBP set up was placed outside of Resident 57's room with a sign posted by the door indicating the instructions, use and purpose of EBP for Resident 57. On December 8, 2025, at 10:38 a.m., an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated she was the CNA assigned to Resident 57. CNA 1 stated Resident 57 used a foley catheter and she was not on EBP before. CNA 1 stated they observe EBP on residents with foley catheter to help protect themselves and the residents from the spread on infection. CNA 1 stated the EBP equipment was just recently set up this morning by the Infection Preventionist Nurse (IPN). On December 10, 2025, Resident 57's record was reviewed. Resident 57 was admitted to the facility on [DATE], with diagnoses including obstructive reflux uropathy (condition blocked urine flow, causing backup and potential kidney damage). The physician order dated November 11, 2025, indicated, .Foley catheter 16# 10 cc bulb (foley catheter size) attached to gravity drainage bag.DX (diagnosis) of urinary retention. There is no documented evidence of an EBP physician order and/or care plan related to Resident 57's foley catheter use since her admission on [DATE]. On December 10, 2025, at 9:03 a.m., an interview with a concurrent record review was conducted with the IPN. The IPN stated Resident 57 had a physician's order for foley catheter use and she did not have an EBP order in place since admitted to the facility on [DATE]. The IPN stated residents who were admitted with foley catheters were placed on EBP to protect residents and staff from infection. The IP stated an EBP order related to foley catheter use should have been in place since Resident 57's admission On December 10, 2025, at 11:45 a.m., an interview was conducted with the Director of Nursing (DON). The DON stated Resident 57 was admitted with a foley catheter since November 11, 2025. The DON stated Resident 57 should have been placed on EBP then. The DON stated this was missed and the EBP was not implemented until December 8, 2025. The DON stated it was important to put residents with foley catheters on EBP to help protect residents and staff from cross contamination of infection. The facility's policy and procedure titled, Enhanced Barrier Precaution, dated March 2024, was reviewed. The policy indicated, .Enhanced barrier Precautions (EBPs) are utilized to reduce the transmission of multi-drug resistant organisms (MDROs) to residents.Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the transmission of multi-drug resistant organisms (MDROs) to the residents. EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities.Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include.dressing.bathing.transferring.providing hygiene.changing linens.changing briefs or assisting with toileting.device care or use.urinary catheter.wound care. EBPs are indicated.for residents with wounds and/or indwelling medial devices.indwelling medical devices include.urinary catheters. EBPs remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at risk.Signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE (Personal Protective Equipment such as gowns gloves and mask) required.

Based on observation, interview, and record review, on four of four residents reviewed for quality of care (Residents 130, 33, 78, and 178), the facility failed to ensure:1.For Resident 130, the ophthalmologist (eye doctor) consult visits were addressed, care-planned and recorded in the resident's record. In addition, the facility did not address Resident 130's right eye cataract surgery performed on December 5, 2025.This failure had the potential for Resident 130 to experience complications and worsened vision due to a possible delay in treatment to address her vision needs;2. For Resident 33, the physician's order to restrict 1500 milliliters (ml - unit of measurement) fluid restriction per day, was followed correctly. In addition, the fluid intake and output monitoring due to fluid restriction was not performed. This failure places Resident 33 at risk for complications related to fluid overload (fluid build up in tissues that may lead to rapid weight gain, swelling in arms, legs, and face, shortness of breath, and heart problems); 3. For Resident 78, the Cervical Thoracic Orthosis (CTO- a rigid medical device used to immobilize and support the neck and upper back) brace was applied according to the physician orders. In addition, there was no comprehensive care plan developed or initiated to address the use of CTO. This failure had the potential to prevent Resident 78 from experiencing the needed therapeutic benefits of the CTO brace to improve her condition; and4. For Resident 178, the facility did not identify, address, and refer to the physician, multiple skin discolorations identified on December 8, 2025. This failure resulted to a delay in treatment and placed Resident 178 at risk for complication. Findings: 1a. On December 8, 2025, at 9:44 a.m., an observation with a concurrent interview was conducted with Resident 130. Resident 130 was observed in lying in bed, alert, and interviewable. Resident 130's right eye was observed with redness, swelling, and with dry, white crusted discharge on the right lower eyelid. In a concurrent interview, Resident 130 stated she had a right cataract surgery performed in December 5 , 2025. On December 10, 2025, Resident 130's record was reviewed. Resident 130 was admitted to the facility on [DATE], with diagnoses including diabetes (high blood sugar). The document titled, Progress Notes, dated August 7, 2025, indicated, .Physician History and Physical.The resident has the capacity to understand and make decisions. The document did not indicate Resident 130 had history of eye problem or disease upon admission to the facility. The following ophthalmology consult notes, provided to the facility by the ophthalmology clinic on December 10, 2025, indicated: -On September 22, 2025, .+(positive) for glaucoma (eye condition that progressively damages the optic nerve, which connects eye to the brain, leading to irreversible vision loss and potential blindness) .blurry vision .unable to see far and close .progressively worse symptoms .FINDINGS .Visually significant cataract (clouding of eye's natural lens, making vision blurry, hazy, or less colorful) .OD (right eye) .glaucoma .Proceed with CE (Cataract Extraction - procedure to remove cloudy eye lens and replace it with a clear artificial one to restore clear vision .; -On November 3, 2025, .Pt (patient) is here for pre-op (Preparation before surgery) .Will proceed with surgery OD (right eye) .Pt understand CE may not improve vision . -On September 5, 2025, a report completed by (name of physician) .Operative Report .Preoperative Diagnosis: Visually significant cataract, right eye .Postoperative Diagnosis: Visually significant cataract, right eye .Indication for surgery: Patient complained of poor vision. Vision cannot be improved by eyeglasses .Procedure: Cataract Extraction with Phacoemulsification (technique used in cataract surgery to break up a cloudy eye lens) and Primary Intraocular Lens Implant (IOL- artificial lens placed inside the eye during cataract surgery) right eye .Patients eye was dressed with Antibiotic and ointment and eye patch and eye shield . -On September 6, 2025, .Patient is S/P (status post) CE with IOL OD, post op (after surgery) day .Patient c/o (complained of) pain OD .Impression: Pseudophakia (condition where the eye's natural lens has been replaced by an IOL).Plan .Ocuflox (eye antibiotic) and Pred Forte (eye drop medication to treat inflammatory eye condition) increased to every 1 hr (hour) OD and return in three days. There was no documented evidence Resident 130 was assessed or evaluated by the licensed nurses or primary physician prior to referral to the ophthalmologist on September 22, 2025. In addition, there was no documented evidence a care plan was developed or initiated to address Resident 130's glaucoma and right eye cataract after it was identified by the ophthalmologist on September 22, 2025. On December 10, 2025, at 12:45 p.m., an interview was conducted with Case Manager (CM). The CM stated she was responsible for arranging needed appointments for the residents such ophthalmology consults. The CM stated Resident 130 complained of her poor vision and inability to see, so she took it upon herself to arrange the appointments with the ophthalmologist. The CM stated she did not inform the licensed nurses of Resident 130's complains of poor vision prior to arranging the ophthalmology consult visits. The CM stated she guessed she had to communicate Resident 130's poor vision problem prior to arranging the ophthalmology consult visits but she did not. On December 10, 2025, at 2:20 p.m., an interview with a concurrent record review was conducted with Licensed Vocational Nurse (LVN) 3. LVN 3 stated Resident 130 had physician's orders for ophthalmology consults in September 22, November 3, and December 5, 2025. LVN 3 stated there was no documentation the licensed nurses noted in their progress notes the results of the ophthalmology visits and there was no care plan developed to indicate the reason for the ophthalmology consults on these dates. On December 11, 2025, at 9:15 a.m., an interview with a concurrent record review was conducted with the Director of Nursing. The DON stated the following: - She was not aware of any vision problem diagnosis for Resident 130 upon admission to the facility; - Resident 130 did not have a physician evaluation for poor vision complaint prior to the referral of an ophthalmology consult; - The CM should have communicated with the licensed nurses about Resident 130's concern on her vision so the licensed nurses can do the proper evaluation and assessment prior to the referral to the ophthalmologist; - A care plan was not developed to address Resident 130's glaucoma and right eye cataract diagnosis. The DON stated this should have been done in September when the ophthalmologist identified it; - There was no progress notes from the licensed nurses indicating the ophthalmology consult visits performed on the resident in September 22, November 3, and September 5, 20205; and - The facility's policy on Referral and Consults were not followed because there was no communication between the licensed nurses and the ophthalmology clinic. 1b. On December 8, 2025, at 9:44 a.m., an observation with a concurrent interview was conducted with Resident 130. Resident 130 was observed in lying in bed, alert and interviewable. Resident 130's right eye was observed with redness, swelling, and with dry, white crusted drainage on the right lower eyelid. In a concurrent interview, Resident 130 stated she had a right cataract surgery performed in December 5 , 2025. On December 10, 2025, Resident 130's record was reviewed. Resident 130 was admitted to the facility on [DATE], with diagnoses including diabetes (high blood sugar). The document titled, Progress Notes, dated August 7, 2025, indicated, .Physician History and Physical.The resident has the capacity to understand and make decisions. The document did not indicate Resident 130 had history of eye problem or disease upon admission tot he facility. On November 3, 2025, .Pt (patient) is here for pre-op (Preparation before surgery) .Will proceed with surgery OD (right eye) .Pt understand CE may not improve vision . -On September 5, 2025, a report completed by (name of physician) .Operative Report .Preoperative Diagnosis: Visually significant cataract, right eye .Postoperative Diagnosis: Visually significant cataract, right eye .Indication for surgery: Patient complained of poor vision. Vision cannot be improved by eyeglasses .Procedure: Cataract Extraction with Phacoemulsification (technique used in cataract surgery to break up a cloudy eye lens) and Primary Intraocular Lens Implant (IOL artificial lens placed inside the eye during cataract surgery) right eye .Patients eye was dressed with Antibiotic and ointment and eye patch and eye shield . -On September 6, 2025, .Patient is S/P (status post) CE with IOL OD, post op (after surgery) day .Patient c/o (complained of? pain OD .Impression: Pseudophakia (condition where the eye's natural lens has been replaced by an IOL).Plan.Ocuflox (eye antibiotic) and Pred Forte (eye drop medication to treat inflammatory eye condition) increased to every 1 hr (hour) OD and return in three days. The physician orders dated December 6, 2025, indicated Resident 130 has been receiving the eye medications, Ocuflox and Pred Forte applied one drop to the right eye every hour awake, after right eye cataract surgery. There was no documented evidence of the following: -Resident 130's ophthalmology consult visits has been noted by the licensed nurses on September 22, [DATE], and December 5, 2005. -Resident 130 was assessed and monitored for complications after the right eye cataract surgery was performed in December 5, 2025; - A care plan was developed or initiated to address Resident 130's right eye post cataract surgery needs; and - Resident 130 was monitored for side effects of the eye antibiotic (Ocuflox) since December 6, 2025. On December 11, 2025, at 9:15 a.m., an interview with a concurrent record review was conducted with the Director of Nursing. The DON stated the following: - There was no progress notes documented by the licensed nurses indicating the result of ophthalmology consult visits performed on the resident in September 22, November 3, and September 5, 2025. The DON stated these should have been done. - When Resident 130 came back from her right eye cataract surgery, the licensed nurses should have conducted an assessment to the right eye and monitored the resident for complications such as redness and swelling, for 72 hours. The DON stated this was not done; - A care plan should have been developed to address Resident 130 right eye post cataract surgery needs; and - There was no documentation Resident 130 was monitored for the adverse effects of the eye antibiotic Ocuflox since started December 6, 2025. The facility's policy and procedure titled, Care Plans, Comprehensive Person Centered, dated December 2016, was reviewed. The policy indicated, .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is develops and implemented for each resident .The Interdisciplinary Team, in conjunction with the resident and his/her family or legal representatives, develop and implement a comprehensive, person-centered plan for each resident . The care plan interventions are derived from thorough analysis of the information gathered .The comprehensive, person-centered care plan will .include measurable goals and objectives .Describe the services that are to be furnished to attain or maintain the resident's highest practicable, physical, mental, and psychosocial well-being . Incorporate identified problem areas .Incorporate risk factors associated with identified problems . Reflect the treatment goals, timetables, and objectives in measurable outcomes . Areas of concern that are identified during the assessment will be evaluated before interventions are added to the care plan . Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's condition change . The facility policy and procedure titled, Referrals, Consults, dated December 2008, was reviewed. The policy indicated, .Referrals for medical services must be based on physician evaluation of resident need and related physician order .Social services or designee will collaborate with the nursing staff or other pertinent disciplines to arrange for services that have been ordered by the physician .Staff will document the referral in the resident's medical record . 2. On December 8, 2025, in interview with a concurrent record review was conducted with Resident 33. Resident 33 was in bed, alert, and conversant. Resident 33 stated he wanted a can of (name of soda). Observed next to Resident 30 was a plastic water pitcher labeled with the resident's name and instructions for a 1500 ml fluid restriction per day. Resident stated he was not on a fluid restriction diet. On December 9, 2025, at 6:10 am, an interview was conducted with Licensed Vocational Nurse (LVN) 4. LVN 4 stated he was the licensed nurse assigned to Resident 130 during the night shift of December 9, 2025. LVN 4 stated Resident 33 was not on fluid restriction or Intake and Output (I&O – monitoring of fluid intake and output) monitoring. On December 9, 2025, at 6:20 am, an interview was conducted with Certified Nursing Assistant (CNA) 2 CNA 2 stated he was the CNA assigned to Resident 33 during the night shift of December 9, 2025. CNA 2 stated Resident 33 was not on fluid restriction or I&O monitoring. CNA 2 stated Resident 33 drank his fluids quite well and consumed the half of his gray water pitcher by bedside during his shift. On December 9, 2025, and observation with a concurrent interview and record review was conducted with Resident 33. Resident 33 was in bed, alert, and eating his breakfast. Observed next to his breakfast tray was a gray plastic water pitcher and an 800 ml white plastic water pitcher labeled with Resident 33's name and, F/R (Fluid Restriction) 1500 cc (cubic centimeter – unit of measurement) per day. Also observed on Resident 33's breakfast tray was an 8 ounce (oz – unit of measurement. One ounce is equivalent to 30 cc) Ensure (supplement), 4 oz milk nourishment, 4 oz apple juice, and 4 oz low fat milk. In a concurrent interview, Resident 33 stated he drank his fluids well and his gray water pitcher was almost empty. Resident's meal ticket on his tray indicated a note that he was on a 1500 ml fluid restriction, with standing orders for 4 oz fluid juice, 4 oz milk, and 8 oz Ensure. On December 10, 2025, Resident 33's record was reviewed. Resident 33 was admitted to the facility on [DATE], with diagnoses including congestive heart failure (CHF-a heart condition where the heart muscle weakens or stiffens, failing to pump enough oxygen rich blood to meet the body's needs causing fluid and blood to back up (congest) in the lungs, legs, and other organs, leading to shortness of breath, fatigue, swelling, and weight gain). The document titled, Order Summary Report indicated on January 23, 2025, Resident 33 had a physician's order for fluid restriction 1500 cc in 24 hours. Total fluid distribution as follows: - Nursing Shift – 600 cc total = 275 cc a.m., 275 cc in the p.m., and 50 cc in the night shift; and - Dietary Meal Distribution – 900 cc total= 420 cc breakfast, 240 cc lunch, and dinner 240 cc. The Care Plan dated March 26, 2025, indicated, .Resident has an actual significant weight gain.Goal.Will not have ill effects related to weight gain to extent possible.Revision on: 12/04/2025.target Date: 02/28/2026.Interventions.Fluid Restriction per physician order.Monitor intake and output. The document titled, Progress Notes, dated November 6, 2025, indicated, .Physician Progress Notes.Patient has persistent BLE (bilateral lower extremities) stinging pain.On fluid restriction for CHF. Has not been cleared by cardiology (medical specialty focused on the heart) to d/c (discontinue) fluid restriction order.ASSESSMENT/PLAN.Fluid restriction.Strict I/Os (Intake and Output). Resident 33's record did not have documented evidence of following the physician's fluid restriction order. Additionally, there was no documented evidence of monitoring fluid intake and output during the fluid restriction period. On December 10, 2025, an interview with a concurrent record review was conducted with Registered Nurse (RN) 1. RN 1 stated the following: -Resident 33 was on a fluid restriction of 1500 ml per day due to his diagnosis of CHF and the licensed nurses and CNAs should monitor the resident's fluid intake and output; -There was no documentation of fluid intake and output monitoring in Resident 33's record. RN 1 stated this should have been done; -Monitoring fluid intake and output was necessary because the resident has CHF and excess fluid can impact his weight; and - There was no care plan developed or initiated specifically to address Resident 33's need for fluid restriction and I&O fluid monitoring related to his CHF diagnosis. On December 11, 2025, at 9:15 a.m., an interview was conducted with the Director of Nursing (DON). The DON stated the following: - When a resident is on a fluid restriction order, they monitor fluid intake and output to check for compliance and effectiveness; - Resident 33's fluid restrictions were not accurately monitored by the licensed nurses and the CNA's. The DON stated this should have been done; and - Inaccurate monitoring of fluid intake and output during fluid restriction may affect Resident 33's weight, potentially causing heart issues and fluid overload. The facility's policy and procedure titled, Encouraging and Restricting Fluids, dated October 2010 was reviewed. The policy indicated, .The purpose of this procedure is to provide the resident with the amount of fluids necessary to maintain optimum health. This may include encouraging or restricting fluids . Verify that there is a physician's order for this procedure .Review the resident's care plan and/or your daily assignment sheet for any special needs of the resident . Follow specific instructions concerning fluid intake or restrictions .be accurate when recording fluid intake . Record fluid intake on the intake side of the intake and output record. Record fluid intake in mL's (milliliters - unit of measurement) .When a resident has been placed on restricted fluids, remove the water pitcher and cup from the room . Be sure an intake and output record is maintained in the resident's room . Documentation .The following information should be recorded in the resident's medical record .The date and time the procedure was performed .the name and title of the individual who performed the procedure .The amount in (mLs) of fluids consumed by the resident during the shift .The type of liquid consumed (i.e. tea, milk, coffee, soup, etc .) The signature and title of the person recording the data . 3. On December 8, 2025, at 2:57 p.m., Resident 78 was observed in the dining/activity room, sitting in the wheelchair. Resident 78 was observed without the neck support brace. In a concurrent interview with Resident 78, Resident 78 was asked about the neck brace. Resident 78 stated she was uncomfortable with the neck brace on and did not want to have it on. On December 9, 2025, at 10:51 a.m., Resident 78 was observed in the hallway, sitting in the wheelchair with the neck support brace. On December 10, 2025, at 1:53 a.m., Resident 78 was observed in the dining area, sitting in the wheelchair with the neck support brace. On December 10, 2025, Resident 78's record was reviewed. Resident 78 was admitted to the facility on [DATE], with diagnoses which included compression fracture (a break and collapse) T5 to T6 (fifth and sixth thoracic [middle section of the vertebral column, located between the neck and the lower back]) vertebrae (backbone). The history and physical dated October 22, 2025, indicated Resident 78 could make her needs known but could not make medical decisions. The Minimum Date Set (an assessment tool) dated December 1, 2025, indicated a Brief Interview for Mental Status (a cognitive assessment tool) score of 7 (severely impaired). The physician order dated November 28, 2025, indicated, .Cervical Thoracic Orthosis brace (CTO brace) when out of bed. During an interview on December 10, 2025, at 11:54 a.m., with the Restorative Nursing Assistant (RNA), she stated the Physical Therapist (PT) or the RNA will apply the CTO brace on the resident. She stated a Certified Nursing Assistant (CNA) can also apply the CTO brace on a resident. She stated the PT usually demonstrates how to apply the CTO brace. During a concurrent interview and record review on December 11, 2025, with the Physical Therapy Assistant (PTA), he stated Resident 78 was alert, oriented and able to follow simple instructions. He also stated Resident 78 was calm and cooperative. He stated Resident 78 had an order to have the CTO brace on when out of bed. He stated the CTO brace was used for immobilization to prevent twisting, bending and any movement that will prevent healing of Resident 78's spine. The PTA stated the CTO brace was fitted for Resident 78 and easy to apply. He stated PT demonstrated to the CNAs how to apply the CTO brace whenever they get Resident 78 out of bed. The PTA stated he was not sure if all the CNAs were given the instructions on how to apply the CTO brace. On December 11, 2025, at 9:10 a.m., Resident 78 was observed lying in bed. CNA 3 was observed sitting in between bed A and bed B. CNA 4 was observed sitting in between bed B and bed C. In a concurrent interview with CNA 3 and CNA 4, who were assigned as sitters (a person who provides one-on-one supervision, companionship, and assistance for elderly or at-risk residents), CNA 3 stated Resident 78's CTO brace was in the closet. She stated the CNA should apply the CTO brace on Resident 78 when out of bed. CNA 3 stated the CNAs received instructions on how to apply the CTO brace. CNA 4 stated there were occasions when Resident 78 refused to put on the CTO brace. CNA 4 stated on December 8, 2025, Resident 78 refused to wear the CTO brace, and she informed PT. CNA 4 stated PT told her Resident 78 should put on the CTO brace when out of bed. During a concurrent interview and record review on December 11, 2025, at 10:01 a.m., with the Director of Nursing (DON), she stated Resident 78 had an order to use CTO brace when out of bed. The DON stated the expectation was for the staff to follow the physician's order. The DON also acknowledged Resident 78 did not have a comprehensive care plan developed to address the use of the CTO brace. She stated comprehensive care plans were utilized to provide patient-centered goals and interventions. The facility policy and procedure titled Physician ORDERS, ACCEPTING TRANSCRIBING, AND IMPLEMENTING (NOTING), dated January 2017, indicated, .Licensed nursing personnel will ensure that written (noting), telephone, and verbal orders will be recorded and implemented . 4. On December 8, 2025, at 10:20 a.m., Resident 178 was observed lying in bed, alert, not able to answer questions. Resident 178 was observed with multiple discolorations (purplish to reddish), with variable sizes, in between the knuckles of the left hand. Resident 178 was not able to answer when asked what happened to his left hand. During an interview on December 12, 2025, at 2:30 p.m., with Treatment Nurse (TN) 1, she stated Resident 178 had an arterial ulcer (a non-healing sore/wound on the legs or feet caused by poor blood flow) on the left calf. She stated Resident 178's arterial ulcer had treatment orders. TN 1 assessed Resident 178 and stated Resident 178 had multiple purplish discolorations on both arms, in-between knuckles of the left hand, both shoulders and on the left calf. TN 1 stated she was not aware of Resident 178's multiple skin discolorations. During an interview on December 12, 2025, at 3:03 p.m., TN 2, she stated she just assessed Resident 178 skin condition. TN 2 confirmed Resident 178 had multiple purplish discolorations on both arms and shoulders, and a large purple discoloration on the left calf. TN 2 stated the multiple skin discolorations should have been identified during showers or during daily care. She stated there was no documentation Resident 178's multiple skin discolorations were identified, assessed, and that the physician was notified. During an interview on December 11, 2025, at 3:20 p.m., with the DON, she stated CNAs utilized a shower sheet when a skin issue was identified. She stated the CNA will give the shower sheet to the treatment nurse who will assess the resident's skin condition and will notify the physician. The DON stated there was no documented evidence that Resident 178's multiple skin discolorations were identified and assessed and reported to the physician. She also stated multiple skin discolorations were considered a change of condition and should have been reported to the physician. The facility policy and procedure titled SKIN INTEGRITY (abrasion/skin tear/surgical wound), revised September 2013, indicated, .The purpose of this procedure is to guide the prevention and treatment of abrasions, discoloration, rashes, skin tears and other skin integrity issues.Staff will inspect skin during care and notify Physician for new skin integrity issue. The facility policy and procedure titled Acute Condition Changes – Clinical Protocol, revised March 2018, indicated, .Direct care staff, including nursing assistants, will be trained in recognizing subtle but significant changes in the resident (for example, a decrease in food intake, increased agitation, changes in skin color or condition) and how to communicate these changes to the Nurse.

Based on interview and record review, the facility failed to ensure a physician conducted the initial visit for four of six residents reviewed, for physician services (Residents 5, 12, 57, and 160). These failures had the potential to result in unidentified medical conditions and/or insufficient provision of medical treatment. Findings:On December 11, 2025, at 3:12 p.m. the following records were reviewed with the Medical Records director (MRD) for physician initial visits:- Resident 5 was admitted to the facility on [DATE]. The document titled, Progress Notes, dated March 12, 2025, indicated the physician history and physical assessment was signed as conducted and completed by Physician Assistant (PA) 1;- Resident 12 was admitted to the facility on [DATE]. The document titled, Progress Notes, dated May 31, 2025, indicated the physician history and physical assessment was signed as conducted and completed by Nurse Practitioner (NP) 2;- Resident 57 was admitted to the facility on [DATE]. The document titled, Progress Notes, dated November 14, 2025, indicated the physician history and physical assessment was signed as conducted and completed by Nurse Practitioner (NP) 1; and- Resident 160 was admitted to the facility on [DATE]. The document titled, Progress Notes, dated October 12, 2025, indicated the physician history and physical assessment was signed as conducted and completed by PA 1.In a concurrent interview, the MRD stated Residents 5, 12, 57, and 160's initial history and physical assessment were not done by their primary physicians. The MRD stated they encourage the primary physicians to do the initial visit (initial history and physical assessment) but she was not sure why it was not done. The MRD stated the primary physicians should conduct the residents' initial history and physical assessment.The facility's policy and procedure titled, Physician Visits, dated April 2013, was reviewed. The policy indicated, .The Attending Physician must make visits in accordance with applicable state and federal regulations.Non-physician practitioners )Physician Assistant, Nurse Practitioners) may perform required visits .as permitted by state and federal regulations .

Based on observation, interview, and record review, the facility failed to ensure a resident received appropriate care to prevent complications of enteral feeding (feeding received directly through a tube in the stomach) when one of five residents (Resident 7) reviewed for tube feeding (TF - nutrition provided through a tube inserted into the stomach) was positioned with the head of the bed (HOB) not elevated 30-45 degrees while receiving tube feeding.This failure had the potential for Resident 7 to experience complications from tube feeding, such as aspiration (food or liquid accidentally enter the lungs), nausea, vomiting, or abdominal pain.Findings:On December 8, 2025, at 12:35 p.m., Resident 7 was observed lying in bed, receiving tube feeding nutrition. Resident 7 was observed awake, and unable to communicate. The tube feeding was infusing, and the HOB was observed flat (not elevated between 30 to 45 degrees). On December 8, 2025, at 12:44 p.m., a concurrent observation and interview was conducted with Certified Nursing Assistant (CNA) 5. CNA 5 was observed entering the room of Resident 7 and elevating the HOB position of Resident 7's bed from flat to approximately 30 degrees. CNA 5 stated the HOB of Resident 7 should have been elevated while he was receiving TF. On December 8, 2025, at 2:32 p.m., a concurrent observation and interview was conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 stated she started the TF on Resident 7 at noon on December 8, 2025. LVN 1 stated the HOB should be elevated 30 degrees when the resident receives TF, per facility practice and nursing practice, to prevent aspiration. LVN 1 stated she did not remember if she elevated the HOB of Resident 7 at 30 degrees when she started him on TF. On December 9, 2025, at 6:57 a.m., in an interview with the Director of Nursing (DON), the DON stated the HOB of Resident 7 should have been elevated 30 to 45 degrees while he was receiving TF. On December 11, 2025, at 9:10 a.m., an interview and concurrent record review was conducted with the DON. The DON stated the policies for tube feeding and administering medications through enteral tube were combined under the name Administering Medications through an Enteral Tube, and there was no specific policy only for tube feeding. On December 11, 2025, at 9:32 a.m., a concurrent observation and interview was conducted with Certified Nursing Assistant (CNA) 6. CNA 6 stated Resident 7 was total care, unable to use the bed controls by himself. CNA 6 stated Resident 7's HOB should be elevated between 30-45 degrees while receiving TF. Resident 7's record was reviewed. Resident 7 was admitted to the facility on [DATE], with diagnoses which included muscle wasting and atrophy (degeneration), dysphagia (difficulty swallowing), gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach), pulmonary fibrosis (a lung disease where lung tissue becomes scarred and thickened, resulting in difficulty breathing and shortness of breath), and dementia (a progressive state of decline in mental abilities). Resident 7's physician orders, dated June 20, 2025, indicated, .Keep HOB elevated due to SOB (shortness of breath) when lying flat . Resident 7's physician orders, dated June 20, 2025, indicated, .Enteral feed (TF) order every shift .via GT (gastrostomy tubing)/Enteral Feeding Pump Start Infusion at noon . Resident 7's care plan was reviewed. The care plan, dated December 3, 2025, indicated, .Enteral Medications: Resident requires enteral medications related to swallowing problems .Will minimize risk of complications related to receipt of enteral nutrition such as aspiration, gastric (stomach) distress, nausea/vomiting .HOB elevated to at least 30 degrees . The facility policy titled, Administering Medications through an Enteral Tube,, revised November 2018, indicated .Review the resident's care plan to assess for any special needs of the resident .Assist the resident to semi-Fowler's position (when patient lies on their back with the head of the bed elevated between 30 to 45 degrees) .

Based on observation, interview, and record review, the facility failed to ensure the call light button was functioning properly for one of eight residents reviewed for resident's rights (Resident 188).This failure had the potential for delayed assistance to meet resident needs. Findings:On December 8, 2025, at 11:57 a.m., an observation with a concurrent interview was conducted with Resident 188. Resident 188 was in bed, alert, and interviewable. Resident 188 stated that her call light button hasn't worked since she was admitted last week. She demonstrated by pressing the call light button on to activate the call light, however, the call light signal bulb located outside of Resident 57's door did not turn on.Resident 188 further stated the nurses were aware of her non-functioning call light button and they had to plug and unplug the call light from the wall in order for it to work. Resident 188 stated she had to wait for someone to pass by her door to ask for help, as it was not working.Resident 188 stated she had turned on the call light at one time, but she was unsure if it worked because no one responded. She eventually transferred herself from the bed to the commode unassisted.On December 9, 2025, Resident 188's record was reviewed. Resident 188 was admitted to the facility on [DATE], with diagnoses including absence of right leg below the knee and abnormalities of gait and mobility.The Physician History and Physical, dated December 5, 2025, indicated Resident 1288 had the capacity to understand and make decisions.The Care Plan Report, dated December 3, 2025, indicated, .ADL (Activities of Daily Living - basic self-care tasks like eating, dressing, bathing, using the toilet, and moving around)/Mobility.Resident is at risk for mobility decline and requires assistance related to fluctuating ADLs, pain, recent hospitalization, recent surgery, weakness.Goal.Will have needs anticipated and met by staff.Interventions.Encourage the use of call light for assistance.On December 9 , 2025, at 5:40 a.m., Certified Nursing Assistant (CNA) 1 was interviewed. CNA 1 stated Resident 188 was moved to another room. CNA 1 stated that Resident 188's call light often gets unplugged when they move the bed. CNA 1 stated the call light button stops working when unplugged, and CNAs need to plug it back in.On December 9, 2025, at 6:35 a.m., an interview with a concurrent record review, was conducted with the Maintenance Staff (MS). The MS stated a nurse from the morning shift asked him to fix the call light by Resident 188's previous bed because it was not working so he replaced it this morning. In a concurrent record review, the MS stated the staff should report and document in the Maintenance Logbook located at the nurse station if a call light button needed repair. The MS reviewed the maintenance log by the nurse station, and it did not indicate a report on Resident 188's non-functioning call light button from December 3, 2025 to December 9, 2025. The facility's policy and procedure titled, Maintenance Service, dated December 2009, was reviewed. The policy indicated, .Maintenance Service shall be provided to all areas of the building.functions or maintenance personnel include.assuring that call lights.are in good working order.

Based on observation, interview, and record review, the facility had a medication error rate of 11.11% when three medication errors occurred out of 27 opportunities during the medication administration, for two out of five residents observed (Resident 142 and 159). These failures included administration of an incorrect dosage form (aspirin chewable tablet administered for a delayed-release order) and administration of as-needed pain medication without required pain assessment prior to administering medication, resulting in medications not being administered in accordance with physician orders and the facility's policies and procedures, which had the potential to compromise residents' medication therapy and safety.Findings: 1. During a medication administration observation on December 8, 2025 at 8:38 a.m., Licensed Vocational Nurse (LVN) 1 was observed preparing and administering seven medications to Resident 142, including aspirin (used to prevent blood clots) 81 mg (milligram - unit of measurement) chewable tablet. During a review of Resident 142's medical record on December 8, 2025, the record indicated a physician order for Aspirin Low Dose Oral Tablet Delayed Release (designed to release the drug later after ingestion rather than immediately) 81 mg with directions to give 1 tablet by mouth two times a day for CVA (cardiovascular accident - stroke) PPX (prophylaxis - preventive medication given to prevent a disease) for 35 days, dated November 5, 2025. During a concurrent interview and record review with LVN 1 on December 8, 2025 at 12:37 p.m., LVN 1 reviewed Resident 142's aspirin order, and acknowledged aspirin 81 mg, chewable tablet was administered instead of the ordered delayed-release aspirin. LVN 1 stated the delayed-release tablet is released later in the intestine and the delayed-release tablet of aspirin should have been administered to the resident. During a concurrent interview and record review with the Director of Nursing (DON) on December 10, 2025 at 9:24 a.m., the DON reviewed Resident 142's aspirin order and stated the correct dosage form of medication should be administered as ordered by the physician. A review of the facility's policy and procedures (P&P) titled, Administering Medications, dated April 2019, indicated, .Medications are administered in accordance with prescriber orders.The individual administering the medication checks the label THREE (3) times to verify. right dosage.before giving medication. 2. During a medication administration observation on December 8, 2025 at 8:38 a.m., LVN 1 was observed preparing and administering seven medications to Resident 142, including a tablet of oxycodone (narcotic medication to relieve pain) 5 mg, without assessing or asking the resident's pain level prior to administration. A review of Resident 142's medical record indicated a physician order for Oxycodone 5 mg IR (immediate release) with directions to give 1 tablet by mouth every 4 hours as needed for moderate pain (4-6) and 2 tablets by mouth every 4 hours as needed for severe pain (7-10) for 2 weeks, dated November 21, 2025. A review of Resident 142's medical record titled Medication Administration Record (MAR), dated December 2025, indicated the resident's pain level was documented as 6 with an entry time of 9:14 a.m. for the dose administered on December 8, 2025. A review of Resident 142's medical record titled Care Plan Report, dated November 5, 2025, indicated, .assess pain every shift and as indicated. During a concurrent interview and record review with LVN 1 on December 8, 2025 at 12:37 p.m., LVN 1 confirmed she did not ask or assess Resident 142's pain level prior to administering oxycodone. LVN 1 confirmed she documented the resident's pain level as 6 in the MAR and stated the documented pain level was not based on the resident's verbal report. LVN 1 stated the correct pain management process is to assess the resident's pain level and location prior to medication, administer the medication as ordered, and reassess and document the resident's pain level after medication administration. During a concurrent interview and record review with the Director of Nursing (DON) on December 10, 2025 at 9:24 a.m., the DON reviewed Resident 142's oxycodone order and stated the physician order requires nursing staff to assess the resident's pain level to determine the correct dose. The DON acknowledged that without a pain assessment, nursing staff cannot determine whether one or two tablets should be administered, and the medication would not be administered in accordance with the physician's order. 3. During a medication administration observation on December 8, 2025 at 9:21 a.m., LVN 1 was observed preparing and administering eight medications to Resident 159, including a tablet of oxycodone 5 mg, without assessing or asking the resident's pain level prior to administration. A review of Resident 159's medical record indicated a physician order for Oxycodone 5 mg with directions to give 1 tablet by mouth every 6 hours as needed for severe pain (7-10), dated November 25, 2025. A review of Resident 159's Medication Administration Record (MAR), dated December 2025, indicated the pain level was documented as 7 with an entry time of 9:50 a.m. for the dose administered on December 8, 2025. A review of Resident 159's medical record titled Care Plan Report, dated November 12, 2025, indicated, .assess pain every shift and as indicated. During a concurrent interview and record review with LVN 1 on December 8, 2025 at 12:37 p.m., LVN 1 confirmed she did not ask or assess Resident 159's pain level prior to administering oxycodone. LVN 1 confirmed she documented the resident's pain level as 7 in the MAR and stated the documented pain level was not based on the resident's verbal report. LVN 1 stated the correct pain management process is to assess the resident's pain level and location prior to medication, administer the medication as ordered, and reassess and document the resident's pain level after medication administration. During a concurrent interview and record review with LVN 2 on December 11, 2025 at 10:40 a.m., LVN 2 reviewed Resident 142's oxycodone order and Resident 159's oxycodone order and stated the medications should be administered according to the physician's order, and assessing the resident's pain level is required as part of as-needed pain medication order to administer the appropriate pain medication and dose, as ordered by the physician. A review of the facility's P&P titled, Administering Pain Medications, dated April 2025, indicated, .procedure is to provide guidelines for assessing the resident's level of pain prior to administering analgesic pain medication.Pain management is a multidisciplinary process that include the following: identifying signs and symptoms of and assessing existing pain; recognizing situations and conditions with the potential for pain; identifying the underlying causes, intensity, duration, type, and characteristics of pain.implementing approaches to pain management based on accepted standards of practice.Conduct a pain assessment as indicated.Administer pain medications as ordered. A review of the facility's P&P titled, Pain Assessment and Management, dated April 2025, indicated, .procedure to help the staff identify pain in the resident.Ask the resident if he/she is experiencing pain.During the pain assessment, gather the following information, as indicated, from the resident.characteristics of pain, including: location; intensity (as measured on a standardized pain scale); description (e.g., aching, burning, rushing, numbness, etc.); pattern (e.g., constant or intermittent); and frequency, timing, and duration.Monitor the resident by performing a basic assessment with enough detail and as needed, with standardized assessment tools (e.g., approved pain scales, etc.) and relevant criteria for measuring pain management (e.g., target signs and symptoms).

Based on observation, interview, and record review, the facility failed to ensure a written copy of the baseline care plan (documented information indicating the resident's initial goals for stay, summary of current medication, dietary instructions and the services and treatments to be provided or arranged by the facility) was provided to one of eight residents reviewed for Care Planning (Resident 188).This failure resulted in Resident 188 to not fully understand, due to the lack of information, the treatments and services being provided by the facility to meet her needs during her stay. Findings:On December 8, 2025, at 11:57 a.m., an observation with a concurrent interview was conducted with Resident 188. Resident 188 was in bed, alert, and conversant. Resident 188 stated she was admitted to the facility last week after a right below the knee amputation surgery. Resident 188 stated she had no idea about her discharge plan or the plan of care during her stay and she did not even know who to ask about it. Resident 188 further stated she did not receive a written copy of her baseline care plan and did not recall discussing it with facility staff.On December 9, 2025, Resident 188's record was reviewed. Resident 188 was admitted to the facility on [DATE], with diagnoses including absence of right leg below the knee and abnormalities of gait and mobility.The Physician History and Physical, dated December 5, 2025, indicated Resident 188 had the capacity to understand and make decisions.The document titled, Baseline Care Plan Person-Centered Care Planning, completed by a licensed nurse, dated December 3, 2025, indicated, .NURSING SERVICES.Cognition.Alert/cognitively intact.Reason(s) for Nursing Services.ADLS (Activities of Daily Living - basic self-care tasks like eating, dressing, bathing, using the toilet, and moving around).PT (Physical Therapy)/OT (Occupational Therapy) Management.The Section E. Baseline Care Plan Summary, Section did not indicate if the Resident or Resident Representative participated in the Baseline Care plan review with a printed /written summary provided. On December 10, 2025, at 9:23 a.m., an interview with a concurrent record review was conducted with Director of Social Services (DSS). The DSS stated they conducted a baseline care plan discussion with Resident 188 on December 3, 2025, and they did not provide a written copy of the baseline care plan. The DSS stated the facility usually did not give a copy of the baseline care plan to the residents.The facility's policy and procedure titled, .Care Plans-Baseline, dated December 2016, was reviewed. The policy indicated, .A baseline plan of care to meet the resident immediate needs shall be developed for each resident within forty eight (48) hours of admission .The resident and their representative will be provided a summary of the baseline care plan that includes but it not limited to .The initial goals of the resident .A summary of the resident's medications , and dietary instructions .Any services and treatments to be administered by the facility and personnel .acting on behalf of the facility .

Based on observation, interview, and record review, the facility failed to maintain a safe environment and provide adequate supervision to prevent accidents for one resident reviewed (Resident 2) when smoking materials were observed at Resident 2's bedside.This failure had the potential for environmental risk, hazards and accidents including fire and/or burn injuries.Findings:On December 9, 2025, at 5:53 a.m., Resident 2 was observed sitting in his motorized wheelchair, well groomed, alert and interviewable with a red carton of cigarettes between his legs. Resident 2 stated he kept his cigarettes with him at bedside.On December 9, 2025, at 7:50 a.m., Resident 2 was observed in his room and a clear yellow lighter was observed on Resident 2's bedside table. Resident 2 stated he kept his cigarettes and lighter with him at bedside.On December 9, 2025, at 7:55 a.m., a concurrent interview and record review was conducted with the Activity Director (AD). The AD stated the facility process is for the activity department to keep the residents' cigarettes and lighters and distribute the residents' cigarettes and lighter during smoke breaks. The AD stated residents were not allowed to keep smoking materials at bedside.On December 10, 2025, at 11:22 a.m., a concurrent interview and record review was conducted with the Director of Nursing (DON). The DON stated the facility process was for all smoking material to be kept with the activity department. The DON further stated residents were not to have smoking materials at bedside and Resident 2 should not have had smoking materials at his bedside.Resident 2's medical record was reviewed.Resident 2 was admitted to the facility on [DATE], with diagnoses which included hypertension (high blood pressure), and congestive heart failure (heart can not pump enough oxygen rich blood to meet the body's needs).The history and physical completed November 13, 2025, indicated Resident 2 had the capacity to make decisions.The smoking assessment dated [DATE], indicated Resident 2 denied smoking or use of tobacco products.A review of the facility policy and procedures titled Smoking Policy, revised September 2014, indicated .no lighting materials (e.g., matches, lighters), tobacco products, or smoking devices will be allowed to be kept in the possession of the resident, either on their person or in their room.All smoking materials will be retained by staff.

Based on observation, interview, and record review, the facility failed to ensure medications were administered in accordance with professional standards of practice for one out of five residents (Resident 159) observed during medication administration. The failure to clarify incomplete physician orders, including a Vitamin D3 (supplement) order without a specified dose and a Toprol XL (metoprolol succinate extended release - medication for high blood pressure) order with an inappropriate holding parameter of hold if HR (heart rate) <110, resulted in unsafe medication orders for Resident 159. Findings: During a medication administration observation on December 8, 2025 at 9:21 a.m., Licensed Vocational Nurse (LVN) 2 was observed preparing and administering medications to Resident 159. 1. During a review of Resident 159's clinical record on December 8, 2025, the record indicated a physician order of Vitamin D3 (Cholecalciferol - supplement), give 1 (one) capsule by mouth one time a day every Thu (Thursday) for supplement, dated November 25, 2025. The order did not specify the medication strength. During a review of Resident 159's medical record titled Medication Administration Record (MAR), for the month of November and December 2025, the MAR indicated vitamin D3 was administered to Resident 159 on November 27, 2025 and December 4, 2025, at 9 a.m. During a concurrent interview and record review with LVN 1 on December 8, 2025 at 12:55 p.m., LVN 1 reviewed Resident 159's vitamin D3 order and confirmed the strength was missing. LVN 1 showed a medication bubble card for Resident 159 labeled vitamin D2 (supplement) 1.25 mg (milligram - unit of measurement) (50,000 units - unit of measurement) filled by the pharmacy on November 25, 2025, with directions to take one capsule by mouth one time a day every Monday for supplement and stated this was the only vitamin D medication available in her medication cart. LVN 1 stated the dose for vitamin D3 should have been clarified to determine which strength to administer to the resident every Thursday. During a concurrent interview and record review with the Director of Nursing (DON) on December 11, 2025, at 3:15 p.m., the DON reviewed Resident 159's vitamin D3 order and stated the expectation for nursing staff is to clarify unclear physician orders, including missing medication strength, upon receipt of the order or prior to medication administration. A review of the facility's policy and procedure (P&P) titled, Medication Administrations, dated April 2019, indicated, .The individual administering medication checks the label THREE (3) times to verify.right dosage.before giving the medication. 2. During a review of Resident 159's clinical record on December 8, 2025, the record indicated a physician order of Toprol XL Oral Tablet Extended Release 24 Hour 100 MG, give 1 (one) tablet by mouth one time a day for HTN (hypertension, high blood pressure), hold if SBP (systolic blood pressure - top number in a blood pressure reading)<110 HR <110, dated November 26, 2025. During a review of Resident 159's medical record titled MAR for December 2025, the MAR indicated the resident's HR was less than 110, and the SBP was greater than 110, and Toprol XL was administered daily to the resident. During a concurrent interview and record review with LVN 1 on December 8, 2025 at 2:42 p.m., LVN 1 reviewed Resident 159's Toprol XL order, acknowledged the resident's heart rate had been less than 110, and confirmed the medication had been administered daily. LVN 1 stated the holding parameter related to heart rate was inappropriate and should have been clarified. During a concurrent interview and record review with the Director of Nursing (DON) on December 10, 2025, at 9:24 a.m., the DON reviewed Resident 159's Toprol XL order and stated the holding parameter of HR <110 was incorrect. The DON stated the expectation for nursing staff is to clarify unclear physician orders, including inappropriate holding parameters, upon receipt of the order or prior to medication administration. During a concurrent interview and record review with LVN 2 on December 11, 2025, at 10:40 a.m., LVN 2 stated physician's medication order is electronically transmitted to the pharmacy, and nursing staff additionally fax the physician's orders to the pharmacy for pharmacy verification. LVN 2 stated if there is a concern with a physician's order, the pharmacy contacts the facility to clarify the order. LVN 2 stated the expectation for nursing staff is to clarify unclear physician's orders. A review of the facility's P&P titled, Medication Administrations, dated April 2019, indicated, .If.a medication has been identified as having potential adverse consequences for the resident.the person preparing or administering the medication will contact the prescriber, the resident's attending physician or the facility's medical director to discuss the concerns. A review of the facility's P&P titled, Medication Orders, Prescriber Medication Orders, dated August 10, 2023, indicated, .Medications are administered only upon clear, complete, and signed order. Medication orders specify the following.Strength of medication.Dosage.Any dose of order that appears inappropriate considering the resident's age, condition, or diagnosis is verified with the attending physician before processing.

Based on observation, interview, and record review, the facility failed to ensure a care plan was initiated and/or developed to address the need and use of indwelling foley catheter ((flexible tube inserted into the bladder to drain urine) for one of two residents reviewed for foley catheter use (Resident 57).This failure has the potential to place Resident 57 at high risk for infection and complications related to foley catheter use. Findings:On December 8, 2025, an observation with a concurrent interview was conducted with Resident 57. Resident 57 was in bed, alert and interviewable. Resident 57 was observed to have a foley catheter with a covered urine drainage bag hanging by the bed and off the floor. In a concurrent interview, Resident 57 stated she had been using the foley catheter since she was admitted to the facility in November 2025.On December 10, 2025, Resident 57's record was reviewed. Resident 57 was admitted to the facility on [DATE], with diagnoses including obstructive reflux uropathy (condition blocked urine flow, causing backup and potential kidney damage).The physician order dated November 11, 2025, indicated, .Foley catheter 16# 10 cc bulb (foley catheter size) attached to gravity drainage bag.DX (diagnosis) of urinary retention.There was no documented evidence a care plan was developed or initiated to address the need and use of a foley catheter for Resident 57 since her admission in November 11, 2025. On December 10, 2025, at 11:45 a.m., an interview was conducted with the Director of Nursing (DON). The DON stated Resident 57 did not have a care plan developed to address the use of a foley catheter. The DON stated that the care plan ensures staff and residents were informed about care procedures and interventions to prevent complications from foley catheter use. The DON stated that without a care plan, the staff won't be able to identify potential issues or properly care for the resident. The facility's policy and procedure titled, Care Plans, Comprehensive Person Centered, dated December 2016, was reviewed. The policy indicated, .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is develops and implemented for each resident .The Interdisciplinary Team, in conjunction with the resident and his/her family or legal representatives, develop and implement a comprehensive, person-centered plan for each resident .The care plan interventions are derived from thorough analysis of the information gathered .The comprehensive, person-centered care plan will .include measurable goals and objectives .Describe the services that are to be furnished to attain or maintain the resident's highest practicable, physical, mental, and psychosocial well-being .Incorporate identified problem areas .Incorporate risk factors associated with identified problems .Reflect the treatment goals, timetables, and objectives in measurable outcomes .The facility's policy and procedure titled, Indwelling catheter Care, Urinary, dated September 2014, was reviewed. The policy in indicated,.The purpose of this procedure is to prevent catheter- associated urinary tract infections.Review the resident's care plan to assess for any special needs of the resident.

Based on observation, interview, and record review, the facility failed to ensure safe and effective pharmaceutical services were provided to meet the needs of the residents when: 1. For Resident 66, medications were left unattended during medication administration.This failure had the potential for medication misuse, contamination, or access by unauthorized individuals, including residents, staff, or visitors. 2. For Resident 142, as-needed controlled substance (CS - medication with high potential for abuse and addiction) pain medication was not administered according to the physician's order.This failure had the potential to result in inadequate pain management, prolonged pain, and unnecessary discomfort for the residents. 3. For two out of nine randomly selected residents (Resident 4 and 142), documentation on Controlled Drug Record (CDR - medication count sheet, an inventory record used to document the receipt, use, and count of CS) did not reconcile with Medication Administration Record (MAR).These failures resulted in inaccurate accountability of controlled substances, which had the potential for misuse or diversion (medication taken by someone other than for whom it is prescribed) of controlled substances. Findings: 1. During a medication pass observation on December 9, 2025 at 8:28 a.m., Licensed Vocational Nurse (LVN) 5 was observed preparing two medications for Resident 66, including folic acid (supplement) and gabapentin (medication for nerve pain). LVN 5 entered the resident's room with the prepared medications on a medication tray and a blood pressure machine with an attached cuff and placed the medication tray on a bedside table away from the resident's bed. LVN 5 drew the privacy curtain and measured the resident's blood pressure, during which time the medication tray remained outside the curtain and out of the nurse's direct observation. After completing the blood pressure measurement, LVN 5 retrieved the medication tray and administered the medications to the resident. During an interview with LVN 5 on December 9, 2025 at 11:56 a.m., LVN 5 confirmed the prepared medications were left unattended and out of his direct observation while he was checking Resident 66's blood pressure. LVN 5 acknowledged the unattended medications could have been accessed by other residents, visitors, or staff. During an interview with Licensed Vocational Nurse (LVN) 2 on December 11, 2025, at 10:40 a.m., LVN 2 stated the medication tray containing medications should always remain under the nurse's control during medication administration. During an interview with the Director of Nursing (DON) on December 11, 2025 at 3:15 p.m., the DON stated medications should not be left unattended during medication administration. A review of the facility's policy and procedures (P&P) titled, Administering Medications, dated April 2019, indicated, .During administration of medications.no medications are kept on top of the cart.must be clearly visible to the personnel administering medications, and.must be inaccessible to residents or others passing by. 2. During a review of Resident 142's medical record on December 8, 2025, the record indicated a physician order for Oxycodone (controlled substance for pain) 5 mg (milligram - unit of measurement) IR (immediate release) with directions to give 1 tablet by mouth every 4 hours as needed for moderate pain (4-6) and 2 tablets by mouth every 4 hours as needed for severe pain (7-10) for 2 weeks, dated November 21, 2025. During a review of Resident 142's medical record titled, Medication Administration Record (MAR), dated November and December 2025, the MAR indicated on November 22, 2025, the resident's pain level was documented as 8, with an entry time of 3:27 a.m. In addition, the resident's pain level was documented as 7 on December 6, 2025, with an entry time of 1:29 p.m., and on December 8, 2025, with an entry time of 1:20 a.m. For all three dates, nursing staff administered oxycodone 5 mg, one tablet, despite the physician's order indicating two tablets for pain levels 7-10. During a review of Resident 142's medical record titled, Medication Count Sheet (controlled drug record, CDR), for oxycodone 5mg tablet, the documentation on the CDR indicated one tablet was removed on November 22, 2025, at 3:27a.m., and December 6, 2025, at 1:29 p.m., consistent with the documentation on the MAR. However, for the administration on December 8, 2025, at 1:20 a.m., the CDR lacked documentation indicating removal of one tablet, despite the medication being documented as administered on the MAR. During a concurrent interview and record review with DON on December 10, 2025, at 9:24 a.m., DON reviewed Resident 142's oxycodone order and confirmed the medication was not administered in accordance with physician's order on dates when the resident's pain level was documented as severe. A review of the facility's P&P titled, Administering Medications, dated April 2019, indicated, .Medications are administered in accordance with prescriber orders.The individual administering the medication checks the label THREE (3) times to verify.the right dosage.before giving the medication. 3a. During a review of Resident 142's MAR and the CDR, dated December 2025, the MAR indicated one tablet of oxycodone 5 mg was administered on December 8, 2025, at 1:20 a.m. However, for this administration, the CDR lacked documentation indicating removal of one tablet, despite the medication being documented as administered on the MAR. During a concurrent interview and record review with the DON on December 10, 2025, at 9:24 a.m., the DON confirmed discrepancies between the CDR and the MAR, including missing CDR documentation for administration documented on December 8, 2025 at 1:20 a.m. 3b. During an inspection of Medication Cart 1A with LVN 6 on December 10, 2025 at 2:27 p.m., blister cards containing controlled substance were randomly selected from the medication cart and reviewed to verify accurate documentation of administration and accountability. Resident 4's record was concurrently reviewed with LVN 6. Resident 4 had a physician's order, dated July 15, 2025, for oxycodone-acetaminophen (a controlled substance for pain) 5-325 mg, one tablet by mouth every four hours as needed for severe pain 7-10. Resident 4's oxycodone-acetaminophen 5-325 mg CDR and December 2025 MAR were reviewed. LVN 6 confirmed the Resident 4's CDR the nursing staff removed and signed out one tablet of oxycodone-acetaminophen 5-325 mg on December 3, 2025 at 11:30 pm., but it was not documented as administered on the MAR. During a concurrent interview and record review with LVN 2 on December 11, 2025, at 10:40 a.m., LVN 2 stated the controlled substance administration process requires nursing staff to remove the controlled substance from the medication cart, document the removal on the CDR, and document the administration in the MAR after administration. During a concurrent interview and record review with the DON on December 11, 2025, at 3:15 p.m., the DON confirmed discrepancies between the CDR and the MAR, including missing MAR documentation for oxycodone-acetaminophen 5-325 mg, despite the CDR indicating one tablet was removed on December 3, 2025 at 11:30 pm. A review of the facility's P&P titled, Administering Medications, dated April 2019, indicated, .The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. As required or indicated for a medication, the individual administering medication records in the resident's medical record: the date and time the medication was administered.the signature and title of the person administering the drug.

Based on interview and record review, the facility failed to provide copies of medical records upon request and within two business days after receiving the request from an attorney on behalf of the resident, for one of two residents reviewed, Resident 1.This failure resulted in Resident 1's legal representative not receiving the requested records within the two working day timeframe.Findings:A review of Resident 1's medical record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included respiratory failure (a condition where the lungs are unable to get enough oxygen into the blood) and type 2 diabetes mellitus (high blood sugar). Further review of the medical record indicated Resident 1 was transferred out to the general acute care hospital on June 24, 2025, and did not return to the facility.On November 13, 2025, at 12:20 p.m., during an interview and record review of medical record requests, the Director of Medical Records (DMR) stated a resident, or their Power of Attorney (a person who have been legally authorized to act on another person's behalf in legal, financial, or medical matters) can request for medical records by completing an Authorization for Use or Disclosure of Protected Health Information form. The DMR stated it takes 24 hours to pull a resident's complete chart from PointClickCare (an electronic health record used by the facility). The DMR stated they have 30 days to fulfill a medical record request. The DMR stated when she receives a medical record request from a law firm or a subpoena, she forwards the request to their legal department. The DMR stated she keeps a folder of medical record requests she received from law firms. The DMR provided the folder, and it included a letter from Resident 1's attorney.A review of the letter sent by Resident 1's attorney dated October 1, 2025 indicated .Please be advised that this office represents (name of Resident 1) .we are requesting copies of (name of Resident 1) .records . Attached to the letter was an Authorization for Use or Disclosure of Protected Health Information that indicated the facility was authorized to release to (name of attorney) all health information pertaining to Resident 1's medical history, mental or physical condition and treatment received and it was signed by Resident 1's family member on August 30, 2025.The DMR stated she received the letter from Resident 1's attorney and sent it to the legal department on October 6, 2025, via email. The DMR stated the legal department retained an attorney for this request. The DMR stated she uploaded Resident 1's entire medical record to a secure link provided by the legal department on November 10, 2025, and had no further communication regarding the release of the records . The DMR stated it was up to the legal department to release Resident 1's medical records. The DMR stated it had been more than 30 days since the record request was received.On November 13, 2025, at 1:29 p.m., during an interview, the Director of Nursing (DON) stated the DMR handled medical record request and if it was for legal matters, the DMR sends it to their legal department. The DON state she does not know if their legal department should follow their policy.On November 13, 2025, at 2:20 p.m., during an interview, the DON stated the DMR does not have the responsibility to fulfill the medical record request of Resident 1's attorney because she already sent it to their legal department. The DON called their Nurse Consultant (NC) on speaker phone. The NC stated the facility's policy indicated they have 30 days to release the medical record if the request came from a law firm. The NC stated the DMR should release the medical record of Resident 1 and should only notify the legal department of the request.A review of the facility's policy and procedure Release of Information dated April 1, 2020, indicated .The resident may initiate a request to release such information contained in his/her records and charts to anyone he/she wishes. Such requests will be honored only upon the receipt of a written, signed and dated request from the resident or representative .non-personnel representative such as legal firms may have access to his/her records within 30 days of written request .

Based on interview and record review the facility failed to ensure that residents maintained acceptable parameters of nutritional status and maintained proper hydration and health. This failure occurred for two of six sampled residents (Residents A and C) when both Residents A and C had measurable weight loss that resulted in transfer to the general acute care hospital for evaluation and treatment. This failure resulted in the overall decline in the Residents A and C's physical well-being. Findings: On [DATE], at 12:55 p.m., an unannounced visit was conducted at the facility for the investigation of two complaints. On [DATE], Resident A's facility medical record was reviewed. The resident was [AGE] years old and was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident A's facility Minimum Data Set, (MDS- standardized assessment for the management of care), dated [DATE], indicated a BIMS, (brief interview for mental status- screening tool to assess mental capability) score of 6 out of 15 (scores ,d+[DATE] indicates severe impairment). Review of Resident A's facility document titled, Order Summary Report, indicated an order dated [DATE], to Monitor Meals three times a day. Review of Resident A's document titled, Weights and Vitals Summary, indicated the following weights for the resident: - [DATE]- 195 pounds - [DATE]- 194 pounds - [DATE]- 192 pounds - [DATE]- 157 pounds - [DATE]- 150 pounds A review of a facility care plan for Resident A, dated [DATE], indicated, Focus: Resident with nutritional risk r/t (related to) general weakness, obesity, therapeutic diet r/t DM2 (type 2 diabetes mellitus- chronic condition that affects the way the body processes blood sugar), and [CONDITION(S)] (hypertension- high blood pressure) dx (diagnosed ) AEB (as evidence by) current weight 195.0# (pounds) . The care plan dated [DATE], further indicated, Goal: Resident will maintain stable weight, adequately hydrated and nourished, no skin b/d (breakdown) through next review date. The care plan indicated it was initiated on [DATE]. The facility care plan for Resident A, dated [DATE], indicated the following interventions: - Diet as ordered . - Document and report MD (medical doctor) if significant weight change - Monitor intake with each meal - Monitor weight per facility protocol - Offer/provide substitutions if intake below 50% per resident's acceptance/request - Provide assistance with meals a (sic) needed - RD (registered dietician)/DSS (dietary staff supervisor) to review and reassess as needed for additional interventions - Supplements as ordered. Further review of Resident A's care plans indicated that the facility failed to revise or update Resident A's care plan with new or modified interventions to address the resident's significant, continuous weight loss. No new interventions were implemented to prevent further weight loss. Review of a facility care plan for Resident A, dated [DATE], indicated, Resident at risk for electrolytes (sic) imbalance (abnormality in the concentration of salt, potassium, and calcium in the body) and dehydration r/t (related to) diuretics (substance that promotes increased production of urine), hx (history) of dehydration . Review of Resident A's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The document further indicated, Full Treatment-primary goal of prolonging life by all medically effective means. Review of Resident A's facility document titled, Nutritional Risk Assessment (Admission/Annual), dated [DATE], indicated, Nutrition Goals/Monitoring and Evaluation: -Altered nutritional needs r/t medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .Current diet order appropriate for medical dx (diagnosis). PO (by mouth) intake appears to n=be (sic) adequate per estimated needs. Goals: Stable weight, adequately hydrated and nourished .Monitored: Weight, PO intake . Review of Resident A's document titled Weights and Vitals Summary, indicated that the resident was weighed on [DATE], and his weight was documented as 157 lbs (pounds). This was a 35 pound weight loss from his previous weight on [DATE], which indicated his weight was 192 lbs. A review of Resident A's ADL (activities of daily living) Sheet, for the month of [DATE], was conducted. In the section titled, Amount Eaten it was documented by a number to represent the percentage of food consumed by Resident A. The document indicated the following percentage by number: - 0 = 0 - 1 = 0 - 25% - 2 = 26% - 50% - 3 = 51% - 75% - 4 = 76%-100% - RR = Resident Refused - RU = Resident Unavailable The ADL documentation indicated for Resident A's food consumption daily by meal: - [DATE]: Breakfast (B) -Blank, Lunch (L) -Blank, Dinner (D)- 3. - [DATE]: B -RU, L-RU, D-2. - [DATE]: B- 2, L- 2, D-Blank. - [DATE]: B- 3, L- 2, D-2. - [DATE]: B- Blank, L- Blank, D-1. - [DATE]: B- 3, L- 1, D-2. - [DATE]: B- 2, L- 2, D-0. - [DATE]: B- 3, L- 2, D-2. - [DATE]: B- 2, L- 2, D-2. - [DATE]: B-RR, L- 1, D-1. Review of a facility progress note for Resident A, dated [DATE], indicated, Nutrition Narrative Note: RD Note for Weight Change: Resident noted with significant weight loss as follows: Comparison Weight [DATE], 195.0 Lbs, (pounds) -19.5%, -38.0 Lbs. Comparison Weight [DATE], 192.0 Lbs, -18.2%, -35.0 Lbs. RD Recommendation: -Re-weigh resident. Further review of Resident A's facility record identified that the Nutrition Narrative Note, dated [DATE], was the first progress note to document acknowledgement of Resident A's significant weight loss. A review of Resident A's facility document titled, Order Summary Report, indicated an order dated [DATE], to re-weight (sic) resident for updated info. Further review of Resident A's, ADL documentation for meal intake indicated the following: - [DATE]: B- 1, L- 1, D-2. - [DATE]: B- 2, L- 2, D-2. - [DATE]: B- 2, L- 2, D-2. - [DATE]: B- 2, L- 2, D-2. - [DATE]: B- 1, L- 1, D-3. - [DATE]: B- Blank, L- Blank, D-3 . A facility progress note for Resident A, dated [DATE], titled Nurse Practitioner Note, was reviewed. In review of the progress note, no documentation was identified that indicated the nurse practitioner had been informed of Resident A's significant weight loss. No change of condition was documented that indicated the facility staff had reported the resident's 38 lb. weight loss. There was no documentation that indicated the nurse practitioner or MD had been informed of the Resident A's poor meal intake. Review of the Resident A's Weights and Vitals Summary, indicated that Resident A was not re-weighed until [DATE], where it documented his weight as 150 lbs. As of [DATE], the resident had lost an additional 7 lbs., for a total weight loss of 45 lbs. in less than one month. Resident A's weight loss was documented in the Focus section of his care plan as, [DATE] Current wt (weight): 150# (pounds) -7# (7 pound loss)/4.4% (4.4 percent loss in weight) X (in) 1 wk (week). Review of a facility progress note for Resident A, dated [DATE], indicated, Nutrition Narrative Note: RD Note for Weight Change: Significant weight loss since admission: Comparison Weight [DATE], 195.0 Lbs, -23.1%, -45.0 Lbs. Comparison Weight [DATE], 157.0 Lbs, -4.5%, -7.0 Lbs. Resident A's progress note dated [DATE], further indicated, Resident with CHF (congestive heart failure- the heart muscle does not pump blood well), Heart disease, [CONDITION(S)] (potentially life-threatening condition caused by the body's response to an infection), DM2 (type 2 diabetes mellitus- chronic condition that affects the way the body processes blood sugar), and pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin). Variable PO (by mouth) intake mostly ,d+[DATE], ,d+[DATE]% with some refusals. The progress note for Resident A further indicated, Weight loss likely r/t (related to) current medical dx (diagnosis), diuretic use 40 mg (milligram) tab QD (every day), and low PO intake. The progress note indicated, RD recommendations: -Diabetic snacks three times a day -Medpass (supplement drink for those at high risk for malnutrition) 120 ml (milliliter) QS (every shift) -[MEDICATION(S)] (Vitamin C-essential nutrient involved in the repair of tissue) 500 mg BID (twice a day) -Prostat (liquid protein for pressure ulcers, wounds, critical illness, and other conditions requiring increased protein) 30 ml TID (three times a day) -[MEDICATION(S)] (mineral for the growth and development and of body tissue) one tablet QD. A review of Resident A's facility progress note dated [DATE], indicated, Nutrition Narrative Note: Resident noted with significant weight changes. Current wt: 150# -7#/4.4% X 1 wk. MD/RP (responsible party) made aware. To follow dietary recommendations discussed by IDT (Interdisciplinary Team - a group of staff members with different professional backgrounds) during weight variance (meeting between department heads to discuss residents with weight loss). After review of Resident A's facility record, it was determined that neither the physician nor the resident's stepdaughter/conservator were notified of Resident A's significant weight loss until [DATE], nine days after the significant weight loss of 38 pounds was initially documented, and three days after his weight was documented with an additional seven pound loss on [DATE], at 150 lbs. The record further indicated the physician, nor the conservator had been informed of Resident A's poor oral intake until [DATE]. Review of a facility progress note for Resident A, dated, [DATE], at 4:04 p.m., indicated, Nutrition Narrative Note: Per DON (Director of Nursing) spoke with conservator and requested labs (name of physician) made aware order CBC, CMP and TSH (laboratory tests for blood and body functions) d/t wt loss, ST (speech therapy) evaluation and treatment indicated d/t noted patient pocketing his food and start w/ [MEDICATION(S)] (medication used to treat depression) 15 mg QHS (every night) for depression m/b poor appetite. A facility progress note for Resident A, dated [DATE], at 4:48 p.m., indicated, Resident alert and oriented X1 noted much quieter than before resident is not talking or expressing needs any more, staff reported resident has been sliding from w/c (wheelchair) so he is positioned in bed for comfort and safety, resident has been refusing to eat has very poor intake. On [DATE], resident's wt was 195.lbs and he gradually and progressively continues to loose (sic) wt, On [DATE], resident's wt was 150.Lbs .Call (sic) resident Daughter and conservator (name) to give an update on resident's condition. MD made aware. A facility progress note for Resident A, dated [DATE], at 7:39 p.m., indicated, pt was noted drowsy, sleeping mostly all the time and poor intake. MD call and aware; MD gave new order to D/C (discontinue) [MEDICATION(S)] 1mg (ordered for Resident's anxiety on [DATE]). Review of a facility progress note for Resident A dated [DATE], at 6:17 p.m., indicated, Patient was transfer out via 911, via gurney with 4 EMTs (emergency medical technicians) due to low BP (blood pressure) result, and lethargic; paramedic came, and assess (sic) the patient; IV (intravenous therapy-medical technique that delivers a liquid directly into the vein) hydration started . Review of Resident A general acute care hospital record titled, Emergency Provider Report, dated [DATE], indicated, History of Present Illness: .He appeared emaciated and dehydrated. He was fluid resuscitated w/ (with) a large bolus (fluids given through an IV) and emergently intubated (medical procedure involving the insertion of a tube inserted into the windpipe to assist with breathing when a person cannot breathe on their own) for airway protection . Resident A's hospital Emergency Provider Report, further indicated, Physical Exam: Constitution: Frail and cachectic (general state of ill health involving marked weight loss and muscle loss) older man .ENT (ears, nose and throat): Mucous membranes dry . Further Review of Resident A's Emergency Provider Report, indicated the following laboratory results, dated [DATE]: - sodium: 167 (normal range ,d+[DATE]). - chloride: 133 (normal range ,d+[DATE]). The record indicated that this result was high. - BUN: (Blood Urea [MEDICATION(S)] -measurement of the chemical urea (waste product that is excreted by the kidneys and measured in the blood). 104 (normal range ,d+[DATE]). The record indicated that this result was high. - creatinine: (waste product produced by muscles removed from the body by the kidneys) result was 38.5 (normal range 0.,d+[DATE].3) The record indicated that this result was high. A review of Resident A's hospital record titled, Critical Care Consult Note, dated [DATE], indicated, Diagnosis, Assessment, and Plan: .Hypovolemic shock (life-threatening condition that results when the body loses more than 20 percent (one-fifth) of the body's blood or fluid supply) and severe dehydration (occurs when the body loses more fluid than it takes in and does not have enough water to carry out normal functions), acute kidney injury (kidneys suddenly stop working properly), severe [CONDITION(S)] (high concentration of sodium in the blood caused when not enough water is consumed), and severe protein calorie malnutrition . Review of Resident A's hospital record titled, Height Weight Group, indicated the following weights for the resident: - [DATE] at 6:37 p.m.- 110.0 lbs. - [DATE] at 5:37 a.m.- 158.6 lbs. - [DATE] at 6:00 a.m.- 172.9 lbs. - [DATE] at midnight -172.0 lbs. - [DATE] at 2:00 a.m.- 172.7 lbs. - [DATE] at 4:00 a.m.- 172.7 lbs. A review of Resident A's hospital record titled, Discharge Summary, dated [DATE], indicated, .Per ED note .Found obtunded (slowed response to stimulation) and hypoxic (absence of enough oxygen in the tissues to sustain bodily functions) in bed at SNF on [DATE] .Fluid resuscitation started, intubated, free water deficit reportedly 4.8 L (liters) .[DATE] Resident A was terminally extubated (withdrawal of mechanical ventilation from critically ill patients who are not expected to survive without respiratory support). The record further indicated Resident A died on [DATE], at 4:30 p.m. On [DATE], Resident C's facility medical record was reviewed. The resident was [AGE] years old and was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident C's facility document titled Order Summary Report, indicated an order dated [DATE], to Monitor Diet Meals three times a day. Review of Resident C's document titled, Weights and Vitals Summary, undated, indicated the following weights for the resident: - [DATE]- 180 pounds - [DATE]- 161 pounds - [DATE]- 157 pounds - [DATE]- 152 pounds - [DATE]- 150 pounds - [DATE]- 152 pounds - [DATE] and [DATE]- 148 pounds - [DATE]- 143 pounds - [DATE]- 136 pounds A review of a facility care plan dated [DATE], for Resident C indicated, Focus: Resident with nutritional risk r/t (related to) general weakness, variable PO (by mouth) intake. The care plan further indicated, Goal: Will have no significant weight loss through next review. The facility care plan for Resident C indicated the following interventions dated [DATE]: -Diet as ordered -Document and report MD if significant weight change -Encourage intake of ,d+[DATE]% -Monitor intake with each meal -Monitor weight per facility protocol -Nourishment as ordered -Offer/provide substitutions if intake below 50% per resident's acceptance/request -Provide assistance with meals a (sic) needed -RD/DSS (dietary staff supervisor) to review and reassess as needed for additional interventions -Supplements as ordered A review of Resident C's facility History and Physical (H&P), dated [DATE], indicated, This resident has the capacity to understand and make decisions. A review of Resident C's facility document titled, Nutritional Risk Assessment (Admission/Annual), dated [DATE], indicated, Nutrition Goals/Monitoring and Evaluation: .PO intake of meals and snacks adequate per estimated needs. No new nutrition interventions at this time. Will continue to monitor and provide interventions as needed. Goals: Stable weight, PO intake adequate per estimated needs .Monitor: Weight trends, PO intake, hydration . A review of Resident C's ADL (activities of daily living) Sheet, for the month of [DATE], was conducted. In the section titled, Amount Eaten it was documented by a number to represent the percentage of food consumed by Resident C. The document indicated the following percentage by number: - 0 = 0 - 1 = 0 - 25% - 2 = 26% - 50% - 3 = 51% - 75% - 4 = 76%-100% - RR = Resident Refused - RU = Resident Unavailable The ADL documentation indicated for Resident C's food consumption daily by meal: - [DATE]: Breakfast (B) -3, Lunch (L) -3, and Dinner (D)- 1. - [DATE]: B -3, L-1, D-3. - [DATE]: B- 3, L- 1, D-RR. - [DATE]: B- 1, L- 1, D-RR. - [DATE]: B- 1, L- 0, D-0. - [DATE]: B- 3, L- 3, D-1. - [DATE]: B- 3, L- 3, D-1. - [DATE]: B- 1, L- 1, D-1. - [DATE]: B- 1, L- 1, D-2. - [DATE]: B-1, L- 0, D-0. - [DATE]: B- 1, L- 1, D-2. - [DATE]: B -RR, L-0, D-2. - [DATE]: B- 2, L- 2, D-RR. - [DATE]: B- 0, L- 1, D-1. - [DATE]: B-3, L-3, D-2. - [DATE]: B- 3, L- 2, D-1. - [DATE]: B- 3, L- 2, D-1. - [DATE]: B- 3, L- 3, D-1. - [DATE]: B-3, L- 3, D-1. - [DATE]: B-1, L- 1, D-1. - [DATE]: B-1, L- 1, D-3. - [DATE]: B-1, L- 0, D-1. - [DATE]: B-0, L-1, D-1. Further review of the Resident C's Weights and Vitals Summary, indicated that Resident C's weight on [DATE], was documented as 161 lbs. The weight indicated a loss of 19 pounds in less than one month. Further review of Resident C's record indicated that the physician had not been notified of the resident's significant weight loss until [DATE]. The notification came six days after the significant loss was identified. Review of a facility progress note for Resident C, dated [DATE], indicated, RD Note for Weight Change: Resident is on monitoring for new admission (Resident C was admitted on [DATE]). Resident noted with significant weight loss since admission as follows: -10.6%, -19 Lbs. Comparison Weight [DATE], 180.0 Lbs. Admission weight may have not been accurate, or included fluid weight. Current diet order provides adequate calorie/protein to meet estimated needs per new admission assessment .No new nutrition interventions at this time. Will continue to monitor weight trends. F/U (follow up) PRN (as needed). Resident C's nutritional note was documented [DATE], six days after the 19 lb. weight loss was identified on [DATE]. A review of Resident C's ADL (activities of daily living) Sheet, for the month of [DATE], was conducted. In the section titled, Amount Eaten it was documented by a number to represent the percentage of food consumed by Resident C. The document indicated the following percentage by number: - 0 = 0 - 1 = 0 - 25% - 2 = 26% - 50% - 3 = 51% - 75% - 4 = 76%-100% - RR = Resident Refused - RU = Resident Unavailable The ADL documentation indicated for Resident C's food consumption daily by meal: - [DATE]: B -3, L-3, D-1. - [DATE]: B -3, L-3, D-2. - [DATE]: B- 3, L-3, D-3. - [DATE]: B- 3, L-3, D-2. - [DATE]: B- 1, L-0, D-1. - [DATE]: B- 0, L-1, D-1. - [DATE]: B- 1, L-1, D-1. - [DATE]: B- 0, L-2, D-2. - [DATE]: B- 2, L-2, D-1. - [DATE]: B -3, L-3, D-3. - [DATE]: B -0, L-1, D-1 Review of the Resident C's Weights and Vitals Summary, indicated that Resident C was weighed on [DATE], the weight was documented as 157 lbs. The weight indicated a four pound loss. Review of a progress note for Resident C, dated [DATE], indicated, RD Note for Weekly Weight Monitoring: Weight loss trend noted: -4.0#/-2.5% X 14 days. Comparison weight 161.0# on [DATE] .Root cause may be current medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Will continue to monitor weight trends. May Increase calories if weight loss trend continues. F/U PRN. Review of the Resident C's Weights and Vitals Summary, indicated that Resident C was weighed on [DATE], the weight was documented as 152 lbs. The weight indicated a five pound loss. Review of a progress note for Resident C, dated [DATE], indicated, RD Note for Weekly Weight Change: Comparison Weight [DATE], 161.0 Lbs, -5.6%, -9.0 Lbs. Comparison Weight [DATE], 157.0 Lbs, -3.2%, -5.0 Lbs. Comparison Weight [DATE], 180.0 Lbs, -15.6%, -28.0 Lbs. .Admission weight may have been in error. No nutrition interventions at this time. Will continue to monitor weight trends, and PO intake. F/U PRN. Review of the Resident C's Weights and Vitals Summary, indicated that Resident C was weighed on [DATE], the weight was documented as 150 lbs. The weight indicated a two pound loss. Review of a progress note for Resident C, dated [DATE], indicated, RD Notes for Weekly Weight Change: Resident noted with weight loss trend: Comparison Weight [DATE], 161.0 Lbs, -6.8%, -11.0 Lbs. Comparison Weight [DATE], 180.0 Lbs, -16.7%, -30.0 Lbs. .Diet order Regular, reg. (regular) texture, thin liquids. Variable PO intake noted. No new nutrition interventions at this time. Will continue to monitor weight trends. Review of the Resident C's Weights and Vitals Summary, indicated that Resident C was weighed on [DATE], the weight was documented as 152 lbs. On [DATE], Resident C was weighed, the weight was documented as 148 lbs. A four pound loss in one week. A review of Resident C's ADL (activities of daily living) Sheet, for the month of [DATE],was conducted. In the section titled, Amount Eaten it was documented by a number to represent the percentage of food consumed by Resident C. The document indicated the following percentage by number: - 0 = 0 - 1 = 0 - 25% - 2 = 26% - 50% - 3 = 51% - 75% - 4 = 76%-100% - RR = Resident Refused - RU = Resident Unavailable The ADL documentation indicated for Resident C's food consumption daily by meal: - [DATE]: B -3, L-3, D-3. - [DATE]: B -3, L-1, D-3. - [DATE]: B -0, L-1, D-RR. - [DATE]: B -0, L-0, D-2. - [DATE]: B 1, L-1, D-2. - [DATE]: B -3, L-3, D-3. - [DATE]: B -3, L-2, D-3. - [DATE]: B -1, L-2, D-2. Review of a progress note for Resident C, dated [DATE], indicated, RD Note for Weight Change: Resident noted with significant weight change as follows: -4.0#/2.6% comparison weight 152.0# on [DATE]. Comparison Weight [DATE], 157.0 Lbs, -5.7%, -9.0 Lbs. .Per MARs (medication administration record), PO intake mostly ,d+[DATE]%. No new nutrition interventions at this time. RD recommendations: -D/C (discontinue) Weekly Weight Monitoring -Continue with monthly weights. F/U PRN. Review of the Resident C's Weights and Vitals Summary, indicated that Resident C was weighed on [DATE], the weight was documented as 148 lbs. Review of a progress note for Resident C, dated [DATE], indicated, RD Note for Weight Change: Resident noted with weight loss trend .Weight loss may be beneficial and d/t appropriate diet. No new nutrition interventions at this time. Will continue to monitor weight trends and PO intake. F/U (follow up) PRN (as needed). Review of a facility IDT note for Resident C, dated [DATE], indicated, Resident noted with significant weight changes. Current wt: 148# + (sic) 32#/17.8% X 3 months. MD/RP made aware. resident (sic) noted with variable PO intake. Resident has history of gastric ulcer, and noted to be a smoker that may curve (sic) appetite. Will continue to follow dietary recommendation discussed by IDT during weight variance. Review of an IDT note for Resident C also dated [DATE], indicated, clarified: Current wt: 148# -32#/17.8% X 3 months. Review of the Resident C's Weights and Vitals Summary, indicated that Resident C was weighed on [DATE], the weight was documented as 143 lbs. A five pound loss. Review of a progress note for Resident C, dated [DATE], indicated, RD Note for Weight Change: Resident noted with weight change as follows: Comparison Weight [DATE], 148.0 Lbs, -3.4%, -5.0 Lbs. Comparison Weight [DATE], 157.0 Lbs, -8.9%, -14.0 Lbs. .PO intake mostly ,d+[DATE]% per MARs. Will continue to monitor weight trends. F/U PRN. Review of a facility IDT note for Resident C, dated [DATE], indicated, Resident noted with significant weight changes. Current wt: 143# -14#/8.9% X 3 months. Resident has history of cancer and currently awaiting restating (sic) staging of brain cancer. Will follow dietary recommendations discussed by IDT during weight variance. Review of the Resident C's Weights and Vitals Summary, indicated that Resident C was weighed on [DATE], the weight was documented as 136 lbs. A seven pound loss in one week. Review of a progress note for Resident C, dated [DATE], indicated, RD Note for Weight Change: Resident noted with significant weight loss as follows: Comparison Weight [DATE], 143.0 Lbs, -4.9%, -7.0 Lbs. Comparison Weight [DATE], 157.0 Lbs, -13.4%, -21.0 Lbs. .PO intake per MARs mostly ,d+[DATE]%. Boost Supplement (nutritional drink that contains protein, vitamins and minerals) and [MEDICATION(S)] (medication that increases weight gain by increasing appetite) for appetite currently on physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . F/U PRN. Review of a facility IDT note for Resident C, dated [DATE], indicated, Resident noted with significant weight changes. Current wt: 136# -7#/4.8% X 1 wk. MD/RP made aware. Resident just placed on appetite stimulant, awaiting effects. Will continue to follow dietary recommendations discussed by IDT during weight variance. Review of Resident C's facility document titled, Order Summary Report, indicated the following orders dated [DATE]: - Boost - [MEDICATION(S)] Acetate Suspension 40MG/ML Give 5 ml by mouth two times a day for Appetite stimulant for 2 Weeks. Further review of Resident C's Order Summary Report, indicated an order dated [DATE], to Send Resident out to (initials of hospital) for weight loss and lethargy . On [DATE] at 11:54 a.m., an interview was conducted with a certified nursing assistant (CNA 1). CNA 1 confirmed that she had provided care for Resident A. CNA 1 stated that she had been monitoring Resident A's meal intake and stated that when the resident was initially admitted he was able to feed himself. CNA 1 stated as time went on, he needed additional assistance to where he was unable to feed himself. CNA 1 stated that she had reported to the charge nurse, everyday, every shift, when the resident did not eat well or refused his meals. On [DATE], at 1:20 p.m., a concurrent interview and record review were conducted with the facility's Director of Nursing (DON). After review of Resident A and Resident C's records with the DON, the DON was asked the facility expectation to follow the facility policy regarding weight assessment and interventions. The DON confirmed that the expectation was to follow the policy. The DON was provided documentation of Resident A's weight loss and the timeline of the notification of the physician and conservator of that loss. The DON was also provided the ADL meal intake documentation for Resident A and reviewed in Resident A's record that no progress notes nor documentation was made that indicated the physician nor his conservator had been informed of the resident's poor meal intake until [DATE]. The DON was then provided the weight loss documentation and timeline of notification for the physician of Resident C's significant weight loss. The DON was asked the expectation of facility staff to notify the physician or responsible party of a change in condition. The DON confirmed that the physician and responsible party were to be notified timely of a resident's change in condition. The DON continued that it would be expected that the notification would be documented in the resident's record. On [DATE], at 1:29 p.m., a concurrent interview and record review were conducted with the DON and Assistant Director of Nursing (ADON). The ADON was provided Resident A's Weights and Vitals Summary. The ADON confirmed that the document listed all the weights taken in the facility. Resident A's weight loss was reviewed with the DON and ADON. The DON and ADON were asked the facility's expectation to notify the physician with a significant change in condition. At this point the ADON stated that she believed she had done a COC for the resident and that she believed the physician had been notified of the resident's weight loss on [DATE]. It was explained that on [DATE], Resident A's entire record had been reviewed and that only three COCs had been identified. The ADON stated that she could have forgot to lock the COC thus causing it not to be identifiable in the record. On [DATE], at 2:06 p.m., a concurrent interview and record review were conducted with the DON and the facility's Nurse Consultant (NC). The NC provided a copy of the SBAR (change in condition) for Resident A. The SBAR indicated that the physician had been notified of the resident's significant weight loss on [DATE], at 5:00 p.m., and that after a 38 pound weight loss the SBAR indicated that the physician's only recommendation was to, Follow dietary recommendations. Resident C's record was then reviewed with the DON and NC. Both the DON and NC were asked if the resident was identified on [DATE], with a 19 pound loss, was the notification of the physician on [DATE], timely. The NC stated, I don't think so. On [DATE], at 8:03 a.m., a phone interview was conducted with the facility's Registered Dietician (RD). The RD was asked why her only intervention had been to re-weight Resident A after it was determined that he had a 35 lb. weight loss in one week. The RD stated that s[TRUNCATED]

Based on observations, interview, and record review, the facility failed to provide five residents (Resident B, C, D, E, and F) in a universe of 137, an environment free from verbal and physical abuse from Resident A. This failure resulted in injuries and feeling of being unsafe, and placing the residents in jeopardy for severe and negative psychosocial response due to ongoing presence of an unsupervised resident who could continue to hurt residents while at the facility. On [DATE], at 3:28 p.m., the Administrator and DON were made aware of the observations, interviews, and documented evidence of Resident A's ongoing behaviors towards facility residents. The Administrator and DON were informed of the lack of sufficient measures in place to prevent an increasing environment of physical abuse from one resident (Resident A). Due to the facility's failure to provide an environment free from physical abuse from Resident A, the Administrator and the DON were verbally notified of an Immediate Jeopardy on [DATE], at 3:30 p.m. The Immediate Jeopardy was removed at 12:34 p.m., on [DATE], in the presence of the Administrator, DON, and Assistant Director of Nursing (ADON), after an acceptable plan of action was presented to CDPH (California Department of Public Health), indicating that facility would provide a 24-hour one on one sitter for Resident A until the resident could be transferred to a behavioral facility in accordance to the physician's recommendation. The plan of action indicated: - Provide direct 1: 1 supervision 24 hours per day until discharge; - Meet with IDT (Interdisciplinary team) to discuss daily plan for safety; - Provide Psychology and Psychiatric evaluation for recommendations; - Discuss condition with (name of physician) for recommendations related to discharge plan and setting and appropriateness; - Contact Public Guardian and send certified letter if unable to contact by telephone; -Continue to make efforts to secure placement in behavioral unit or setting with fewer people; -In-service staff regarding resident safety; and - Provide Social Service visits daily until discharge. Findings: On [DATE], at 8:30 a.m., an unannounced visit was conducted at the facility to investigate two complaints regarding resident to resident abuse. On [DATE], at 8:50 a.m., Certified Nursing Assistant (CNA) 1 was interviewed. She stated Resident A was blind and could be aggressive. CNA 1 stated the nurses were supposed to take him when he went outside his room. She stated Resident A would try to hit when somebody was in his pathway. On [DATE], at 9 a.m., Resident A was observed sitting in a wheelchair at the corner of the outside patio. There were two residents by the shaded area of the patio and three more residents a few feet away from Resident A. There was no staff member present on the outside patio. On [DATE], at 9:03 a.m., Resident G was interviewed. She stated she knew Resident A. Resident G stated,she Did not want to mess up with him (pointing at Resident A). She stated,If he felt you were near, he (Resident A) will hit you. Resident G stated he (Resident A) would wheel over anybody who tried to be in his way. She stated she heard he (Resident A) hit a female resident, who fell and died . On [DATE], at 9:05 a.m., Licensed Vocational Nurse (LVN) 1 was interviewed. LVN 1 stated Resident A was blind. She stated anybody who saw Resident A should try to avoid him. LVN 1 stated when he (Resident A) went out of his room, he would try to move past anybody. On [DATE], Resident A's record was reviewed. Resident A was re admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The facility history and physical indicated Resident A did not have a capacity to understand and make decisions. Resident A's MDS (Minimum Data Set- an assessment tool) dated [DATE], Section B (Hearing, Speech, and Vision) indicated, Resident A's vision was coded as severely impaired, which meant, no vision or sees only light, colors or shapes; eyes do not appear to follow objects. Resident A's eye doctor consultation, dated [DATE], indicated Resident A had [MEDICAL CONDITION] (clouding of the normally clear lens of the eye) on both eyes, and [DIAGNOSES REDACTED] (condition of involuntary eye movement). The document further indicated Resident A was uncooperative and agitated during the eye exam. Resident A's progress notes indicated the following: a. [DATE], Resident A had aggressive behavior and an altercation (fight) with roommate; b. [DATE], a resident (Resident B) reported to have been hit by Resident A; c. [DATE], two residents (including Resident B) were witnessed to have hit Resident A; This incident on [DATE], was a few days after Resident A had an altercation with Resident B. d. [DATE], Resident A slapped Resident C's face side to side after Resident C yelled out; e. [DATE], Resident A hit a resident's (Resident D) face four (4) times after being told not to hit; According to progress notes, Resident A had been involved in several altercations from [DATE] to [DATE]. Resident A's care plan was reviewed with the ADON on [DATE], at 10:34 a.m. She acknowledged Resident A's care plan did not reflect the incidents involving Resident A's behavior of physical aggression with Resident B, Resident C, and Resident D. Resident A's care plan related to mood disorder was initiated on [DATE], and was revised on [DATE]. The care plan indicated Resident A would become upset and would strike out. The interventions were to approach resident in a calm non-threatening manner, speak in a calm voice, remove people out of resident's pathway when exhibiting behaviors, and assess for possible triggers for behavior. There was no re-evaluation of the care plan to address the resident's increasing behaviors since [DATE]. Resident A's psychiatry follow-up notes dated [DATE], indicated Resident A was very irritable, and verbally aggressive. The document indicated staff had reported Resident A's increasing aggressive behavior and the resident (Resident A) had physically hit patients as well as staff. The document further indicated a recommendation to restart [MEDICATION NAME] (used to treat [MEDICAL CONDITION] mania). There was no documented evidence a care plan was initiated to address Resident A's increasing aggressiveness as noted on the psychiatry notes on [DATE]. Resident B's record was reviewed. Resident B was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The history and physical indicated Resident B had the capacity to understand and make decisions. Resident B's nurse's notes indicated th following: a. On [DATE], Resident B had physical contact with Resident A. The two residents had to be separated. No injuries were noted; b. On [DATE], indicated Resident B reported being hit by Resident A on her face, and right hand. Resident B had skin discoloration and was treated with an ice bag. Resident C's record was reviewed. Resident C was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The history and physical dated February 7, 2017, indicated Resident C had no decision making capacity. Resident C's change of condition notes, dated [DATE], indicated Resident C was in her wheelchair when Resident A came out and asked about the time. Resident C yelled out and Resident A turned quickly and slapped her face side to side. Resident C was assessed after the incident and was noted with skin tear on her left inner eye and had complained of pain (,[DATE] on a scale of ,[DATE] pain level). According to the facility's pain level monitoring guide, a pain level of ,[DATE] meant severe pain. Resident D's record was reviewed. Resident D was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The history and physical indicated Resident D had the capacity to understand and make decisions. Resident D's nurse's notes dated [DATE], indicated Resident D was coming into facility and asked Resident A if it was ok to let her get out of his way. Resident A hit Resident D in the face four (4) times, in her forehead, eyes, and left bottom lip. Resident D was assessed with [REDACTED]. Resident E's record was reviewed. Resident E was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident E's nurse's notes dated [DATE], indicated Resident E had a fall, complained of right hip pain, and was transferred to the acute hospital. Resident E's radiology result dated [DATE], indicated an acute displaced fracture (the bone snaps into two or more parts and moves so that the two ends are not lined up straight) of the femoral (thigh bone) neck ([MEDICAL CONDITION]) . Resident E's acute hospital history and physical dated [DATE], indicated, .based on history given by the facility, the patient (Resident E) was pushed out of her wheelchair by another resident at the skilled nursing facility and regretabbly fell and sustained a [MEDICAL CONDITION] .x-ray (radiologic testing) showing right subcapital (head of thigh bone) [MEDICAL CONDITION] which was acute (new onset) . Resident E's acute hospital consultation report dated [DATE], indicated, .Recommendations: As the patient (Resident E) demonstrates a right [MEDICAL CONDITION], this necessitates surgical intrvention .Surgical (physical procedure to correct or relieve injury) intervention is to include a right hemiarthroplasty (hip replacement) . Resident E's acute hospital death summary report dated [DATE], indicated, .The patient (Resident E) was admitted to hospice on [DATE], after a hospital stay complicated by [MEDICAL CONDITION] after being pushed from a wheelchair. Postoperatively, the patient developed a pneumothorax (abnormal collection of air in the chest causing a collapsed lung). She was transferred to ICU (intensive critical unit- caters to patients with severe and life threatening illness and injuries) .her condition never really improved and she continued to deteriorate .expired shortly thereafter . The above documentation indicated Resident E had to undergo hip replacement after the fall incident involving Resident A. Resident E expired 6 days after the incident at the facility. Resident F's record was reviewed. Resident F was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident F's nurse's notes dated [DATE], indicated Resident F was on his Geri chair in the hallway when he cried out loud when bumped by another resident. Resident F was noted with skin tear on left lower leg (1.5cm (centimeter) x 8 cms or .5 x 8 inches). On [DATE], at 11:05 a.m., Resident B was interviewed. She stated he (Resident A) punched her on one occasion. Resident B stated he (Resident A) hit her friend (Resident D) four times. She further stated he (Resident A) would call everybody nigger. She stated the staff should watch him. He (Resident A) was always by himself. Resident B further stated she would use the other door to exit to the patio so she would not have to be near him (Resident A). On [DATE], at 11:15 a.m., Resident D was interviewed. She stated he (Resident A) punched her in the face. Resident D stated it was fast, Resident A asked for the time and as she answered him, he (Resident A) reached out and punched her. She stated she just came into the facility and was not aware of his (Resident A) behavior. Resident D further stated she did not think he (Resident A) was blind. She thought he could see. She stated he (Resident A) even called her [***] . Resident D stated she just want to stay away from him (Resident A). On [DATE], at 12:03 p.m., the DON was interviewed. He stated Resident A's behaviors of being aggressive were discussed by the IDT, and interventions were discussed as well. The DON was unable to provide any documented evidence of any IDT notes discussing measures to address the different incidents involving Resident A. On [DATE], at 10:47 a.m., LVN 2 was interviewed. She stated she was the nurse in charge during the incident involving Residents A and Resident E. LVN 2 stated Resident A was in the hallway and suddenly there was a commotion. She saw Resident E on the floor when she went to investigate the commotion. LVN 2 stated Resident E said, He (Resident A) ran over me. LVN 2 stated Resident E complained of leg pain during the assessment. LVN 2 stated Resident A had to be watched over all the time to be redirected. Resident E's record from the acute hospital dated [DATE], indicated, .based on history given by the facility, the patient (Resident E) was pushed out of her wheelchair by another resident at the skilled nursing facility and regrettably fell and sustained a [MEDICAL CONDITION] . On [DATE], at 11:50 a.m., a Physician Assistant (PA) from behavioral health services was interviewed. She stated Resident A had an existing baseline behavior of irritability towards anybody who bumped into him, even on medication or not. The PA stated Resident A needed redirection all the time. She further stated he (Resident A) might be better off in a facility with smaller population due to risk of bumping into a lot of residents which could trigger the behavior of being aggressive towards others. On [DATE], at 2:45 p.m., LVN 3 was interviewed regarding the incident involving Residents A and F on [DATE]. She stated she saw Resident A come out of the resident's room and make a quick left turn bumping into Resident F who was sitting on a Geri chair by the wall of room [ROOM NUMBER]. LVN 3 stated Resident F sustained a skin tear on the left leg. She stated Resident A suddenly came out of the room by himself. LVN 3 stated she did not think it was smoking time when Resident A came out of the room. The facility policy and procedure was reviewed. The policy titled, Abuse Prevention, effective [DATE], indicated, .Prevention .The staff will identify, correct, and intervene in situations in which abuse, neglect, and/or misappropriation of resident property are more likely to occur. (e.g. physical environment that may make abuse and/or neglect more likely to occur, supervision of staff to identify inappropriate behaviors and the assessment, care planning and monitoring of resident(s) with needs and behaviors which might lead to conflict or neglect.) .Occurrences, patterns and trends will be assessed by administrative staff, licensed staff, and interdisciplinary team to determine the corrective action based on the results of the investigation .If a resident incident is reported, discovered or suspected, where the health, welfare, or safety of the resident (S) is involved, the Center will take steps to provide a safe environment for the resident (s) as indicated by the situation .

Based on observation, interview and record review, the facility failed to ensure an environment safe and free from any harm was provided for five residents (Resident B, C, D, E, and F) from a universe of 137. The failure to provide adequate supervision to one resident (Resident A) while at the facility had caused injury and harm to five residents (Resident B, C, D, E, and F) while at the facility. Findings: On [DATE], at 8:30 a.m., an unannounced visit to the facility was conducted to investigate a complaint related to resident abuse. On [DATE], at 8:50 a.m., Certified Nursing Assistant (CNA) 1 was interviewed. She stated Resident A was blind. CNA 1 stated Resident A could be aggressive and would hit others. She stated Resident A would run over anybody in his path. CNA 1 stated staff should assist Resident A as soon as he decided to go out of his room to smoke. On [DATE], at 9 a.m., Resident A was observed sitting in a wheelchair at the corner of the outside patio. There were two residents by the shaded area of the patio and three more residents a few feet away from Resident A. There was no staff member present on the outside patio. On [DATE], at 9:03 a.m., Resident G was interviewed. She stated she knew Resident A. Resident G stated, she Did not want to mess up with him (pointing at Resident A). She stated, If he felt you were near, he (Resident A) will hit you. Resident G stated he (Resident A) would wheel over anybody who tried to be in his way. She stated she heard he ( Resident A) hit a female resident, who fell and died . On [DATE], at 9:05 a.m., Licensed Vocational Nurse (LVN) 1 was interviewed. She stated Resident A was blind. LVN 1 stated residents should avoid Resident A, since he could not see where he was going. On [DATE], Resident A's record was reviewed. Resident A was re admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The facility history and physical indicated Resident A did not have a capacity to understand and make decisions. Resident A's MDS (Minimum Data Set- an assessment tool) dated [DATE], Section B (Hearing, Speech, and Vision) indicated, Resident A's vision was coded as severely impaired, which meant, no vision or sees only light, colors or shapes; eyes do not appear to follow objects. Resident A's eye doctor consultation, dated [DATE], indicated Resident A had cataracts (clouding of the normally clear lens of your eye) on both eyes, and [DIAGNOSES REDACTED] (condition of involuntary eye movement). Resident A's progress notes indicated the following: a. [DATE], Resident A had aggressive behavior and an altercation (fight) with roommate; b. [DATE], a resident (Resident B) reported to have been hit by Resident A; c. [DATE], two residents (including Resident B) was witnessed to have hit Resident A; This incident on [DATE], was few days after Resident A had an altercation with Resident B. d. [DATE], Resident A slapped Resident C's face side to side after Resident C yelled out; e. [DATE], Resident A hit a resident's (Resident D) face four (4) times after saying not to hit her; According to progress notes, Resident A had been involved in several altercations from [DATE] to [DATE]. Resident A's care plan was reviewed with the ADON (Assistant Director of Nursing) on [DATE], at 10:34 a.m. She acknowledged Resident A's care plan did not reflect the incidents involving Resident A's physical aggressive behavior towards Resident B, Resident C, and Resident D. There was no documented evidence a care plan to address the ongoing behavior of being physically aggressive towards others was initiated for Resident A. Resident A's psychiatry follow-up notes dated [DATE], indicated, Pt (patient-Resident A) was very irritable, verbally aggressive. Staff reports that pt has been increasingly aggressive and has physically hit patients as well as staff. Resident B's record was reviewed. Resident B was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident B's nurse's notes dated [DATE], indicated Resident B reported being hit by Resident A on her face, and right hand. Resident B had skin discoloration and was treated with an ice bag. Resident C's record was reviewed. Resident C was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident C's change of condition notes, dated [DATE], indicated Resident C was in her wheelchair when Resident A came out and asked about the time. Resident C yelled out and Resident A turned quickly and slapped her face side to side. Resident C was assessed after the incident and was found to have a skin tear on her left inner eye and had complained of pain (,[DATE] on a scale of ,[DATE] pain level). According to the facility's pain level monitoring guide, a pain level of ,[DATE] meant severe pain. Resident D's record was reviewed. Resident D was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident D's nurse's notes dated [DATE], indicated Resident D was coming into facility and asked Resident A if it was ok to let her get out of his way. Resident A hit Resident D in the face four (4) times, in her forehead, eyes, and left bottom lip. Resident D was assessed with [REDACTED]. Resident E's record was reviewed. Resident E was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident E's nurse's notes dated [DATE], indicated Resident E had a fall, complained of right hip pain, and was transferred to the acute hospital. Resident E's radiology (x-ray-photographic image of the internal composition of a part of the body) ) result dated [DATE], indicated an acute displaced fracture (the bone snaps into two or more parts and moves so that the two ends are not lined up straight) of the femoral (thigh bone) neck (hip fracture). Resident F's record was reviewed. Resident F was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident F's nurse's notes dated [DATE], indicated Resident F was in his Geri chair in the hallway, he (Resident F) cried out loud when bumped by another resident (Resident A). Resident F was noted with a skin tear on left lower leg (1.5cm/ centimeters x 8 cms or 0.5 x 3.1 inches). On [DATE], at 11:05 a.m., Resident B was interviewed. She stated he (Resident A) punched her on one occasion. Resident B stated he (Resident A) hit her friend (Resident D) four times. She further stated he (Resident A) would call everybody nigger. She stated the staff should watch him. He (Resident A) was always by himself. Resident B further stated she would use the other door to exit so she would not have to be near him. On [DATE], at 11:15 a.m., Resident D was interviewed. She stated he (Resident A) punched her in the face. Resident D stated it was fast. He (Resident A) asked for the time and as she answered him, the resident (Resident A) reached out and punched her. She stated she just came into the facility and was not aware of his (Resident A) behavior. Resident D further stated she did not think he (Resident A) was blind. She thought he could see. She stated he (Resident A) even called her [***] . On [DATE], at 12:03 p.m., the DON (Director of Nursing) was interviewed. He stated Resident A's behaviors were discussed by the IDT (interdisciplinary team), and interventions were discussed as well. The DON was unable to provide any documented evidence of any IDT notes discussing measures to address the behavior of punching and striking out to any residents he bumped into. On [DATE], at 10:47 a.m., LVN 2 was interviewed. She stated she was the nurse in charge during the incident involving Residents A and Resident E. LVN 2 stated she heard a commotion during shift change. She stated Resident A was in the hallway and Resident E was already on the floor when she went to investigate the commotion. She stated Resident E said, He (Resident A) ran over me. LVN 2 stated Resident E complained of leg pain during the assessment. She stated Resident A had to be watched over all the time to be redirected. Resident E's record from the acute hospital dated [DATE], indicated, .based on history given by the facility, the patient (Resident E) was pushed out of her wheelchair by another resident at the skilled nursing facility and regrettably fell and sustained a hip fracture . Resident E's consultation notes at the acute hospital dated [DATE], indicated, .patient demonstrates a right hip fracture, this necessitates surgical (physical procedure to correct injury) intervention .Surgical intervention is to include right hemi arthroplasty (procedure in which the hip joint is replaced by a prosthetic implant) . Resident E's acute hospital death summary report dated [DATE], indicated, .The patient (Resident E) was admitted to hospice on [DATE], after a hospital stay complicated by hip fracture after being pushed from a wheelchair. Postoperatively, the patient developed a pneumothorax (abnormal collection of air in the chest causing a collapsed lung). She was transferred to ICU (intensive critical unit- caters to patients with severe and life threatening illness and injuries) .her condition never really improved and she continued to deteriorate .expired shortly thereafter . On [DATE], at 11:50 a.m., a Physician Assistant (PA) from a behavioral consultation was interviewed. She stated the resident (Resident A) had an existing baseline behavior of irritability towards anybody who bumped into him, even on medication or not. The PA stated the resident (Resident A) needed redirection all the time. She further stated he (Resident A) might be better off in a facility with smaller population which would also decrease the chances of altercations. On [DATE], at 2:45 p.m., LVN 3 was interviewed regarding the incident involving Residents A and F on [DATE]. She stated she saw Resident A come out of the resident's room and make a quick left turn bumping into Resident F who was sitting in a Geri chair by the wall of Room 40. LVN 3 stated Resident F sustained a skin tear on the left leg. She stated Resident A suddenly came out of the room by himself. The facility policy and procedure was reviewed. The policy titled, Abuse Prevention, effective [DATE], indicated, .Prevention .The staff will identify, correct, and intervene in situations in which abuse, neglect, and/or misappropriation of resident property are more likely to occur. (e.g. physical environment that may make abuse and/or neglect more likely to occur, supervision of staff to identify inappropriate behaviors and the assessment, care planning and monitoring of resident(s) with needs and behaviors which might lead to conflict or neglect.) .Occurrences, patterns and trends will be assessed by administrative staff, licensed staff, and interdisciplinary team to determine the corrective action based on the results of the investigation .If a resident incident is reported, discovered or suspected, where the health, welfare, or safety of the resident (S) is involved, the Center will take steps to provide a safe environment for the resident (s) as indicated by the situation .

Based on interview, and record review, the facility failed to ensure one (Resident A) in a universe of 142 residents received the necessary care when adequate staff assistance was not provided during ADL (activities of daily living) care. The failure to provide adequate assistance in accordance with the comprehensive assessment and plan of care resulted in Resident A's fall from bed. The resident suffered knee pain, and sustained femur (thigh bone) fractures to both legs which required transfer to an acute care hospital for evaluation and treatment. Findings: On September 20, 2016, at 12:25 p.m., an unannounced visit was conducted at the facility to investigate a complaint related to quality care issues. On September 20, 2016, Resident A's record was reviewed. Resident A was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident A's MDS (Minimum Data Set-an assessment tool) dated March 10, 2016, indicated the following: a. Section C (cognitive pattern) Resident A had a BIMS (Basic Interview for Mental Status- brief screener that aids in detecting cognitive impairment) score of 10. According to CMS's (Centers for Medicare & (and) Medicaid Services) RAI (Resident Assessment Instrument) Manual a BIMS score of 10 meant cognition was moderately impaired. b. Section G (Functional Status) bed mobility (how resident moves to and from lying position, turns side to side and positions body while in bed), Resident A needed extensive assistance from staff to change position and required two people to physically assist with positioning her body and turning from side to side. Review of Resident A's care plan related to ADL dated September 22, 2015, indicated Resident A required one to two persons to assist during ADL's. On September 20, 2016, at 2:40 p.m., Licensed Vocational Nurse (LVN) 2 was interviewed. She stated Resident A fell from bed when a Certified Nursing Assistant (CNA) 1 turned her. LVN 2 stated Resident A was very much dependent on staff. She stated Resident A would need two persons to provide care for her. On September 20, 2016, at 3:10 p.m., LVN 1 was interviewed. She stated Resident A was obese (recorded weight was 352.4 pounds on June 2, 2016) and would need two people to assist during provision of care. LVN 1 stated CNA 1 was providing ADL care by himself when Resident A fell from the bed on June 21, 2016. She stated CNA 1 should have asked another staff to help him with Resident A. LVN 1 further stated the bed was elevated to the high position during the fall. She stated it was a bad fall. On September 20, 2016, at 3:30 p.m., CNA 2 was interviewed. She stated CNAs were supposed to obtain reports from the charge nurses on special instructions such as how much assistance a resident needs prior to start of care. CNA 2 stated the CNAs were expected to get another person to assist during ADL care if appropriate. On September 20, 2016, at 3:35 p.m., CNA 3 was interviewed. She stated a resident who needed two person assist should always have two staff during provision of care to ensure safety during turning and repositioning. CNA 3 stated the resident should be turned closest to staff during provision of care for safety. On October 3, 2016, at 11:30 a.m., the Director of Staff Development (DSD) was interviewed. He stated he would always suggest two people to assist a heavy set resident for safety. The DSD stated the CNA should always ask for assistance if a resident was assessed to need two people. Review of the facility document, titled SBAR (Situation/Background/Assessment/Recommendation-Nurses' Progress Note and Physician/NP (Nurse Practitioner)/PA (Physician Assistant) - communication of changes in condition) dated June 21, 2016, indicated, . res. (Resident A) had slipped off the bed . Res (Resident A) complained of 7/10 pain (a scale of 1 - 10 with one being the least pain a person has ever had to ten indicating the worst pain ever suffered by the resident) to BLE (bilateral lower extremities) . Resident A's facility physician and telephone order dated June 21, 2016, indicated the physician ordered a STAT (immediately) x ray (photographic or digital image of the internal composition of a part of the body) of bilateral (both) knees due to Resident A's complaint of pain after the fall. Resident A's facility diagnostic imaging report, dated June 21, 2016, indicated: a. left knee: comminuted (crushed/broken to small pieces) [MEDICATION NAME] (across) fracture distal femur (thigh bone); and b. right knee: comminuted [MEDICATION NAME] fracture distal femur. The above x-ray which was taken after Resident A's fall on June 21, 2016, indicated Resident A had fractures on bilateral (left and right ) lower extremities. Resident A's facility transfer record dated June 21, 2016, was reviewed. Resident A was transferred to the acute hospital due to right knee fracture. Resident A's hospital emergency notes, dated June 21, 2016, at 2:06 p.m., indicated, HPI (history of present illness)-General Illness .Chief Complaint Altered mental status .patient (Resident A) was found by her bed after a possible unwitnessed fall out of bed at nursing home today. As per nursing home staff pt. (patient) is normally A (alert) x (times) O (oriented) x 3. Pt is unable to provide history . The hospital radiology report dated June 21, 2016, indicated: a. right knee- acute (new) displaced (not aligned) and impacted (bone breaks into multiple fragments which are driven into each other) distal femoral metaphyseal fracture ([MEDICAL CONDITION] bone just above the knee); b. left knee- supracondylar [MEDICAL CONDITION] femur with intercondylar extension (bone breaks extends into the round end of the thigh bone); c. right femur- (same as right knee result) acute displaced and impacted distal femoral metaphyseal closed fracture; and d. left femur-osteopenia (bone loss) with an essentially nondisplaced (aligned) supracondylar fracture (above the rounded end of the bone) of the left femur extending into the intercondylar region. According to an article from American Academy of Orthopedic Surgeons, last reviewed in August 2011, the thigh bone is the longest and strongest bone in the body, and it usually takes a lot of force to fracture (break) it. According to an information provided by Harvard Health Publication, Femur fractures have the potential to cause dangerous, sometimes life-threatening complications, such as significant bleeding inside the thigh, with blood loss of one quart or more. A femur fracture also may cause blood clots (gel-like clumps of blood) to form within the large veins (blood vessel which carries blood to the heart) of the thigh. If these clots break free and travel through the bloodstream (the blood circulating through the body of a person), they may eventually lodge in the lungs, creating a life-threatening condition called a [MEDICAL CONDITION] embolism (blockage in one of the arteries of the lungs). Resident A's hospital hematology (study, diagnosis, treatment, and prevention of diseases related to blood) reports indicated Resident A's hemoglobin level (used to measure the severity of [MEDICAL CONDITION]) from June 21 to June 30, 2016, were 10 gm/dL (grams/deciliter- unit of measurement), 10 gm/dL, 8.5 gm/dL, 8 gm/dL, 7.9 gm/dL, 8.2 gm/dL, 7.9 gm/dL, 7.5 gm/dL, and 8.0 gm/dL. Normal hemoglobin levels for the acute care hospital are 12.0 to 16.0 gm/dL. According to National Heart, Lung and Blood Institute, updated May 18, 2012, one of the main cause of [MEDICAL CONDITION] (lowered ability of the blood to carry oxygen) was blood loss, which could be due to trauma or surgery. Resident A's hospital ortho (orthopedic-branch of medicine dealing with the correction of deformities of bones or muscles) consult dated June 22, 2016, indicated bilateral distal femur fractures with significant osteopenia (reduction in bone volume to below normal levels). Non op (operational) treatment recommended at this time. Resident A was put on a NWB (non weight bearing-no weight) status on bilateral lower extremities. Resident A's discharge summary from the hospital dated July 25, 2016, indicated Resident A was critically ill with poor overall long term prognosis and would be placed in a long term acute care setting (care for difficult to treat, chronically critically ill patients who require specialized and aggressive goal-directed care over an extended recovery period). On October 5, 2016, at 1:05 p.m., Resident A's family member was interviewed. He stated the ortho doctor did not do a surgical intervention because the risk for more infection outweighed the benefit for his mom (Resident A).

Based on observation, interview and record review the facility failed to provide care that maintained respect and dignity for two residents (Resident 6 and 7) in a universe of 143, when Resident 7 was observed with a dried brown matter in her hair and across her forehead, clothing, bedding and privacy curtain. Resident 6 was made to wait for an extended period of time before assistance was provided which resulted in the resident sitting in his own waste until a facility staff member came to change him. These failures had the potential to impact the residents' self-esteem and self-worth. Findings: On February 19, 2016, at 8:15 a.m., an unannounced visit was conducted at the facility to investigate two complaints. On February 19, 2016, at 9:45 a.m., Resident 7 was observed. The resident was observed wearing a diaper which appeared to be filled with fluid. A dried brown matter was observed in the resident's hair, across her forehead, on her hands, and under her fingernail. The dried brown matter was observed on the resident's clothing, smeared on the bed linens, blanket, the right side bed rail and the privacy curtain. Attempts were made to engage Resident 7 in conversation, but the resident did not respond. The resident was observed attempting to cover herself with the soiled linens. The call light was observed to be hanging down near the ground on the right side of the bed, out of reach of Resident 7. On February 19, 2016, between 9:30 and 9:45 a.m., staff was observed going in and out of the Resident 7's room without staff attending to the resident's needs. On February 19, 2016, Resident 7 was observed for a second time. Resident 7 was in the same condition as observed earlier. The dried brown matter was now observed on the resident's legs and her pillow. The resident was alert. Attempts were made again to interview her, but Resident 7 was unable to respond to questions. At 10:10 a.m., on February 19, 2016, a certified nursing assistance (CNA 2) was observed walking into Resident 7's room carrying a clear plastic bag of what appeared to be clean linens. CNA 2 was asked when the last time the resident was changed or attended to. CNA 2 stated the resident was changed at 6:30 or 7 a.m. CNA 2 further stated she was the last one to change Resident 7. CNA 2 was asked how often residents are to be checked the CNA stated every two hours. When asked if this resident had been checked since 6:30 or 7 a.m., this morning CNA 2 stated, No. CNA 2 further stated she was not able to tend to the resident sooner due to being short staffed. CNA 2 said she had two more residents to care for than normal. On February 19, 2016, Resident 7's record was reviewed. Resident 7 was admitted to the facility initially on May 15, 2010, with [DIAGNOSES REDACTED]. A review of Resident 7's, History and Physical, (H&P) dated August 18, 2015, indicated the resident, does NOT have the capacity to understand and make decisions. On February 19, 2016, at 10:35 a.m., an interview was conducted with Resident 6. When Resident 6 was asked about staff responding to call lights. Resident 6 stated the three to eleven shift is the worst. He stated he was blind and that he had to wait for assistance. He further stated that he had soiled himself waiting. Resident 6 said he has had to sit in his soil until someone comes. He stated that made him feel bad. On February 19, 2016, Resident 6's record was reviewed. Resident 6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 6's, H&P, dated July 25, 2015, indicated the resident, has capacity to understand and make decisions. An interview was conducted with the Director of Staff Development (DSD) on February 19, 2016, at 12:12 p.m The DSD was asked about the facility policy for rounding and checking on residents. The DSD stated residents should be checked every two hours. The DSD was informed of the observation of Resident 7 and the condition in which she was observed. The DSD stated that that was, wrong and should not have happened. An interview was conducted with the Director of Nursing (DON) on February 19, 2016, at 2:30 p.m The DON was asked for the facility policy on rounding and checking on residents. The DON stated the residents should be checked every 2 hours. With regards to Resident 7, the DON stated they were aware, It was a dignity issue, and had dealt with the situation. Requests were made for facility policy and procedures for the rounding or monitoring of residents. The DON stated there were no policies that addressed the timely monitoring of residents.

Based on interview and record review, the facility failed to ensure the fluid intake and output for one of three sampled residents (Resident 1) was consistently monitored and evaluated to ensure proper hydration was maintained. This failure resulted in Resident 1 being transported to the emergency department and admitted to the acute hospital for severe dehydration with elevated laboratory values that indicated dehydration. Findings: On November 4, 2015, at 2:15 p.m., an unannounced visit was made to the facility to investigate two complaints. On November 4, 2015, Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. blood), hypertension (high blood pressure), and [MEDICAL CONDITION] (disease of the kidneys leading to [MEDICAL CONDITION]). A review of the document titled, Physician admission orders [REDACTED]. In section, Enteral Feeding: [DEVICE] (delivery of a nutritionally complete fluid, directly into the stomach or small intestine) with Nephro (tube feeding used for kidney patients) at 35cc (cubic centimeter; a cc is the equivalent to a milliliter)/hr (per hour) to start @ 12 noon to provide 840cc in 24 hours, infuse until volume 840cc is completed .flush tube/cc 100 H20 (water) Q shift (every shift) or 6 hours. A review of Resident 1's document titled, NUTITION ASSESSMENT AND REVIEW, dated September 13, 2015, indicated, Weight: 143.4 lb. (pounds) (65.18 kg {kilogram}) .FL (fluid) 1600-2000cc/Day (25-30cc/kg), for fluid intake. It further indicated, 900cc, 1620kcal (kilo calories) .200cc H20 flushes Q shift (600cc +657cc {free water in tube feeding}) 1257cc fluids, H20 flushes to be adjusted as appropriate .will cont monitoring . A review of Resident 1's document titled, DEHYDRATION, dated September 14, 2015, indicated a dehydration potential assessment score of 10. The document further indicated by a check mark, Will be free from signs and symptoms of dehydration daily until next review .BUN (Blood Urea Nitrogen - a kidney function test)/Creatinine (kidney function test)/electrolytes levels will be within normal limits until next review. In section, Approach Plan, the following interventions were indicated by a check mark to, Monitor for signs and symptoms of dehydration .Monitor I&O (input and output) per protocol .Monitor intake only .Monitor output only . A review of the document titled, NURSING CARE NOTES, and the telephone order document both dated September 15, 2015, indicated, RD (Registered Dietician) recommend: 1). DC (discontinue) previous TF (tube feeding), change to Nephro to 45cc/hr to start @ 12 pm to provide 900cc/1620kcal via [DEVICE] per enteral pump ([DEVICE] pump) in 24 hrs or until dose of 900cc is met. 2). D/C previous H20 flushes and change to H20 flushes 200cc Q shift . To provide Resident 1 with 600cc per day of water per day via flushes. A care plan initiated for Resident 1 on September 15, 2015, was reviewed. In the section titled, Goals, it indicated, Patient will be adequately nourished and hydrated during stay . In section, Interventions, it indicated, TF rate and H20 flushes to be adjusted as appropriate .NSG (nursing) to observe for s/s (signs and symptoms) of fluid imbalance (dehydration or fluid overload). A review of Resident 1's document titled, ANNUAL WEIGHT CHART 2015, indicated the date of admission was September 13, 2015, with admission weight of 143.4 lbs. The document further indicated on September 22, 2015, the resident's weight was 136.2, a seven pound weight loss. A review of the history and physical dated September 16, 2015, indicated, This resident (Resident 1) has the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS - a comprehensive assessment tool) dated September 25, 2015, section titled, Brief Interview for Mental Status, (BIMS) was left blank. A review of Resident 1's, PHYSICIAN'S PROGRESS RECORD, dated September 18, 2015, indicated, Mucous membranes dry .skin dry . Resident 1's acute hospital emergency department record was reviewed on November 19, 2015, and indicated Resident 1 was admitted to the acute hospital emergency department on September 25, 2015, for [MEDICAL CONDITION] (not enough oxygen passes from the lungs into the blood) and in acute and [MEDICAL CONDITION] with [MEDICAL CONDITION] (high level of sodium level in the blood which coincides with dehydration or not having enough fluids). A review of Resident 1's hospital, History and Physical, (H&P) dated September 25, 2015, indicated, Chief Complaint: [MEDICAL CONDITION] and found to be in acute on (sic) [MEDICAL CONDITION] with [MEDICAL CONDITION]. Section, HISTORY, of the H&P indicated, .His (Resident 1) laboratory data showed severe [MEDICAL CONDITION] with sodium of 157, (test to evaluate sodium level in the blood, normal level 137-145; high levels coincide with dehydration or not having enough fluids), as well as acute on (sic) [MEDICAL CONDITION] with a BUN of 220 (normal level 9.0-20.0; high levels may be due to dehydration or not having enough fluids) and creatinine of 12.7 (normal level of 0.7 to 1.3; high levels may be due to dehydration or not having enough fluids). It further indicated, Subsequently, a Foley catheter was inserted and he was aggressively hydrated (intravenously) with 3L (liters or 3000cc) of NS (normal saline used to hydrate) boluses and maintenance fluid of 150cc/hr, with very little urine output . In section, IMPRESSION, of the same H&P, it indicated, 3.Oliguric (decreased urine output) acute kidney injury on (sic) [MEDICAL CONDITION]-most likely secondary to ischemic (restriction in blood supply to tissues)/septic (infected with bacteria) acute tubular necrosis (kidney disorder involving damage to the tubule cells of the kidneys) and severe dehydration .5.[MEDICAL CONDITION], the patient has a free water deficit of approximately 5L (5000cc). It further indicated, .Continue Foley and monitoring of strict I&Os (Intake and Output). A phone interview was conducted with the Director of Nursing (DON) on November 19, 2015, at 4:47 p.m The DON was asked about the monitoring of I&O's for Resident 1. The DON stated the I&Os were under the previous policy, that with admission to the facility on a [DEVICE], I&Os would not be monitored unless the resident had a Foley catheter. When asked if this resident had a Foley catheter, the DON stated it was discontinued before admission to the facility. The DON further stated for [DEVICE] only, the facility does not monitor I&O's. In a phone interview with the DON on November 23, 2015, at 4:12 p.m., the DON was asked how a resident with a [DEVICE] was monitored to ensure they received adequate hydration if no I&O's were documented. The DON stated they monitored input by the documentation on the MAR (Medication Administration Record) the administration of the tube feedings and water flushes. When asked about the monitoring of output, the DON stated the Certified Nurses Assistants (CNA) documented output on the ADL (Activities of Daily Living) sheet by notating the number of times the resident had urinated. When asked how the facility monitored residents for dehydration, the DON stated residents were assessed by licensed staff daily for signs and symptoms of dehydration. When asked what signs and symptoms the staff looked for, the DON stated the staff would look for dry mouth and mucus membranes and at skin turgor. A review of the facility ADL documentation for Resident 1 indicated the number of continent (able to control your bladder) and/or incontinent (unable to control your bladder) episodes per day, per shift, but not the volume of output. A phone interview was conducted with the DON on November 24, 2015, at 9:40 a.m The DON was asked if Resident 1 was on a physician ordered fluid restriction. The DON stated, No. A phone interview was conducted with the facilities Registered Dieticians (RD 1 and 2) on November 24, 2015, at 9:52 a.m RD 1 was asked about Resident 1's fluid intake and how much he should have received daily; RD 1 stated she considered the Resident's [MEDICAL CONDITION] and [MEDICAL CONDITION] (chronic liver damage) and possible fluid shift when determining his intake. She stated she didn't want to begin with too much fluid; she wanted to maintain fluid balance. RD 1 was asked if Resident 1 had a fluid restriction, RD 1 confirmed Resident 1 was not on any fluid restrictions. RD 2 was asked about the formula used to determine the appropriate fluid intake for a resident. RD 2 stated they calculated 25-30cc/kg of fluid by counting the free water in the tube feeding and the water flushes. When asked how they would monitor for dehydration, RD 2 stated they would monitor by looking at labs and nursing notes for signs and symptoms of dehydration. RD 2 further stated Resident 1 was sent out to the hospital before they could check his tolerance. RD 2 stated they would check his tolerance and increase fluid as needed. RD 2 stated because of the residents kidney issues they needed to monitor his tolerance. When RD 2 was asked again about the calculations for fluid intake, RD 2 stated it would be between 1600-2000cc of fluid per day. When asked about the Residents weight in determining the fluid intake, RD 2 stated he was receiving, Very close to 1600cc's. RD 2 stated they chose to check his tolerance before increasing his fluid intake due to his [MEDICAL CONDITION] and [MEDICAL CONDITION]. A calculation was done to evaluate necessary fluid intake for Resident 1. Based the general guideline for determining baseline daily fluid needs which is to multiply the Residents body weight in kg times 30cc (2.2lbs = 1kg). Resident 1's admission weight was 143.4 lbs. in kilograms was 65.1. By multiplying 65.1 and 30cc the total daily fluid need is approximately 1953cc a day. The facility was administering 900cc of tube feeding plus 600cc of H20 flushes a day for a total of 1500cc of fluid per day. That is a 453cc difference. Resident 1 was in the facility for 12 days. Twelve days at a 453cc deficit a day equals 5432cc. Per the acute hospital records, Resident 1 was found to have a, Free water deficit of approximately 5L. (5000cc) On December 9, 2015, at 2:07 p.m., an interview was conducted with CNA 1. CNA 1 was asked about the documentation of episodes of incontinence on the facility ADL sheet. When asked if the number listed on the ADL sheet was the number of times the resident was found wet or the number of times the diaper had been changed regardless of the resident being found wet, CNA 1 stated it was the number of diaper changes. On December 9, 2015, at 2:17 p.m., an interview was conducted with CNA 2. CNA 2 was asked about the documentation of episodes of incontinence on the facility ADL sheet. When asked if the number listed on the ADL sheet was the number of times the resident was found wet or the number of times the diaper had been changed regardless of the resident being found wet, CNA 2 stated it was the number of times the diaper is changed it does not signify if the resident was wet. A review of the facility's policy and procedure titled, HYDRATION, undated indicated, The facility shall provide each resident with sufficient fluid intake to maintain proper hydration for optimum functioning of various body systems. It further indicated, Each resident will be provided an amount of fluid as indicated to prevent dehydration and maintain health .Resident suspected of or exhibiting signs of dehydration or consuming less that their fluid needs will need of further assessment and evaluation. The signs and symptoms may include but not limited to: Dry skin .Dry mucous membranes .Decreased urine output . A review of the facility policy and procedure titled, RECORDING INTAKE AND OUTPUT, dated March 1993 indicated, To monitor intake and output to assure adequate hydration .Each nursing assistant and licensed nurse records the amount consumed and the amount voided .

Based on interview, record review, and facility policy review, the facility failed to ensure one female resident (Resident A) was free from sexual abuse from a male employee (Certified Nurses Aide 1). Findings: An interview was conducted on February 18, 2015, at 10 a.m., with the Director of Nursing (DON). The DON stated Resident A informed CNA 2 (Certified Nurse Aide) on February 16, 2015, that she (Resident A) had a relationship with CNA 1 for approximately four or five months. Resident A indicated the relationship was consensual and consisted of kissing. The DON indicated during an interview she conducted with CNA 1, he admitted to kissing Resident A on the cheek and an open mouth kiss. The DON stated the facility was unaware of the relationship between Resident A and CNA 1. CNA 1 was suspended on February 16, 2015, then terminated on February 18, 2015. An interview was conducted with Resident A on February 18, 2015, at 10:45 a.m. She stated since October 2014, CNA 1 had been assisting her with her care needs. Resident A stated during the night shift on February 15, 2015, CNA 1 told her she was very special, and got touchy. The resident stated CNA 1 kissed her and attempted to clean her genital area, stating he wanted to please her down there. Resident A stated, He tried to reach me down there, but I was too dry, so he wet his fingers and tried again, that's when I told him to stop. I didn't report the kissing until after he tried to penetrate me with his finger. Resident A indicated she needs assistance to get to the bathroom, and during the night shift she will wear an incontinent pad. A psychologist assessed Resident A on February 17, 2015, and documented Resident A admitted to being touched in an inappropriate way by a male staff member. expressed relief that she had done the correct behavior in reporting abuse to staff. continued psychotherapeutic intervention is needed. The psychologist described Resident A's mood as Depressed, Anxious.Feels worthless. A record review was conducted on February 18, 2015. The record indicated Resident A was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The physician documented on November 8, 2014, the resident has the capacity to understand and make decisions. The Minimum Data Set (MDS- assessment tool) dated November 18, 2014, indicated Resident A can understand others and has the ability to understand. There are no problems with short or long term memory and there are no problems with cognitive skills for daily decision making. Resident A needs extensive assist with one person physical assist for toileting and personal hygiene. The resident uses a wheelchair for mode of transportation. A care plan was developed for Resident A on January 12, 2015, for [MEDICAL CONDITION]- approaching male resident to get in her bed. A review of the Social Service Director's (SSD) notes dated January 12, 2015, indicated Resident A was counseled regarding asking a male resident to join her in her bed. The SSD counseled the resident regarding the inappropriateness of her behavior. A phone interview was conducted on February 18, 2015, at 2 p.m., with CNA 1. He stated he worked the night shift on February 16, 2015, and was assigned to care for Resident A. He checked on Resident A because she needed a diaper change, he administered peri-care (cleansing procedure of the outer female genitalia after urinating or defecating), because it's part of the care. He stated he purchased personal wipes for Resident A, and explained that he would touch her private parts to check if Resident A was soiled. CNA 1 indicated he was not trained to physically touch the residents, stating, I did this on my own. CNA 1 admitted kissing Resident A on the mouth and forehead more than twice. On February 18, 2015, at 2:24 p.m., an interview was conducted with the Director of Staff Development (DSD). The DSD was asked to explain the process of how the CNAs are trained to assess if a resident has soiled their incontinent pad. The DSD stated if the residents are alert but incontinent (unable to control bladder), the CNAs should ask the residents if their disposable brief needs to be changed. The CNAs can look under the disposable brief by removing the velcro from the brief to observe a soiled diaper. The CNAs are not taught to physically touch the residents peri area. The DSD indicated Resident A is continent and wears disposable briefs during the night shift and needs assistance to go to the bathroom. The CNAs are taught to ask, look and visually check. A review of the CNA flow sheets for February 2015, revealed that Resident A did not have any documented incontinent episodes throughout all shifts through February 15, 2015. A review of the police report dated February 16, 2015, documented I was dispatched to the (name of this facility and address) reference a possible past sexual assault involving patient and employee at the facility. O3 (identified as DON) statement: a patient O1 (identified as Resident A) informed O3 that a male staff member O2 (identified as CNA 1) touched her inappropriately between 02-15-15 2300 hours (11 p.m.) and today's date 0700 (7 a.m.). O2 placed his hand underneath O1's diaper/underwear and began to fondle her vagina. O2 has fondled her vagina in the past. O1 and O2 have been sexual in nature, kissing . O1's statement: . O1 and O2 were engaged in mutual french kissing .used his own money and purchased O1 over the counter medication wipes and he treated O1 by applying the wipes to her vagina area . O2 reached underneath her diaper and began to fondle her vagina. O1 told him she was dry and felt non-lady like. O2 walked to the bathroom doused his hands in water and returned and again attempted to penetrate O1's vagina with his fingers at which point she told him No. Next, I talked to O2. O2's statement: .He admitted to purchasing medicated vaginal wipes. O1 and O2 became intimate and kissed on several occasions. O2 said part of his job responsibilities are to provide baths to persons to include cleaning their anuses, penis', and vagina's. He did check O1's diaper to determine if it was saturated and needed to be replaced. he left the room being her diaper did not need to be changed. An interview was conducted with CNA 2, on February 20, 2015, at 1:30 p.m. CNA 2 indicated that she had been assigned to care for Resident A on a regular basis for two months. She stated she worked the day shift. CNA 2 revealed that Resident A developed a trust and rapport with her that included jokes, laughter and inquiring about family members. CNA 2 indicated Resident A had anxiety issues, such as moving her hands a lot, and would get loud and would yell about anything. The resident informed CNA 2 that she liked CNA 1 because he was nice to her. On the morning of February 16, 2015, CNA 2 was preparing Resident A for her shower when the resident told CNA 2 that a male CNA on the night shift had kissed her and attempted to stick his hand inside her underwear and play with her. It didn't feel good. CNA 2 stated the resident told the male CNA to stop because she didn't like it. The male CNA asked Resident A, Why aren't you getting wet. he said he was going to try every night because he wants to make her feel good. CNA 2 stated Resident A admitted the male CNA was (CNA 1's name omitted). CNA 2 immediately informed the nursing supervisor. A review of the facility policy and policy, dated 2014, titled, (name of corporation omitted) Abuse Prevention and Reporting Policy, indicates . 2. All employees are informed of the California state law which defines abuse of an elder or dependent adult as any of the following:. treatment with resulting. mental suffering. c. Sexual Abuse - Sexual harassment, sexual coercion, and sexual assault are examples.

Based on interview and record review, the facility failed to ensure for one of three sampled residents, Resident 1, was accurately assessed for possible weight loss and a decline in nutritional status by: 1. Failing to document reporting Resident 1's poor intake to licensed staff; 2. Failing to document alternative meals offered; and, 3. Failing to verify documentation of Resident 1's poor intake. These failures placed Resident 1 at risk for a potential decline in her nutritional status and for possible unintended weight loss. Findings: On March 14, 2013, at 1:15 p.m., an unannounced revisit was conducted. During an interview with the Director of Staff Development (DSD), on March 14, 2013, at 1:20 p.m., she stated all licensed staff and all Certified Nursing Assistants (CNAs) had been inserviced on weight loss prevention for residents. The DSD stated if the CNA staff noticed a resident was not eating well, the CNAs were to notify the charge nurse and document if a resident was offered a meal substitute. On March 14, 2013, the record for Resident 1 was reviewed. Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The document titled "Nutritional Approach" dated March 1, 2013, indicated Resident 1 was at risk for "Unavoidable weight loss r/t (related to) Alzheimer's." The document titled "Food Consumption Log" dated March 2 through March 14, 2013, indicated: "Key: G (Good)= 75%, F (Fair)= 50% to 75% and P (Poor)= less than 50%." The document indicated that Resident 1 had eaten poorly nine times during this period. During an interview with the Director of Nurses (DON), on March 14, 2013, at 3:20 p.m., she stated the CNAs had been inserviced on monitoring residents who eat poorly. The DON reviewed the record and was unable to find documentation that a nurse had been notified eight of the nine times that Resident 1 ate poorly, or that a substitute meal was offered. On March 14, 2013, at 3:35 p.m., an interview and concurrent review of Resident 1's record was conducted with Licensed Vocational Nurse 1 (LVN 1).The document titled "Nurse's Weekly Progress Notes" dated March 7, 2013, indicated that Resident 1 had eaten "Good" at breakfast, "Good" at lunch, and "Good" at dinner. LVN 1 stated "Yes those are my notes." The document titled "Food Consumption Log" dated March 2 through March 14, 2013, indicated that on March 7, 2013, Resident 1 ate "Fair" at breakfast, "Good" at lunch, and "Fair" at dinner. LVN 1 stated that the documentation on the "Food Consumption Log" was done by the CNAs. LVN 1 stated she did not know why her documentation indicating how Resident 1 ate was different from the CNAs documentation. LVN 1 stated she had documented Resident 1's meal intake on March 7, 2013, as being "Good" for all three meals because "I ask the CNAs how the resident is eating and chart what they say." LVN 1 stated that she "Doesn't look at the (charting the CNAs do) on the Food Consumption Log." LVN 1 stated "Sometimes (when i review charts) I say Hey, why didn't they (CNAs) chart good when the resident doesn't eat good." LVN 1 reviewed her charting and the CNA's charting of Resident 1's meal intake for March 7, 2013, and stated "I am glad you pointed that (the difference in charting) out. I am really going to start checking what they (CNAs) chart." A review of the inservice records was conducted with the DSD on March 14, 2013. Six CNA inservice records titled "...Record of Inservice Training" dated February 14, 2013, were reviewed. The area on the documents titled "Subject Covered" was blank for five of the six documents. The DSD stated a power point presentation titled "Weight Loss Prevention" was used to inservice CNAs. Page three of the power point titled "Certified Nursing Assistants Role in Weight Loss Prevention", indicated "Documentation of meal percentages of 50% or less requires the offering of an alternative meal and notification of the charge nurse." The DSD reviewed Resident 1's "Food Consumption Log" on March 14, 2013. The "Food Consumption Log" dated March 2 through March 14, 2013, indicated that Resident 1 had eaten poorly ("less than 50%") nine times. The DSD was unable to find documentation that an offering of an alternative meal or that the charge nurse had been notified for eight of the nine times.

Based on interview and record review, the facility failed to ensure a resident, (Resident 1), maintained an acceptable nutritional status by failing to monitor, evaluate, revise, and implement interventions for Resident 1's progressive weight loss. This failure led to a decline in Resident 1's nutritional status and a 28 pound weight loss over a seven month period or 14% of Resident 1's initial body weight. Findings: An unannounced visit was made to the facility on [DATE], at 9:15 a.m., to initiate an investigation of a complaint. The record for Resident 1 was reviewed on November 2, 2012. Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Social Services Notes dated March 5, 2012, indicated Resident 1 was admitted to .from home. The admission Minimum Data Set (MDS- an assessment tool) dated March 14, 2012, indicated Resident 1 was Independent- no help or staff oversite at any time to eat. The quarterly MDS dated [DATE], indicated Resident 1 needed Supervision- oversight, encouragement or cueing while eating. The form titled Yearly Weight Chart--2012 indicated Resident 1's admission weight on March 3, 2012, was 153.2 pounds (lbs). The form titled Yearly Weight Chart--2012 indicated Resident 1's monthly weights were: March 12, 2012-146 lbs. (loss of 7.2 lbs.) March 19, 2012-150.2 lbs. (gain of 3.8 lbs.) March 20, 2012-146.6 lbs. (loss of 3.6 lbs.) March 24, 2012-149.8 lbs. (gain of 3.2 lbs.) March 26, 2012- 147.8 lbs. (loss of 2 lbs.) This was a total of a 5.4 lb. weight loss or 3.5 % of Resident 1's admission weight, during the month of March 2012. Additional recorded monthly weights indicated the following: April 25, 2012- 150.4 lbs. (gain of 2.6 lbs.) May 23, 2012- 148.6 lbs. (loss of 1.8 lbs.) June 23, 2012-149.8 lbs. (gain of 1.2 lbs.) July 25, 2012-146.4 lbs. (loss of 3.4 lbs) August 25, 2012-142.4 lbs. (loss of 4 lbs.) September 28,2012-138.0 lbs. (loss of 4.4 lbs October 23, 2012-131.8 lbs. (loss of 6.2 lbs.) October 26,2012-125.2 lbs. (loss of 6.6 lbs.) This was a total of a 28 lbs. weight loss in seven months or 14% of Resident 1's admission weight. Resident 1 had a 16.7% weight loss during the six month period, from April through October 2012. The form titled Resident Transfer Record dated October 26, 2012, indicated Resident 1 was transferred to a hospital emergency room . The form indicated Resident has been losing weight. On November 2, 2012, the hospital record of Resident 1 was reviewed. Resident 1 was admitted on [DATE] with [DIAGNOSES REDACTED]. The hospital physician's History and Physical Report, dated October 26, 2012, indicated, She was brought by the patient's family since.She has lost weight, about 30 pounds, in the last few months. The hospital form titled MD (medical doctor) Notes completed by the emergency room physician dated October 26, 2012, indicated Exam.appears malnourished (a condition resulting from inadequate consumption of foods especially proteins, inadequate intake of essential vitamins, minerals). The form also indicated Assessment/Plan (Problem List).Dehydration, Dysphagia,Weight loss.[DIAGNOSES REDACTED] (low potassium). The results of the hospital blood tests for Resident 1, dated October 27, 2012, at 7:05 a.m., indicated Resident 1's pre-[MEDICATION NAME] level ( a test used to assess nutritional status) was 7.6. The hospital reference range (normal range) was 17.6-36.0. The American Family Physician Journal, dated April 15, 2002 indicated a pre- [MEDICATION NAME] of 7.6 (Resident 1's test result) .dictates the need for aggressive nutritional support. The hospital physician's progress notes, dated November 2, 2012, indicated that Resident 1 had a gastrostomy tube (a tube inserted through the abdomen into the stomach, and used to administer liquid nutrition) placed in the hospital. An interview and concurrent record review was conducted with the facility's Registered Dietitian (RD), on December 11, 2012, at 10:40 a.m. The RD stated she initiated the form titled Nutrition Approach on March 3, 2012. The form indicated Resident 1 was a Risk for unintended weight loss.weigh q ( every) month. The form indicated Resident 1's admission weight was 153.2 lbs. The form titled Yearly Weight Chart-2012 was reviewed with the RD. The RD was asked how she calculated the percentage of Resident 1's weight loss. She stated that she Usually uses the resident's admission weight (153.2 lbs.), but with her I didn't, because I used the 149.8 lb weight. This weight was recorded on March 24, 2012, 21 days after Resident 1 had been admitted . The RD stated it was Up to me to review weights every month and address the weights in the Resident Care Conferences (a meeting attended by staff to discuss resident care), and at the Weekly Weight Meetings. The RD stated she reviewed the Director of Nurses (DON) weight log book and the form titled Resident Consumption Log ( a form used by CNAs (Certified Nursing Assistant) to document how much food a resident eats). The Resident Care Conferences, dated March 20, 2012, June 19, 2012, and September 18, 2012, were reviewed. The RD was unable to find documentation that Resident 1's weight loss had been addressed. The RD was asked if she had assessed why Resident 1 was having weight loss. She stated, I don't know. It's not my job (to assess the resident). It's the nurses job. They would always call me if they need me. The RD stated she did recommend Resident 1 be given a liquid nutritional supplement in March and in October 2012. During an interview with CNA 1 on December 11, 2012, at 9:35 a.m., she stated that she had provided care for Resident 1 one to two days a week since Resident 1's admission on March 3, 2012. CNA 1 stated Resident 1 Was never a good eater, (was) a very picky eater, and ate the food her family provided. CNA 1 stated Resident 1 refused to drink the nutrition drinks the facility provided. During an interview with CNA 2, on December 11, 2012, at 11:10 a.m., she stated that she had provided care for Resident 1 one to two days a week since July 2012. CNA 2 stated Resident 1, All the time ate a little and slow. CNA 2 stated she offered snacks, she refused (them), and Since I started taking care of her, (she) refused her special drinks. An interview and concurrent record review was conducted with the DON on December 11, 2012, at 12:10 p.m. The DON was asked how a resident's food intake was monitored. She stated it was All (staff) our jobs to monitor how much a resident ate. The DON stated nurses assess the residents' nutritional status i.e., intake, weight loss, receiving any nutritional supplements, likes and dislikes of foods, and then use the information to develop a plan of care for the resident. The DON reviewed Residents 1's record and was unable to find documentation that a care plan had been developed, implemented, and/or revised to address Resident 1's observed and documented poor food and nutritional supplement intake, and Resident 1's weight loss for the months of April, May, June, July, August, and September 2012. The DON stated residents were weighed weekly when first admitted and then monthly thereafter as long as their weight was stable. The DON stated if a resident's weight was not stable, they would be weighed more frequently as needed. The DON stated weights would be logged in a book that was brought to the weekly weight meetings for review. The DON stated weights were also logged on the form titled Yearly Weight Chart in the residents chart. Resident 1's form titled Yearly Weight Chart-2012 was reviewed with the DON. Resident 1's documented weights on the form were compared to the weight log book brought to the weekly weight meetings. The DON was unable to locate Resident 1's weight of 149.8 used by the RD for weight loss calculation. There was no documentation of the 149.8 lb. weight located in the log book brought to the care conferences. Resident 1's weights were reviewed with the DON. The DON stated Maybe we should monitor people better if they have a weight loss like that. The facility policy and procedure titled Policy and Procedure for Weekly Weight Meeting undated, indicated 1. Identify residents.who are at risk for weight loss secondary to.poor eating habits. The facility document titled Nutritional Assessment Protocol undated, indicated Nursing staff will notify the R.D. of any Resident assessed to be at risk nutritionally.poor appetite. Telephone calls were made to Resident 1's Physician on December 12, December 13, and December 19, 2012, in an attempt to discuss the resident's weight loss. As of January 24, 2013, the physician had not returned the calls.