Every finding on record at Sanctuary at Ohio Valley

Based on medical record review and staff interview, the facility failed to ensure resident Pre-Admission Screening and Resident Review (PASRR) documents were accurate to resident current conditions and diagnoses. This affected one (Resident #5) of three residents reviewed for PASRR documents. The census was 79. Findings Include: Resident #5 was admitted to the facility on [DATE]. Her diagnoses were cerebral infarction, diabetes mellitus type II, muscle weakness, abnormal posture, constipation, atrial fibrillation, unspecified psychosis, hypertension, Chronic Obstructive Pulmonary disease, hyperlipidemia, anxiety, depression, renal dialysis, chronic kidney disease, arteriovenous fistula, end stage renal disease, and morbid obesity. Review of her Minimum Data Set (MDS) assessment, dated 01/28/25 revealed she had minimal cognitive impairment. Most recent PASSR was completed on 11/29/23 with a diagnosis of mood disorder. A new diagnosis of unspecified psychosis was added on 04/12/24 and a new PASSR was not completed with the addition of the new diagnosis. Interview with the Assistant Director of Nursing #180 on 03/05/25 at 09:37 A.M. verified a new PASSR should have been completed with the addition with the new diagnosis of unspecified psychosis.

Based on observation, interview, medical record review and facility policy review the facility failed to ensure Resident #59 had a physicians order for oxygen therapy. This affected one (Resident #59) of one residents reviewed for respiratory care. The facility census was 79. Findings include: Review of the medical record for Resident #59 revealed an admitted [DATE] with diagnoses including chronic respiratory failure with hypoxia, chronic obstructive pulmonary disorder, chronic pulmonary embolism, and hypertension. Review of the physician orders dated 03/25 revealed Resident #59 did not have an order for oxygen therapy. Resident #59 had an order for Bilevel positive airway pressure (BiPap), a mechanical breathing device, to be worn as tolerated except during meals. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #59 was cognitively intact and refused care four to six days of look back period. Resident #59 was depended on staff for completion of most activities of daily living. Resident #59 received oxygen therapy and used a non invasive mechanical ventilator-BiPap. Review of the plan of care revised on 12/09/24 revealed Resident #59 had oxygen therapy related chronic obstructive pulmonary disorder with shortness of breath with exertion and when lying flat. Oxygen to be applied per order, continuously, via nasal cannula. The goal stated Resident #59 oxygen saturation level would be kept as desired levels as set by the physician through the review date. The interventions included to administer oxygen as ordered, provide aerosol treatments as ordered, change oxygen tubing per facility guidelines, keep the head of bed elevated to residents comfort level to relieve or prevent shortness of breath, medications as ordered, monitor oxygen saturation level as ordered and observe for signs and symptoms of dyspnea. Observations on 03/03/25, 03/04/25 and 03/05/25 confirmed Resident #59 was receiving oxygen at four liters per minute via nasal cannula. Interview on 03/03/25 at 2:17 P.M. with Resident #59 confirmed he was wearing oxygen at four liters per minute via nasal cannula. Interview on 03/05/25 at 10:10 A.M. with Unit Manager #840 confirmed Resident #59 was wearing oxygen at four liters per minute via nasal cannula and Resident #59 did not have an order for oxygen via nasal cannula. Review of the facility policy titled Oxygen Administration without a date revealed oxygen wa administered under orders of a physician unless an emergency.

Based on interview, medical record review, and facility policy review the facility failed to ensure Resident #80 had physician order for dialysis treatment and care. This affected one (Resident #80) of two residents reviewed for dialysis. The facility census was 79. Findings include: Review of the medical record for Resident #80 revealed an admitted [DATE] with diagnoses including acute kidney failure with tubular necrosis, chronic kidney disease stage five, hypertension and congestive heart failure. Review of the physician orders dated 03/25 revealed Resident #80 did not have a physician order for dialysis treatment, the name of the facility or contact information and no orders for care and treatment of dialysis port. Review of the nursing progress notes from 02/10/25 through 03/05/25 revealed one note on 02/28/25 at 3:40 P.M. indicated the local dialysis center was notified of Resident #80 discharge date of [DATE] from the facility and residents request for chair time change. No other progress notes addressing Resident #80 leaving the facility or returning from dialysis treatment. Review of the admission Medicare five day Minimum Data Set (MDS) dated [DATE] revealed Resident #80 was cognitively intact with no behaviors. Resident #80 required staff assistance with activities of daily living. The MDS did not indicate Resident #80 was receiving dialysis treatment. Review of the facility provided communication sheets between the facility and dialysis confirmed Resident #80 received dialysis treatment on Tuesday, Thursday and Saturday of each week. Review of the plan of care dated 02/25/25 revealed Resident #80 had renal failure but the plan of care did not include information related to dialysis treatment. Interview on 03/04/25 at 2:45 P.M. with Resident #80 confirmed he was feeling bad (tired) after returning from dialysis treatment. Interview on 03/05/25 at 10:10 A.M. with Unit Manager #840 confirmed Resident #80 had dialysis treatment three times per week. Unit Manager #840 also confirmed Resident #80 did not have orders for dialysis treatment, dialysis treatment center information or care of dialysis site. Unit Manager #840 confirmed the orders were placed in Resident #80 medical record on this date of 03/05/25. Review of the facility policy titled Hemodialysis with no date revealed the physician order for dialysis would include the type of access for dialysis and location, the dialysis schedule, the nephrologist name and phone number, the dialysis facility name and phone number, the transportation arrangement to and from the dialysis facility, any medication administration or withholding of specific medications prior to dialysis treatments and any fluid restriction if ordered by the physician.

Based on record reviews and interviews, the facility failed to ensure a resident with Post Traumatic Stress Disorder (PTSD) was appropriately assessed to identify the cause of the residents PTSD and minimize triggers and/or re-traumatization. This affected two residents (#23 and #70) out of two residents identified by the facility as having PTSD/trauma. The facility census was 79. Findings include: 1. Record review for Resident #23 revealed the resident was admitted to the facility on [DATE] and had diagnoses including cerebrovascular disease, acute and chronic respiratory failure, hyperlipidemia, insomnia, anxiety, depression, peripheral vascular disease, hypertension, atherosclerosis, Post-Traumatic Stress Disorder (on 5-9-18), transient ischemic attack, and chronic obstructive pulmonary disease. Review of the Minimum Data Set (MDS) assessment, dated 02/11/25, revealed this resident was assessed to have intact cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 15 out of 15. This resident was assessed to have an active diagnosis of PTSD. Review of the active care plans for Resident #23 revealed no plan of care was in place addressing the cause of PTSD, triggers which may cause re-traumatization, or interventions to reduce the risk of re-traumatization and provide care for PTSD. Further record review for this resident revealed no assessment had been completed to identify the cause of PTSD for Resident #23 and to identify potential triggers which may cause re-traumatization. Interview with the Social Services Director #210 on 03/04/25 at 03:34 P.M. verified an assessment of the cause of PTSD and possible triggers for Resident #23 had not been completed and there were no plan of care created to address causes and triggers of PTSD. 2. Record review for Resident #70 revealed the resident was admitted to the facility on [DATE] and had diagnoses including hemiplegia and hemiparesis, atrial fibrillation, aphagia, gastro-esophageal reflux disease, muscle weakness, hyperlipidemia, right hand contracture, Post-Traumatic Stress Disorder (added 5-29-24), benign prostatic hyperplagia, constipation, depression, hypertension, hypothyroidism, and low back pain. Review of the Minimum Data Set (MDS) assessment, dated 02/06/25, revealed this resident was assessed to have moderate cognitive impairment evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 9. This resident was assessed to have an active diagnosis of PTSD. Review of the active care plans for Resident #70 revealed no plan of care was in place addressing the cause of PTSD, triggers which may cause re-traumatization, or interventions to reduce the risk of re-traumatization and provide care for PTSD. Further record review for this resident revealed no assessment had been completed to identify the cause of PTSD for Resident #70 and to identify potential triggers which may cause re-traumatization. Interview with the Social Services Director #210 on 03/04/25 at 03:34 P.M. verified an assessment of the cause of PTSD and possible triggers for Resident #70 had not been completed and there were no plan of care created to address causes and triggers of PTSD.

Based on interview, medical record review and facility policy review the facility failed to ensure Resident #22 and Resident #72 had low blood sugar parameters and directions of action when obtaining accucheck blood sugars with sliding scale insulin. This affected two (Resident #22 and Resident #72) of five residents reviewed for unnecessary medications. The facility census was 79. Findings include: 1. Review of the medical record for Resident #22 revealed an admitted [DATE] with diagnoses including cerebrovascular disease, diabetes mellitus type two, schizoaffective disorder, hypothyroidism and mood disorder. Review of the physician orders dated 03/25 revealed Resident #22 received Novolog (fast acting insulin) injection solution 100 units per milliliter (ml) per sliding scale. Inject insulin subcutaneously before meals and at bedtime. Inject as per sliding scale if blood sugar was 200-249 give two units, 250-299 give four units, 300-349 give six units, 350-400 give 8 units, 401-450 give 10 units and call the physician or Nurse Practitioner for further orders. The order did not include a low blood sugar parameter or what to do if blood sugar was low. Review of the nursing progress notes from 01/01/25 through 03/05/25 was silent on Resident #22 blood sugar results. Review of the plan of care revised on 04/18/23 revealed Resident #22 had altered endocrine status related to diabetes mellitus and hypothyroidism. The goal for Resident #22 was blood sugars to remain at acceptable level through review date. The interventions included to be alert to medications that may cause changes in resident's blood sugar levels such as steroids, potassium and some antibiotics, monitor blood sugar as needed for symptoms of hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar) for example change in hunger, thirst, or anxiety, change in level of consciousness, fruity breath and alterations in urinary patterns, administer diabetes medication as ordered, educate resident/family/caregiver that compliance was essential to prevent complications of diabetes, nails should be cut straight across and obtain fasting blood glucose levels as ordered by physician. Interview on 03/06/25 at 9:24 A.M. with Licensed Practical Nurse (LPN) #490 confirmed a low blood sugar would be 70 or below but based on the residents normal. LPN #490 also had knowledge on procedure for low blood sugar and confirmed Resident #22 did not have orders to include what a low blood sugar reading was or instructions of what to do. 2. Review of the medical record for Resident #72 revealed an admitted [DATE] with diagnoses including rheumatic mitral stenosis, diabetes mellitus type two, shortness of breath, anxiety, depression and dementia. Review of the physician orders dated 03/25 revealed Resident #72 received Humalog solution (fast acting insulin) 100 units per ml, inject subcutaneously before meals and at bedtime. Inject per sliding scale: 200-249 give two units, 250-299 give four units, 300-349 give six units, 350-399 give eight units, 400 plus give 10 units and call physician for further orders. The order did not include a low blood sugar parameter or what to do if blood sugar was low. Review of the nursing progress notes from 01/01/25 through 03/05/25 revealed no documentation of blood sugar results. Review of the Medicare five day Minimum Data Set (MDS) dated [DATE] revealed Resident #72 was cognitively impaired with no behaviors. Resident #72 required assistance from staff to complete activities of daily living. Resident #72 had diagnosis of diabetes mellitus and received four insulin injections during the look back period. Review of the plan of care revised on 07/25/24 revealed Resident #72 had altered endocrine status related to diabetes mellitus. The goal was blood sugars would remain at acceptable levels for resident through review date. The interventions included to monitor blood sugars as needed for symptoms of hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar) such as change in hunger, thirst and anxiety, change in level of consciousness, fruity breath and alteration in urinary pattern, administer diabetes medication as ordered by physician, monitor for compliance with diet and document any problems. Interview on 03/06/25 at 9:24 A.M. with Licensed Practical Nurse (LPN) #490 confirmed a low blood sugar would be 70 or below but based on the residents normal. LPN #490 also had knowledge on procedure for low blood sugar and confirmed Resident #72 did not have orders to include what a low blood sugar reading was or instructions of what to do. Review of the facility policy titled Timely Administration of Insulin did not address parameters for low and high blood sugar or directions for care.

Based on medical record review, staff interview, review of the Electronic Information Dissemination and Collection (EIDC) portal for Self-Reporting Incidents (SRI) and review of the facility policy, the facility failed to report an allegation of sexual abuse to the state agency and failed to implement the abuse policy. This affected one (Resident #64) of three reviewed for sexual abuse. The facility census was 82. Findings include: Medical record review revealed Resident #64 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, diabetes mellitus type two, psychotic disorder, dementia, and depression. Review of Resident #64's admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #64 had a Brief Interview for Mental Status (BIMS) score of one of 15, indicating severely impaired cognition. Resident #64 required staff assistance with activities of daily living. Review of Resident #64 nursing progress notes dated 11/29/24 through 12/18/24 revealed no documentation related to the allegation of sexual abuse, initial assessment of resident, physician notification or family notification. Review of the plan of care dated 12/17/24 revealed Resident #64 had behavioral symptoms related to inappropriate sexual behaviors. The goal was to have fewer episodes of behaviors by the review date. The interventions included administering medications as ordered, assessing the residents understanding of the situation, allowing resident time to express himself, providing re-education, discussing the situation calmly, documenting episodes of inappropriate behaviors and interventions to decrease the behavior. Review of the EIDC for online SRI reporting on 12/17/24 confirmed the facility did not report the allegation of sexual abuse on 12/08/24. Review of the incident/accident log for October 2024, November 2024 and December 2024 revealed no incidents documented related to sexual abuse allegations. Attempted an interview on 12/17/24 at 12:01 P.M. with Resident #64 revealed the resident was alert, oriented to name only and could not focus on questions. Interview on 12/17/24 at 12:56 P.M. with Licensed Practical Nurse (LPN) #55 revealed she had notified Director of Nursing (DON) #47 about the allegation of sexual abuse as reported by Certified Nursing Assistant (CNA) #20 and #56 on 12/08/24. Interview on 12/17/24 at 10:10 A.M. with DON #47 revealed she and Assistant Director of Nursing (ADON) #77 had arrived at the facility within the hour of receiving the call from LPN #55. DON #47 revealed she and ADON #77 interviewed the staff, sent CNA #20 home, interviewed the resident and other residents. DON #47 confirmed she did not file an SRI with State Agency at that time and did not notify the physician or family. Review of the facility policy titled Freedom from Abuse, Neglect and Exploitation dated 11/23/17 stated the facility will report to the State Agency and one or more law enforcement entities any reasonable suspicion of a crime against any individual who is a resident or receiving care from the facility. A reportable crime included sexual abuse. There was no definition of sexual abuse. The policy also stated the facility's report to the State Agency and law enforcement will be coordinated and completed by the Administrator and/or Designee according to the specified timeframe. This deficiency represents non-compliance investigated under Complaint Number OH00160669.

Based on record review and interview the facility failed to complete the Pre-Admission Screening and Resident Review (PASARR) Identification Screen correctly for two residents (Resident #20 and #58) out of six residents reviewed during the annual survey. The facility census was 64. Findings include. 1. Medical record review for Resident #58 revealed an admitted [DATE]. Diagnoses included but were not limited to [CONDITION(S)], idiopathic aseptic necrosis of right femur, right femur fracture, [CONDITION(S)], major depressive disorder, generalized anxiety disorder, unspecified mood disorder, [CONDITION(S)] disorder, and history of alcohol dependence. Review of Resident #58's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #58's Clinical Admission Paperwork-Long Term Care Referral dated 08/08/22 revealed diagnoses including [MEDICAL RECORD OR PHYSICIAN ORDER] . Current medications included but were not limited to [MEDICATION(S)] one milligram by mouth twice daily, start date of 07/14/22, [MEDICATION(S)] 10 milligrams by mouth once daily for depression, start date of 07/15/22, and [MEDICATION(S)] 50 milligrams by mouth once daily for depression, start date of 07/15/22. Review of Level 1 Pre Admission-Screening and Resident Review (PASARR) Identification Screen completed on 08/12/22 revealed no diagnoses of mental illness were indicated in section E,1. No diagnoses of a substance use related disorder was indicated section E,2 of the PASARR. And no [CONDITION(S)] medications were indicated in section E,6 of the PASARR. Interview on 09/14/22 at 9:27 A.M. with Social Worker #265 confirmed the PASARR completed on 08/12/22 for Resident # 58 did not indicate any diagnoses of mental illnesses in section E,1., did not indicate any diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] ., and did not indicate any [CONDITION(S)] medications were checked in section E,6. 2. Record Review of Resident #20 revealed this resident was admitted to the facility on [DATE] with the following medical Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set(MDS) assessment completed on 02/09/22 revealed this resident had severe cognitive impairments. Resident #20 was admitted with an active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Preadmission Screening and Resident Review(PASARR) revealed this was completed by sending facility on 09/28/21. On Section E(Indications of Serious Mental Illness) the information provided this resident did not have any of the mental disorders listed. This included Mood Disorder, which was one of the resident's medical diagnoses on admission. On 09/14/22 at 9:33 AM Interview with Social Service Director #265 verified Mood Disorder was an active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She also verified this diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observations, interviews, and record reviews, the facility failed to administer oxygen as ordered by the physician and failed to obtain physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility census was 64. Findings include: 1. Record review for Resident #36 revealed this resident was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . This resident had no known allergies. Review of the annual Minimum Data Set (MDS) assessment, dated 07/14/22, revealed this resident had severely impaired cognition. This resident was assessed to require extensive assistance from one staff member for bed mobility, extensive assistance from two staff members for transfers, extensive assistance from one staff member for toileting, and extensive assistance from one staff member for eating. This resident was assessed to have used oxygen while in the facility. Review of the care plan, revised on 01/21/22, revealed this resident had altered respiratory/pulmonary status/difficulty breathing. Interventions included to change and date nebulizer tubing weekly, change and date oxygen tubing weekly, oxygen saturation levels as ordered, and oxygen settings at two liters per minute via nasal cannula. Review of the active physicians order, dated 04/10/22, revealed this resident was ordered to receive oxygen at two liters per minute continuously by nasal cannula due to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 09/12/22 at 3:00 P.M. revealed Resident #36 was sitting on the back porch of the facility and was not observed to have oxygen being administered. There was not an oxygen concentrator or tank located on the back porch where the resident was sitting. Observation on 09/13/22 at 1:11 P.M. revealed Resident #36 was lying in bed and did not have oxygen being administered. There was not an oxygen concentrator located in the room for the residents use. Observation and interview with Licensed Practical Nurse (LPN) #345 on 09/13/22 at 1:36 P.M. verified Resident #36 did not have oxygen being administered and did not have an oxygen delivery device located in the room. LPN #345 stated Resident #36 had been on oxygen previously but had not had oxygen administered for approximately one week. LPN #345 verified Resident #36 continued to have an active order for the administration of oxygen at two liters per minute continuously which had been inaccurately documented by nursing staff as being administered. 2. Record review for Resident #38 revealed this resident was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS assessment, dated 07/08/22, revealed this resident had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 15. This resident was assessed to require extensive assistance from two staff members for transfers, bed mobility, and toileting and was assessed to require limited assistance from one staff member for eating. This resident was assessed to use oxygen while a resident of the facility. Review of active physicians orders revealed no order for the administration of oxygen. Observation on 09/12/22 at 10:30 A.M. revealed Resident #38 was observed lying in bed with oxygen being administered at a rate of three liters per minute via nasal cannula. The humidification bottle connected to the oxygen concentrator was almost out of water. Observation on 09/13/22 at 2:15 P.M. revealed Resident #38 was observed to have oxygen being administered at a rate of three liters per minute and the water humidification bottle attached to the concentrator was empty. Observation and interview with LPN #345 on 09/13/22 at 2:30 P.M. verified Resident #38 was being administered oxygen at a rate of three liters per minute via nasal cannula and the water humidification bottle attached to the oxygen concentrator was empty. LPN #345 verified Resident #38 did not have an active physicians order for the administration of oxygen.

Based on resident interview, staff interview and a test tray, the facility failed to ensure food was served at an appetizing temperature. This had the potential to affect all residents except three residents (Resident #17, #48, and #78) who received no food from the kitchen. The facility census was 75. Findings include: Interview of Resident #45 on 01/13/20 at 2:44 P.M. revealed sometimes the hot foods were served cold. A test tray was requested on 01/15/20. The test tray was loaded on to the meal cart at 12:07 P.M. The meal cart arrived on the hallway at 12:08 P.M. The first tray was served at 12:10 P.M., and the last tray was served at 12:30 P.M. The temperature of the food on the test tray at 12:31 P.M. included: the hot ham and cheese sandwich was 110 degrees Fahrenheit (F) and cool to taste, the potato wedges were 108 degrees F and cool to taste, and the milk was 60 degrees F and warm to taste. The temperatures were verified with Licensed Practical Nurse (LPN) #20. The facility identified Residents #17, #48, and #78 did not receive food from the kitchen. Interview of Dietary Manager #30 on 01/16/19 at 9:10 [NAME]M. confirmed the food was not served hot enough.

Based on observation, staff interview and medical record review, the facility failed to ensure a resident with mental disorders received treatment for [REDACTED].#28) of two sampled residents reviewed for mood and behavior. The facility census was 75. Findings include: Review of Resident #28's medical record revealed he was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #28's annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the following: Resident # 28's speech was unclear, he was rarely understood, he rarely understands, his short and long-term memory was impaired, he recalled staff names and faces and had severely impaired decision making. Resident #28 had minimal depression, had no indicators of [MEDICAL CONDITION], had other behaviors one to three days of the assessment reference period that did not significantly impact him or other residents, he did not reject care and did not wander. Resident #28 required extensive assistance of two staff for bed mobility, transfers, did not walk and was dependent on one staff for locomotion using a wheel chair. Resident #28 received an antipsychotic medication, an antianxiety medication and an antidepressant medication seven of the past seven days. Resident #28 received no psychological therapy. Review of Resident #28 quarterly MDS 3.0 assessment dated [DATE] revealed the following changes; he had moderate depression and expressed no behaviors. Resident #28 was dependent on two staff to transfer. Review of Resident #28's progress notes dated 11/11/19 at 8:30 P.M. revealed he hit Resident #46 in the left shoulder. The residents were separated. Review of the facility's investigation, completed on 11/15/19, revealed a recommendation for psychological assessment. Review of Resident #28's plan of care dated 11/11/19 revealed he was easily annoyed by another resident and had a physical altercation with another resident. The care plan called for psychiatric/psychogeriatric consult as indicated. Review of Resident #28's behavioral health therapy and counseling progress note dated 12/09/19 revealed a diagnostic assessment was completed, and an individual treatment plan was developed. Review of Resident #28's individualized service plan dated 12/09/19 called for therapeutic services one to four times a month. There was no evidence therapeutic services were provided after 12/09/19. Observation of Resident #28 on 01/14/20 at 2:56 P.M., on 01/15/20 at 8:39 [NAME]M. and 10:20 [NAME]M. revealed he was in bed asleep. Interview of the Director of Nursing on 01/16/20 at 10:48 [NAME]M. confirmed the behavioral health services were not provided to Resident #28 since 12/09/19.

Based on staff interview and medical record review, the facility failed to ensure residents who received [MEDICAL CONDITION] drugs had target behaviors identified and were monitored for those behaviors. This affected two (Residents #28 and #50) of five sampled residents reviewed for unnecessary medications. Findings include: 1. Review of Resident #28's medical record revealed he was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #28's annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the following: Resident # 28's speech was unclear, he was rarely understood, he rarely understands, his short and long-term memory was impaired, he recalled staff names and faces, and had severely impaired decision making. Resident #28 had minimal depression, had no indicators of [MEDICAL CONDITION], had other behaviors one to three days of the assessment reference period that did not significantly impact him or other residents, he did not reject care and did not wander. Resident #28 required extensive assistance of two staff for bed mobility, transfers, did not walk and was dependent on one staff for locomotion using a wheel chair. Resident #28 received an antipsychotic medication, an antianxiety medication and an antidepressant medication seven out of the past seven days. Review of Resident #28 quarterly MDS 3.0 assessment dated [DATE] revealed the following changes; he had moderate depression and expressed no behaviors. Resident # 28 was dependent on two staff to transfer. Review of Resident #28's plan of care dated 10/10/17 and revised 11/11/19 revealed he had target behaviors of easily annoyed and upset by other residents, physical aggression toward other residents and staff, inappropriate sexual behaviors directed toward staff, and cursing and yelling at others. Review of Resident #28's (MONTH) 2020 monthly physician orders [REDACTED]. Review of Resident #28's behavior monthly flow sheet for (MONTH) and (MONTH) 2019 revealed the identified target behavior was agitation. Review of the (MONTH) 2020 behavior monthly flow sheet revealed the identified target behaviors were [MEDICAL CONDITION], restless and anxiety. Interview of State tested Nursing Assistant (STNA) #24 on 01/15/20 at 2:26 P.M. revealed Resident #28 did not express many behaviors. STNA #24 stated sometimes he would want to leave the facility, he sometimes did not want to be touched, he may think he was younger than he was, and he hits staff occasionally. STNA #24 stated he sleeps during the day and was up at night. Interview of Licensed Practical Nurse (LPN) #9 on 01/15/20 at 2:31 P.M. revealed Resident #28 had behaviors at times, but it was due to his disease because he could not understand what was going on. LPN #9 stated he tried to leave the facility as he was looking for his family. LPN #9 stated he got loud with the staff and sometimes had hit staff. LPN #9 stated Resident #28 did not hallucinate or have delusions. Interview of the Director of Nursing (DON) on 01/16/20 at 10:48 [NAME]M. confirmed there was no evidence the facility monitored Resident #28's behaviors to support the use of his psychoactive medication. 2. Review of Resident #50's medical record revealed he was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #50's annual MDS 3.0 assessment dated [DATE] revealed the following; Resident #50 had clear speech, he usually understands, he was understood, and cognition was intact. Resident #50 had minimal depression, no indicators of [MEDICAL CONDITION], no behaviors and did not reject care. Resident #50 required supervision with set-up help for bed mobility, transfers, walking and for locomotion. Resident #50 received antipsychotic medication, antianxiety medication and antidepressant medication seven of the seven previous days. Review of Resident #50's quarterly MDS 3.0 assessment dated [DATE] revealed the following changes; Resident # 50 was independent with bed mobility, transfers, walking and locomotion. Review of Resident #50's plan of care dated 12/15/18 revealed target behaviors of being withdrawn, showing little interest or pleasure in doing things, fixation of going home, verbal aggression and sexually inappropriate behavior. Review of Resident #50 (MONTH) 2020 physician orders [REDACTED]. Review of Resident #50's behavior monthly flow sheet for (MONTH) and (MONTH) 2019 revealed the identified target behaviors were anxiety, delusions and overly concerned with his health. Review of the (MONTH) 2020 behavior monthly flow sheet revealed the identified target behaviors were agitation, anxiety and restlessness. Interview of STNA #17 on 01/16/20 at 3:00 P.M. revealed Resident #50 had no behaviors, no delusions or hallucinations. STNA #17 stated he was more confused lately and that was not like him. Interview of the LPN #9 on 01/16/20 at 3:15 P.M. revealed Resident #50 would repeat the same thing over and over, he would fixate on calling his wife and wanting to go home. LPN #9 stated Resident #50 did not hallucinate or have delusions. Interview of the DON on 01/16/20 at 2:59 P.M. confirmed there was no evidence the facility monitored Resident #50's behaviors to support the use of his psychoactive medication.

Based on staff interview, resident interview, medical record review, review of a self reported incident form, review of a facility investigation report, and review of the facility abuse policy, the facility failed to ensure a resident was free from misappropriation of resident property. This affected one of 64 residents residing in the facility (Resident #44). Findings include: Review of the medical record for Resident #44 revealed an admission date of [DATE]. Review of a Minimum Data Set assessment completed 01/14/19 revealed a brief interview for mental status (BIMS) score of 15 indicating intact cognition. Review of a self reported incident form revealed Resident #44 reported to the administrator on the morning of 02/25/19 that he had $158.00 cash, 90 [MEDICATION NAME] pain pills, and his ATM card stolen from the lock box in his room yesterday evening. He presented the administrator with a damaged gray lock box and his written statement. The self reported incident form stated the resident seemed frustrated at the loss of money and the hassle of canceling ATM card. Review of the facility investigation revealed Resident #44 reported he came out to the lounge around 3:45 P.M. on 02/24/19. He closed his room door. After supper, around 5:45 P.M., he returned to his room and could see the room door was open. When he entered the room, the nightstand drawer was open about 5-6 inches. The right wardrobe door was open a few inches. The top drawer of the wardrobe was open a little and that was where he kept his lock box. The lid of the box looked like it was pried open, but the lid was closed. He had the key so it had to be pried open. They took a new bottle of pills, $158 dollars, and his ATM card out of his wallet. The resident stated the last time he went to pay his bills in the community he checked his mailbox at home and had received a refill of 90 [MEDICATION NAME] pills in the mail from the veterans administration. He stated he thought the lock box would be the safest place to keep them. The resident canceled the ATM card after it was taken. The report stated the police were notified on 02/25/19 at 9:40 A.M. The facility conducted an investigation but could not determine who took the items. The facility provided the resident with a new lock box. Review of the self reported incident form dated 02/25/19 revealed the allegation of misappropriation was substantiated by the facility. Interview with Resident #44 on 03/13/19 at 11:25 A.M. revealed the facility had provided him with a lock box to store items in. He stated he kept the lock box in the drawer of his closet. He stated that on Thursday 02/21/19, he counted the money in his wallet and noted he had $158.00. He stated he kept his wallet containing the money and three ATM cards, and the bottle of 90 [MEDICATION NAME] pills in the lock box. He stated he left his room on Sunday 02/24/19 about 3:15 P.M. and returned after supper around 5:45 P.M. He stated when he left his room no drawers were open and his room door was closed. He stated when he came back to his room the room door was open and his closet and bedside table drawers were open. When he lifted the lock box out of the drawer, the lid came open and appeared to have been pried open. The bottle of 90 [MEDICATION NAME], $158.00, and one ATM card were gone from the lock box. He stated he reported it immediately to the nurse on duty. He stated he canceled the ATM card and there was no activity on it after it was taken. He stated the facility provided him with a new lock box after the incident. Interview with the Administrator on 03/13/19 at 10:50 A.M. confirmed the facility substantiated misappropriation since Resident #44's items were missing from his lock box including pills, money, and an ATM card. He confirmed the lock box appeared to have been pried open. He confirmed the resident was provided with another lock box of similar style after the incident. Review of the facility policy titled Freedom from Abuse, Neglect, and Exploitation revealed the purpose of the procedure was to comply with reporting of crimes that may occur at the facility. To prevent, detect, treat, intervene in, and prosecute elder abuse, neglect, and exploitation. The policy stated reportable crimes included theft/robbery. The facility policy included a definition of misappropriation of resident property as the deliberate misplacement, exploitation or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. This deficiency substantiates Complaint Number OH 943.

Based on staff interview, resident interview, medical record review, review of a self reported incident form, review of a facility investigation report, and review of the facility abuse policy, the facility failed to develop and implement written policies for the investigation of allegations of abuse, neglect, and misappropriation. This affected one of 64 residents residing in the facility (Resident #44). Findings include: Review of the medical record for Resident #44 revealed an admission date of [DATE]. Review of a Minimum Data Set assessment completed 01/14/19 revealed a brief interview for mental status (BIMS) score of 15 indicating intact cognition. Review of a self reported incident form revealed Resident #44 reported to the administrator on the morning of 02/25/19 that he had $158.00 cash, 90 [MEDICATION NAME] pain pills, and his ATM card stolen from the lock box in his room yesterday evening. He presented the administrator with a damaged gray lock box and his written statement. The self reported incident form stated the resident seemed frustrated at the loss of money and the hassle of canceling ATM card. Review of the facility investigation report revealed Resident #44 reported he came out to the lounge around 3:45 P.M. on 02/24/19. He closed his room door. After supper, around 5:45 P.M., he returned to his room and could see the room door was open. When he entered the room, the nightstand drawer was open about 5-6 inches. The right wardrobe door was open a few inches. The top drawer of the wardrobe was open a little and that is where he kept his lock box. The lid of the box looked like it was pried open, but the lid was closed. He had the key so it had to be pried open. They took a new bottle of pills, $158 dollars, and his ATM card out of his wallet. The resident stated the last time he went to pay his bills in the community he checked his mailbox at home and had received a refill of 90 [MEDICATION NAME] pills in the mail from the veterans administration. He stated he thought the lock box would be the safest place to keep them. The resident canceled the ATM card after it was taken. The report stated the police were notified on 02/25/19 at 9:40 A.M. Review of the investigation report revealed no evidence the facility interviewed all staff on duty during the time frame when the items were alleged to have been taken. The facility did not determine who took the items. The facility provided the resident with a new lock box. Interview with the Director of Nursing on 03/13/19 at 10:00 A.M. confirmed she did not interview all staff on duty during the time frame (3:15 P.M. to 5:45 P.M.) when the items were alleged to have been taken. She stated she only interviewed the staff who were working on the back hall where the resident resided. She confirmed there were three nursing assistants, one nurse, and a housekeeper working on the front hall that were not interviewed regarding the missing items. (LPN #70, STNAs #71, #72, #73, and housekeeper #74). Review of the self reported incident form dated 02/25/19 revealed the allegation of misappropriation was substantiated by the facility. Interview with Resident #44 on 03/13/19 at 11:25 A.M. revealed the facility had provided him with a lock box to store items in. He stated he kept the lock box in the drawer of his closet. He stated that on Thursday 02/21/19, he counted the money in his wallet and noted he had $158.00. He stated he kept his wallet containing the money and three ATM cards, and the bottle of 90 hyrdocodone pills in the lock box. He stated he left his room on Sunday 02/24/19 about 3:15 P.M. and returned after supper around 5:45 P.M. He stated when he left his room no drawers were open and his room door was closed. He stated when he came back to his room the room door was open and his closet and bedside table drawers were open. When he lifted the lock box out of the drawer, the lid came open and appeared to have been pried open. The bottle of 90 [MEDICATION NAME], $158.00, and one ATM card were gone from the lock box. He stated he reported it immediately to the nurse on duty. He stated he canceled the ATM card and there was no activity on it after it was taken. He stated the facility provided him with a new lock box after the incident. Interview with the Administrator on 03/13/19 at 10:50 A.M. confirmed the facility substantiated misappropriation since Resident #44's items were missing from his lock box including pills, money, and an ATM card. He confirmed the lock box appeared to have been pried open. He confirmed the resident was provided with another lock box of similar style after the incident. Review of an addendum to Abuse Reporting Requirements policy, it stated it response to allegations of abuse, neglect, exploitation, or mistreatment, the facility will have evidence that alleged violations are investigated. The policy did not give any further information on how the investigation would be conducted. The policy did not include steps to investigate different types of alleged violations of abuse, neglect, or misappropriation. The policy did not include identifying and interviewing all involved persons including witnesses or others who might have knowledge of the allegation. Interview with the Director of Nursing on 03/13/19 at 12:55 P.M. confirmed the abuse policy did not include any steps to take regarding the investigation of allegations of abuse, neglect, or misappropriation. This deficiency substantiates Complaint Number OH 943.

Based on staff interview, resident interview, medical record review, review of a self reported incident form, review of a facility investigation report, and review of the facility abuse policy, the facility failed to thoroughly investigate an allegation of misappropriation of resident property and failed to take appropriate corrective action. This affected one of 64 residents residing in the facility (Resident #44). Findings include: Review of the medical record for Resident #44 revealed an admission date of [DATE]. Review of a Minimum Data Set assessment completed 01/14/19 revealed a brief interview for mental status (BIMS) score of 15 indicating intact cognition. Review of a self reported incident form revealed Resident #44 reported to the administrator on the morning of 02/25/19 that he had $158.00 cash, 90 [MEDICATION NAME] pain pills, and his ATM card stolen from the lock box in his room yesterday evening. He presented the administrator with a damaged gray lock box and his written statement. The self reported incident form stated the resident seemed frustrated at the loss of money and the hassle of canceling ATM card. Review of the facility investigation report revealed Resident #44 reported he came out to the lounge around 3:45 P.M. on 02/24/19. He closed his room door. After supper, around 5:45 P.M., he returned to his room and could see the room door was open. When he entered the room, the nightstand drawer was open about 5-6 inches. The right wardrobe door was open a few inches. The top drawer of the wardrobe was open a little and that is where he kept his lock box. The lid of the box looked like it was pried open, but the lid was closed. He had the key so it had to be pried open. They took a new bottle of pills, $158 dollars, and his ATM card out of his wallet. The resident stated the last time he went to pay his bills in the community he checked his mailbox at home and had received a refill of 90 [MEDICATION NAME] pills in the mail from the veterans administration. He stated he thought the lock box would be the safest place to keep them. The resident canceled the ATM card after it was taken. The report stated the police were notified on 02/25/19 at 9:40 A.M. Review of the investigation report revealed no evidence the facility interviewed all staff on duty during the time frame when the items were alleged to have been taken. The facility did not determine who took the items. The facility provided the resident with a new lock box. Interview with the Director of Nursing on 03/13/19 at 10:00 A.M. confirmed she did not interview all staff on duty during the time frame (3:15 P.M. to 5:45 P.M.) when the items were alleged to have been taken. She stated she only interviewed the staff who were working on the back hall where the resident resided. She confirmed there were three nursing assistants, one nurse, and a housekeeper working on the front hall that were not interviewed regarding the missing items. (LPN #70, STNA's #71, #72, #73, and housekeeper #74). Review of the self reported incident form dated 02/25/19 revealed the allegation of misappropriation was substantiated by the facility. Interview with Resident #44 on 03/13/19 at 11:25 A.M. revealed the facility had provided him with a lock box to store items in. He stated he kept the lock box in the drawer of his closet. He stated that on Thursday 02/21/19, he counted the money in his wallet and noted he had $158.00. He stated he kept his wallet containing the money and three ATM cards, and the bottle of 90 [MEDICATION NAME] pills in the lock box. He stated he left his room on Sunday 02/24/19 about 3:15 P.M. and returned after supper around 5:45 P.M. He stated when he left his room no drawers were open and his room door was closed. He stated when he came back to his room the room door was open and his closet and bedside table drawers were open. When he lifted the lock box out of the drawer, the lid came open and appeared to have been pried open. The bottle of 90 [MEDICATION NAME], $158.00, and one ATM card were gone from the lock box. He stated he reported it immediately to the nurse on duty. He stated he canceled the ATM card and there was no activity on it after it was taken. He stated the facility provided him with a new lock box after the incident. Interview with the Administrator on 03/13/19 at 10:50 A.M. confirmed the facility substantiated misappropriation since Resident #44's items were missing from his lock box including pills, money, and an ATM card. He confirmed the lock box appeared to have been pried open. He confirmed the resident was provided with another lock box of similar style after the incident. He confirmed with this type of lock box, the whole box could be stolen as it was small enough to be carried out of a room. Review of an addendum to Abuse Reporting Requirements policy, it stated it response to allegations of abuse, neglect, exploitation, or mistreatment, the facility will have evidence that alleged violations are investigated. It stated if the alleged violation was verified, appropriate corrective action must be taken. This deficiency substantiates Complaint Number OH 943.

Based on observation, record review and interview the facility failed to ensure respiratory care for residents was consistent with professional standards of practice. This affected two (Resident #22 and Resident #212) of three residents reviewed for respiratory care. Findings include: 1. Medical record review of Resident #212 revealed an admission date of [DATE] (previous admission date of [DATE]) and [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 12/03/18, revealed Resident #212 had no cognitive deficits and received oxygen therapy. Review of the December, (YEAR) physician orders [REDACTED]. Observation on 12/05/18 at 10:50 A.M. revealed Resident #212 was receiving oxygen at four liters per minute via nasal cannula. The oxygen tubing was dated 11/13/18. During interview on 12/05/18 at 10:58 A.M. with the Assistant Director of Nursing (ADON) #44, she verified the oxygen tubing was dated 11/13/18 and had not been changed. Review of the facility's oxygen administration policy (revised (MONTH) 2010) revealed documentation of the date and time of the tubing was changed should be documented. 2. Review of Resident #22's medical record revealed he was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #22's admission MDS dated [DATE] revealed the resident's speech was clear, he understands, was understood by others, and his BIMS was 13, indicating intact cognition. Resident #22 did not receive oxygen. Review of Resident #22's physician orders [REDACTED]. Observation of Resident #22 on 12/03/18 at 3:20 P.M. revealed the resident received humidified oxygen at three (3) LPM. The oxygen tubing was not dated. Observation of Resident #22's oxygen tubing on 12/05/18 at 9:08 A.M. revealed the tubing was not dated. Interview of the DON on 12/05/18 at 3:28 P.M. revealed the oxygen provider was supposed to change the oxygen tubing and date it, but he did not. Review of the facility's oxygen administration policy (revised (MONTH) 2010) revealed documentation of the date and time of the tubing was changed should be documented.

Based on medical record review, staff interview and facility policy and procedure review, the facility failed to identify duplicate medication therapy to treat one resident's [MEDICAL CONDITION]. This affected one (Resident #50) of five residents reviewed for unnecessary medications. Findings Include: Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated the resident had clear speech, usually understood others, made herself understood and had no cognitive deficit as indicated in a Brief Interview for Mental Status (BIMS) score of 13. The MDS indicated the resident received antidepressant medications. Review of the resident's plan of care dated 05/23/18 revealed the resident had an actual alteration in sleep pattern related to anxiety and [MEDICAL CONDITION]. The facility implemented the interventions, medication as ordered, monitor for effectiveness, side effects and adverse reactions of medication and offer non pharmacological interventions to help aid in sleep. Review of the resident's monthly physician's orders [REDACTED]. review of the resident's medical record revealed [REDACTED]. On 12/05/18 at 3:10 P.M. interview with Director of Nursing (DON) verified the resident had duplicate drug therapy for the resident's sleep disorder, [MEDICAL CONDITION]. Review of the facility's [MEDICAL CONDITION] Medication Use, not dated revealed the facility's pharmacy and/or pharmacist will assist in providing information about medications that may include box warnings, appropriate dosing, medication categories, drug interactions and medication safety information.

Based on medical record review and staff interview the facility failed to ensure a resident who received an antipsychotic medication had an indication for the use of that medication. This affected one of five residents reviewed for unnecessary medications (Resident #22). Findings include: Review of Resident #22's medical record revealed he was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #22's admission MDS dated [DATE] revealed the resident's speech was clear, he understands, was understood by others, and his BIMS was 13, indicating intact cognition. Resident #22 routinely received an antipsychotic medication for seven days, had no gradual dose reduction and a gradual dose reduction was not clinically contraindicated. Resident #22 had no indication of [MEDICAL CONDITION], did not have behaviors, and did not reject care. Review of Resident #22's monthly medications revealed he received an antipsychotic medication ([MEDICATION NAME]) 25 milligrams at bedtime for [MEDICAL CONDITION]. Review of Resident #22's progress notes and behavior tracking from 09/27/18 to 12/05/18 revealed the resident had two episodes of yelling. Interview of State tested Nursing Assistant (STNA) #47 on 12/05/18 at 2:16 P.M. revealed she had never seen Resident #22 have any behaviors. Interview of STNA #62 on 12/05/18 at 2:22 P.M. revealed Resident #22 had no behaviors. Interview of the Director of Nursing on 12/05/18 at 3:10 P.M. confirmed [MEDICAL CONDITION] was not an indication for the use of the [MEDICATION NAME].

Based on review of staffing schedules and staff interview the facility failed to provide the services of a registered nurse for at least eight consecutive hours a day, seven days a week. This had the potential to affect all 63 residents in the facility. Findings include: Review of the October 2017 staffing schedules revealed on 10/01/17, 10/07/17, 10/08/17, 10/14//17 and 10/15/17 there was no registered nurse (RN) working in the facility. Interview with the Director of Nursing (DON) on 10/19/17 at 2:11 P.M. confirmed there was no RN coverage for eight consecutive hours a day on the dates noted above.

Based on record review and staff interview the facility failed to ensure resident personal funds were placed in interest bearing accounts. This affected 11 residents (Resident #63, #55, #72, #64, #2, #3, #56, #17, #68, #19 and #1) of 20 residents who had personal fund accounts managed by the facility. Findings include: On 10/19/17 a review of resident funds accounts revealed the resident funds accounts totaled $7,379.99. The funds for the following residents were not placed in an interest bearing account by the facility. Resident #63 received Medicaid funding and had a current account balance of $775.27. The funds were not placed in an interest bearing account. Resident #55 received Medicaid funding and had a current account balance of $350.34. The funds were not placed in an interest bearing account. Resident #72 received Medicaid funding and had a current account balance of $300.00. The funds were not placed in an interest bearing account. Resident #64 received Medicaid funding and had a current balance of $454.00. The funds were not placed in an interest bearing account. Resident #2 received Medicaid funding and had a current balance of $666.21. The funds were not placed in an interest bearing account. Resident #3 received Medicaid funding and had a current balance of $1,040.83. The funds were not placed in an interest bearing account. Resident #56 received Medicaid funding and had a current balance of $1,212.20. The funds were not placed in an interest bearing account. Resident #17 received Medicaid funding and had a current balance of $652.00. The funds were not placed in an interest bearing account. Resident #68 received Medicaid funding and had a current balance of $330.00. The funds were not placed in an interest bearing account. Resident #19 received Medicaid funding and had a current balance of $1,026.34. The funds were not placed in an interest bearing account. Resident #1 received Medicaid funding and had a current balance of $230.31. The funds were not placed in an interest bearing account. On 10/19/17 at 2:51 P.M., interview with Business Office Manager #5 confirmed the above resident fund accounts were not in an interest-bearing account.

Based on observation and staff interview the facility failed to ensure pureed food was served at the proper consistency. This affected seven residents (Resident #6, #25, #36, #39, #62, #67, and #72) of seven residents identified to receive pureed meal trays. The facility census was 63. Findings include: Observation of the puree food preparation on 10/18/17 at 11:05 A.M. revealed Cook #46 prepared pureed pasta salad and pureed vegetable soup. The completed products were thin (ran off the spoon) and were not smooth. The food was placed on tray line. The pureed food was tasted by the surveyor and Dietary Manager #23 at 11:21 A.M. Dietary Manager #23 confirmed the puree was not smooth, the two pureed food items were runny and did not mound on the spoon. Review of the recipes for the pureed pasta salad and vegetable soup revealed the food was to be pureed smooth. Interview with the Administrator on 10/19/17 at 8:18 A.M. confirmed pureed foods should be a smooth consistency and mound on the spoon not run off it. The facility identified seven residents, Resident #6, #25, #36, #39, #62, #67, and #72 who received pureed meal trays.

Based on observation, record review and interview the facility failed to prevent, identify, implement timely interventions, and reassess Resident #100 and #105's significant weight loss. Harm occurred to Resident #100, who received all nutrition/hydration via a gastrostomy tube with enteral feeding, when the facility failed to identify the resident had a 25 pound weight loss in 50 days while receiving [MEDICATION NAME] 1.5 tube feeding through her gastrostomy tube ([DEVICE]). During this time there was no evidence individualized and comprehensive interventions were attempted or the physician was consulted to prevent additional weight loss and promote weight gain. Harm occurred to Resident #105 when the facility failed to identify the resident had a significant decrease in appetite and a ten pound weight loss in 90 days. During this time the facility did not notify the physician of the decrease in appetite, which caused the resident to lose weight until 08/04/16. This affected two residents (Resident #100 and #105) of four residents reviewed for weight loss. Findings include: 1. Review of the medical record for Resident #100 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The nutritional plan of care dated 03/15/16 documented that Resident #100 was at a risk for weight loss. The interventions included weigh resident per physician order, report weights to dietician, update physician of any weight loss and monitor labs. Review of a discharge Minimum Data Set ((MDS) dated [DATE] revealed the resident was cognitively impaired and received nothing by mouth. The assessment identified Resident #100's weight at 79 pounds with no weight loss of 5% or more in the last month or loss of 10% or more in the last six months. Resident #100 received greater than 51% of total calories through her [DEVICE] feedings. Review of the quarterly MDS assessment, dated 06/21/16 identified Resident #100's weight at 63 pounds with no weight loss of 5% or more in the last month or loss of 10% or more in the last six months. Resident #100 received greater than 51% of total calories through her [DEVICE]. Record review revealed weekly weights were completed from 03/15/16 through 08/03/16. On 03/15/16 the resident's admission weight was documented to be 93 pounds. On 04/12/16 the resident's weight was 86 pounds. On 05/16/16 the resident's weight was 65 pounds. On 06/13/16 the resident's weight was 61 pounds. On 07/18/16 the resident's weight was 61 pounds. And on 08/03/16 the resident's weight was documented as 62 pounds. Review of the initial nutritional assessment dated [DATE] revealed Resident #100's weight was reflected at 98 pounds. The assessment revealed the resident received all nutrition/hydration via gastrostomy tube with the current formula of [MEDICATION NAME] 1.5 at 35 milliliters (mls) per hour which provided 1260 calories, and 53 grams of protein. The estimated nutritional needs section was incomplete. Review of the readmission nutritional assessment dated [DATE], after a hospital stay for [MEDICAL CONDITION], revealed Resident #100's weight was 68 pounds with a Body Mass Index (BMI) of 11.7-severely underweight. The resident received all nutrition via [DEVICE] of [MEDICATION NAME] 1.5 at 45 mls per hour. The estimated nutritional needs indicated the resident required 861 calories and 36-46 grams of protein. The dietician recommended an increase in tube feeding of [MEDICATION NAME] 1.5 to 55 mls per hour to provide 1980 calories and 83 grams of protein with 1002 mls of free water due to significant weight loss and under- weight status. Review of the nutritional progress notes revealed the dietician documented on 05/25/16 the resident with gradual weight loss, and recommend again an increase of the tube feeding of [MEDICATION NAME] 1.5 to 55 mls per hour. A weekly note dated 06/16/16 indicated the dietician documented Resident #100's weight was stable at 64 pounds since the tube feeding was increased to 55 mls per hour. Since the resident's weight was stable without weight gain the dietician recommended increasing [MEDICATION NAME] 1.5 to 60 mls per hour to promote weight gain. This would provide 1980 calories and 90 grams of protein. Also, recommended to decrease the water flush to 30 mls for a total of 2163 mls per day. On 07/21/16 a quarterly note indicated Resident #100's weight was 61 pounds. The dietician recommended a speech therapy evaluation as the resident was more alert and might be able to eat. Also the dietician recommended an increase of the tube feeding [MEDICATION NAME] 1.5 to 65 mls per hour due to weight loss. This would provide 2340 calories, 97 grams of protein with 1563 mls of free water. Review of the physician progress notes [REDACTED]. On 04/25/16 the physician documented no significant change in condition per nursing, no recent illness or injury reported and no new issues or concerns. On 05/06/16 the readmission note did not address Resident #100's weight loss. On 07/05/16 the physician documented no significant change in condition, no recent illness or injury and no new issues or concerns. Review of the nursing progress notes indicated on 05/01/16 Resident #100 had an extra-large emesis of coffee ground substance with no residual. The physician was notified and an order received to send the resident out to the emergency room for evaluation and treatment. The guardian was notified. Resident #100 returned to the facility on [DATE] with a weight of 66 pounds. The physician and guardian were made aware of the return however, no notification of the weight change. On 05/10/16 the nurse documented a weight review was completed and noted a significant weight loss in 30 days. The resident was recently hospitalized due to [MEDICAL CONDITION] with [MEDICAL CONDITION]. The resident received nothing by mouth, had an intravenous line for hydration, and an [MEDICAL CONDITION] stricture with a fluid filled stomach and esophagus on 05/01/16. The documentation did not indicate the physician was notified of significant weight loss at that time. On 06/10/16 the nurse documented the resident with noted weight loss of four pounds times one month. The resident remained nothing by mouth status and continued to receive gastrostomy tube feedings as per the orders and tolerated without difficulty. The physician was made aware of the weight decrease and ordered a dietary consult and the medications were reviewed with no changes. A message was left for the guardian and the dietician regarding the weight decrease. An interview with the director of nursing (DON) on 08/03/16 at 10:21 A.M. revealed Resident #100 had been discussed with the dietician and the physician but had no documentation of the discussions. The DON confirmed the weights for Resident #100 indicated a significant weight loss and from 03/15/16 through 05/16/16 with neither the physician nor the dietician were notified. Observations were made during the course of the four day survey of Resident #100 on 08/02/16 at 2:17 P.M. and on 08/03/16 at 10:42 A.M. During the observations made, the resident was observed receiving [MEDICATION NAME] 1.5 at 65 mls per hour via continuous pump and water flushes as ordered. Review of the weight loss policy dated 06/11/08 revealed the nurse will ensure that each resident on the unit was weighed as ordered, ensure that all residents with unplanned weight loss were monitored by the physician and dietician, monitor the weight log each week for completeness and accuracy, monitor the charts of all residents with unplanned weight loss to ensure that interventions and documentation were appropriate and monitor intake records to ensure they were recorded appropriately. The dietician and the DON were to review the weights. The policy also stated that residents with tube feeding with a noted weight loss of five pounds or more in 30 days; the physician and the dietician would be notified of the weight loss. The STNA's record meal intake for all residents after meals and at the end of the shift and notify the nurse of any resident who shows a decreased appetite or intake and refuses food or fluids. 2. Review of Resident #105's record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS 3.0 assessment, dated 06/30/16 revealed the resident was cognitively impaired with symptoms of depression and hallucinations. Resident #105 required limited assistance from staff for eating. The assessment identified Resident #105 had a swallowing disorder and was on a therapeutic diet. The assessment revealed Resident #105's was 165 pounds with no weight loss of 5% or more in the last month or 10% or more in the last six months. Review of the plan of care revealed a plan for potential nutrition and hydration problems. Interventions included, on 06/17/16 to change diet to regular with super nutritional program and health shakes by mouth three times daily. On 08/04/16 the care plan was updated to obtain stat labs, consult dietician on next visit due to decreased oral intake, speech therapy consult, encourage the resident to sit up in a chair during meals, health shakes by mouth with medication pass and start [MEDICATION NAME] as per physician order. Review of the physician orders [REDACTED]. Review of Resident #105's weights revealed on 04/09/16 the resident weighed 165 pounds. On 05/16/16 the resident weighed 156 pounds. On 08/01/16 the resident's weight was documented to be 128 pounds with a reweight on 08/04/16 of 157 pounds. Review of Resident #105's meal intake record from 06/04/16 through 08/03/16 revealed on multiple occasions the resident ate 25% or 0% of meals. On 06/07/16 ate 25% of dinner, 06/09/16 ate 25% of dinner, 06/10/16 25% of breakfast, 06/11/16 ate 0% of breakfast and dinner, 06/13/16 ate 0% of lunch and 25% of dinner, 06/17/16 at 0% of breakfast and dinner, 06/20/16 at 0% of breakfast, 06/22/16 ate 25% of breakfast, 06/23/16 ate 25% of breakfast, 06/25/16 ate 25% of breakfast and dinner, 06/26/16 ate 25% of breakfast, 06/27/16 ate 25% of breakfast, 06/29/16 ate 25% of lunch, 07/01/16 ate 25% of breakfast, 07/02/16 ate 25% of breakfast and lunch, 07/04/16 ate 25% of breakfast and lunch, 07/06/16 ate 25% of breakfast, 07/07/16 ate 25% of breakfast and dinner, 07/12/16 ate 25% of breakfast and dinner, 07/13/16 ate 0% of breakfast, 07/14/16 ate 0% of 07/14/16, 07/16/16 ate 0% of lunch, 07/17/16 at 0% of breakfast and lunch, and 25% of dinner, 07/18/16 ate 0% of breakfast, 07/19/16 ate 0% of breakfast and lunch, 07/28/16 ate 0% of breakfast and 25% of lunch, 07/29/16 ate 25% of breakfast and lunch, 07/31/16 ate 0% of dinner, 08/01/16 ate 0% of breakfast and dinner, 08/02/16 ate 0% of breakfast, 25% of lunch and dinner, and on 08/03/16 ate 0% of breakfast, and 25% of lunch. Review of the initial nutrition assessment dated [DATE] revealed Resident #105 weighed 165 pounds with a BMI of 23. The current diet order was regular. The estimated nutritional needs were 1520 calories and 75 grams of protein. The dietician recommended the resident continue with a regular diet. A readmission nutrition assessment dated [DATE] revealed Resident #105 weighed 167 pounds with a BMI of 23. The current diet order was regular texture, no concentrated sweets and no added salt. The estimated nutritional needs were 1520 calories and 75 grams of protein. The dietician recommended the resident continue with the diet as ordered. A readmission nutrition assessment dated [DATE] revealed Resident #105 weighed 131 pounds with a BMI of 18.3. The current diet order was no concentrated sweets, no added salt and regular texture. The estimated nutritional needs were 1419 calories and 59 grams of protein. The dietician recommended changing the diet to liberal regular with super nutritional program and health shakes three times daily. Review of the physician progress notes [REDACTED]. Also noted the resident was on a regular diet with no concentrated sweets. A progress note dated 06/08/16 stated the resident was seen for complaints of heartburn. The physician documented in spite of [MEDICATION NAME] and [MEDICATION NAME] the resident was complaining of heartburn on and off during the day. The physician gave an order to add [MEDICATION NAME] 1 gram by mouth at bedtime. A readmission progress note dated 06/22/16 from hospital stay for treatment of [REDACTED]. A progress note on 07/06/16 and 07/24/16 revealed no nutritional concerns noted. Review of the nursing progress notes revealed no documentation until 08/04/16 10:04 A.M. that Resident #105 had been refusing to sit up and had been eating approximately 25% of meals for the past couple of days. The resident's family brought in snacks and resident stated he ate a cake. Earlier on 08/04/16 at 9:34 A.M. the nurse documented the physician was notified of decreased appetite and the State tested Nursing Assistant (STNA) reported the resident had been spitting up a small amount of clear liquids with meal this morning. At 12:46 P.M. the nurse documented the physician was notified of current weight of 157 pounds, a seven pound weight decrease within one week. Review of the physician orders [REDACTED]. An interview with STNA #35 on 08/04/16 at 3:26 P.M. revealed Resident #105 had a decline in appetite over the last few weeks. STNA #35 stated she reported all meal refusals to the nurse after documenting on the care kiosk. All residents who refused or ate less than 50% were offered an alternate meal. An interview with the DON on 08/04/16 at 11:25 A.M. revealed the DON was notified on 08/03/16 of decrease in appetite and weight loss for Resident #105. Review of the weight loss policy dated 06/11/08 revealed the nurse will ensure that each resident on the unit was weighed as ordered, ensure that all residents with unplanned weight loss were monitored by the physician and dietician, monitor the weight log each week for completeness and accuracy, monitor the charts of all residents with unplanned weight loss to ensure that interventions and documentation were appropriate and monitor intake records to ensure they were recorded appropriately. The dietician and the DON were to review the weights. The policy also stated that residents with tube feeding with a noted weight loss of five pounds or more in 30 days; the physician and the dietician would be notified of the weight loss. The STNA's record meal intake for all residents after meals and at the end of the shift and notify the nurse of any resident who shows a decreased appetite or intake and refuses food or fluids.