Every finding on record at Sage Creek Post-Acute

Based on interview, record review, and document review, the facility failed to ensure a resident's care plan was reviewed and updated following an actual fall for 1 of 2 sampled residents (Resident 2). The deficient practice placed the resident at risk for repeated falls.Findings include: Resident 2 (R2) was admitted on [DATE] and readmitted on [DATE], with diagnoses including Parkinson's dementia and history of falls.A re-admission assessment dated [DATE], revealed R2 had a brief interview of mental status (BIMS) of 11 (moderately impaired cognition), with no wandering behaviors and had fall history prior to readmission.R2's fall care plan initiated 06/13/2026, revealed R2 was at risk for falls due to unsteady gait with a goal of not experiencing a fall related to risk factors.A nurse's note dated 06/28/2028, documented emergency services came to the facility to advise staff R2 was found on the ground in a nearby shopping complex parking lot.Hospital records dated 06/28/2026, revealed R2 eloped from the facility and was found by a bystander on the ground in a shopping complex parking lot. R2 reported falling and complained of left buttocks and knee pain.A nurse's note dated 06/29/2026, revealed R2 was transported back to the facility on [DATE] at approximately 10:00 PM.The medical record lacked documented evidence R2's fall care plan was revised following a fall incident on 06/28/2026.On 07/30/2026 at 10:05 AM, the Registered Nurse (RN) assigned to R2 on the day of the fall incident indicated the fall care plan was not revised because the fall happened outside the facility. The RN indicated being uncertain on whether the fall care plan needed to be revised and deferred to the DON.On 07/30/2026 at 11:37 AM, the Director of Nursing (DON) indicated the resident's fall care plan should have been revised even if the fall happened outside the building during an elopement.On 07/30/2026 at 12:14 PM, the DON confirmed R2 was a fall risk, had a fall care plan in place and the care plan was not reviewed or updated after the resident's actual fall on 06/28/2026.The facilitly's Comprehensive Person-Centered Care Plan policy revised March 2022, documented assessments were ongoing and care plans were revised as information about the residents' conditions changed.Complaint 3064998

Based on observation, interview, record review and document review, the facility failed to ensure an elderly resident did not leave facility premises without supervision or authorization and post-elopement prevention measures were adequately performed for 1 of 2 sampled residents (Resident 2). The deficient practice resulted in the resident falling in a nearby shopping complex resulting in hospitalization.Findings include:Resident 2 (R2) was admitted on [DATE] and readmitted on [DATE], with diagnoses including Parkinson's dementia and history of falls.A re-admission assessment dated [DATE], revealed R2 had moderately impaired cognition, no wandering behaviors, and had a history of falls prior to admission.A nurse's note dated 06/28/2028, documented emergency medical services (EMS) came to the facility to advise staff R2 was found on the ground of a nearby shopping complex parking lot. EMS notified the facility R2's son had instructed EMS to send R2 to the hospital for evaluation.A facility transfer form dated 06/28/2026, revealed the physician was notified of R2's elopement and transfer to the hospital.Hospital records dated 06/28/2026, revealed EMS brought R2 to the emergency department after falling at a shopping complex parking lot and was complaining of left buttocks and knee pain. R2 had eloped from the skilled nursing facility because R2 wanted to take a walk.On 07/20/2026 at 8:52 AM, the receptionist demonstrated the front door locking mechanism using an overhead switch system. The receptionist explained front doors were locked by 8:00 PM after visiting hours and were unlocked at 6:30 AM when the receptionist started morning shift. The receptionist indicated R2 walked out through the front doors while the Sunday receptionist was taking routine break, and the front desk was unmanned.On 07/30/2026 at 8:48 AM, R2 sounded alert and articulate over the phone. R2 recalled walking out through the facility's front door on a Sunday using a walker because R2 did not want to be in the facility anymore and wanted to go home. R2 indicated falling on her butt and taken to the hospital.On 07/30/2026 at 8:51 AM, R2's family member indicated being out of town when the incident occurred and was notified by the facility regarding R2's elopement and eventual hospitalization. R2's family member recalled being informed R2 was able to leave the facility because there was nobody at the front desk. R2's family member stated the situation could have been worse and was totally preventable.On 07/30/2026 at 9:50 AM, the RN assigned to R2 on 06/28/2026 recalled a nurse had called in and the RN who was supposed to be the charge nurse had to work the floor. The RN confirmed no one in the facility noticed R2 was missing until EMS pounded on the South emergency exit door and informed facility staff R2 was found on the ground in a nearby shopping complex parking lot. The RN indicated R2 returned from the hospital on the evening of the same day and was placed on one-on-one supervision.On 07/30/2026 at 11:25 AM, the Director of Nursing (DON) defined elopement as a resident leaving the premises without facility knowledge and supervision. The DON confirmed R2 eloped on 06/28/2026 by walking through the front entrance door while the weekend receptionist was on routine break. The DON corroborated with the RN's account staff did not notice R2 was missing for about 45 minutes until EMS came to the facility. The DON indicated the facility had taken the following corrective actions since R2's elopement incident:One-on-one (1:1) supervisionA physician order dated 06/30/2026, documented to provide R2 with 1:1 supervision to ensure that resident does not exit the facility unsupervised, every shift for exit seeking behavior until 07/06/2026 23:59. Re- evaluate necessity with provider and to continue supervision further.The medication administration record (MAR) revealed 1:1 supervision was not recorded as being provided from 07/06/2026 until R2's discharge on [DATE].On 07/30/2026 at 11:41 AM, the DON explained the stop date for the 1:1 supervision was 07/06/2026 so the nurse's stopped signing off on the task on 07/06/2026. The medical record lacked documented evidence of a re-evaluation was done to evaluate necessity of continued supervision with the provider.On 07/30/2026 at 11:45 AM, the DON confirmed a re-evaluation by the physician was not performed on 07/06/2026 to evaluate necessity for continued supervision for R2. The DON confirmed the 1:1 supervision was not recorded as provided on 07/07/26, 07/08/2026, 07/09/2026 until discharge 07/10/2026 because the order ended on 07/06/2026 in the absence of re-evaluation from the provider on 07/06/2026.On 07/30/2026 at 11:50 AM, the DON indicated when physician orders were confusing, nurses must clarify them with the physician which in this case the nurse could have asked the physician whether to continue or discontinue R2's 1:1 supervision since a re-evaluation was not performed.Training on Front Desk CoverageThe Front Desk Coverage guidance dated 06/29/2026, revealed the front desk was to be staffed and attended at all times during operational hours. An unattended front desk removed the facility's primary point of awareness for resident movement and created an immediate safety risk for residents, visitors and staff. No staff member may leave the front desk without securing confirmed coverage. The training was mandatory for all front desk staff.On 07/30/2026 at 8:02 AM, receptionist employed for four years indicated the facility had three receptionists. Receptionist 1 worked full-time from Mondays through Fridays from 6:30 AM to 4:00 PM, Receptionist 2 worked part-time Mondays through Thursdays from 4:00 PM to 8:00 PM and Receptionist 3 worked Friday evenings and Saturdays and Sundays from 8:00 AM to 8:00 PM. According to Receptionist 1, each receptionist was given two 15-minute breaks and a 30-minute lunch break.A facility reported incident (final) report dated 06/29/2026, documented one of the action steps to be taken by the facility was to review front desk coverage protocol and re-train all front desk staff to ensure continuous reception coverage was maintained even during break periods.The in-service sign-in sheet for Front Desk Coverage - Unattended Front Desk Prevention dated 06/29/2026 had 11 staff signatures with only one receptionist on the list.On 07/30/2026 at 2:07 PM, the Administrator confirmed the facility had three receptionists and there was only one receptionist on the in-service sign-in sheet.Elopement protocol reviewOn 07/30/2026 at 2:07 PM, the Administrator indicated elopements were never acceptable because residents' safety could not be guaranteed outside facility premises. According to the Administrator, the facility's goal was to prevent elopement using protocols which included review of elopement protocols upon hire, annually and as needed. The Administrator indicated R2's actual elopement led the facility to re-educate staff regarding elopement protocols.On 07/30/2026 at 10:19 AM, RN1 indicated not receiving re-training or elopement policy review after R2's incident.On 07/30/2026 at 10:27 AM, RN2 indicated not being in the facility when the in-services regarding elopement review were provided.On 07/30/2026 at 10:31 AM, certified nursing assistant (CNA1) could not recall being provided with an elopement policy review in-service.On 07/30/2026 at 10:35 AM, CNA2 indicated hearing about R2's elopement but did not receive formal re-training on elopement after the incident.On 07/30/2026 at 10:41 AM, CNA3 indicated the elopement policy was not reviewed with the CNA after R2's incident.On 07/30/2026 at 10:48 AM, a Licensed Practical Nurse (LPN) indicated being on vacation when elopement training was provided and was not able to attend.On 07/30/2026 at 10:54 AM, CNA4 indicated being in the facility during R2's elopement and indicated not receiving re-training on the facility's elopement policy.The Wandering and Elopement policy/Steps for Preventing Elopement training dated 06/29/2026 and 06/30/2026 had 46 staff signatures. The names of the two RNs, four CNAs and one LPN who were interviewed did not appear in the in-service sign-in sheets.On 07/30/2026 at 2:20 PM, the Administrator confirmed the facility had 77 employees and confirmed not all staff had received the elopement training.The Wandering and Elopement policy dated 2001, documented the facility would identify residents who were at risk for wandering and elopement. Employees who observed a resident leaving the premises would be re-directed by staff and get help from other staff if needed. When a resident was missing, initiate the elopement/missing resident protocol.FRI 3064998

Based record review, document review, and interview, the facility failed to communicate an episode of shortness of breath requiring intervention to the hemodialysis clinic prior to treatment for 1 of 32 sampled residents (Resident 28). The deficient practice had the potential for the hemodialysis provider to initiate treatment without knowledge of the resident's recent symptoms, which could have impacted treatment decisions and placed the resident at risk for complications.Findings include:Resident 28 (R28) was admitted [DATE], readmitted [DATE], with diagnosis including unspecified encephalopathy, anemia, end stage renal disease, and dependence on renal hemodialysis. On 04/28/2026 at 11:46 AM, R28 reported they recently became sick at hemodialysis. R28 explained being sent to the hospital by the hemodialysis clinic and hospitalized .A Care Plan initiated 04/15/2026, documented R28 required hemodialysis. Goals included R28 would be free of signs or symptoms of complications related to hemodialysis.A Respiratory Note dated 04/20/2026 at 9:01 AM, documented R28 was checked due to a drop to 88% in the oxygen level in the blood. R28 was readjusted for better gas exchange and a nurse provided treatment. R28's oxygen level improved to 94%. R28's breath sounds were diminished in all lobes and heard bilaterally. R28 was provided oxygen at two liters via nasal cannula for hemodialysis. R28's white blood cells were elevated and a chest x-ray would be ordered.A Nurse's Note dated 04/20/2026 at 10:03 AM, documented R28 had complaints of congestion in the morning. R28 went to the hemodialysis appointment.A Nursing Hemodialysis Communication Observation/assessment dated [DATE], the form used to communicate resident information between the facility and the hemodialysis clinic on hemodialysis days was reviewed. The section to be completed by the licensed nurse prior to hemodialysis treatment contained resident and access information and vitals including an oxygen saturation of 92%. The section designated to report R28's general condition including recent changes was left blank. The form lacked documented evidence the hemodialysis clinic was notified R28 had an episode of shortness of breath prior to departure from the facility for hemodialysis. A Nurse's Note dated 04/20/2026 at 1:36 PM, documented the hemodialysis clinic reported R28 was sent to a hospital emergency room for evaluation due to congestion and confusion.A Nurse Practitioner Note dated 04/20/2026 at 11:57 PM, documented patient was sent to acute hospital from the hemodialysis clinic due to altered mental status and shortness of breath. On 04/29/2026 at 12:49 PM, a Registered Nurse (RN), explained a communication form had to be completed prior to the resident leaving for hemodialysis. The form included most recent medication administered, last meal, most recent vitals, pain level and a section to report any findings or changes for the resident. The RN confirmed an incident of shortness of breath, even if it was resolved, needed to be reported to the hemodialysis clinic on the communication form to ensure they were aware of the event, and the resident was monitored during hemodialysis. On 04/30/2026 at 9:00 AM, the Assistant Director of Nursing (ADON) acknowledged R28's hemodialysis communication form did not include information regarding the congestion and shortness of breath R28 experienced prior to hemodialysis. The ADON explained the information should have been included in the form to alert the hemodialysis clinic of a new condition and to help prevent complications during the hemodialysis treatment. On 04/30/2026 at 2:00 PM, the Director of Nursing (DON), confirmed communication regarding R28's condition of shortness of breath was not provided to the hemodialysis clinic. The DON stated changes in the resident including shortness of breath should have been reported to the hemodialysis clinic to ensure increased monitoring and timely intervention, and to prevent complications during hemodialysis.A Nursing Home Out Patient Dialysis Agreement dated 08/21/2017, documented effective coordination of medical care for residents who would be receiving care from both parties would be provided. A facility policy titled End-Stage Renal Disease, Care of a Resident with, revised September 2010, documented agreements between the facility and the contracted End Stage Renal Disease facility included all aspects of how the resident's care would be managed including how information would be exchanged between the facilities.

Based on observation, record review, interview, and document review, the facility failed to obtain physician orders for the insertion, use, and monitoring of a peripheral intravenous (IV) catheter, and failed to ensure IV site care and dressing requirements were followed for 1 of 32 sampled residents (Resident 23). The deficient practice had the potential to result in complications related to improper IV management, including infection, infiltration, or other adverse outcomes such as phlebitis.Findings include:Resident 23 (R23) was admitted on [DATE] with diagnoses including metabolic encephalopathy, metabolic acidosis, rhabdomyolysis, and a history of neuropathy.On 04/28/2026 at 9:00 AM, R23 was observed with an intravenous (IV) catheter inserted in the left forearm. The dressing on the IV site did not contain a label with information of the insertion date or the date of the last dressing change.A physician order dated 04/24/2026 documented dextrose sodium chloride 5-0.45% IV solution to be administered at 70 milliliters per hour IV for one liter once. The medication administration record (MAR) revealed the IV solution was administered as ordered on 04/24/2026.The medical record lacked documented evidence that physician orders were obtained for the IV catheter insertion or for required IV site care, including monitoring for bleeding, catheter dislodgement, infiltration, signs of infection, dressing changes, and discontinuation of the IV catheter.On 04/28/2026 at 2:21 PM, a Licensed Practical Nurse (LPN) who provided care to R23 confirmed the observation. The LPN was unable to provide a rationale for R23 having an IV catheter that was not in use and acknowledged to be unaware of its presence. The LPN reviewed the physician orders and confirmed although R23 had received IV fluids, there were no orders for the catheter's insertion, use, monitoring, or discontinuation.On 04/30/2026 in the afternoon, the Director of Nursing stated nursing staff should have obtained physician orders for the IV catheter insertion and required care and acknowledged that the catheter should have been discontinued when it was no longer in use.The facility policy titled Peripheral IV Catheter Insertion (undated) documented a provider's order was required prior to inserting a peripheral IV catheter. The policy further indicated a label containing the date and time of insertion, the initials of the nurse who performed the procedure, and the length and gauge of the catheter was to be placed on the catheter site. This information was also required to be documented in the resident's medical record.

Based on observation, interview, record review and document review the facility failed to ensure: 1) a sequential compression device (SCD- a device used to prevent blood clots by promoting blood circulation) was accurately documented, applied and in use as ordered by the physician for 1 of 32 sampled residents (Resident 8) and 2) a physician order for fluid restriction was followed for 1 of 32 sampled residents (Resident 2). The deficient practice had the potential to place residents at risk for blood clot formation and electrolyte imbalance. Findings include: 1)Resident 8 (R8) was admitted to the facility on [DATE] with diagnoses including unspecified dementia, chronic obstructive pulmonary disease, and rhabdomyolysis. A Physician order dated 04/12/2026 documented sequential compression device (SCD) to bilateral lower extremities while in bed every shift. A Physician progress note dated 04/12/2026 documented R8 required deep vein thrombosis (DVT) precautions and to place SCDs. On 04/28/2026 at 9:49 AM, R8 was lying in bed, an SDC machine was hanging on the foot board at the foot of R8's bed. The SCD machine was not turned on. On 04/29/2026 at 9:53 AM, R8 was lying in bed, an SCD machine was hanging on the foot board at the foot of R8's bed. The SCD machine was not turned on. Review of R8's Medication Administration Record (MAR) for 04/2026 documented the SCD was applied as per physician orders daily at 6:30 AM. On 04/29/2026 at 12:04 PM, a Licensed Practical Nurse (LPN) explained was unaware if R8's SCD was currently applied. The LPN acknowledged had documented the SCD was applied at 6:30AM and that staff should round frequently to ensure the machine was on and functioning. On 04/29/2026 at 12:17 PM, the LPN confirmed R8's SCD machine was not turned on. On 04/29/2026 at 1:11 PM, the LPN explained the SCD for R8 was used to help prevent deep vein thrombosis due to R8 not getting up and walking. The LPN explained the SCD machine should be checked and monitored throughout the day to ensure it was turned on and functioning properly. On 04/30/2026 at 8:06 AM, R8 was lying in bed, no SCD machine was observed in R8's room. On 04/30/2026 at 8:13 AM, a Registered Nurse (RN) confirmed R8 had no SCD machine. The RN acknowledged had documented on R8's MAR the SCD was applied as per physician orders at 6:30AM and explained the SCD machine should have been checked to ensure it was available and turned on prior to documenting the treatment was provided. The RN located the SCD pump in a plastic bag lying in R8's bedside chair underneath a blanket. The RN explained the process would be to ensure the machine was turned on and functioning properly as per physician orders. The RN explained R8 needed the SCD machine to prevent blood clots as R8 could not get up out of bed and reposition independently. On 04/30/2026 at 11:38 AM, the Director of Nursing (DON) explained the SCD machine was used to help to prevent blood clots in residents, especially for residents unable to take anticoagulants. The expectations would be for staff to utilize the SCD machine according to physician orders and to document application of the SCD after ensuring the machine was connected, turned on, and functioning properly. On 04/30/2026 at 1:42 PM, the DON explained there was no facility policy specific to the use of SCD or implementing physician orders. The facility policy titled Charting and Documentation, revised 07/2017, documented documentation in the medical record would be complete and accurate. 2) Resident 2 (R2) was admitted on [DATE], with diagnoses including hyponatremia and acute kidney injury. A physician order dated 04/20/2026 documented a total daily fluid restriction of 1,000 milliliters (mL). The order specified dietary fluids were limited to 480 mL per day, consisting of 240 mL at breakfast, 120 mL at lunch, 120 mL at dinner, and an additional 240 mL of Nepro daily. Nursing provided fluids were limited to 280 mL per day, with 140 mL allocated to the morning and 140 mL to the night shift. On 04/29/2026 at 9:20 AM, a water pitcher was observed on the resident's bedside table containing approximately 500 mL of water; the pitcher had a total capacity of 800 mL. An empty plastic cup with a capacity of approximately 7 ounces was also observed on the bedside table. On 04/30/2026 at 12:00 PM, a water pitcher and a cup of water were observed on the resident's bedside table. The cup contained approximately 200 mL of water, and the pitcher contained approximately 400 mL. A Registered Nurse (RN) confirmed the observation. The RN explained residents who were on fluid restrictions typically received approximately 120 mL of water with each medication pass. The RN acknowledged the pitcher should not have been placed in R2's room because it allowed the resident unrestricted access to fluids, making it difficult for staff to accurately monitor and control the resident's total daily fluid intake as ordered by the physician. On 04/30/2026 at 12:15 PM, R2 was observed eating in the dining area of the east hall. The dietary ticket on the meal tray indicated a fluid restriction of 4 ounces (oz). The meal provided to R2 included a cup of soup (4 oz, equivalent to 120 mL), a glass of cranberry juice (8 oz, equivalent to 240 mL), and ice cream (4 oz, equivalent to 120 mL). The total amount of fluids served was approximately 16 oz, which was three times the amount prescribed for the resident's fluid restriction. This observation was confirmed by a Certified Nursing Assistant (CNA), who stated R2 was on a fluid restriction. The CNA acknowledged the fluids served were not consistent with the information documented on the dietary ticket. On 04/30/2026 at 1:42 PM, the Director of Nursing (DON) acknowledged the physician ordered fluid restriction should have been followed. The DON stated that R2 had been showing improvement in their clinical condition, as reflected in recent laboratory results, but regardless of the improvement, staff were expected to comply with all physician orders, including fluid restrictions. The facility policy titled Encouraging and Restricting Fluids, last revised in October 2010, indicated specific physician instructions regarding fluid restrictions were to be followed. The policy stated when a resident was placed on a fluid restriction, water pitchers and cups were to be removed from the resident's room.

Based on observation, interview, record review, and document review, the facility failed to obtain and review health and vaccination status at the time of admission for a companion pet residing with a resident for 1 of 18 sampled residents (Resident 3). The failed practice created a potential risk for the spread of animal transmitted disease and compromised safety and well-being of other residents and staff. Findings include: Resident 3 (R3) R3 was admitted [DATE], with diagnosis including encounter for orthopedic aftercare following surgical amputation and acute osteomyelitis left ankle and foot, severe sepsis without septic shock, and chronic systolic congestive heart failure. On 05/13/2025 at 9:00 AM, R3 was observed in bed, pleasant and welcoming. R3 lifted the blankets and revealed a small dog. R3 explained the dog was an alert dog, a companion, and had been with R3 since admission to the facility. A Health Certificate dated 05/13/2025 (15 days post admission), documented lab test results and vaccination records for R3's companion dog. R3's medical record lacked documented evidence the health and vaccination status of R3's dog was received and reviewed by the facility at R3's admission on 04/29/2025 and prior to 05/13/2025. On 05/14/2025 at 12:21 PM, the Assistant Director of Nursing (ADON)/Infection Preventionist (IP), explained service animals were allowed on a case-by-case basis at the discretion of the Administrator. The process of allowing a pet to reside at the facility included assessment of the resident's ability to care for the dog independently and review of health and vaccination records for the dog to ensure safety for all. The ADON/IP explained R3 had a companion dog residing with R3 due to anxiety. The ADON/IP reported during the process of admission, the dog's vaccine records were to be reviewed and a copy kept with the receptionist. On 05/16/2025 at 8:30 AM, the Director of Nursing (DON), acknowledged the health and vaccination record for R3's dog was not received by the facility until 05/13/2025. The DON confirmed review of the health and vaccination record was to be completed upon admission. The DON explained the consequences of having a dog at the facility could be catastrophic, up to and including death, if anyone was bit by a dog with rabies or other diseases. The DON reported the facility could have done better to review and document the results of the health and vaccination records of the animal. On 05/16/2025 at 4:15 PM, the Receptionist explained kept all animal health records at the reception desk. The Receptionist confirmed had received R3's dog companion's health and vaccine record on 05/13/2025. The Receptionist acknowledged the health and vaccination record should have been received upon R3's admission and was not received by the facility until 05/13/2025. On 05/16/2025 at 4:30 PM, the ADON/IP acknowledged the health and vaccination record for R3's dog had not been received at the facility until 05/13/2025. A facility policy titled Pets, Animals, and Plants, dated 2001, included animals had to be in good health, received a health evaluation by a licensed veterinarian within the past year and have proof of vaccination for animal-borne diseases and negative tests for enteric parasites.

Based on observation, interview, record review and document review, the facility failed to ensure a urinary bag and tubing were positioned to allow for proper drainage of urine and a physician's order for routine perineal care (the cleaning of the area between the anus and genitals to prevent infections) and a securement device was followed for a resident with an indwelling catheter for 1 of 18 residents (Resident 16). The deficient practice placed the resident at risk for a urinary tract infection (UTI). Findings include: Resident 16 (R16) R16 was admitted on [DATE] and readmitted on [DATE], with diagnoses including neuromuscular dysfunction of the bladder, urine retention and encounter for attention to other artificial openings of the urinary tract. A nursing admission assessment dated [DATE], revealed R16 was admitted with an indwelling catheter. A physician's order dated 03/29/2025, documented indwelling urinary (Foley) catheter care: cleanse with soap and water every shift. A physician's order dated 03/29/2025, documented to secure indwelling catheter tubing using anchoring device to prevent movement and urethral traction. On 05/14/2025 at 8:04 AM, R16 laid in bed with head of bed elevated approximately 30 degrees. A covered urinary bag was observed hanging on the right side of R16's bed and dark yellow urine was observed throughout the Foley catheter tubing. R16's urine was not draining into the urinary bag; the bag was positioned higher than the distal portion of the urinary tubing which was dangling on the floor. R16 explained staff cleaned catheter insertion site during shower days on Wednesdays and Saturdays and when incontinence care was provided after bowel movements. R16 stated staff did not wash perineal area with soap and water every shift and certainly not last night or the day before. On 05/14/2025 at 8:18 AM, the certified nursing assistant (CNA) assigned to R16 gathered supplies to perform perineal care. The CNA prepared two basins, one with warm soapy water and the other contained rinse water. The CNA cleaned the resident's perineal area from inside out changing wash cloths as needed and later cleaned the urinary tubing. The CNA verbalized peri care was expected to be done once every shift, to which R16 responded the night shift CNA and the CNA yesterday did not perform perineal care to the resident. The CNA indicated being assigned to R16 the day before and acknowledged failing to perform perineal care to R16 on 05/13/2025 but could not speak on behalf of the night shift CNA. On 05/14/2025 at 8:30 AM, the CNA emptied the urinary bag and described the contents as 100 cubic centimeters (cc) of dark yellow urine. The CNA confirmed the urinary tubing was filled with stagnant urine from the catheter insertion site throughout the length of the tubing and was dangling on the floor. The CNA indicated urine was not properly draining into the urinary bag because the bag was positioned higher than the portion of the tubing which was on the floor. The CNA explained the urinary tubing had dangled to the ground because there was no securement device which was typically placed on the resident's thigh to ensure stabilization of the tubing and proper positioning. The CNA confirmed orders for a securement device and perineal wash were not followed for R16. On 05/14/2025 at 8:35 AM, the Assistant Director of Nursing (ADON) indicated an anchoring device was used for all residents who had a Foley catheter for the purpose of stabilizing the urinary tubing to prevent tugging, discomfort, and to facilitate proper drainage of urine due to gravity. The ADON indicated staff were expected to monitor every resident's indwelling catheter to be positioned properly to allow for proper drainage because backed up urine in the tubing placed residents at risk for developing a UTI. The ADON indicated washing the perineal area with soap and water was standard care for all residents with an indwelling catheter and should be done each shift to ensure the insertion site remained clean thereby avoiding a UTI. R16's medication administration record (MAR) revealed perineal care was provided to R16 on 05/13/2025 on day shift. On 05/14/2024 at 11:25 AM, the Licensed Practical Nurse (LPN) acknowledged signing for R16's perineal care on 05/13/2025 based on the CNA's report the task was performed. On 05/14/2024 at 11:46 AM, the CNA confirmed telling the LPN perineal care was completed when it was missed on 05/13/2025 on day shift. The CNA acknowledged this was a mistake on the CNA's part. On 05/16/2025 at 7:10 AM, the LPN was inside R16's room when R16 told the surveyor the night shift CNA did not perform perineal wash on the resident. The LPN indicated the night CNA had left the facility at 6:00 AM and was not available for interview. The Urinary Catheter Care policy revised August 2022, documented catheter care served the purpose of preventing urinary catheter-associated complications such as UTI. The procedure required using a clean washcloth with warm water and soap to cleanse and rinse the catheter insertion site for routine daily hygiene, ensure the catheter remained stabilized with a securement device, and position the drainage bag to allow for proper drainage and prevent urine from flowing back.

Based on observation, interview, record review, and document review, the facility failed to ensure accurate documentation a protein supplement had been administered without direct observation of the resident's consumption of the protein supplement for 1 of 18 sampled residents (Resident 11). The deficient practice had the potential to compromise the resident's nutritional status and weight. Findings include: Resident 11 (R11) was admitted to the facility on [DATE] with a weight of 231.2 pounds (lbs.) and diagnoses of Parkinsonism, infection and inflammatory reaction due to internal right hip prosthesis, and cirrhosis of the liver. A nutritional assessment for R11, completed on 04/13/2025, referenced the resident was wearing well fitted dentures, required cues at meals to feed self, did not have any swallowing issues, had surgical wounds, and was at risk for malnutrition. A weight change note on 04/10/2025 indicated R11's weight was 222.3 lbs. while food intake was 50 to 100%. Recommendation was for R11 to continue with the current diet regimen and if R11's weight continues to trend down, adjustments to the diet regimen included increased calories for weight maintenance. A weight change note on 04/17/2025 noted R11's weight was 215.2 lbs. while food intake had declined to 25 to 100%. Recommendation was for R11 to add Ensure 500 kilocalories (Kcals) with 18 grams (g) of protein two times a day for wound healing and risk for malnutrition. An order was written by the physician for Ensure two times a day for at risk for malnutrition one carton 240 milliliters (ml). A weight change note on 04/24/2025 indicated R11's weight was 210.6 lbs. while food intake remained at 25 to 100%. Recommendation was for R11 to continue Ensure 500 kcals with 18 g protein two times a day and add a multivitamin with minerals daily for wound healing and risk for malnutrition. A physician Progress note on 05/10/2024 noted R11 has lost 18 lbs. since admitted to the facility on [DATE]. On 05/13/2025 at 01:54 PM, R11 had six unopened Ensure drinks on the over bed table. On 05/14/2025 at 12:15 PM, the Registered Dietitian (RD) indicated R11 was on Ensure twice per day at 9am and 2pm for weight loss and to assist with weight stabilization. R11's weight had hovered around 213 since the multivitamin addition. The RD was not sure the last time was in R11's room and was surprised to hear there were six Ensures on R11's bedside table. The RD stated the expectation was for the staff to document the supplement intake correctly and to notify the RD if the resident was not drinking the supplements. To the RD's knowledge, the family of R11 was not bringing in any supplements/ensure. According to the Medication Administration Record (MAR), as of 05/13/2025, it was documented R11 had been drinking 240ml, which is a whole carton of ensure, everyday twice a day with only three exceptions. On 05/03/2025 AM 200 ml was consumed; on 05/05/2025 PM 100 ml was consumed; and on 05/03/2025 AM zero ml was consumed. On 05/14/2025 at 02:52 PM, R11's Licensed Practical Nurse (LPN) stated when 240 ml is written in the MAR for an Ensure, it is what the resident consumed, not just what was given to the resident. For the May MAR as of 05/13/2025, R11 had not consumed one carton, and consumed less than half of another carton. The rest of the Ensure cartons were completely consumed based off the MAR. The LPN was not sure why there were six Ensure cartons on R11's overbed table. The LPN explained had worked three 12-hour shifts and both of R11's ensure passes are during this LPN's shift. The LPN revealed the shift has a split hall which can be difficult to run back and forth to meet the residents' needs on both sides of the building. The LPN stated relied on the Certified Nursing Assistant (CNA) to let the LPN know how much R11 consumed of the Ensure because it takes R11 a while to finish a carton of Ensure. The LPN explained it could be possible the CNA did not give the LPN the correct information on the amount of Ensure R11 consumed. On 05/14/2025 at 03:31 PM, R11 stated the LPN had come in and removed all the Ensures from the over bed table earlier in the day. R11 also stated only gets the Ensures from the facility, as they would bring them to the room twice a day. R11 revealed no family/friends from outside the facility bring Ensures. On 05/14/2025 in the afternoon, the Director of Nursing (DON) indicated the expectation would be for the nurse to give the drink carton to the resident and make certain the resident had access to it and the resident was able to open and drink it. Then the nurse would need to go back to verify the drink carton was consumed and then document the amount of the drink consumed. R11 had a care plan for malnutrition with an intervention to provide diet, supplements, and vitamins/minerals per physician order. The facility policy titled Documentation of Medication Administration, revised November 2022, documented the administration of medication would be documented immediately after it is consumed.

Based on observation, interview, record review, and document review, the facility failed to obtain physician orders for the insertion of intravenous (IV) lines for 2 of 18 sampled residents (Resident 149 and 150). The failed practice had the potential to result in inappropriate medical treatment and compromised resident safety. Findings include: Resident 149 (R149) R149 was admitted [DATE] and readmitted [DATE], with diagnosis including dysphagia following unspecified cerebrovascular disease, chronic obstructive pulmonary disease with acute exacerbation, and pneumonia. On 05/13/2025 at 9:55 AM, R149 was observed in bed. R149 had an IV line on top of the right hand, covered with an undated bandage. A small amount of blood was visible in the line. R149 reported the IV line was previously used for medication but was no longer used. R149 explained the IV leaked fluids at times, was slightly painful, and R149 felt a bump at the insertion site that changed and varied in size from small to large. R149's medical record lacked documented evidence a physician order was obtained for insertion of the IV line. R149's medical record lacked documented evidence the IV line was inserted. On 05/14/2025 at 2:56 PM, A Registered Nurse (RN), confirmed the medical record lacked physician orders and documentation for insertion of R149's IV line. The RN acknowledged a physician's order was to be obtained for the insertion of IV lines. On 05/14/2025 at 3:09 PM, the Assistant Director of Nursing (ADON)/Infection Preventionist (IP), confirmed R149's medical record lacked documented evidence a physician order was obtained for insertion of the IV line. The ADON/IP acknowledged a physician order should have been obtained for the insertion of the IV line. Resident 150 (R150) R150 was admitted [DATE], with diagnosis including displaced mid-cervical fracture of left femur, subsequent encounter for closed fracture with routine healing, iron deficiency anemia, and dysphagia. On 05/13/2025 at 10:13 AM, R150 had an IV line on the left arm. R150 reported was unsure whether the IV line was still being used or not. R150's medical record lacked documented evidence a physician order was obtained for insertion of the IV line. On 05/14/2025 at 2:03 PM, a Registered Nurse (RN), acknowledged a physician order should have been obtained for the insertion of an IV line. On 05/15/2025 at 4:25 PM, the ADON/IP, confirmed the medical record lacked physician orders for insertion of R150's IV line. The ADON/IP acknowledged a physician order should have been obtained for insertion of R150's IV line. A facility policy titled Peripheral IV Catheter Insertion dated 2001, documented a provider's order was necessary for the procedure to start an IV. Documentation included the date and time of the procedure, the type, length and gauge of the catheter, type of antiseptic agent used, and the signature and title of the person recording the data.

Based on observation, interview, document review and record review, the facility failed to ensure resident was free from unnecessary medications. Specifically, a pain medication prescribed for severe pain was administered to 1 of 18 sampled residents (Resident 16) when resident was not experiencing a specific level of pain as ordered by the physician. The deficient practice exposed the resident to potential adverse effects of opioid use, including constipation and narcotic dependence. Findings include: Resident 16 (R16) R16 was admitted to the facility on [DATE], and readmitted on ,d+[DATE]/ 2025, with diagnoses including osteoarthritis of the knee, (a chronic condition marked by joint pain, stiffness, and decreased mobility). R16's medical record documented Brief Interview for Mental Status (BIMS) of 10 (moderate cognitive impairment). The hospital discharge summary (undated) documented R16 experienced right hip pain without evidence of fracture following a mechanical fall. A Physician's order dated 03/28/2025, documented to give Hydrocodone-Acetaminophen 5-325 (Opioid pain medication) Milligrams (mg) one tablet by mouth every six hours as needed for severe pain, defined as a pain level of 7-10 on the pain scale (a scale used to determine a resident's level of pain with 0 being no pain and 10 being most pain). R16's Medication Administration Record (MAR) for March 2025, to May 2025 revealed Hydrocodone-Acetaminophen was administered to R16 outside of the prescribed pain scale parameters of 7-10 level on the following dates: -03/30/2025 Pain level 2 at 10:21 AM -04/04/2025 Pain level 5 at 2:32 PM -04/11/2025 Pain level 6 at 2:31 AM -04/11/2025 Pain level 5 at 9:37 AM -04/12/2025 Pain level 4 at 4:17 AM -04/13/2025 Pain level 6 at 4:52 PM -04/14/2025 Pain level 6 at 2: 16 AM -04/17/2025 Pain level 4 at 4:19 AM -04/17/2025 Pain level 6 at 2:38 PM -04/18/2025 Pain level 6 at 9:08 PM -04/19/2025 Pain level 6 at 4:44 AM -04/19/2025 Pain level 6 at 4:18 PM -04/20/2025 Pain level 0 at 9:02 AM -04/242025 Pain level 6 at 4:54 AM -04/24/2025 Pain level 6 at 9:23 PM -04/25/2025 Pain level 6 at 5:47 AM -04/25/2025 Pain level 6 at 9:23 PM -04/26/2025 Pain level 0 at 4: 13 PM -05/01/2025 Pain level 5 at 10:15 PM -05/02/2025 Pain level 5 at 5:01 AM -05/02/2025 Pain level 6 at 6:09 PM -05/03/2025 Pain level 5 at 12:28 AM -05/03/2025 Pain level 5 at 7:25 PM -05/07/2025 Pain level 6 at 10:25 PM -05/08/2025 Pain level 5 at 5:58 AM -05/08/2025 Pain level 6 at 9:07 PM -05/09/2025 Pain level 5 at 3:33 AM -05/09/2025 Pain level 5 at 11:15 PM -05/10/2025 Pain level 5 at 6:11 AM On 05/13/2025 at 9:28 AM, R16 verbalized pain was from right leg and forthcoming appointment with physician for knee shot. On 05/14/2025 at 3:23 PM, the Assistant Director of Nursing (ADON) explained the expectation was for nurses to administer Hydrocodone-Acetaminophen to R16 at the pain scale level of 7-10 per physician orders. The ADON reviewed R16's MAR, and confirmed the Hydrocodone-Acetaminophen had been administered 30 times between 03/28/2025 through 05/14/2025 outside of the ordered parameters. The ADON indicated nursing staff had not followed physician's orders. The ADON verbalized administering Hydrocodone-Acetaminophen when the resident reported pain below the 7-10 constituted an excessive dosage and was considered unnecessary medication. On 05/14/2025 at 03:36 PM, the Licensed Practical Nurse (LPN) assigned to indicated R16's pain comes from the lower extremities. The LPN indicated nurses who administered Hydrocodone-Acetaminophen to R16 with a pain scale below 7-10 were not following the physician's order. The LPN explained the process when the resident's pain level is below 7, the resident should be given Acetaminophen and non-pharmacological interventions such as repositioning, massaging, distracting with activities like TV, and interaction with staff. The LPN indicated Hydrocodone-Acetaminophen was considered a narcotic and controlled medication, typically ordered for severe pain. The LPN stated when Hydrocodone-Acetaminophen was administered for mild to moderate pain or below pain level 7-10, this was considered overmedication or unnecessary medication. On 05/15/2025, at 1:04 PM, the Consultant Pharmacist confirmed nursing staff did not adhere to the physician's orders regarding the administration of Hydrocodone-Acetaminophen for R16. The physician's order specified Hydrocodone-Acetaminophen was to be administered only for pain rated between 7-10 on the pain scale. The Consultant Pharmacist indicated Hydrocodone-Acetaminophen had been administered outside of these specified pain parameters on 30 occasions between 03/ 28/2025, and 05/2025. The Consultant Pharmacist stated these instances are where the administration of unnecessary medication occurs. The Facility policy titled Administering Medications, revised April 2019, documented medications must be administered in strict accordance with the prescribing physician's orders. The Facility policy titled Pain Assessment and Management, revised October 2022, documented residents receiving opioid medications for the long-term management of chronic pain are at increased risk for opioid-related complications, including overdose.

Based on observation, interviews, and document review, the facility failed to ensure an expired medication for a current resident and medication for a discharged resident was removed from active stock of medications and destroyed or sent back to the pharmacy. The deficient practice put residents at risk of receiving ineffective medications. On 05/16/2025 at 8:20 AM, the South medication room revealed a medication (antibiotic) for a discharged resident in the stock of active medications. There was a medication labeled for a current resident of Daptomycin 400 mg/Normal Saline 100 milliliters (antibiotic) which had a do not use after date of 05/13/2025, mixed in with the active medications. On 05/16/25 at 8:30 AM, the Charge nurse indicated when a resident was discharged , the nurse would be informed by case management of what medications would be going with the resident. Generally, for intravenous medications, the process would be to send back to pharmacy. The charge nurse confirmed medications were present and should have been removed from the active stock. On 05/16/25 at 9:20 AM, the Director of Nursing indicated expired medications and medications for discharged residents would be destroyed or picked up by the pharmacy. The medications for discharged residents should be removed from active stock and to immediately remove expired medication as the efficacy could be impacted. The facility policy titled Storage of Medications (revised November 2020) documented drug containers having missing, incomplete, improper, or incorrect labels were to be returned to the pharmacy for proper labeling. Discontinued, outdated, or deteriorated drugs or biologicals were to be returned to the dispensing pharmacy or destroyed.

Based on observation, interview, record review, and document review, the facility failed to ensure a completed Physician Orders for Life-Sustaining Treatment (POLST) form reflecting the resident's do not resuscitate (DNR) status was obtained and maintained in the medical record for 1 of 18 sampled residents (Resident 147). The failed practice had the potential to result in the resident not receiving care consistent with the resident's resuscitation preferences. Findings include: Resident 147 (R147) R147 was admitted [DATE], with diagnosis including osteomyelitis of vertebra lumbar region, lack of coordination, and abnormalities of gait and mobility. On 05/13/2025 at 8:48 AM, R147 was observed walking in the room. R147 was alert and oriented and participated in conversation. R147 reported was admitted to the facility the previous night. The electronic medical record documented R147's code status as DNR. A Care Plan dated 05/13/2025, lacked documented evidence the DNR code status determination was included in the care plan. The medical record lacked documented evidence a POLST form was completed for R147 at admission. On 05/15/2025 at 10:21 AM, the Medical Records Director confirmed R147's medical record lacked documented evidence a POLST form was completed. On 05/15/2025 at 12:50 PM, the DON explained the facility's procedure to complete a POLST form included the document must have been signed by both the resident and the medical provider. Completion of the POLST should have been done prior to a DNR status entered in the electronic medical record, to confirm the resident's decision of DNR. The DON explained residents were to remain a full code in the electronic medical record until the POLST form with a DNR determination was signed by both the medical provider and the resident. The DON confirmed the medical record lacked documented evidence the DNR code status was care planned for R147. The DON acknowledged R147 should have had a POLST form completed at admission. The DON acknowledged an incorrect code status determination had the potential to place the resident at risk of not having clear directives in place based on their preferences. A facility policy titled Advanced Directives revised September 2022, documented the resident had the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. Advanced directives were honored in accordance with state law and facility policy.

Based on interview, record review and document review, the facility failed to ensure nephrostomy care was provided in accordance with physician's order and facility policy for 1 of 4 sampled residents (Resident 2). The deficient practice placed the resident at risk for complications related to the nephrostomy tubes. Findings include: Resident 2 (R2) R2 was admitted on [DATE], with diagnoses including malignant neoplasm of the bladder and sepsis. A hospital discharge summary dated 09/20/2024, revealed R2 had bilateral nephrostomy tubes (a thin, flexible tube inserted through the back into the kidneys to allow drainage of urine to bypass a blockage to urine flow). R2's nephrostomy became obstructed and needed to be revised. A physician's order dated 09/22/2024, documented to provide nephrostomy care every shift, may change bag as needed. The Medication Administration Record (MAR) for September 2024, lacked documented evidence nephrostomy care was performed on 09/22/2024 evening shift (PM), 09/23/2024 morning and evening (AM/PM shift) and on 09/24/2024 (PM shift). On 03/13/2025 at 1:14 PM, the Assistant Regional Director of Clinical Services (ARDCS) explained nephrostomy care included emptying the bag, making sure the nephrotomy was draining below the level of the kidney, checking for kinks, and identifying and reporting complications. The ARDCS confirmed there was no documentation nephrostomy care was provided on 09/22/2024 (PM shift), 09/23/2024 (AM/PM shift) and 09/24/2024 (PM shift). The ARDCS indicated nephrostomy care ensured complications such as infections and skin breakdown were prevented and should be carried out as ordered. The Care of Nephrostomy Tube policy revised October 2010, documented a physician's order was required for nephrostomy care procedure. Nephrostomy care included: 1) Check placement of the tubing and integrity of the tape during assessments, 2) Ensure drainage is below the level of kidneys, 3) Check for kinks, 4) Empty drainage bag, 5) Change drainage bag monthly or as needed and 6) notify physician of complications such as dislodgement. Complaint #NV00072509

Based on observation, interview, record review and document review, the facility failed to ensure 1) an intravenous (IV) medication bag was labeled with the resident's name for 1 of 4 sampled residents (Resident 4) and 2) the facility's policies on peripheral IV insertion and removal were followed for 1 of 4 sampled residents (Resident 2). The deficient practice placed residents at risk for medication errors and complications related to IV accesses. Findings include: Resident 4 (R4) R4 was admitted on [DATE], with diagnoses including diverticulitis (an inflammation or infection of one or more small pouches in the digestive tract) of large intestines. On 03/13/2025 at 8:27 AM, a Licensed Practical Nurse (LPN) was preparing to administer Ciprofloxacin IV 400 milligrams (mg)/200 milliliters (ml) reconstituted solution to R4. The IV medication was pre-packaged in an aluminum container with a sticker label taped in front. After removing the IV medication bag from the aluminum package, the LPN affixed the sticker label unto the IV medication bag. The sticker label contained the resident's name, medication name, dose, route and frequency. After priming the IV tubing, the LPN entered R4's room. On 03/13/2025 at 8:46 AM, an empty IV medication bag attached to IV tubing was observed hanging on an IV pole at the right side of R4's bed. The IV bag read Metronidazole 500 mg/100 ml, the IV bag did not have a sticker label bearing the resident's name. The LPN confirmed the observation. On 03/13/2025 at 8:48 AM, the LPN explained reconstituted IV antibiotics such as Metronidazole and Ciprofloxacin came in aluminum packs for protection and were always delivered with a sticker label bearing the resident's name and order specifications. The LPN stated the facility process required nurses to remove the sticker label from the original package and affix the sticker on the IV bag. According to the LPN, the practice ensured the six rights of medication administration (right medication, right patient, right time, right dose, right route and right frequency) were being followed. The LPN indicated the medication administration record revealed the Metronidazole was last administered to R4 on 03/13/2025 at 6:19 AM by the night shift nurse. A physician's order dated 03/10/2025, documented to give Metronidazole Solution 500 mg/100 ml, intravenously every eight hours for diverticulitis for seven days. On 03/13/2025 at 2:21 PM, the Assistant Regional Director of Clinical Services (ARDCS) indicated the night nurse should have taken the sticker label from the original package and affixed the label on the IV medication bag to demonstrate the medication was prescribed and intended for R4. According to the ARDCS, administering unlabeled IV medication bags went against the facility practice. The Administering Medications policy documented the individual administering the medication must verify the resident's identity before administering the medication and verify the medication was for the right resident, right medication, right time, right method prior to administering medication. Medications ordered for a particular resident may not be administered to another resident. Resident 2 (R2) R2 was admitted on [DATE], with diagnoses including malignant neoplasm of the bladder and sepsis. A hospital discharge summary dated 09/20/2024, documented R2 was treated for sepsis and was being monitored by infectious disease team. R2 had completed antibiotic therapy and R2's discharge medications did not include any intravenous (IV) medications. The admission assessment dated [DATE], lacked documented evidence R2 was admitted with an IV access. A physician's order dated 09/20/2024, documented to change peripheral IV access every 72 hours and as needed for dislodgement, may extend for seven days for poor venous access as needed. Rotate IV site. A physician's order dated 09/21/2024, documented to give Piperacillin Sodium-Tazobactam reconstituted solution 3.375 grams intravenously every eight hours for leukocytosis (elevated white blood cells indicative of infection) for seven days. A physician's order dated 09/21/2024, documented normal saline flushes, use 10 milliliter (ml) IV every 12 hours for patency. First administration morning shift on 09/21/2024. The medical record lacked documented evidence a physician's order to insert a new peripheral line or discontinue an existing peripheral line was obtained and carried out. On 03/13/2025 at 2:08 PM, the Charge Registered Nurse (RN) recalled being assigned to R2 on a few occasions, but the RN could not recall if R2 was admitted with an IV access or whether the resident's IV line was inserted at the facility. The RN emphasized R2 had an IV access because the RN recalled administering IV medications to R2. On 03/13/2025 at 1:49 PM, the Assistant Regional Director of Clinical Services (ARDCS) confirmed R2's medical record reflected R2 was not admitted with an IV access. The ARDCS acknowledged there was no evidence a physician's order was obtained to remove an existing peripheral line or to insert a new one. The ARDCS indicated peripheral lines were intended for short term use and were typically replaced every 72 hours unless the physician ordered to maintain the line for longer use. The ARDCS indicated documentation requirements for peripheral line insertion and/or removal were not followed in the case of R2. The Peripheral IV Catheter Removal policy dated 2001, listed documentation requirements to include any communication with the physician, date and time of the procedure, location of catheter, which was removed, reason for removal (end of treatment, complication, rotation of site, etc.). The Peripheral IV Catheter Insertion policy dated 2001, listed documentation requirements to include provider's order, date and time of procedure, type, length and gauge of catheter, insertion site (specific vein and limb), number of attempts, condition of IV site, resident's response to the procedure and signature and title of person who performed the procedure.

Based on interviews, record review, and document review, the facility failed to ensure wound care physician orders were being implemented daily for two sampled residents (resident 1 and resident 2). The deficient practice increased the risk of further skin breakdown and infections. Findings include: Resident 1 (R1) R1 was admitted on [DATE] and readmitted on [DATE] with diagnoses including rhabdomyolysis (breakdown of muscle tissue), and sepsis. A physician order dated 08/28/2024 documented to apply ace wraps to bilateral lower extremities due to swelling every shift. A physician order dated 09/06/2024 documented to apply Triad and antifungal powder to right flank and leave open to air. The medical record lacked documented evidence of ace wrap or treatment to right flank was performed on the following dates: - 09/07/2024 - 09/08/2024 - 09/12/2024 - 09/13/2024 A physician order dated 09/06/2024, documented to clean left lateral foot with wound cleanser or normal saline, pat dry, apply skin prep and leave open to air every Wednesday, Friday, and Sunday. A physician order dated 09/06/2024, documented to cleanse right heel with wound cleanser or normal saline, pat dry, apply triad and honey, cover with foam dressing every Wednesday, Friday, and Sunday. A physician order dated 09/06/2024 documented to clean right lateral foot with wound cleanser or normal saline, pat dry, apply triad and honey, and cover with foam dressing every Wednesday, Friday, and Sunday. A physician order dated 09/06/2024 documented to cleanse coccyx with normal saline or wound cleanser, pat dry, apply triad to peri-wound, honey gel to wound base, and cover with border gauze then a foam dressing every Wednesday, Friday, and Sunday. A physician order dated 09/06/2024 documented to cleanse left heel with normal saline or wound cleanser, pat dry, and cover with a foam dressing every Wednesday, Friday, and Sunday. A physician order dated 09/06/2024 documented to cleanse left lateral knee with betadine, apply calcium alginate and cover with a foam dressing every Wednesday, Friday, and Sunday. A physician order dated 09/06/2024 documented to cleanse spine with normal saline or wound cleanser, pat dry, apply triad to peri-wound, honey-gel to wound base and cover with a border gauze and then a foam dressing every Wednesday, Friday, and Sunday. The medical record lacked documented evidence physician orders were implemented on 09/08/2024 (Sunday) and 09/13/2024 (Friday) regarding multiple wounds for R1. Resident 2 (R2) R2 was admitted on [DATE] with diagnoses including muscle weakness and end stage renal disease. A physician order dated 09/09/2024 documented to cleanse right groin puncture site with normal saline or wound cleanser, pat dry, apply dry dressing daily and as needed. The medical record revealed no regular treatment or as needed treatment was completed on the following dates: - 09/13/2024 - 09/14/2024 - 09/15/2024 A physician order dated 09/09/2024 documented to cleanse coccyx with normal saline or wound cleanser, pat dry, apply zinc and leave open to air daily. The medical record lacked documented evidence wound care was performed on the following dates: - 09/13/2024 - 09/15/2024 - 09/20/2024 - 09/21/2024 - 09/25/2024 On 09/26/2024 at 9:55 AM, a wound care Licensed Practical Nurse (LPN) indicated being familiar with R1 and R2. The LPN verbalized there was coverage every day of the week for wound care. One nurse would work the first part of the week (Monday, Tuesday, and Wednesday) and would double up on Wednesday for weekly rounds with the wound physician. A different nurse would work Wednesday, Thursday and Friday. The wound nurse indicated there would be coverage on the weekend as well. On 09/26/2024 at 12:51 the LPN indicated when treatment was done it would be documented in the treatment administration record (TAR). The LPN acknowledged there were missing dates for R1 and R2. The LPN explained the process would be to document in the TAR or a progress note and if it was not in either place, the treatment would be considered as not being completed. The LPN confirmed for the dates in question, wound care was not completed for R1 or R2 and there were no progress notes to explain the missing dates. The LPN explained there was a period in September where the facility was in the process of replacing a wound nurse and when new staff was in place, some of the wound treatments might have been missed. On 09/26/2024 at 1:49 PM the Director of Nursing (DON) explained the expectation of nursing staff would be to document in TAR when wound care was completed or make a progress note to explain why wound care was not performed as ordered. The DON acknowledged the missing dates in the treatment administration record and verbalized it was not acceptable. The DON indicated consequences of not following the physician orders could potentially cause skin breakdown and further injury. The facility policy titled Wound Care Purpose (revised October 2010) documented to verify physician order, to document type of wound care given, date and time wound care was provided, name and title of person providing wound care, any changes in condition and assessment data of wound observation. The stated purpose of policy was to promote healing of wounds.

Based on observations, interviews, record reviews, and document review, the facility failed to ensure 1) the ordered parameters were followed to manage the resident's pain for 1 of 15 sampled residents (Resident 12), and 2) the pain medication was administered prior to wound care treatment for 1 of 15 sampled residents (Resident 20). The deficient practice could have the potential to result in discomfort, and prolonged or unmanaged pain. Findings include: 1) Resident 12 (R12) R12 was admitted on [DATE] and readmitted on [DATE], with diagnoses including urinary tract infection and immunodeficiencies. A Care Plan dated 06/14/2024, documented R12 was at risk for pain or discomfort due to general body pain, neuropathies, recent fall, urinary tract and weakness or surgical aftercare. The interventions included to administer medication as ordered. On 06/25/2024 at 10:10 AM, R12 was in bed with facial grimacing. R12 indicated was in frequent pain and unsure what pain medication had been receiving. R22 indicated the pain was not managed. On 06/25/2024 at 1:05 PM, R22 was in bed restless and agitated. R22 indicated the pain medication was not helping and ineffective. A Physician order dated 06/09/2024, documented Norco oral tablet 5-325 milligram (mg) to give one tablet by mouth every 6 hours as needed for pain (moderate pain level 4-6/10). A review of the MAR revealed the Norco was administered when the pain level was out of the ordered parameter: -06/10/2024 at 10:53 AM, pain level of 7 -06/10/2024 at 11:35 PM AM, pain level of 3 -06/11/2024 at 10:39 AM, pain level of 7 -06/12/2024 at 10:13 AM, pain level of 7 -06/17/2024 at 10:13 AM, pain level of 7 -06/18/2024 at 10:28 AM, pain level of 7 -06/18/2024 at 5:09 PM, pain level of 7 -06/18/2024 at 11:35 PM, pain level of 3 -06/19/2024 at 10:22 AM, pain level of 7 -06/19/2024 at 5:35 PM, pain level of 7 -06/20/2024 at 11:35 PM, pain level of 10 -06/27/2024 at 9:43 AM, pain level of 7 A Physician order dated 06/10/2024, documented Tylenol oral tablet 325 mg to give two tablets by mouth every 4 hours for pain (pain level 1-3/10). A review of the Medication Administration Record (MAR) revealed the Tylenol was administered when the pain level was out of the ordered pain level parameters: -06/17/2024, Tylenol was administered when the pain level was 7/10. -06/25/2024, Tylenol was administered when the pain level was 4/10. A Physician order dated 06/10/2024, documented Norco oral tablet 5-325 milligram (mg) to give two tablets by mouth every 6 hours as needed (PRN) for severe generalized body pain (severe pain level of 7-10/10). A review of the MAR revealed the Norco was administered the Norco was administered when the pain level was out of the ordered pain level parameters: -06/24/2024: Norco was administered with pain level of 3 out 10 (3/10). On 06/27/2024 at 12:45 PM, during the Wound Care Treatment Nurse (WCTN) indicated R12 had a lot of pain due to multiple wounds. The WCTN indicated R12's pain should have been managed effectively to promote resident's comfort. On 06/27/2024 at 12:52 PM, a Licensed Practical Nurse (LPN) confirmed the ordered parameter to manage R12's pain was not followed. The LPN indicated the physician's order should have been verified and administered as ordered. On 06/27/2024 at 12:57 PM, the Charge Nurse (CN) confirmed the ordered pain parameters had not been followed. The staff were expected to adhere to the orders to ensure the resident's pain was managed appropriately, avoiding both overmedication and undermedication. On 06/28/2024 at 9:42 AM, the Director of Rehabilitation Services (DORS) indicated the resident's pain should have been managed appropriately as ordered to ensure the resident's compliance and participation in therapy. The DORS) indicated R12 had complained of pain in the lower back and shoulder during therapy. On 06/27/2024 at 2:36 PM, during a telephone interview the Attending Physician conveyed the importance of adhering to the prescribed parameters for effective pain management. The attending physician indicated the staff members should not have administered opioids unless the pain level was moderate to severe, as ordered. A facility policy titled Pain Assessment and Management revised October 2022, indicated to appropriate assessment and treatment of pain. Pain management was defined as the process of alleviating the resident's pain based on the clinical condition and established treatment goals. Pain management was a multidisciplinary care process included implementing approaches to pain management. A facility policy titled Administering Medications revised April 2019, indicated medications were administered as prescribed. 2) Resident 20 (R20) R20 was admitted on [DATE], and readmitted on [DATE], with diagnoses including stage 4 pressure ulcer of sacral region, osteomyelitis of vertebra, and sacral region, and chronic pain. On 06/25/2024 at 12:03 PM, R20 was lying in bed in a supine position. R20 was alert and verbally responsive and indicated had suffered with multiple wounds. R20 indicated the pain medications were ineffective. R20 indicated was on frequent pain. On 06/27/2024 at 1:45 PM, wound care treatment observation was conducted at bedside. The WCTN provided the wound care with the assistance of a Certified Nursing Assistant (CNA). R20's sacral wound had extended across the sacrum and buttocks with severe tissue damage. R20 was grimacing and groaning of pain while being turned to the side. R20 requested for pain medication. The WCTN requested the pain medication to the Registered Nurse (RN). On 06/27/2024 at 1:55 PM, the RN entered the room with the pain medication, but R20 was repositioned on the right side and R20 did not want to be turned back and forth because of the severe pain. The LPN waited until the wound care was completed. When R20 was asked what was the level of pain, R20 responded a pain scale of 10/10. On 06/27/2024 at 2:36 PM, the WCTN indicated R20 was admitted with wounds, status post debridement. The WCTN assumed the pain medication was administered already since R20 had just completed the therapy. The WCTN confirmed the pain medication should have been requested prior to the wound care for at least one hour ensuring the comfort of R20. The WCTN confirmed R20 was in severe pain during wound care. On 06/27/2024 PM at 3:40 PM, the RN explained the WCTN did not ask or communicate the wound care would be provided at the time. The RN indicated pain medication should have been administered prior to wound care because R20 had severe pain issues. On 06/28/2024 at 9:27 AM, the Director of Rehabilitation Services (DORS) indicated R20 was in and out of the facility and had a lot of pain. The DORS indicated on 06/25/2024, R20 declined to exercise due to pain issues. On 06/27/2024 at 2:36 PM, during a telephone interview, the Attending Physician indicated it was appropriate to administer the pain medication at least an hour before wound care treatment to manage the pain and ensure R20's comfort. A facility policy titled Pain Assessment and Management revised October 2022, indicated to appropriate assessment and treatment of pain. Pain management was defined as the process of alleviating the resident's pain based on the clinical condition and established treatment goals. Pain management was a multidisciplinary care process included implementing approaches to pain management.

Based on observation, interview, record review, and document review, the facility failed to ensure a splint was applied to treat a fractured shoulder as ordered for 1 of 15 sampled residents (Resident 22). The deficient practice may increase the risk of further injury, delayed healing, and potential complications related to the untreated fracture. Findings include: Resident 22 (R22) R22 was admitted on [DATE], with diagnoses including a history of falling and a nondisplaced fracture of the greater tuberosity of the left humerus (left upper arm bone). The Brief Interview of Mental Status dated 05/23/2024, documented a score of 15/15, which indicated R22's cognitive status was intact. A Physician order dated 06/20/2024, documented non-weight bearing of the left upper extremity with the left arm sling on at all times. Release every shift and check for skin integrity. On 06/25/2024 at 12:05 PM, R22 was in bed and indicated having fallen at home, which sustained a left fractured shoulder. R22 indicated could barely walk without assistance. R22 indicated had been using a sling, but it was not applied daily. On 06/26/2024 at 10:00 AM, R22 was in bed, awake, and verbally responsive. No sling was in place. R22 revealed the fractured shoulder continued to cause pain, and the sling was inconsistently applied. On 06/26/2024 at 1:45 PM, a Licensed Practical Nurse (LPN) indicated R22 had a fractured shoulder on the left shoulder due to a previous fall incident at home. The LPN confirmed R22 was required to wear a sling at all times, but it was not in place. The LPN indicated R22 was wearing a sling earlier but could not find the sling in place or in R22's room. The LPN had instructed the Certified Nursing Assistant (CNA) to look for the sling. On 06/26/2024 at 1:50 PM, the Director of Staff Development (DSD) indicated R22's sling was applied this morning but was uncertain as to why the sling was not in place. The DSD indicated the staff was responsible for applying the sling and should have ensured placement as ordered. On 06/26/2024 at 2:05 PM, another CNA tried to look for a sling and applied it to R22. On 06/27/2024 at 2:30 PM, R22 was in bed with a sling in place. The sling was loose. R22 indicated the sling was not fitting properly, was not the right kind, and was not helping with the fractured shoulder. The LPN confirmed the observation. On 06/28/2024 at 8:58 AM, the Director of Rehabilitation Services (DORS) indicated R22's left fractured shoulder was due to a fall incident at home and the reason for hospitalization . The DORS indicated R22 was weak and required maximum assistance with lower body dressing, toileting, bed mobility, and only ambulating five feet during the initial evaluation. The DORS indicated the licensed nurse or therapist was responsible for ensuring the sling was applied as ordered to immobilize R22's fractured shoulder to prevent further injury. A facility policy titled Assistive Devices and Equipment, revised in January 2020, documented the facility maintained and supervised the use of assistive devices and equipment for residents.

Based on observation, interview, record review, and document review, the facility failed to ensure fall interventions and management had been implemented when a resident's risk factors were identified upon admission and categorized as high risk for falls for 1 of 15 sampled residents (Resident 22). The deficient practice could have the potential for further fall incidents and inadequate management of existing fall-related injuries. Findings include: Resident 22 (R22) R22 was admitted on [DATE], with diagnoses including a history of falling and a nondisplaced fracture of the greater tuberosity of the left humerus (left upper arm bone). A Care Plan dated 05/16/2024, documented R22 was at risk for falls related to altered balance while standing and/or walking, a history of falls, fractures, weakness, and an unsteady gait. The interventions included keeping the bed in a low position. On 06/25/2024 at 12:05 PM, a yellow star fall indicator was in place by R22's entrance door frame. R22's bed's height was at waist level, no fall mats in place. R22 was in bed and indicated had fallen at home, resulting in a left shoulder fracture. R22 indicated could barely transfer or walk without assistance. On 06/26/2024 at 11:07 AM, R22 was in bed, awake and verbally responsive. R22 indicated the fractured shoulder was painful. R22 indicated had fallen at the facility few days ago. A Licensed Practical Nurse (LPN) confirmed R22's bed's height was in high position and should have been lowered because R22 was a high risk for fall. The Nursing Progress Notes dated 06/19/2024, documented R22 had an unwitnessed fall; R22 was found on the floor; an assessment was performed and R22 was put back to bed. R22's bed was set to the lowest position, and the charge nurse and physician were notified. The Post-Fall-Review dated 06/19/2024, documented a score of 17, which indicated R22 was a high risk of falling. R22 suffered a recent fall. R22 exhibited a loss of balance while standing and required hands-on assistance to move from place to place. A Care Plan revised on 06/20/2024 documented R22 had an unwitnessed fall and was at risk for a change in neurological status, fear of falls, injury, loss of range of motion, pain, and recurring falls. The unwitnessed fall occurred on 06/19/2024. The interventions included keeping the bed in a low position. On 06/26/2023 at 12:52 PM, another LPN indicated the facility fall protocols utilized a fall indicator: a red star indicating high risk and a yellow star indicating moderate risk. The facility kept the fall risk bracelet from the hospital. The LPN explained the fall risk resident was monitored every hour, and the bed was placed in the lowest position with the fall mat in place. If the resident's fall was unwitnessed, a neuroassessment was initiated, risk management was completed, and the physician and the family were notified. On 06/26/2023 at 1:06 PM, a Registered Nurse (RN) confirmed R22 was at high risk for falling due to a recent fall and had fallen at home, which resulted in a shoulder fracture. The RN confirmed R22's bed was not in the lowest position. On 06/26/2024 at 1:31 PM, a Certified Nursing Assistant (CNA) indicated if a resident was at high risk for falling, the resident's bed should have been in a low position to prevent the impact of a fall. The CNA explained the importance of conducting frequent rounds at least every hour to ensure the safety of the residents. On 06/27/24 at 08:02 AM, R22 was seated at the edge of the bed with the breakfast tray set up at the bedside. R22's bed was in a high position, with the head of the bed elevated at 45 degrees. R22 attempted to transfer to the chair by grabbing the rails. Both lower extremities were hanging off the bed and tiptoeing on the floor. A Physical Therapist (PT) walking by in the hallway was called and assisted R22. The PT confirmed R22's bed was in a high position. The PT indicated the staff would be reminded of R22's fall precautions. On 06/28/2024 at 8:58 AM, the Director of Rehabilitation Services (DORS) indicated R22 had sustained a fractured shoulder due to a fall incident at home, which was the reason for hospitalization . The DORS indicated R22 was weak, required maximum assistance with lower body dressing, toileting, and bed mobility, and could only walk five feet. The DORS indicated R22 was a high risk for falls. A facility policy titled Falls and Fall Risks, Managing, revised March 2018, documented based on previous evaluations and current data, the staff would identify interventions related to the resident's specific risks and causes to prevent the resident from falling and to try to minimize complications from falling. The fall risk factors contributed to the risk of falls included incorrect bed height.

Based on observation, interview, record review and document review, the facility failed to ensure perineal care (process of washing the genitalia and anal area to maintain hygiene and prevent infections) was provided in accordance with facility procedure for a resident with an indwelling catheter and urinary tract infection (UTI) history for 1 of 15 sampled residents (Resident 15). The deficient practice placed the resident at risk for recurrent UTI. Findings include: Resident 15 (R15) R15 was admitted on [DATE] and readmitted on [DATE], with diagnoses including Alzheimer's disease, chronic kidney disease stage four and urinary tract infection. On 06/25/2024 in the morning, R15 laid awake in bed, was able to respond to simple questions but had difficulty sustaining conversation. A covered indwelling urinary catheter bag was hanging on left side of bed, stabilized by an anchor on left leg. A Physician Order dated 05/25/2024, documented to cleanse indwelling catheter site with warm soap and water. Rinse then pat dry, every shift. On 06/27/2024 at 10:30 AM, a Certified Nursing Assistant (CNA) prepared two basins, one with warm water and the other with soap and water. Upon pulling up R15's gown, the urinary catheter was observed to be kinked and looped around the anchor stabilizer. The CNA confirmed the catheter tubing was kinked and looped around the anchor stabilizer causing urine obstruction and some backed up urine. The CNA unkinked the urinary tubing and proceeded to 1) wash the tubing with soap and water, 2) rinse the tubing with plain water and 3) dry the tubing with clean cloth. The CNA then placed the tubing back into the anchor stabilizer, announced the procedure was complete while placing a new incontinent brief on R15. On 06/27/2024 at 10:47 AM, the CNA acknowledged not washing R15's perineal area. On 06/27/2024 at 11:16 AM, the Infection Preventionist (IP) was present when the CNA acknowledged perineal care was not performed during R15's urinary catheter care this morning. The CNA explained perineal care was part of catheter care and was defined as washing the resident's genital area with soap and water to prevent infections. The CNA verbalized when perineal care was not performed, residents with indwelling catheters were placed at a higher risk for infection and discomfort. On 06/27/2024 at 11:20 AM, the IP indicated the CNA did not follow the facility's procedure for urinary catheter care when the CNA missed to clean R15's perineal area as detailed in the policy. The IP stated R15 was transferred to the hospital on 05/18/2024 for treatment of a urinary tract infection (UTI) and returned to the facility on [DATE] with antibiotic therapy. The IP indicated the CNAs practice placed R15 at a higher risk for another UTI. The Urinary Catheter Care policy revised August 2022, documented the purpose for this procedure was to prevent catheter-associated complications, including urinary tract infection. Perineal hygiene procedure included washing the urethral meatus (the opening at the end of the urethra where urine exits the body) using a washcloth with warm water and then rinse. Keep the catheter tubing free of kinks.

Based on observation, interview, record review, and document review, the facility failed to ensure: 1) a resident's baseline weight was obtained upon admission and weekly weights were obtained thereafter for 1 of 15 sampled residents (Resident 168), and 2) a nutritional assessment was completed for residents with significant weight change for 2 of 15 sampled residents (Residents 20 and 16). The deficient practice had the potential for the facility to delay implementing nutritional interventions to prevent weight loss. 1) Resident 168 (R168) R168 was admitted on [DATE] and readmitted on [DATE], with diagnoses including an amputation stump, absence of the right and left legs below the knee. Review of R168's medical record revealed the following recorded weights: -01/30/2024: 114.2 pounds (lbs.) -01/24/2024: 114.0 lbs. -01/22/2024 (no weight was obtained on Monday) -01/15/2024 (no weight was obtained on Monday) -01/08/2024 (no weight was obtained on Monday) -01/05/2024 (no baseline weight was obtained upon admission) -11/08/2023: 130.0 lbs. (previous weight before discharge). -11/01/2023: 132.0 lbs. -10/31/2023: 132.0 lbs. Review of R168's medical record revealed the following recorded admissions and discharges: -02/02/2024, R168 was discharged . -01/05/2024: Active status -11/17/2023, R168 was discharged . -10/28/2023: Active status The Admission Nutritional Risk Assessment, dated 01/09/2024, documented a weight loss of 16 lbs. The Registered Dietitian (RD) recommended R168's weight should have been obtained. R168's medical records lacked documented evidence the weight was obtained upon admission and weekly weights were obtained thereafter. On 06/28/2024 at 11:35 AM, the RD started working in the facility in November 2023. The RD indicated the process of weight management was to obtain the resident's weight upon admission and weekly thereafter on Mondays, and to reweigh for any discrepancies on Tuesdays. The RD confirmed R168's weight was not obtained upon admission on 01/05/2024, nor were the weekly weights on 01/08/2024, 01/15/2024, and 01/22/2024. The RD recounted the nursing department was advised verbally but was uncertain as to why R168's weights were not obtained. The RD confirmed the weight was taken on 01/24/2024, which was 19 days after R168's admission. The RD acknowledged R168 had a documented weight loss of 16 lbs. The RD explained the previous weight on 11/08/2024 (previous admission), was 130 lbs., and the weight on 01/24/2024, was 114 lbs. which was more than two months after R168's previous discharge. The RD explained the computation was automatic if no baseline weight was obtained on readmission. The RD conveyed the baseline weight was crucial, as were the weekly weights, to monitor the changes and prevent delayed interventions. On 06/28/2024 at 12:41 PM, the [NAME] Clerk (WC) indicated started obtaining the residents' weights two months ago. The Weight Day was every Monday, and all the residents got weighed. The residents reweigh on Tuesdays for refusal or for any discrepancies. The RD was notified of all the weights in the event of a discrepancy. The WC explained the RD was in charge of monitoring the resident's weight and providing directions. On 06/28/2024 at 1:48 PM, the Charge Nurse (CN) indicated the process was to obtain the weights upon admission and weekly thereafter. The CN confirmed there was no documentation of R168's refusal of the weights or the physician was notified of the missed weights. A facility policy titled Weight Assessment and Intervention March 2022, documented residents were weighed upon admission and at intervals established by the interdisciplinary team. 41903 2) Resident 20 (R20) R20 was admitted on [DATE] and readmitted [DATE], with diagnosis including dysphagia following unspecified cerebrovascular disease, chronic respiratory failure with hypoxia, and unspecified protein-calorie malnutrition. A Nutritional Risk assessment dated [DATE], documented most recent weight was 218 pounds (lbs) and R20 had inconsistent intake. Weight change was anticipated with edema and diuretic order. A Care Plan initiated 05/01/2024, documented nutritional risk, potential for altered nutrition and hydration status related to recent hospitalization . A Nutritional Risk document, undated, documented R20 had the potential for altered nutrition and/or hydration status related to recent hospitalization . Goal was for R20 not to exhibit signs/symptoms of malnutrition to extent possible. Interventions included Registered Dietician to reassess as indicated and ongoing monitoring. Review of R20's medical record revealed the following recorded weights which reflected a significant weight loss of 17 lbs, for a total of 7.80 percent (%) weight loss between 04/22/2024 and 04/29/2024: 6/22/2024 19:59 - 200.0 lbs 6/17/2024 21:31 - 197.0 lbs 6/11/2024 17:58 - 196.2 lbs 6/3/2024 17:59 - 197.0 lbs 5/27/2024 15:29 - 195.0 lbs 5/26/2024 20:16 - 193.0 lbs 5/7/2024 19:50 - 205.6 lbs 5/6/2024 08:59 - 201.0 lbs 4/29/2024 19:08 - 201.0 lbs 4/23/2024 18:08 - 218.0 lbs 4/22/2024 20:19 - 218.0 lbs A Weights and Vitals Summary dated 05/06/2024, documented 201 lbs. Weight 04/22/2024 was 218.0 lbs, -7.8%, -17 lbs. The medical record lacked documented evidence R20 was reassessed or had a nutritional assessment completed following the significant weight loss of 7.80%. On 06/28/2024 at 10:11 AM, the Registered Dietitian (RD) acknowledged R20 had weight loss identified on 04/23/2024 of 7.8% for 1 week. The RD reported reasons for not reporting a change of condition, or reassessment of R20 included RD was unable to verify weight loss for R20 due to refusal to be reweighed, the RD felt R20 was well with weight loss, and R20 was moving from obese to overweight. The RD reported not concerned with weight loss due to R20's overweight condition. The RD confirmed a nutritional assessment was not completed at the time of significant weight loss and the next nutritional assessment was not performed until 05/30/2024. On 06/28/2024 at 11:07 AM, the RD explained the purpose of a nutritional assessment was to evaluate the resident's risk for malnutrition and to maintain good nutrition status. According to the RD, not completing a comprehensive nutritional assessment for a resident with significant weight loss may result in deterioration of health status. 40142 Resident 16 (R16) Resident # 16 was admitted on [DATE] and readmitted on [DATE], with diagnoses including unspecified fracture of thoracic vertebra, chronic heart failure and adult failure to thrive. A Risk for Malnutrition form dated 05/02/2024, documented R16 was at risk for malnutrition due to diagnoses including multiple fractures of ribs, recent hospitalization , respiratory issues, and congestive heart failure. The Dietary Interview Pre-screen dated 05/03/2024, documented R16 dietary order was carbohydrate-controlled chopped mixed texture, thin liquids, with fortified foods. The document did not include R16's food preferences likes and dislikes. The five-day scheduled prospective payment system (PPS) minimum data set (MDS) dated [DATE], revealed R16 had moderately impaired cognition and required set up assist with supervision for eating. Review of R16's medical record revealed the following recorded weights which reflected a significant weight loss of 13.3 percent (%) in a span of 30 days from 05/03/2024 to 06/03/2024: 05/03/2024: 132.9 pounds (lbs.) 05/04/2024: 131.6 lbs. 05/06/2024: 129.1 lbs. 05/14/2024: 123.0 lbs. 05/20/2024: 117.4 lbs. 05/27/2024: 115.2 lbs. 06/03/2024: 115.2 lbs. A nutrition narrative note dated 05/29/2024, documented R16's weight change was not significant for the week but a significant change in weight was being anticipated the following week on R16s monthly weights. R16's current weight was normal as well as body mass index (BMI). R16's oral intake was greater than 75 % and dietary manager had met with R16 to update dietary preferences. The point of care (POC) meal consumption report dated 05/04/2024 to 05/31/2024 revealed R16 had six recorded meal consumptions of 0%-25% and 29 recorded meal consumptions of 26%-50%. The medical record lacked documented evidence the dietary manager met with R16 to update the resident's food preferences after 05/03/2024. On 06/28/2024 at 9:38 AM, a Registered Nurse (RN) indicated being familiar with R16 who was admitted with multiple fractures and was oftentimes alert and oriented. R16 was placed on one-on-one feeding assistance beginning readmission on 06/25/2024 due to arm injuries and poor meal consumptions. On 06/28/2024 at 9:42 AM, a Certified Nursing Assistant (CNA) who was frequently assigned to R16 indicated R16's meal consumptions fluctuated because R16 was very picky with food. According to the CNA, R16 liked morning cereal like cheerios, rye bread and disliked eggs in any form. The CNA indicated R16's average meal consumption was 50%. On 06/28/2024 at 11:15 AM, R16 laid in bed watching television. R16 looked down on bilateral hands which were covered with white gauze and explained staff needed to assist the resident with meals due to hand injuries from a recent fall. R16 indicated being picky with food and would love to be served more salads which the resident seldom got and expressed a dislike eggs. R16 verbalized not being able to recall if anyone had come to ask the resident about food preferences and dislikes. On 06/28/2024 at 10:11 AM, the Registered Dietitian (RD) explained newly admitted resident were weighed by nursing staff on admission. Weekly weights were done each Monday and if there was a variance of five percent or more from week to week, the nursing staff were expected to re-weigh the resident and alert the RD. The RD indicated the Dietary Manager was expected to obtain each resident's food preferences, disliked and allergies within 24 hours from admission and date collected was reflected in the Dietary Interview/Pre-Screen form. Admission nutritional assessments were completed by the RD within seven days of the resident's admission, but the RD was uncertain whether a nutritional assessment needed to be completed when a significant weight loss or gain was identified. On 06/28/2024 at 10:18 AM, the RD reviewed R16's weight and confirmed R16 had a significant weight loss of 13.3 % from 05/03/2024 to 06/03/2024. The RD reviewed R16's admission nutritional assessment which contained: 1) Type of assessment, 2) Pertinent diagnoses, 3) Physical and mental functions, 4) skin conditions, 5) relevant labs, 4) Height/Weight/BMI and weight change, 5) Nutritional Intake, 6) Diet order, 7) supplement order, 8) Estimated nutritional needs, 9) Recommendations, and 10) Care plan revision. The medical record lacked documented evidence a nutritional assessment was completed when R16 had a significant weight change on 06/03/2024. On 06/28/2024 at 10:49 AM, the RD explained residents were weighed on Mondays and the inter-disciplinary team (IDT) identified and addressed weight changes on Wednesdays. The RD confirmed a nutritional assessment was not initiated nor completed for R16 when the resident's significant weight change was identified during the RD's visit with the resident on 05/27/2024 and later confirmed by the resident's monthly weight on 06/03/2024. The RD indicated not being aware the Dietary Manager did not document R16's food preferences and dislikes as noted in the RD's note dated 05/27/2024. The RD indicated not being aware R16 disliked eggs and liked cereals, salads, and rye bread. On 06/28/2024 at 11:07 AM, the RD explained the purpose of a nutritional assessment was to evaluate the resident's risk for malnutrition and to maintain good nutrition status. According to the RD, not completing a comprehensive nutritional assessment for a resident with significant weight loss may result in deterioration of health status. On 06/28/2024 at 11:40 AM, the dietary manager indicated performing R16's dietary screening on 05/03/2024 where the resident did not state any food preferences and dislikes. The dietary manager recalled meeting with the resident on 05/08/2024 and 05/13/2024 to review preferences, likes and dislikes but the dietary manager failed to document the information in the resident's electronic health record. The dietary manager acknowledged unless information obtained during dietary screening was entered into the resident's medical record, this would not populate in the resident's meal ticket and would not be viewable by other members of the IDT. On 06/28/2024 at 1:08 PM, the Regional Director of Clinical Services indicated a nutritional assessment was expected to be completed upon identification of a significant weight change (gain or loss). The assessment was expected to be completed within of 24 hours from identification. According to the Regional Director of Clinical Services, the purpose of completing a nutritional assessment after a significant weight loss was timely identification of root cause and contributory factors for the weight change which would lead to appropriate interventions. The Regional Director of Clinical Services indicated when meal consumptions were being reported as low and accompanied by downward trending weights, the dietary manager and/or the RD could visit with the resident to review and update the resident's food preferences and dislikes as indicated. The Regional Director of Clinical Services indicated the dietary manager's revisits on 05/8/2024 and 05/13/2024 should have been documented in R16's medical record. The Nutritional Assessment policy dated 2001, documented a comprehensive assessment, a nutritional assessment, including current nutritional status and risk factors for impaired nutrition, shall be conducted for each resident. The RD in conjunction with the nursing staff and healthcare practitioners will conduct a nutritional assessment for each resident upon admission and as indicated by a change of condition that placed residents at risk for impaired nutrition. Complaint #NV00070487