Every finding on record at Sheridan Memorial Nursing Home

Based on interview and record review, the facility failed to ensure a resident was free from abuse and neglect of care needs for 1 (#1) of 3 sampled residents. The deficient practice resulted in the resident feeling worthless, anxious, confused, and feeling like she was being punished. Findings include: Review of a Facility-Reported Incident, dated 3/7/26, showed resident #1 reported she was forced to remain in a recliner in the day lounge rather than in her bed. The resident also stated she was denied water upon request and did not have access to a call light or any other way to summon help if needed. The report also showed that the resident repeatedly expressed feeling as if she was being punished for something.During an interview on 4/8/26 at 8:28 a.m., staff member H stated she was assigned to care for resident #1 on the day shift on 3/7/26. Staff member H stated resident #1 was in a recliner in the day lounge when she came on shift on the morning of 3/7/26. Staff member H stated resident #1 was sitting in a recliner, which was unusual for her. The staff member stated that resident #1 was usually in her bed when the day shift started. Staff member H stated while receiving a report from staff member M, staff member M stated, She (resident #1) doesn't get any water because she would need to get up. This comment was made in front of several staff members (H, J, M, and N) and resident #1. Staff member H stated she did not see any water near the resident in the day lounge. Staff member H stated she and staff member J assisted resident #1 to her room to get her settled into her bed for a while before breakfast. Staff member H stated that resident #1 said her call light had not been answered during the night. Staff member H stated the resident repeatedly thanked the staff for anything they did for her, and the resident seemed more anxious than usual.During an interview on 4/8/26 at 3:45 p.m., staff member J stated that when she came on shift on the morning of 3/7/26, resident #1 was seated in a recliner in the day lounge. While assisting resident #1 from the day lounge to her room, accompanied by staff member H, staff member J described the resident as distraught. She stated the resident said, I don't know why I was treated that way, and repeatedly thanked the staff for helping her and was worried about it (the treatment she received overnight on 3/7/26) happening again. Staff member J stated that resident #1 needed frequent reassurance that it would not happen again.During an interview on 4/9/26 at 7:50 a.m., resident #1 stated she remembered the incident that occurred on 3/7/26. Resident #1 stated the treatment she received during the night shift (from 3/6/26 at 6:00 p.m. to 3/7/26 to 6:00 a.m.) made her feel like she, . was not worth anything .they wouldn't bring me any water .I don't understand why they were treating me that way.Review of resident #1's Facility Reported Event investigative file, dated 3/7/26, showed the following interviews and written statements:- Resident #1, in her transcribed interview, stated, They would not give me any water to drink. Because I get up to many times and I also could not have my call light. They kept me out in that awful room in a chair that was not comfortable. [sic]- Staff member J reported, in her written statement, an allegation of abuse on 3/7/26 which involved resident #1 and staff member M. Staff member J's written statement, dated 3/7/26, showed resident #1 reported she had been told, . not to call for help and had an awful night . did not understand why this happend [sic] to her. (confusion) The resident also kept repeating why she was being punished. - Staff member H reported, in her written statement, that she received a hand-off report from staff members M and N, who were sitting on either side of resident #1. During the report, resident #1 requested water, and staff member M told her no because she would have to use the bathroom again. Staff member H reported that staff members M and N laughed in front of resident #1. While assisting resident #1 from the day lounge to her room, assisted by staff member J, the resident told them her . night was terrible, and she was told, . could not use her call light or have an ice pack.- Staff member I reported, via an email statement, she was told (by staff member J) the resident claimed she was told not to use her call light, was refused an ice pack, and was refused water overnight. Staff member I then reported the abuse allegation involving resident #1 to staff member B.- Staff member M, in her transcribed interview, reported she had to redirect resident #1 to use her call light before getting up, rather than after she had finished. Staff member M stated that resident #1 also made a statement about being punished, and staff member M told the resident she did not want the resident to fall. Staff member M stated that resident #1 got up from her bed three times without using her call light until she was finished in the bathroom.- Staff member M, in her written statement dated 3/6/26 (incorrect, should have been dated 3/7/26), showed that after the second time resident #1 got up to the bathroom without using her call light, staff member M stated the resident's emergency bathroom light went off. Staff member M stated the resident was not listening to reason, and she brought resident #1 out to the day lounge just to keep an eye on her.Review of the abuse meeting notes, dated 3/12/26, showed staff members A, B, C, S, and T were in attendance. The following concerns were identified:- Resident (#1) was placed in a recliner in a common area to be watched more closely. The resident asked to return to bed. This was dismissed.- An overbed table was placed across the resident to keep her in the recliner. This could not be corroborated by staff present in the facility.-The resident's walker was moved farther away, limiting mobility.- Resident #1 reported feeling punished.The group determined the incident represented abuse, and it was reported to the State Survey Agency.Review of the facility policy titled Abuse, dated 8/7/25, showed, Purpose: . Each resident/patient has the right to be free from abuse, .and it is the facility's responsibility to prevent not only abuse, but also those practices and omissions, neglect, .that if left unchecked, lead to abuse. Residents/patients must not be subjected to abuse by anyone, including, but not limited to facility staff .

Based on interview and record review, the facility staff failed to use a gait belt when ambulating a resident, resulting in a minor injury, which was a skin tear with tendon exposure to the left fourth digit, requiring only nursing treatment for 1 (#4); and failed to evaluate and modify Interventions to prevent future falls for 3 (#s 2, 4, and 5) of 3 residents sampled for falls. These deficient practices contributed to continued falls for the residents and increased the risk of potential injuries. Findings Include:1. Review of a Facility-Reported Incident, dated 11/4/25, showed resident #4 fell while ambulating with staff member K. Resident #4 was using a rolling walker and was wearing supplemental oxygen. Staff member K turned her back on the resident, and the resident lost her balance, falling backward onto her bottom. The report showed the resident hit her left arm and hand on the door jam and sustained a minor injury, which was a skin tear with tendon exposure on her left fourth finger. The resident was not wearing a gait belt. A dressing was applied by the nurse, and no further medical care was required.Review of a list of resident falls between 10/1/25 and 4/6/26 showed resident #4 sustained unwitnessed falls on 1/17/26, 2/3/26, 2/12/26, and 2/19/26, and a near miss on 11/29/25.Review of resident# 4's nursing progress note, dated 11/29/25, showed the resident was ambulating in the hallway still wearing her oxygen (which was still connected to the concentrator in her room. The resident tripped on the tubing and tipped towards the wall. The note showed a CNA was able to catch her before she fell.During an interview on 4/8/26 at 9:12 a.m., staff member K stated resident #4 always had staff with her when she was walking. Staff member K stated that she always uses a gait belt during resident transfers or walking. Staff member K could not explain why resident #4 was not wearing a gait belt on 11/4/25. Staff member K stated she was behind the resident and turned around to answer a question. While having her back to resident #4, the resident lost her balance and fell backward onto her bottom.During an interview on 4/8/26 at 3:40 p.m., staff member J stated the CNAs were expected to use gait belts for all residents who required assistance with transfers or ambulation. Staff member J said she could not think of a circumstance that would justify not using a gait belt, and every resident had their own gait belt.Review of the Facility's policy titled, Mechanical Lift & Transfer Procedures of Patients/Residents, dated 10/1/25, showed a gait belt was to be used when staff assistance was needed to get a resident out of a chair or bed, when transferring from a wheelchair to the toilet, and to provide support when ambulating. The procedure for using a gait belt included, . E. Properly grasp belt and/or handles of belt for effective use.J. Holding onto the belt and standing a few steps behind the patient/resident, assist patient/resident when walking.2. Resident #2During an interview on 4/8/26 at 12:15 p.m., staff member S stated the MDS nurse was primarily responsible for updating resident care plans.During an interview on 4/8/26 at 1:15 p.m., staff member F stated she was responsible for updating care plans when necessary. When asked how the IDT evaluated the effectiveness of fall interventions, staff member F stated she did not routinely attend the weekly fall meetings. But she believed the post-fall documentation included interventions in place at the time of the fall and any new interventions implemented after a fall. She stated the initial fall incident note was revised to include daily resident status notes for five days after the fall, and any information on causes and new interventions determined by the fall team. Staff member F stated she had not been updating the fall care plans.Review of the Fall Meeting Notes, dated between 10/16/25 and 2/23/26, showed the following for resident #2:- Unwitnessed fall on 10/27/25 at 8:00 p.m. while walking in her room and tripped over her own feet, no injuries, cause was unsafe balance gate, new interventions of checking all shoes are safe and reminding the resident to use her walker even when in her room.- Unwitnessed fall on 11/28/25 at 8:50 a.m., found on the bathroom floor, trying to put on another brief, no injuries, cause was dehydration, seen in ED for new onset of confusion, dietician recommended increasing water intake and decreasing soda intake.- Unwitnessed fall on 12/23/25 at 10:45 p.m., missed her recliner when trying to sit down and landed on her bottom, skin tear on her left arm requiring band aid, cause was documented as, Increase in weakness, confusion. New medication Primidone 50mg qhs, four-wheel walker not used in the room. Documented interventions were, Possibility to a 2-wheel walker, and possibility of room change. When resident is up in the room queue to be using the walker, pare down the room. Nursing to remind her to make sure that the chair is behind her. [sic]- Unwitnessed fall on 1/10/26 at 5:45 a.m., found on the bathroom floor, cause was documented as, Sepsi(s) onset, alter mental status, [sic] Interventions were documented as, When tremors are getting bad and all of sudden falling asleep, report to the provider. Will need to stand by assist and gait belt. - Unwitnessed fall on 1/11/26 at 9:15 a.m., found on the floor in another resident's room, reported she tripped and fell on the floor, cause documented as, Unsteady and in a different room and having tremors. Interventions documented as, When tremors are getting bad and all of sudden falling asleep, report to the provider. Will need to stand by assist and gait belt.- Unwitnessed fall on 1/24/26 at 8:30 p.m., found on the floor in her room, cause documented as, Patient has had increased weakness and confusion since last hospitalization. Interventions were documented as, OT to reassess-may recommended trial switching to FWW instead of 4WW for more stability. Keep encouraging patient to call for assist with all transfers. Discuss room move closer to desk for more supervision.- Unwitnessed fall on 2/23/26 at 8:00 p.m., found on the floor of her room, the resident stated her walker hit the edge of the door frame. The cause was documented as the resident was unsteady, and interventions were documented as, If up walking in the hall during the evening staff to walk with her.- Unwitnessed fall on 2/26/26 at 8:00 p.m., found on the floor of her room. The cause was documented as, Forgets to use the call light after using the restroom. Interventions were, Staff need to check in on the resident after taking to the bathroom to assist afterwards.Review of resident #2's Fall Care Plan, dated 4/7/26, showed the addition of the intervention to use a gait belt. No other care plan changes were documented between 11/26/25 and 4/7/26.3. During an interview on 4/8/26 at 10:35 a.m., staff member L stated it was the expectation that gait belts would be used for all assisted transfers and ambulation. Staff member L stated that each resident should have their own gait belt.Review of resident #5's Fall Risk Assessment, dated 10/13/25, showed the resident was at a high risk for falls.Review of the Fall Meeting Notes, dated between 10/16/25 and 2/23/26, showed the following for resident #5:- Unwitnessed fall on 10/13/25 at 11:05 p.m., found on the bathroom floor. The cause was documented as, More Parkinson activity where he freezes, wheelchair may not have been locked. Interventions were documented as, Make sure to round every hour to check on the resident.- Unwitnessed fall on 11/4/25 at 9:55 p.m., found on the floor next to his bed. The cause was documented as Resident does not call for staff. Interventions were documented as, Find out where the wheelchair is being located, making sure that every time we leave his room that the wheelchair is locked and nearby.-An Unwitnessed fall on 2/11/26 at 00:15 a.m., the resident was found on the floor between his recliner and his bed. The cause was documented as, Resident does not want to call for assistance. Interventions were documented as, Resident is resistant to walker and asking for help. Attempt a toileting schedule. A visualization to assist as needed.Resident #5 sustained unwitnessed falls on 1/24/26 and 1/25/26. The Fall Meeting notes failed to show any details or discussion of these falls.Review of resident #5's Fall Care Plan, dated 11/6/25 and 1/29/26, failed to show any changes in the care plan.Review of the facility's policy titled, Fall Prevention, dated 2/4/25, showed the purpose was . to promote proactive health-care practices for patient/resident care planning which minimize the risk for falls. The policy also showed, . IV. Every attempt will be made to safely support the patient/resident's rights for independence and self-determination by creatively activating the least restrictive methods for fall prevention that are effective. The procedure was, . Nursing staff will be informed of each patient/resident's risk level and initiated care plan interventions.Interventions may be added to the care plan to prevent further falls.During an interview on 4/8/26 at 2:42 p.m., staff member C stated she had not been updating the care plans after the weekly fall meeting.

Based on observation, interview, and record review, the facility staff failed to safely use a sit-to-stand lift when transferring a resident, causing injuries to include fractured ribs, and the resident was hospitalized for further evaluation, for 1 (#26) of 4 sampled residents for accidents. Findings include:Review of a facility reported incident, sent to the State Survey Agency, dated 6/20/25, showed resident #26 was found to have a large area of bruising over his right chest wall with swelling. The area was firm and tender to touch. Resident #26 was sent to the ED for further evaluation. The facility investigation concluded the used of the sit-to-stand lift for transferring resident #26 was the cause of the injury. The investigation did not show if the facility determined the lift sling being used was appropriate for resident #26. The resident was found to have an elevated PT/INR that caused significant bruising and hematoma on the right chest wall. Resident #26 did not complaint of pain in that area, per the documentation, until the morning of 6/20/25 when the bruising was noted by staff when getting resident #26 dressed. During an observation and interview on 7/30/25 at 8:47 a.m., staff member O demonstrated the use of the sit-to-stand device when transferring a resident from the wheelchair to a recliner. Staff member O said she had worked with resident #26 for several years, and he was transferred with the assistance of the sit-to-stand lift. Resident #26 was a bigger man and required an XXL sling when using the lift. Staff member O said PT would evaluate the resident and determine if a sit-to-stand lift was appropriate for the resident and make recommendations on the strap size to be used. Staff member O said if a staff member used a sling that was too small, it would force a resident against the metal bars of the device, and the strap would be too tight across the resident's chest. Staff member O said she felt a strap that was too small for resident #26 was used to transfer him, and he sustained the rib fractures. Staff member O said resident #26 had good leg strength when he transferred. During an interview on 7/30/25 at 2:40 p.m., staff member B said resident #26 had sustained two rib fractures, and due to his coumadin use, a large hematoma occurred, which was from the use of the sit-to-stand lift. The incident had been investigated for a fall and abuse, however, the location of the right-sided rib fractures was in the area of the strap used for the resident's transfer. Staff member B said it was noted that resident #26 had been leaning to his right-side while being transferred, for the week before his injury. Staff member B said a PT evaluation for the continued use of the sit-to-stand lift was going to be scheduled. Staff member B said the use of the sit-to-stand had been discussed in a huddle (group staff discussion). Staff member B said an individualized check-off for staff on the use and operation of lifts had not been provided following the injury to resident #26. During an interview on 7/30/25 at 2:57 p.m., staff member F said she was responsible for the investigation of resident #26's injury. Staff member F said she was notified on 6/20/25 of the injury of unknown origin that had occurred for #26. An investigation was initiated, and it was determined that the strap on the sit-to-stand lift had caused the resident's rib fractures. Staff member P decided to stop the use of the lift, and then a Hoyer lift was used for transfers until resident #26 could be evaluated for the use of the sit-to-stand lift. Staff member F said the findings were shared in a staff huddle, and staff were shown the appropriate use, sling placement, and how to use the stand correctly. The facility was attempting to have enough slings for each resident to have an individual sling. The staff had Relias (staff training program) training on lift use, but the staff had not received actual individualized check-off evaluations for the correct use of the lift since the injury had occurred with resident #26. Staff member F said she believed the sit-to-stand lift was included in resident #26's care plan but did not believe the sling size for use was listed on the care plan. Review of resident #26's Emergency Department Reports, dated 6/20/25, showed: .History of Present Illness [AGE] year old male patient who presented to the [Hospital Name] ER from [Facility Name] with complaints of bilateral chest wall pain; right more than left.patient does have dementia. He is anticoagulated on oral Coumadin. Medical Decision Making . A CT scan of the chest revealed a bilateral chest wall hematoma measuring approximately 13.6 cm x 5.5 cm x 4.2 cm. Due to patient position, it is only partially visualized therefore difficult to fully characterize. Suspected minimally displaced acute to subacute fractures involving posterior aspects of right-sided ribs 10 and 12.Assessment/Plan .2. Rib fractures Patient with minimally displaced acute to subacute fractures involving posterior aspects of right-sided ribs 10 and 12. 3. Atrial fibrillation, chronic Patient with known, chronic Atrial Fibrillation on chronic anticoagulation with Coumadin 8 mg daily. Most recent INR of 5.7. Will hold his oral Coumadin for 1 week. [sic] Review of resident #26's Resident Plan Report, not dated, showed: .ADLS Resident is at risk for self care deficit related to cognitive loss at baseline, legally blind, needing staff assistance for all ADLs. 2. [Resident #26] needs staff assistance with all transfers. 3. [Resident #26] uses the sit to stand for all transfers. [sic] Review of a facility-provided document, Care Plan Modification- Post-Injury, dated 6/20/25, approved by staff member F, showed: . As per the Safety/Risk Nurse request, the resident's care plan has been updated following a recent injury and emergency room visit. The following measures are to be implemented (for #26) to ensure the resident's safety and prevent further injury: Lift Use Restriction: Due to rib fractures and a large hematoma on the right side, the resident is no longer permitted to use the sit-to-stand lift. Transfer Protocol: Effective immediately, all transfers must be performed using the Maxi Move or full-body lift only. [sic]

Based on observation, interview, and record review, the facility failed to establish a grievance policy which included information on how to file a grievance anonymously for 2 (#s 19 and 20) of 21 sampled residents; and failed to post the grievance officer's address and phone number in a prominent location. This deficient practice affected all who have the right to file a grievance anonymously and who to contact if they wish to file a grievance. Findings include: During an interview on 7/29/25 at 9:21 a.m., resident #20 said he did not know anything about how to file a grievance or the grievance process. He did not know there was a process to file a grievance anonymously. Resident #20 said he had not seen a grievance form or a place to deposit the form. During an observation on 7/30/25 at 9:56 a.m., there was no information posted identifying who the grievance officer was and the required contact information for the grievance officer. During an interview on 7/30/25 at 11:44 a.m., resident #19 stated she had not filled out a complaint or grievance before. Resident #19 stated she did not know where to find grievance or complaint forms or how to drop forms off for staff to review. Resident #19 stated if there was an issue with something, she would let a nurse know. Resident #19 stated she would ask a nursing staff member for a complaint form if she had a big concern to address that she could not tell someone about verbally. During an interview on 7/30/25 at 12:18 p.m., staff member G stated she had been in her new position for about a month. Staff member G stated she was the grievance officer and would handle resident grievances and complaints. Staff member G stated she had not had to fill out a grievance form for a resident yet. Staff member G stated if residents had a concern or complaint, the staff member would take care of the issue and it was discussed verbally, without documenting it. Staff member G stated the staff member notified of the concern would then notify the specific department for the area of concern, for it to be addressed right away. Staff member G stated the staff member who was originally made aware of the issue would discuss the incident with the resident and family, to see if they were fine with how the concern was resolved, before filling out an official complaint form. During an interview on 7/30/25 at 2:00 p.m., staff member B stated when a resident wanted to submit a grievance anonymously, it was the same process as submitting a written grievance. Staff member B stated the person wanting to submit a grievance would have to ask a staff member for the grievance form, which was contained in an electronic form that had to be printed off for the resident. During an interview on 7/30/25 at 3:18 p.m., staff member F stated she was the grievance officer for the facility. Staff member F confirmed there was no posting in the facility that noted her as the grievance officer or her required contact information. During an observation and interview on 7/30/25 at 4:04 p.m., staff member D stated the wooden box on the nurses’ station counter was where residents could put forms into for staff to review. Staff member D stated, “See the box here, this shows 'Suggestions' on the front, not complaints or grievances.” Staff member D stated the box had been used for placing grievance forms in the past. Staff member D stated a staff member had changed it, and had not returned it to being used as a locked grievance or complaint drop box. Review of the facility’s policy titled, “Patient Complaints and Grievances,” last revised 3/13/25, lacked information on how to submit a grievance anonymously.

Based on interview and record review, the facility failed to maintain documentation of the Medical Director's (or Designee's) attendance and participation for Quality Assurance and Performance Improvement (QAPI) meetings, which were at a minimum, required to be completed quarterly. The Medical Director had involvement in the oversight of the care and services, and ensuring services met professional standards for care, and provided oversight for the review and approval of policies and procedures. This failure could affect all residents. Findings include:During a record review of the facility QAPI binder, on 7/30/25 at 4:18 p.m., one document for April 2025 was found in which a medical provider attended the scheduled facility QAPI meeting. Review of documents with meeting dates from September 2024 to March 2025, and May 2025 to July 2025, did not show a medical provider or director in attendance at the QAPI meetings, although attendance was required. During an interview on 7/30/25 at 4:33 p.m., staff member B and staff member D stated they were filling in to answer QAPI-related questions for staff member L. Staff member B stated staff member L would lead the QAPI meetings for the facility. Staff member B stated QAPI meetings were held monthly, except for the months of July and December. Staff member B stated staff member C had a medical provider attend QAPI meetings as a designee at times. Staff member B stated staff member C also attended QAPI meetings through video conferencing. Staff member B stated the facility did not have sign-in sheets to show the staff members attending QAPI meetings and said it might be a good idea to have them in place. Staff member B stated staff member L kept track of attendance by writing the names of the staff attending in the attendance section of the QAPI meeting minutes. Staff member B stated staff member C attended monthly medical provider meetings, where issues discussed in QAPI could be reviewed. During an interview on 7/30/25 at 5:23 p.m., staff member C stated he started his role at the facility in January 2025. Staff member C stated that the previous staff member in his position informed him of the requirement for attending regularly scheduled QAPI meetings. Staff member C stated he usually attended QAPI meetings via video conferencing calls. Staff member C stated that the last QAPI meeting he attended for the facility was in May 2025. Staff member C stated he might have been off to the side, or off camera, during a video conference for a QAPI meeting, and with a different medical provider as the designee attending in April 2025. Review of a facility policy titled, [Facility Name] Quality Assurance Performance Improvement (QAPI) Plan, last revised 7/24/2024, showed: . Guidelines for Leadership . V. The Nursing Home Quality Assurance Assessment (NHQAA) committee will consist of the Medical Director . and others if deemed necessary. The team will meet at least quarterly; and at times with the Quality Committee Meeting. The DON or Quality Director will lead the meeting and report on performance improvements, areas of focus, and other pertinent information. A request was made on 7/30/25 at 5:36 p.m. for the QAPI sign-in attendance documentation to verify the medical director or designee's attendance at the required meetings, from July 2024 to the date of the survey, but no documents were received before the end of the survey.

Based on observation, interview, and record review, the facility staff failed to uphold proper infection prevention and control practices during medication administration for 3 (#s 2, 22, and 27) of 4 residents receiving medication. Findings include:During an observation on 7/29/25 at 3:52 p.m., staff member Q prepared medications for resident #27, and failed to perform hand hygiene prior to handling the medications for the administration to resident #27. One of the two medications to be given to #27 was dropped onto the surface of the cart by a staff member Q, and then picked up with a plastic spoon. The medication was placed in the medication cup. Staff member Q failed to perform hand hygiene before administering the medications to resident #27, and the surface of the medication cart was not observed to be sanitized prior to the medication preparation. During an observation on 7/30/25 at 7:23 a.m., staff member Q administered medication to resident #22, but failed to perform hand hygiene prior to handling medications for the resident and administering them.During an observation on 7/30/25 at 7:43 a.m., staff member Q entered resident #2's room, then left the room and returned to administer the medications. During that time, staff member Q was observed touching the counter at the nurses' station, resident #2's call light, resident #2's water cup, and resident #2's hand before administering the medications, or after. Staff member Q failed to perform hand hygiene before administering medications to resident #2.During an interview on 7/30/25 at 7:50 a.m., staff member Q stated hand hygiene should occur before and after resident contact.During an interview on 7/30/25 at 10:17 a.m., staff member D stated that she reviewed the facility's huddle trainings, which showed no training information specific to infection prevention during medication administration.A review of the facility's policy, Nursing Home Medication Administration, last revised 6/11/2025, showed: .II. Preparing Medications and Administering Medications:A. Wash hands. [sic]A review of the facility's policy, Hand Hygiene, last revised 4/17/2024, showed: .Definitions:.Hand Hygiene:- Cleaning your hands by using either handwashing (washing hands with soap and water), antiseptic hand wash, or antiseptic hand rub (i.e. alcohol-based hand sanitizer including foam or gel).Procedure:I. Key Moments to perform Hand hygiene:.C. Before and after any direct contact with a patient's intact skin.E. After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient.H. Before and after glove use. [sic]

Based on interview and record review, the facility failed to identify a resident's past history of trauma and failed to identify triggers to avoid re-traumatization for 1 (#5) of 21 sampled residents. Findings include: Review of resident #5's electronic health record showed the resident was seen for the treatment of chronic post-traumatic stress disorder, by NF4. Review of the NF4 provider notes for resident #5 showed the following: -1/30/24, . 1. Chronic post-traumatic stress disorder - Recent medication changes have actualized and been effective . - 4/8/24, .2. Chronic post-traumatic stress disorder - Will increase the venlafaxine by double from 75 mg to 150 mg. - 5/6/24, .2. Chronic post-traumatic stress disorder - She was either in a dissociative state today or acutely confused. Regardless she still having quite a bit of depression. Will increase the venlafaxine from 150 mg daily to 225 mg. [sic] - 8/20/24, .2. Chronic post-traumatic stress disorder, F43.12 Post-traumatic stress disorder, chronic. - 12/11/24, .2. Chronic post-traumatic stress disorder, F43.12 Post-traumatic stress disorder, chronic . During an interview on 7/30/25 at 3:43 p.m., when an interview was being conducted on resident #5's history of post-traumatic stress disorder, NF3 stated resident #5 was in a physically and verbally abusive marriage, had experienced the loss of her son in a tragic accident, and was left in the hospital by her parents for a period of time when she was diagnosed with Polio. NF3 stated resident #5 did have times when past feelings were triggered, such as stating her ex-husband was at the facility or that she saw him out the window, and he's trying to get her. NF3 stated resident #5's post-traumatic stress disorder diagnosis had been discussed with staff, but not lately, because the staff had changed. Review of resident #5's comprehensive care plan lacked the identification of the post-traumatic stress disorder. The care plan lacked the identification of identified triggers or interventions for these in an attempt to avoid re-traumatization. Review of resident #5's Quarterly MDS assessment, dated 5/8/25, showed, . Section I - Active Diagnoses .Psychiatric/Mood Disorder .I6100. Post Traumatic Stress Disorder (PTSD) was not checked. A request was made for resident #5's trauma informed care assessment for the diagnosis of PTSD, on 7/30/25 at 1:45 p.m. No information was provided by the end of the survey. During an interview on 7/30/25 at 5:15 p.m., staff member E stated resident #5 had a diagnosis of PTSD when it was brought to her attention. Staff member E stated there wasn't a process to ensure diagnoses were communicated to staff from specialized providers. A request was made for resident #5's social history and social assessment, on 7/30/25 at 5:36 p.m., no information was provided by the end of survey.

Based on interview and record review, the facility failed to recognize, identify, and call a physician for confirmation of a coumadin order not being discontinued or held, for a resident with a critical lab value, for 1 (#26) of 3 sampled residents on coumadin. Findings include:During an interview on 7/30/25 at 10:47 a.m., staff member B said resident #26 was discharged from the emergency department with no medication changes. Resident #26's Coumadin dosage was not stopped, and it was not questioned by the nursing staff. Staff member B said his expectation was for staff to use their nursing judgment and if they had a question, contact the provider for clarification. Staff member B said critical thinking should have been used, especially when the patient had a known elevated PT and INR.During an interview on 7/30/25 at 2:40 p.m., staff member C said he had intended to hold the Coumadin for resident #26. The medication was held in the hospital EMR system but the hold order did not follow through to the long-term care EMR system. The INR level was not above ten, so there was no need to treat the elevated level with a reversal agent. Staff member C said he had intended for the medication to be held, and it was an error on our part. Staff member B said that during the investigation, a communication problem between the hospital and the long-term care facility was identified.During an interview on 7/30/25 at 2:57 p.m., staff member F said she was responsible for the investigation of resident #26's injury. The investigation identified that the injury was caused by the use of the sit-to-stand lift. The large hematoma was from the use of Coumadin. Staff member F said she knew resident #26 was on Coumadin but did not include the medication as a part of the investigation. She had not done an investigation for the Coumadin order not being correct.Review of a facility document, Hospital Progress Note, dated 6/10/25, written by staff member C, showed: . Assessment/Plan1. Atrial fibrillation, chronic[AGE] year old male patient with known, chronic Atrial Fibrillation on chronic anticoagulation with Coumadin 7mg daily, Most recent INR of 1.4 Will increase to oral Coumadin 8mg daily. Recheck INR in 2 weeks. [sic]Review of resident #26's Emergency Department Reports, dated 6/20/25, showed: .Assessment/Plan.3. Atrial fibrillation, chronicPatient with known, chronic Atrial Fibrillation on chronic anticoagulation with Coumadin 8mg daily. Most recent INR of 5.7. Will hold his oral Coumadin for 1 week.Review of a facility document, Long Term Care/Swing Bed Documents, dated 6/20/25, written by staff member P, showed: Resident returned to the nursing home from the hospital at 10:45. Report was received from the ED nurse, who noted no changes in the resident's medications. The ED documented a large hematoma on the right side of the chest, along with rib fractures at the 10th and 12th ribs (confirmed via CT scan). [sic]Record review of resident #26's Discharge Instructions, dated 6/20/25, showed: .Medications. Unchanged, warfarin (warfarin 3 mg oral tablet), 1 tablet by mouth, every day, take with 5mg tab for a total of 8mg qdUnchanged, warfarin (warfarin 5 mg oral tablet), 1 tablet by mouth, every day, Take with 3mg tablet to total 8mg QPM.Record review of resident #26's Medication Administration Record, showed resident #26 received:6/20/25 at 3:35 p.m., Warfarin 8 mg orally6/21/25 at 3:37 p.m., Warfarin 8 mg orallyReview of resident #26's Resident Plan Report, not dated, showed: .Bleeding PrecautionsAt risk for bleeding related to anticoagulant therapy due to atrial fibrillation treatment.8. Nursing to follow Anticoagulant Therapy policy and procedure for [Facility Name].Review of a facility policy, Anticoagulant Therapy review, dated 6/11/25, showed: .Procedure:.II. Lab results are communicated to the primary care provider (PCP), or on call provider when PCP is unavailable, via HER [sic] message center or a direct call from lab or nursing. If the INR is:.D. greater than 3.2 with bleeding or greater than 6.0 without bleeding - the nurse will hold the medication, and the provider will be notified within two (2) hours for additional orders. [sic]

Based on interview and record review, the facility failed to promptly refer a resident with lost partial dentures to dental services for 1 (#11) of 21 sampled residents. The deficient practice caused the resident to go without his partial denture, and the resident had experienced a weight loss. Findings include:During an interview on 7/30/25 at 12:46 p.m., NF1 stated when she came to pick up resident #11 for a home visit on the Christmas holiday, he was not wearing his upper partial dentures. NF1 stated she was informed by staff when she came to pick up resident #11 that his upper partial dentures were missing. NF1 stated the partial dentures were never found, and the facility had not offered to refer the resident to dental services for the missing partial dentures or to replace them. NF1 stated she, and her family, were disappointed that the partial dentures were missing because they planned to take a family photo, and the loss of dentures would compromise how resident #11 looked in the family photo. NF1 stated resident #11 was on a pureed diet, and he didn't like the pureed texture. NF1 stated resident #11 had lost weight. Review of resident #11's EHR showed a progress note, dated 12/25/24, where a facility licensed nurse documented, Resident OOF with wife and son at 1000 (10:00 a.m). He will possibly stay overnight. They will see how it goes. Residents partial are also missing at this time. Room and bathroom searched and message sent to staff of missing item. [sic] Review of a facility document titled Resident Weight Report, dated July 15, 2025, showed resident #11 had experienced a 15% weight loss in six months. Review of resident #11's comprehensive care plan showed: . Cognitive - Communication Resident has cognitive loss r/t Alzheimer's disease, impaired ability to make needs known, . BIMs: 3/2025: unable to perform. BIMs: 6/2025: unable to perform due to severe cognitive loss. A request was made for documentation related to resident #11's missing partial on 7/30/25 at 5:36 p.m. There was no documentation provided before the end of the survey. During an interview on 7/30/25 at 5:51 p.m., staff member B stated the staff did not even know resident #11's partial was missing. Review of the facility's policy titled Dental Services, last revised 12/12/2023, showed: .Procedure: . III. Denture Care: .B. The facility's responsibility will be determined in accordance with the facility policy and CMS regulations. The facility is responsible for the loss or damage of dentures: 1. If [Facility Name] is responsible for breaking or losing the dentures. 2. If the patient/resident is not competent or suffers from dementia, the patient/resident cannot be held responsible, and the facility is responsible.

Based on observation, interview, and record review, the facility failed to ensure as needed psychotropic medications were limited to 14 days unless there was provider documentation explaining the rationale for continuing the medication, for 1 (#8) of 16 sampled residents. Findings include: During an observation on 7/1/24 at 3:58 p.m., resident #8 was lying in her bed with her eyes closed. Resident #8 did not rouse or open her eyes to her name being spoken in a normal voice. Review of resident #8's provider order, dated 2/29/24, showed the resident had an order for lorazepam, twice a day, as needed, for anxiety or shortness of breath. Review of resident #8's MAR, dated from 2/29/24 to 7/3/24, showed the resident received as needed doses of lorazepam on 4/4/24 at 5:43 p.m. and 4/11/24 at 10:30 a.m. No other as needed doses of lorazepam were documented as given. During an interview on 7/3/24 at 11:21 a.m., staff member B stated she was not aware resident #8 had an order for as needed lorazepam which was in place for more than 14 days. Staff member B stated the medication nurse, or the care coordination nurse, was responsible for ensuring as needed psychotropic medications were not provided for more than 14 days unless a rationale was documented by the medical provider. Review of resident #8's Medication Regimen Reviews, dated June 2023 thru May 2024, failed to show the pharmacist identified the as needed use of lorazepam for more than 14 days. The review forms failed to show the pharmacist contacted the provider regarding the issue. Review of the facility policy titled, Psychotropics, dated 8/23/23, showed orders of as needed psychotropic medications were limited to 14 days and only for specific clearly documented circumstances.

Based on interview and record review, the facility failed to ensure the pharmacist was monitoring a resident receiving an as needed psychotropic medication for an excessive duration for 1 (#8) of 16 sampled residents. Findings include: Review of resident #8's MAR, dated from 2/29/24 to 7/3/24, showed the resident received as needed doses of lorazepam on 4/4/24 at 5:43 p.m. and 4/11/24 at 10:30 a.m. During an interview on 7/3/24 at 11:21 a.m., staff member B stated she was not aware resident #8 had an order for as needed lorazepam which was in place for more than 14 days. Staff member B did not know why the pharmacist did not address the situation with the medical provider. Review of resident #8's Medication Regimen Reviews, dated March of 2024 thru May 2024, failed to show the pharmacist identified the as needed use of lorazepam for more than 14 days. The review forms failed to show the pharmacist contacted the provider regarding the issue. Review of the facility policy titled, Psychotropics, dated 8/23/23, showed the pharmacist was responsible for monitoring the use of psychotropic medications and was supposed to notify the physician when the medications are due for review.

Based on interview and record review, the facility failed to report an allegation of verbal abuse within 24 hours of the incident, for 1 (#19) of 16 sampled residents for abuse reporting. Findings include: Review of a Facility Reported Incident submitted to the State Survey Agency, dated 10/10/23, showed there was an allegation of verbal abuse by a staff member, towards resident #19. The report showed the incident occurred before 8:00 a.m. on 10/5/23 and was reported to staff member F at 11:30 a.m. on 10/5/23. The initial report of the incident was not submitted until 10/10/23, which was five days after the required reporting timeline. During an interview on 7/3/24 at 9:15 a.m., staff member B stated she was responsible for submitting abuse allegations to the state reporting portal. Staff member B was not able to explain why the initial report to the incident portal was not submitted within 24 hours of the incident. Staff member B stated she was aware of the required reporting timelines. Review of the facility's policy titled, Abuse, dated 8/27/23, showed, B. The Nursing Home will immediately contact Bounds (the State Survey Agency's reporting portal) via a secure web page. The policy failed to show the reporting timelines for incidents being reported to the State Survey Agency's reporting portal.

Based on observation, interview, and record review, the facility failed to identify bilateral grab bars as a potential restraint, and did not complete a risk assessment, obtain a consent, or have restraint monitoring, for 1 (#10) of 16 sampled residents with bilateral grab bars in place. Findings include: During an observation on 7/1/24 at 1:53 p.m., bilateral grab bars were observed on resident #10's bed. During an interview on 7/1/24 at 4:16 p.m., NF3 said he probably gave consent for the bilateral grab bars, because resident #10 fell out of bed and got bruised up. NF3 said resident #10 had head scans due to falls and hitting her head. During an observation on 7/2/24 at 10:05 a.m., bilateral grab bars were observed on resident #10's bed. Review of resident #10's electronic medical record failed to show documentation a risk assessment was completed, a physician's order obtained, or a signed consent authorizing the use of bilateral grab bars on resident #10's bed. Review of resident #10's MDS with an assessment reference date of 4/11/24, showed resident #10 is dependent for turning and repositioning. During an interview on 7/2/24 at 12:50 p.m., staff member B said resident #10 would not be able to use her bilateral grab bars as an assistive device. Staff member B said the grab bars for resident #10 would be a place to hang the call light and bed controls. Review of the facility document titled, Restraint Policy, dated August 23 of 2023, included the statement . restraints would not be used for convenience .

Based on interview and record review, the facility staff failed to include 1 (#14) of 16 sampled residents, in care plan meetings. Findings include: During an interview on 7/2/24 at 8:05 a.m., resident #14 said she was not invited to any care plan meetings. Resident #14 stated her family goes, but she was not invited. Resident #14 said she would like to go to the meeting. Review of resident #14's electronic medical record failed to show any documentation of the resident being invited to attend her care plan meetings. Review of resident #14's MDS showed resident #14 was assessed for her cognitive condition using a Brief Interview for Mental Status. The result was a score of 13; cognitively intact. During an interview on 7/2/24 at 9:00 a.m., staff member C said she calls, emails, or talks to resident family members to invite them to care plan meetings. Staff member C said she does not document the invitations to the care plan meetings. Staff member C stated she will invite resident #14 to her care plan meetings going forward.

Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent elopements resulting in a fall with injury for 1 (#1) out of 1 sampled resident. Findings include: Review of a facility incident for resident #1 dated, 5/29/24 showed, .Resident (#1) eloped from the facility. Resident fell out of w/c in the street outside the building and received injuries to his head. Facility was not aware resident had eloped from the building . Incident Description: Resident was attempting to get onto elevator prior to elopement .Staff that were downstairs outside came up the stairs and informed us that one of our residents were downstairs. Staff down immediately to assist. Resident had fallen out of his wheelchair into the street .Noted bleeding and hematoma to his R upper eyebrow. Superficial rash to hairline .On call provider to unit to assess resident .Findings .The resident went down the elevator to door B4 and exited out as another person entered the building. The resident fell out of their chair in the road next to the curb. A right-side facial injury was noted, laceration above the eye, abrasion on the hairline and bruising .Resident had been outside earlier with staff due to restlessness and wanted to go to the garage .Can be a 1:1 situation at times .Restlessness interventions: Quotes on wander guard system, Risk and Maintenance will gather information. Rounding on the residents and offering the patio, also offer recliner more if they are restless. A new wander guard was placed in the wheelchair .[sic] Review of the document Office/Clinical Notes after resident #1's fall dated, 5/29/24 showed, .History of Present Illness .patient with a fall outside from his wheelchair. He did partially catch himself but landed downward with one side of his face (right side) making contact with the ground. Patent reports he did not lose consciousness. He feels shaken up but fine .sustained a right-sided upper facial contusion .Skin abrasion was noted but no need for sutures or staples . During an observation and interview on 6/11/24 at 10:45 a.m., resident #1 was in his wheelchair ambulating independently on the unit. Resident #1 stated he was from Medicine Lake and his wife visited him frequently. He stated he liked to go outside. Resident #1 had a healed abrasion above his right eye. During an interview on 6/11/24 at 11:02 a.m., Staff member D stated resident #1 has eloped multiple times from the facility prior to the elopement on 5/29/24 but would elope to the hospital, which was connected by a set of doors. Staff member D stated he was very restless and had periods of confusion. Staff member D stated resident #1 had owned a bar and often wanted to leave and have a beer. Staff member D stated resident #1 was very observant and learned how to turn off the chirper on the door leading to the hospital. Staff member D stated his wheelchair has a roam alert band attached to it, and sometimes the roam alert system did not work correctly. The facility was looking into getting a new system. Staff member D stated the staff try to engage resident #1 in activities, but he usually was not interested. He liked to watch TV and would sit in a recliner for a bit. During an interview on 6/11/24 at 11:25 a.m., staff member B stated, each internal hallway door, including the doors to the hospital have a chirper on the door. Staff member B stated the chirper made a loud noise when the door was opened. This chirper could be turned off with a key. Staff member B stated the key to the chirper was always left in the key slot so anyone could turn it off. Staff member B stated the external door, which was also the main door to the building had a Roam Alert System staff member B stated it was a delayed egress system that would initiate if a resident had a wander guard bracelet on. The door would lock for 15 seconds, then open. This allowed staff members to stop residents with the wander guard on or before they exit the facility. Staff member B stated resident #1 was admitted to the facility almost a year ago with a broken neck. Since then, he had been rehabilitated and was mobile. Staff member B stated he has periods of confusion and becomes restless. Staff member B stated resident #1 had a friend in the hospital a few months ago and he would be taken over to visit. Staff member B stated she believed that is what started the elopements. Resident #1 learned how to turn off the chirper on the door by turning the key to the off position. Then on 5/29/24 he eloped down the elevator and out the main door to the parking lot and fell . Staff member B stated it was hard to create interventions because he was unpredictable, fast, and intermittently confused. Staff member B stated the facility did not know how to evaluate his confusion because it would come and go. Staff member B stated he was able to get to the main door before the wander guard system had time to initiate and lock. Staff member B stated the facility did not foresee resident #1 eloping out of the building until he did so on 5/29/24. Review of resident #1's Admission Elopement Risk assessment dated , 8/17/23 showed, he was at risk of elopement. Review of resident #1's Roam Alert Sensor assessment dated , 2/22/24 showed, the roam alert sensor was placed on 8/22/23. During an interview on 6/11/24 at 12:10 p.m., staff member C stated, I watched back the video and he (resident #1) got in the elevator with a visitor and went down the elevator and caught the main door right before it was going to latch and exited the building. Staff member C stated 5/29/24 was a Wednesday and the VA is open that day so there was a lot of visitors in and out of the building. Staff member C stated she thought resident #1 exited the building when staff members were pre-occupied. Staff member C stated the Roam Alert System did alarm, but staff get used to hearing the alarm and do not react. During an interview on 6/11/24 at 12:50 p.m., staff member B stated, right before the elopement on 5/29/24 resident #1 tried to get out of the facility multiple times. Staff member B stated she took him outside before the elopement because he was restless. Staff member B stated after taking him outside, she caught him three times trying to go down the elevator. Staff member B stated it would have been beneficial to have more supervision for resident #1 knowing he was restless and was actively attempting to elope. A Review of Nursing Progress for resident #1 dated, 5/31/24 showed, Elopement on 5/29/24 14:15 the resident went down the elevator to door B4 and exited out as another person entered the building .Residents had been outside earlier with staff due to restlessness and wanted to go to the garage .During the (staff job titles) were doing checks of the wander guard since the resident was attempting to get out. Can be a 1:1 situation at times. .1245 - Resident has been restless, roaming the halls, attempting to get on the elevator .We went downstairs to look for his garage, we went outside. Resident saw his garage was not there. He seemed content .1330 staff tried to redirect him to another activity without success .resident continues to be restless and up and down the halls. Staff on unit are aware he is very active and mobile and to keep an eye on his as much as possible Resident attempting to make his way on the elevator x3 even after staff try and redirect. Two of the incidents he was witnessed by the staff, but the roam alert system did not engage .New roam alert monitor received from purchasing. Checked and put on wheelchair .1415 Staff that were downstairs outside came up the stairs and informed us that one of our residents were downstairs . [sic] Review of a facility reported incident for resident #1 dated, 6/6/24 showed, Hospital called to notify nursing home that resident was in the Atrium by the stairwell-hospital. Resident brought back to nursing home by hospital staff. Resident stated he got out the north doors and that the alarm did not go off .Resident is a poor historian and wasnt able to state what he was doing/wanting. He has fluctuating confusion and isn't always able to express needs/wants. No injuries were sustained. No medical treatment was needed. Immediate interventions included: calling (staff job title) to check on roam alert system . Review of the after action meeting documentation dated, 6/10/24 for resident #1's elopement on 6/6/24 showed, .Risk is currently looking at 2 companies we currently use in the facility for updated wander guard system for the nursing home .Resident had exited out the same door on 5/29/24 and a letter was sent to the spouse explaining out capabilities and concerns with their ability to find a way to exit the building. They have not brought their concerns back, that was sent on 6/3/24 . (staff names) express concern with the 1:1 needed and what additional intervention. Intervention: When the resident gets agitated and wants to leave set up the TV or iPad with old sports games. Set up a mini bar so they can serve drinks. It is important to contact (name of staff) that there may be a need for just a 1:1 staff with resident at this time . During an interview on 6/11/24 at 2:50 p.m. staff member B stated the facility did not have a protocol for what 1:1 supervision was. Staff member B stated it is the discretion of the nurse on shift. Staff member B stated the facility should have a protocol for what 1:1 supervision was. Review of resident #1's current care plan showed, .Elopement on 5/29/24 14:15 the resident went down the elevator and exited out as another person entered the building .Can be a 1:1 situation at times .Interventions: Quotes on wander guard system, .risk management will gather information, rounding on residents and offering the patio, also off recliner more even if they are restless, a new wander guard was placed in the wheelchair Elopement 6/6/24 resident eloped down the elevator and though door B4 .Staff educating resident to ask for help if he wants to go outside. Resident verbalizes understanding but he does not always remember that you told him. Will continue to educate throughout the day. Resident often is looking for a beer or trying to get out to go to the bar .Orders placed: resident may have 2 non-alcoholic beers a day after lunch. [sic] Review of the facility's policy and procedure titled, Elopement with a revision date of, 6/28/23 showed, .Definitions: Elopement - occurs when a patient/resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. Elopement can be purposeful or accidental .Policy: It is the policy of (Name of Hospital Association) to provide a safe environment for our wandering patient/residents and to reduce the risk of elopement.

Based on observation, interview, and record review, the facility staff failed to prevent a pressure ulcer for 1 (#19) of 2 sampled residents. This deficient practice resulted in harm for the resident due to surgical intervention, ongoing dressing changes, and a MRSA infection in the wound. Findings include: During an observation on 6/6/23 at 7:45 a.m., resident #19 was sitting in a Broda chair and appeared to be sleeping. During an observation on 6/6/23 at 9:35 a.m., resident #19 was sitting in a Broda chair by the nurse's station. Resident #19 was in the same position that he was in 2 hours earlier in the morning. During an interview on 6/6/23 at 2:17 p.m., NF2 stated resident #19 developed a wound on his coccyx after he was admitted to the facility. Resident #19 was admitted to the facility on [DATE]. NF2 stated resident #19 had to have the wound surgically debrided, and a wound machine to help heal the sore. NF2 stated resident #19's wound is much better now. During an observation and interview on 6/7/23 at 10:00 a.m., staff member C was going to do wound care for resident #19. The surrounding tissue of #19's wound was pink, and the wound bed showed red granulation tissue. Resident #19's coccyx wound started at the base of the coccyx and went into the gluteal crease. During an interview on 6/7/23 at 10:15 a.m., staff member C stated resident #19 currently had MRSA in his coccyx wound. Staff member C stated at one-time resident #19 required surgical debridement and a VAC dressing. Staff member C stated resident #19 did not have the VAC dressing at this time, and the dressing changes were ordered to be changed daily. During an interview on 6/7/23 at 10:20 a.m., staff member F stated resident #19 was to be checked and repositioned hourly. A review of resident #19's Integumentary Assessment, dated 8/23/22 showed: - .Skin integrity-intact. A review of resident #19's Integumentary Assessment, dated 9/5/22, 9/18/22, 9/27/22, and 10/2/22 showed: - .Skin integrity impaired. No location of the wound was noted on the assessment. A review of resident #19's Pressure ulcers assessment, dated 12/25/22 through 6/5/23 showed: - . Pressure ulcer staging-IV - .pressure ulcer dressing-Wound VAC. 12/25/22 - .wound wash, calcium alginate. 1/28/23 - .clean with wound wash apply medi-honey and packing. Change daily. 4/11/23 - .wound wash, foam, and packing strip 4/22/23. Surgical wound notes, nurse's notes on coccyx wound, wound VAC orders, and all dressing change orders were requested. The requested documentation was not received by the end of the survey. On 6/7/23 at 3:15 p.m., staff member G stated they had none of the requested information on the coccyx wound for resident #19 and could not get it. A review of a facility document titled, Skin Ulcer/Wound, dated 4/12/23, showed: -It is the policy of [Facility Name] to prevent the formation of skin ulcers and wounds .

Based on observation, interview, and record review, the facility staff failed to ensure storage of schedule II-V medications were in separately locked, permanently affixed compartments; ensure that all drugs and biologicals used in the facility were labeled in accordance with professional standards, including expiration dates; and failed to remove expired items for disposal for one medication room and one medication cart. Findings include: During an observation on 6/6/23 at 4:18 p.m., staff member C was present during the medication room and medication cart review, and the following items were found: - pneumococcal 13 valent was in the refrigerator with an expiration date of [DATE], - acetaminophen suppositories 650 mg were in the refrigerator with an expiration date of 6/1/23, - Lidocaine liquid was in the refrigerator with an expiration date of 3/23, - [NAME] occult liquid was in the cabinet with an expiration date of 4/22, - Aspercreme was in the cabinet with an expiration date of 2/23, - brimonidine tartrate solution was in the cart with an expiration date of 12/22, and - A half full box of TB syringes were in the medication room with an expiration date of 2/23. Morphine sulfate 100mg/5mL was in the medication room refrigerator with no lock on the refrigerator, and the medication room door was open. The lock system was lying on the counter next to the refrigerator, and staff member C stated, It was broken a while back and maintenance was aware. During an interview on 6/6/23 at 4:40 p.m., staff member C stated she knew the medication room and medication cart needed to be cleaned out, but had not had a chance to do so since returning to her position at the facility. A review of the facility's policy, Disposal of wasted, unused and expired medications, with an effective date of 1/11/2023, showed: - .A. 2. Load medications into the Rx Destroyer bottle, funnel use is optimal, a. Load pills, capsules, liquids, suppositories, powders, creams .

Based in interview and record review, facility staff failed to complete and report findings in a timely manner for investigations for 5 (#s 6, 13, 14, 17, and 28) of 5 sampled residents. Findings include: Centers for Medicare and Medicaid services had directed long term facilities to report the findings of their investigations within five days of the date of incident occurring. 1. Review of a facility reported incident showed an allegation of staff to resident abuse for resident #6. This allegation occurred on 8/21/22, and was reported to the State Survey Agency on 8/21/22. The facility's investigation and findings were not reported to the State Survey Agency until 10/8/22. There was 48 days between the submission of the allegation, and the submission of the final investigation. During an interview on 6/7/23 at 2:23 p.m., staff member B was not aware of the delay in reporting the findings of this incident. Staff member B said the findings for all investigations should be reported to the State Survey Agency within five days from the date the incident occurred, which would have been 8/25/22. 47752 2. A review of a facility reported incident showed an allegation of resident-to-resident abuse involving resident #17. This allegation was reported to the State Survey Agency on 2/3/23. The investigation and findings were completed by the facility and were not reported to the State Survey Agency until 2/15/23. There were 12 days between the report of the allegation and submission of the final investigation findings. 3. A review of a facility reported incident showed an allegation of resident-to-resident abuse involving resident #14 and resident #13 on 4/17/23. This allegation was reported to the State Survey Agency on 4/17/23. The investigation and findings were completed by the facility and were not reported to the State Survey Agency until 5/9/23. There were 22 days between the report of the allegation and submission of the final investigation findings. 4. A review of a facility reported incident showed an allegation of resident-to-resident abuse involving resident #17 and resident #28 on 4/22/23. This allegation was reported to the State Survey Agency on 4/22/23. The investigation and findings were completed by the facility and were not reported to the State Survey Agency until 5/11/23. There were 20 days between the report of the allegation and the submission of the final investigation findings. Review of a facility policy titled, Abuse, revised on 5/26/23, showed: . G. All investigations will be completed by the facility within 5 bluishness [business] days . [sic]

Based on interview and record review, the facility staff failed to provide psychotropic consent forms explaining the risks and benefits to residents or family members for 6 (#s 17, 19, 20, 22, 28, and 30) of 8 sampled residents. Findings include: 1. During an observation on 6/6/23 at 8:33 a.m., resident # 17 was lying in bed with her eyes closed. During an interview on 6/6/23 at 12:20 p.m., staff member C stated resident #17 went in cycles where she was more active and alert. Staff member C stated resident #17 was more active in the afternoons and evenings. On 6/6/23 at 2:33 p.m., a call was placed to NF4 regarding the risks and benefits consent form for psychotropic medications. NF4 had not called back by the end of the survey. During an interview on 6/7/23 at 7:58 a.m., staff member B stated psychotropic consents were completed on admission or with any changes. A record review of resident #17's medication administration record, dated June 2023, showed the following psychotropic medications: - Lorazepam (Ativan) 0.25 mg PO qHS, mood swings. - clonazepam (Klonopin) 0.5 mg PO qDay, tremors/jerking. - Quetiapine (Seroquel) 25 mg PO BID. - divalproex sodium (Depakote sprinkles) 250 mg PO qDay, mood swings, aggressive behavior. - divalproex sodium (Depakote sprinkles) 125 mg PO qHS, mood swings, aggressive behavior. - mirtazapine (Remeron) 15 mg PO qHS. [sic] Psychotropic consent forms were requested for resident #17 and were not received by the end of the survey. 2. During an observation on 6/6/23 at 7:45 a.m. and 9:35 a.m., resident #19 was sitting, slightly reclined in a Broda (reclining/rolling) chair with his eyes closed and appeared to be asleep. During an interview on 6/6/23 at 2:17 p.m., NF2 stated she did not recall anyone from the facility talking to her about resident #19's mood medications or explaining the risks or benefits of the medications to her. NF2 stated she had never signed any paperwork about resident #19's medications. A record review of resident #19's medication administration record, dated June 2023, showed: - divalproex sodium (Depakote sprinkles)125 mg PO qDay, Anxiety| Irritability| Dementia. - Lorazepam (Ativan) 0.25 mg PO BID. [sic] 3. On 6/6/23 at 1:31 p.m., a call was placed to NF5 regarding the risks and benefits psychotropic consent form. NF5 did not call back prior to the end of the survey. A record review of resident #28's medication administration record, dated June 2023, showed the following psychotropic medications: - Lorazepam (Ativan) 1 mg PO qHS, Anxiety. [sic] No psychotropic consent form was provided for resident #28 by the end of the survey. 4. During an observation on 6/6/23 at 8:22 a.m., resident # 30 was sitting in a recliner in her room loudly yelling out. During an observation on 6/6/23 at 8: 30 a.m., an activities aid entered the room and read the paper and talked with resident #30. During an observation on 6/6/23 at 9:09 a.m., resident # 30 was sitting in her room yelling out. During an interview on 6/6/23 at 9:46 a.m., staff member C stated resident #30 constantly yelled and screamed out. Staff member C stated, [Resident #30] does this all day and all night. The yelling and screaming bother the other residents, she is very disruptive all the time. Staff and residents are all very frustrated. Staff member C also stated, Staff try to go in and do one on one care with her, but we don't have the staff for them to sit in there all day, every day. [Resident #30] is completely different when her family is here. During an interview on 6/6/23 at 12:16 p.m., NF3 stated the resident had a steady decline since March of this year, and the doctors were not sure what was causing the rapid decline. NF3 stated resident #30 was admitted on [DATE] and since that time the facility's doctors have been changing her medications. NF3 stated she did not recall the facility staff reviewing the risks or benefits with her or having her sign a consent form. A review of resident #30's medication administration record, dated June 2023, showed the following psychotropic medications: - Lorazepam (Ativan) 0.5 mg PO BID. - escitalopram (Lexapro) 10 mg PO qDay. [sic] 48261 5. Review of resident #20's medication orders, dated 6/7/23, reflected resident #20 was taking three psychotropic medications: - Depakote 250 mg in the morning and at 2 p.m., and 125 mg at bedtime, - Aricept 5 mg tab at bedtime, and - duloxetine 30 mg daily. Documentation of resident #20 or family notification and consent to use psychotropic medications, including risks vs benefits was requested on 6/6/23 and not received by the end of the survey. 6. Review of resident #22's medication orders, dated 6/6/23, reflected resident #22 was taking two psychotropic medications: - mirtazapine 7.5 mg at bedtime, and - venlafaxine 75 mg daily. Documentation of resident #22 or family notification and consent to use psychotropic medications, including risks vs benefits was requested on 6/6/23 and not received by the end of the survey. During an interview on 6/7/23 at 3:36 p.m., staff member G stated the facility, Only gets verbal consent and does not have documented consent of this (consent for use of psychotropic medications) and would have to dig a long time to find a note to show the verbal consent was given. Staff member G stated the facility, Knew this was an issue and we're working on it. A request was made for the psychotropic consent policy on 6/6/23. As of the end of the survey, the psychotropic consent policy was not received.

Based on interview and record review, facility staff failed to protect all residents in the facility during an investigation of allegations of abuse for 6 (#s 1, 6, 12, 17, 20 and 28) of 6 sampled residents. Findings include: 1. Review of a facility reported incident, dated 8/21/22, showed resident #6 had made allegations of physical abuse against staff member J. The facility reported incident did not show staff member J had been removed from resident care contact during the investigation. During an interview on 6/7/23 at 2:26 p.m., staff member B said staff member J was not suspended during the investigation into allegations of abuse made by resident #6. Staff member B said staff member J could not provide care to resident #6. Staff member J continued to provide direct resident care to all the other residents in the facility. The facility failed to protect all residents from potential abuse during a staff to resident investigation of physical abuse by a staff member. Staff member B did not provide any additional information on monitoring staff member J as he continued to provide cares for the rest of the residents in the facility. Review of a facility policy titled, Abuse, revised on 5/26/23, showed: .VI. Protection: residents/patients will be protected during the investigation process by staff awareness during shift-to-shift reporting, care planning, and daily documentation. VII. B. suspension or termination of the employee will occur with or without pay, pending investigation. 47752 2. A review of a facility reported incident, dated 4/25/22, showed resident #s 12 and 17 had an allegation of resident-to-resident abuse. Resident #17 hit resident #12. Both residents were separated and monitored for side effects. The physician and responsible parties were notified. A review of a facility reported incident, dated 7/9/22, showed resident #17 and resident #20 were involved in an alleged incident of resident-to-resident abuse. Resident #17 had hit resident #20. Both residents were separated and monitored for side effects. The physician and families were notified. A review of a facility reported incident, dated 3/18/23, showed resident #17 and resident #28 were involved in an alleged incident of resident-to-resident abuse. Resident #17 had hit resident #28 and knocked her glasses off her face. Resident #28 was assessed by a nurse and was found to have no injuries noted. There was no mention of any nursing assessment of resident #17. The physician and families were notified. A review of a facility reported incident, dated 4/4/23, showed resident #17 slapped resident #28 in her room and took a stuffed bear. Resident #17 was escorted out of resident #28's room and the stuffed bear returned. No injuries were noted to resident #28. The physician and families were notified. A review of a facility reported incident, dated 4/17/23, showed resident #17 had struck resident #1 on the feet. Resident #1 was assessed for injuries. Staff attempted to redirect resident #17 without success. The physician and families were notified. A review of a facility reported incident, dated 4/22/23, showed resident #17 had wandered into resident #28's room. Resident #28 asked resident #17 to leave. Resident #17 became agitated and hit resident #28. Resident #28 hit resident #17 back. Resident #17 was escorted out of resident #28's room. Both residents were assessed for injuries. The physician and families were notified. Resident #17 was the aggressor in six of six facility reported incidents. During an interview on 6/7/23 at 7:58 a.m., staff member B stated she did not interview other residents or staff about the incidents. Staff member B stated she got the statements from the staff on duty at the time of the incidents. Staff member B stated every incident is discussed in the abuse committee meeting and addressed with staff at the daily huddle. Staff member B stated incidents and new interventions were discussed at that time with staff. Staff member B stated they had tried multiple different interventions with resident #17. During an interview with on 6/7/23 at 12:59 p.m., staff member D stated, We try to keep a close eye on [Resident #17] to avoid any more altercations. Staff member D stated resident #17 was no longer as active as she once was. A review of a facility document titled, Abuse, with a revision date of 5/26/23 showed: - .Each resident/patient has the right to be free from abuse, and corporal punishment, and it is the facility's responsibility to prevent abuse . - Residents/patients must not be subjected to abuse by anyone, including but not limited to facility staff, other residents . The abuse policy does not address the interventions or steps used to prevent resident-to-resident abuse.

IMMEDIATE JEOPARDY On 4/13/22 at 10:58 a.m., the facility CEO, CNO, DON, and RCC were notified that an Immediate Jeopardy existed in the area of F689; Accidents, Hazards, Supervision, and Devices. The Severity and Scope identified for the Immediate Jeopardy was identified to be at the level of K, and upon removal of immediacy lowered to an H. Based on observation, interview, and record review, the facility failed to sufficiently address safety concerns related to falls, elopements, and [CONDITION(S)], to include: - Prevent skin injuries due to [CONDITION(S)] from hot coffee, to include a 2nd degree burn, and with no interventions implemented to prevent further [CONDITION(S)], for 1 (#21); - Failed to prevent repeated elopements and correct safety failures with the alarming door system for wandering residents, for 1 (#33), and when #33 eloped in cold weather the elopement resulted in the resident's feet hurting, she had a blister on the bottom of her feet, and the ends of her toes were red and inflamed; - The facility failed to prevent repetitive falls for residents with high fall risk scores for 2 (#s 11 and 31) and #11 had a skin tear, bruising, and blood blister from the falls; - Failed to address and implement beneficial interventions to address root causes to prevent repeated falls for a resident who had a change in status and one of the falls resulted in #4 sustaining a [CONDITION(S)] and she needed to be sent to the ER for treatment, for 1 (#4); - And, the facility to prevent 9 falls for 1 (#33) who had bruising, a head hematoma, pain, laceration to eye, and injury to her buttocks from falls, of 4 sampled residents. Findings include: Resident [CONDITION(S)]: 1. Review of a nursing progress note, dated 2/23/22, showed staff got resident #21 up for the evening meal, and it was noted the resident had spilled coffee on herself. The resident was examined by nursing, and there was a noted red area on the resident's right chest, and another reddened area on the resident's right thigh. During an interview on 3/30/22 at 2:10 p.m., staff members A and B stated the coffee burn incident, noted in the nursing note on 2/23/22, regarding resident #21, happened during snack pass time between 3:00 p.m. and 3:30 p.m. on 2/23/22. The coffee cart started at 3:00 p.m. Staff member A stated the snack cart probably got to resident #21 at 3:30 p.m. Staff member A stated the staff started getting residents ready for supper around 3:45 p.m. to 4:00 p.m. Staff member A stated the investigation showed resident #21 possibly had the hot coffee on her clothing and skin for approximately 10-15 minutes. Staff members A and B stated they quickly talked to activities about giving resident #21 something cooler to drink, such as cooler coffee. Staff member A stated the kitchen was asked if they could do a cold brew. Kitchen staff stated they could bring the coffee out after it was cooler instead. Staff member B stated she had not talked to the kitchen manager who had not known what the kitchen should do, and did not document a conversation with the cook. There was nothing on resident #21's diet card about providing the resident with cool coffee. Staff member A stated staff was not leaving the coffee unless they could sit with the resident. Staff member A stated all staff were alerted to the interventions for resident #21. Staff member B stated she thought the dietary staff tested the coffee temperatures monthly/weekly. Staff member A stated there was not a safety assessment completed to assess resident #21's ability to sense if coffee was too hot to drink or to assess the resident's ability to hold the coffee. Review of nursing progress notes for resident #21 related to the spilled hot coffee incident on 2/23/22 showed the following: - On 2/23/22 the resident had spilled coffee on herself during the afternoon snack pass. There was a red area measuring 6 cm in circumference on right chest just above the breast and another reddened area was noted on the right thigh measuring 5 cm in circumference. There were no complaints of pain from the resident. In a conversation on the phone earlier with her daughter, the resident stated she was burning up. At that time staff didn't put two and two together, information on it was passed on to the next shift. Review of a Physician Progress note showed the provider had not reviewed the wound to the resident's chest until 3/14/22. - On 2/24/22 the resident had an area on her right thigh and in the center of her breasts where she spilled coffee yesterday. They are both light red with a raised area underneath, no blistering noted. Thigh raised area measures about 12 cm x 10 cm and the chest burn measures 8 cm x 10 cm. - On 2/28/22 the residents skin was assessed. The skin to right upper thigh is intact first degree burn. Skin is red and splotchy. Measures approximately 4 cm x 6 cm. Area cleansed and left open to air. No sign of infection, no drainage, tenderness or pain noted. The skin on the resident's chest was a second degree burn. No drainage noted. No signs of infection. No tenderness or pain at this time. Open area measures 1.5 cm x 1 cm, while red splotchy intact skin surrounding measures 3 cm x 3 cm. Area cleansed and covered with small piece of [MEDICATION(S)] and large Band-Aid. - On 3/1/22, no change in condition except the wound on the chest is not as deep as it was on previous assessment. - On 3/4/22 no change in measurements. The wound was continuing to heal. - On 3/7/22 no change in measurements. The wound was continuing to heal. - On 3/10/22 three burn wounds were located to right upper thigh. All three wounds were dry and healing. Dressing applied to site. One burn wound located to middle chest-second degree burn. Wound site is dry and healing. No signs or symptoms of infection. No drainage noted. Continues to heal. Dressing applied to site. - On 3/14/22 middle chest 1 cm x 0.3 cm second degree burn. Area is now scabbed over and is without redness or drainage. Area is left open to air. Right upper thigh burn not examined today as resident did not want to pull down her pants at this time. - On 3/16/22 burn to middle chest is open to air and is scabbed over. No drainage or redness noted. Three dried scabbed areas on her right upper thigh from a burn. No redness or drainage noted. Open to air. - On 3/17/22 three burn wounds are located to right upper thigh. All three wounds are dry and healing. Left open to air. One burn wound located to middle chest-second degree burn. Wound site is dry and healing. Left open to air. - On 3/21/22 mid chest second degree burn measures 1 cm x 0.3 cm dry light brown scab without redness or complaint of discomfort. Area is left open to air. Right upper thigh burn. Top scab measures 0.2 cm x .04 cm and is dry without redness. Right outer area is pink without scab and measures 0.5 cm x 0.3 cm. Right lower measures 2 cm x 0.7 cm and pink without scab. Areas left open to air. - On 3/28/22 area to mid chest healed. Area to right thigh area red, dry, no open areas. - On 3/29/22 area to mid chest area healed. Area to right thigh red, dry, no open areas. No change in size. During an observation and interview on 3/30/22 at 11:21 a.m., the resident was seated at the dining room table. She was sipping on a glass of water with a straw. Resident #21 did not have any coffee. The resident was not asked by staff if she wanted any coffee. Staff member K stated the resident was no longer served coffee. Review of resident #21's care plan, not dated, did not show problems, goals or interventions for skin care related to the coffee spill. During a QAPI interview on 3/30/22 at 3:45 p.m., staff member C stated she heard about the burn incident with resident #21, was not aware of the extent of it, and it should have been investigated by the IDT. She felt she should have been notified of the severity of the burn as quality director. Resident Falls: 2. Review of resident #4's Admission MDS showed the resident did not have falls prior to admission, which was in mid December 2021. Shortly after admission, per the resident's current care plan she began to fall, and from admission to 2/28/22, she had at least six falls. These falls were on: 12/28/21, 1/2/22, 1/17/22, 1/19/22, 2/4/22, and 2/28/22. The resident's care plan, dated 3/4/22, showed she had a diagnosis of dementia, and a BIMS score of 3, with 15 being the highest level of cognition, showing she had severe cognitive impairment. The care plan showed the resident had disturbed sleep patterns, was restless, had agitation, anxiety, a decline in ADLs, had a communication, vision, and hearing deficit, pain which may not be verbalized, used an assistive device while ambulating, needed assistance with her ADLs, and had begun to decline in her overall health status. a. On 12/27/21, a review of the Fall IDT meeting notes showed the resident fell while leaning forward as she was walking with her walker. She was assisted to the floor. Staff were to inform her of how long she had been walking, to offer to help her to bed, encourage rest, and offer pain medication. The note showed she was having possible anxiety when she was restless. The note did not show how the facility addressed the resident falling while she was walking, as far as her mobility, strength, positioning, or safety with the walker. b. Review of resident #4's Fall Incident report, dated 1/2/22, showed the resident was walking into another resident's room and fell while turning around. Resident #4 was found in a sitting position and sustained a laceration to the back of her head. The resident was sent to the emergency room . Neurological checks were initiated following the visit to the emergency room . The resident returned with staples on her head. The fall incident report asked if the resident was confused, agitated or impulsive pre-fall and the nurse documented, Yes, resident had dementia. Review of the facility's Falls/Incidents Meeting, dated 1/4/22, showed resident #4 had a witnessed fall in the afternoon of 1/2/22 in another resident's doorway. The resident was attempting to turn around and lost her balance and hit her head on the doorway. Resident #4 was sent to the emergency room and returned with 3 staples in her head. New interventions for fall prevention included, Change made to pain medications. The interventions did not address the resident losing her balance while turning. Following the fall, the nurses documented the resident's cognition has changed, she is hard to redirect, approach, agitated . She does appear to be walking slightly to the side as well . She remains confused and agitated with staff when trying to talk with her or redirect her to rest. It was found the resident had a urinary tract infection, and treatment was started. A review of the Neuro Check sheet for resident #4's fall on 1/2/22 was incomplete. A review of resident #4's nursing notes for 1/10/22 showed she would only stay in bed for 2 to 3 minutes, and then get back up. She had agitation, continued on the antibiotic for her [CONDITION(S)]. She had [MEDICATION(S)] (for pain) 25 mg QHS for a 1 week trial which was completed, so it showed the order was increased to 50 mg PO QHS x2 weeks. c. A review of resident #4's Fall incident report showed on 1/19/22 the resident fell , while walking fast, with her walker, and she refused help. The resident was unable to explain what occurred. The form showed the fall committee reviewed the fall details, and the Resident is hard to redirect when she has thoughts in her mind. She often won't listen to staff and will almost run away from them. The interventions implemented did not address behavioral interventions for staff related to her falls, but rather showed the family could visit when she would not rest or was agitated, and staff would try to redirect her to her bed/chair or wheelchair when exhausted. A review of resident #4's nursing notes for 2/2/22 showed her only activity that week was to get up to use the bathroom. She was, just in bed sleeping a lot which was a change in comparison to a few weeks ago. d. Review of resident #4's Fall Incident report, dated 2/4/22, showed the resident fell in the bathroom at 22:53 (10:53 p.m.) and sustained a small skin tear to her left elbow. The note showed it had been six days since the resident had a bowel movement. When the resident was being assisted up from the commode, the resident started to stand and became unresponsive. Neurological checks were initiated because the resident reported she hit her head. After, the resident became nauseated and began dry heaving into the basin. The note showed the family and physician would not be notified at that time, unless there were changes warranting a call. A review of resident #4's nursing notes for 2/7/22 showed she was not eating or drinking, so much so that she was, having some difficulty with bowel movements. Orders for [MEDICATION(S)] 100 mg BID were received. Review of the facility Falls/Incidents Meeting document, dated 2/8/22, showed resident #4 had an unwitnessed fall in the bathroom. The resident was found on the floor between the wall and toilet, covered in feces. The resident had been given something to help her have a bowel movement 30 minutes prior to the fall. The resident stated she hit her head but had no visible injury. Neurological checks were initiated due to the resident hitting her head. The note showed, Could be possible she had a vasovagal event that caused her fall? The concerns with the vasovagal event was not addressed further, or why the resident was unresponsive. Review of resident #4's Neuro Check sheet, dated 2/4/22 through 2/7/22, showed the resident was sleeping for some of the evaluations. Staff did not wake the resident to complete the assessments. On 2/4/22 at 2200, the form showed the resident was unresponsive. A review of resident #4's physician progress notes, dated 2/7/22, showed, She had a slight fall Friday night in the bathroom, basically slid down the chair. There were no injuries . There is [sic] been no issues of bowel movements . The physician did not note anything about the unresponsive event that occurred during the fall on 2/4/22. During an interview on 4/12/22 at 2:28 p.m., staff member A stated residents should be awakened to do neurological checks when a resident hits their head. A review of the physician progress notes for resident #4 showed on 3/7/22, She had a fall last month, no injuries, thought to be a vasovagal problem . No further f/u was completed on the concern. This was a month after the fall occurred. 3. Resident #31 was admitted on [DATE], and had six falls from the time of admission to 3/28/22. Review of resident #31's Fall Risk Assessment, dated 3/17/22 and 4/13/22, showed resident #31 had a score of 22, high risk for falls. Review of a facility document, titled Falls/Incidents Meeting, showed the following: - On 11/13/21 resident #31 had an unwitnessed fall. The resident was unable to state what happened. The resident was found in the day lounge on the floor by the recliner. It appeared he went to try and get up and slid to the floor. No injuries noted. No new interventions were implemented. Existing interventions for falls were non-slip socks, walker near him at all times, and toileting schedule; - On 11/24/21 resident #31 had a fall, no listed area of the building, no injury. Fall/incident team met and discussed intervention interventions-constant monitoring; - On 11/27/21 resident #31 had a fall, no injury. Fall/incident team met and discussed interventions - possibly get the resident ready first thing or with night shift. The resident hung out in the day room for a lot of the day, so he can be visualized easily. Sitter in the day room; - On 12/27/21 resident #31 had an unwitnessed fall. The resident was found crawling around on the floor in the day lounge. He was crawling towards his walker. No injuries noted. Nursing staff to assist in providing the resident with activities so the resident has things to do throughout the day when he might be bored. Offer to lay down in bed in the afternoon to rest; - On 2/28/22 resident #31 had a witnessed fall. The resident stood up and lost his balance; - On 3/28/22 resident #31 had an unwitnessed fall. Unable to communicate what happened. Had attempted to get out of bed and fell to the floor. Offer to call his wife when ambulatory, make sure he is wearing non slid socks at bedtime, and make sure walker is near his bedside at night. The facility failed to determine a root cause for resident #31's falls, and failed to assess the resident's care plan interventions to determine effectiveness of the interventions in place for the prevention of falls as they occurred, or for future falls. During an interview on 4/12/22 at 2:15 p.m., staff member A stated the staff report whether the interventions currently in place were effective. Staff member A stated falls were monitored and they (IDT) met weekly to discuss residents who had fallen in the last week. Staff member A stated they monitored medication changes, labs, and blood sugars. Staff member A stated choosing interventions can be difficult. Staff member A stated sometimes it is hard to come up with new interventions. The facility failed to proactively monitor resident #31's risk for falls, failed to identify a root cause for the falls, and develop an effective plan to prevent repetitive falls. 4. Review of a facility document, titled Falls, showed resident #11 had five falls between 11/8/21 to 3/28/22. Review of a facility document titled Falls/Incident Meeting, dated 2/8/22, showed resident #11 was found on the floor in the day lounge on 2/7/22. Review of resident #11's Long Term Care progress note, dated 2/28/22, showed the resident had difficulty with movement, frequent falls, joint pain, and stiffness. Review of a facility document titled Falls/Incidents, dated 3/29/22, showed resident #11 had two falls, one on 3/24/22 and one on 3/27/22: - On 3/24/22 resident #11 had an unwitnessed fall in the lounge bathroom. Resident found sitting upright on floor with legs extended. - On 3/27/22 resident #11 had an unwitnessed fall in her room. The resident was found lying on her left side. The floor was wet. The resident had an incontinent episode. Night gown was all wet with urine and stool. There were no documented Falls/Incident Meetings for 11/2021 or 12/2021 provided, detailing resident #11's falls. Review of resident #11's Fall Risk Assessment, dated 3/23/22, showed the resident was a high risk for falls with a score of 19. Any score above 13 is at a high risk for falls. Review of resident #11's Fall Risk Assessment, dated 4/13/22, showed the resident was a high risk for falls with a score of 25. Review of resident #11's Care Plan, dated 3/29/22, showed the resident had a fall risk score of 22, high risk. The care plan showed the following interventions: - Staff to monitor resident when she is walking-assist as needed . - Staff to anticipate her needs as able . - Room closer to desk for monitoring . - Frequent checks for resident safety . - Increased falls notify MD . - Round on resident to keep track of her whereabouts . - Encourage resident to toilet throughout the day/night to decrease need to get up on her own when her balance is off . The care plan did not show dates of interventions implemented before the resident's falls and after the resident's falls. The facility failed to determine if interventions on the care plan were effective in the prevention of falls for resident #11. The facility did not increase supervision for resident #11 who had five unwitnessed falls. It was unclear per the care plan, what was to be monitored specifically, what needs were to be anticipated, or what staff would monitor for when the resident was walking. Review of resident #11's Rounding sheets, dated 2/17/22 through 4/13/22, showed multiple dates/times were incomplete. Review of resident #11's Physician Progress Note, dated 3/5/22, showed a routine scheduled visit. The resident's progress note showed, There have been no falls. Review of resident #11's Nursing Progress Notes showed the following: - On 11/8/21 at 12:00 p.m., resident #11 was found on floor and sustained a skin tear to the left forearm. - On 12/18/21 at 5:00 p.m., resident #11 slid to the floor in the lounge area. - On 2/7/22 at 6:51 p.m., resident #11 had an unwitnessed fall in the resident lounge. No injury. Fall occurred in the lounge by a table. She had been sitting in the chair at the table. Family updated. No provider notification. - On 3/24/22 at 9:34 p.m., resident #11 had an unwitnessed fall in the lounge bathroom. The resident was found sitting upright on the floor with legs extended. Family would be notified in the morning. No provider notification. - On 3/27/22 at 12:00 p.m., resident #11 was found on the floor of her room surrounded by urine and feces. Family updated. No provider notification. The resident sustained a bruise/blood blister to the left elbow. The facility failed to assess for head injuries during falls. Resident #11 was unable to complete the BIMS assessment, and was documented with moderately impaired cognition, and unable to confirm or deny hitting her head. During an interview on 4/12/22 at 2:28 p.m., staff members A and B stated neurological checks were only done on residents if they hit their head. Staff members A and B stated they assessed residents for obvious evidence of hitting their head. Staff members A and B stated if a resident was found sitting up, they determined they had not hit their head because of poor core strength, so no neurological checks would be initiated. 5. During an observation and interview on 3/29/22 at 9:02 a.m., resident #33 was able to get up from a chair in the lounge, and walk independently down the hall. She walked with an unsteady gait. The resident had a resolving yellow bruise around her left eye. Staff member H stated resident #33 falls all the time. Review of resident #33's care plan/profile history report, showed the resident had 7 falls on: 1/6/22 - did not hit her head 1/6/22 - did hit her head and developed a small hematoma and complaints of right shoulder discomfort 1/11/22 - did hit her head but no injury noted 2/16/22 - no injury noted 3/3/22 - hit head but no injury noted 3/4/22 - did not hit head but minor injury to right buttocks 3/7/22 - hit head, minor injury with hematoma and bruising to left forehead Review of resident #33's Fall incident reports showed she also fell on [DATE] and 3/23/22, sustaining a laceration to her left eye brow. Review of resident #33's Fall incident report, dated 1/6/22, showed staff heard a loud noise, and found the resident on the floor. The resident was able to verbalize that she hit her head on the bed and then again on the floor when she fell . She denied any pain or injury. The post fall assessment showed resident #33 was unsteady on her feet for four days after the fall, and was diagnosed with a [CONDITION(S)]. The change in her plan of care was to look into moving her closer to the nurses desk. It also showed her Latvian had been decreased. Review of resident #33's Fall committee note, dated 1/6/22, showed fall interventions were, proper footwear, rounding, bed lowest locked position. New interventions were move closer to nurses desk 'when available', toileting schedule, resident is in day lounge often, remind to use walker. Review of resident #33's Fall incident report, dated 1/7/22, showed the resident stood up from the chair in the lounge and fell right over hitting the right side of her head. The interventions in place to prevent the resident from falling were toileting schedule, non slip footwear, patient/family education. It did not specify what the education would include. Review of resident #33's Fall committee note, dated 1/7/22, showed the note was identical to the note on 1/6/22. Review of resident #33's Fall incident report, dated 1/11/22, showed staff heard a noise that sounded like a fall. The resident was found in the lounge, lying on her back. She stated she hit her head. Review of resident #33's Fall incident report, dated 2/26/22, showed staff saw the resident lose her balance and fall backward against the sofa in the lounge. New interventions were to offer her to slow down when she was getting up and walking, and try a rollator 4WW. Review of resident #33's Fall incident report, dated 3/4/22, showed the resident fell in her room against the wall and to the floor. There was a hematoma to the back of her head. The Post fall assessment showed the resident was more unbalanced and unsteady on her feet. Bruising to her left forehead was now moving into corner of left eye and upper cheek. A CT was scheduled and showed no new findings. Review of the Fall committee note, dated 3/4/22, showed new interventions were to follow up with lab and radiology, remind staff to keep the door open to her room, and look into buying candy cigarettes for her. Review of resident #33's Fall incident report, dated 3/7/22, showed the resident had an unwitnessed fall, possibly in the lounge or the public bathroom. She sustained a hematoma and small pinpoint wound. The fall committee note, dated 3/7/22, showed new interventions were identical to the interventions on 3/4/22. The fall was unwitnessed. Review of resident #33's Fall committee note, dated 3/20/22, showed the resident had a fall in the clean utility room. She stated she was looking for cigarettes. Review of resident #33's Fall incident report, dated 3/23/22, showed the resident came to her door, turned to her left, and fell into the doorway of the next room. She hit her left temple on the floor. Staff had asked her to wait before she ambulated because she was unsteady. A Band-Aid was applied to her forehead laceration. Review of resident #33's Fall committee note, dated 3/23/22, showed the 'new' intervention was to offer candy cigarettes when unsettled, agitated, wandering, roaming, etc. Resident #33's nine Fall incident reports and Fall committee notes did not include a root cause analysis for the falls. During an interview on 3/30/22 at 1:35 p.m., staff member A stated the facility had just received the candy cigarettes yesterday (3/29/22), so she was not able to evaluate the effectiveness of the intervention for resident #33. Review of resident #33's care plan/profile history report, dated 1/19/22 to 3/8/22, showed fall interventions were: Fall assessment after each fall Resident uses walker and 1 SBA for ambulating Call light in reach Clutter free walkway/well lit room Bed in low position Anticipate her needs Good fitting shoes Personal objects within reach Room close to nurses desk During an interview on 3/29/22 at 1:40 p.m., staff member A was asked about the relevance of the interventions to prevent resident #33 from falling, since she does not use a walker, ambulates independently, was unable to use the call light, and did not wear shoes. Staff member A stated sometimes the electronic health record system generates generic interventions. Elopements 6. During an observation and interview on 3/29/22 at 8:50 a.m., resident #33 was sitting in the resident lounge eating breakfast. She had a resolving yellow bruise around her left eye. Staff member H stated resident #33 falls all the time, wanders, and had recently eloped out of the east door. During an observation on 3/29/22 at 9:02 a.m., resident #33 walked unsteadily to the east door, and pushed on the handle, setting off the alarm. Staff redirected her to the lounge. Resident #33 got up from the chair in the lounge and wandered into another resident's room. She pushed all the stuffed animals off of a shelf and walked back into the hall. Review of a Facility Reported Incident (FRI) sent to the State Survey Agency, dated 1/29/22, showed the resident had eloped out of the facility. The FRI showed: At 1700 nurse (Name) and 2 CNAs were passing supper trays. She noticed that resident was not in lounge. Checked all areas of building. About 15 to 20 minutes earlier the door alarms had sounded. The nurse looked toward lounge, a CNA was in the vicinity of the door. Thinking that person was taking care of the situation. When later questioned, they said no, no one was by the door. The alarm was just going. If you stand by door after alarm sounds for 30 seconds, the door will unlock and open. Fire regulation. Hospital CNA said she would take her vehicle and go by her house and look. Nurse was heading to desk to call the sheriff's office to report her missing. A [NAME] by had found her [resident] walking outside. They knew who she was, picked her up and took her to her sons house. Daughter-in-law brought her back to facility, Family notified. Resident was outside in her bare feet and no coat. She was warmed up and feet examined. No injuries noted, but she said that her feet were stinging and burning on the bottom. Presently, she is looking for her cigarettes. Will monitor for any injuries that may present themselves through the next 24 to 48 hours. Appropriate notification was not made by nurse on shift. Facility looking further into this matter. Review of a nursing progress note, dated 1/29/22, showed the staff nurse was passing supper trays. She noticed that the resident was not in the lounge. She asked if the CNAs knew where resident #33 was, and they did not know. The nurse documented I knew then she must have gotten out. Review of resident #33's medical record showed no nursing documentation for examination of her feet on 1/30/22. Review of a nursing progress note, dated 1/31/22, showed the resident complained her feet were hurting. A blister was found on the bottom of her foot, and the ends of her toes were red and inflamed. Review of resident #33's nursing progress note, dated 2/1/22, showed the resident had an intact blister on her right middle toe. No measurements or further description was included in the progress note. Review of the facility Risk Incident Report, dated 1/31/22, showed the resident had been caught at the North door when the door had alarmed, pushing on the door until it released. It was noted that at the start of the AM shift that both chirpers were off. Upon the search of the resident they were both off again. The chirpers (audible sound) was a system that alarms when residents try to open the door. Review of the After Action Report for staff, dated 2/17/22, 19 days after resident #33's elopement, showed, The wander guard system is outdated and we are unable to get parts for the system. We are unable to add doors to the current system also. Set up hourly count of our high-risk wanderers. The conclusion included updating the policy at the desk with additional paper forms, easier to follow and missing steps. Will complete once we have updated policy. During an interview on 3/30/22 at 1:20 p.m., staff member A stated the policy had not been updated, but was waiting for approval from a hospital committee. Review of the Elopement policy showed it was dated 5/11/21. Review of the After Action report, dated 2/17/22, for all facility staff, showed, Education for the whole facility on who our high risk wanderers are. Staff member A needs to check with (Name) to see what the appropriate way to do this would be. And, Looking into adding a wander guard and chirper check off for each shift. Review of a morning huddle note, dated 2/17/22, showed staff were 'working on' making a chirper/check list and flight risk rounding sheet, after resident #33's elopement. The elopement occurred on 1/29/22. Review of a facility staff meeting agenda form, dated 1/31/22, showed Elopement - See After Action Report. The attendees listed on the form did not include all facility employees, but 64 percent of employees. During an interview on 3/30/22 at 1:30 p.m., staff member A stated all employees should have read the After Actio[TRUNCATED]

Based on observation, interview, and record review, the facility failed to provide the care and services necessary to maintain the highest practible physical, mental, and psychosocial well-being; failed to prevent a severe weight loss with no evalution of the effectiveness of current dietary interventions; no thorough evaluation of persistent dry heaves or effective medication mangagement; no evaluation for a possible decline in the ability to swallow food and fluids or assessmemt of cognition; no follow-up on a documented decline in mood; no evaluation of pain as a possible cause of anxiety and loss of appetite; and no assessments for dehydration and the choice to receive IV fluids, for 1 (#4) of 3 sampled residents. Findings include: During an observation and interview on 3/29/22 at 8:30 a.m., resident #4 was lying bed with a large basin on her stomach. Her lips were dry. She stated she was not good, and reached for a sip of water. After the sip, she began to have dry heaves. During an interview on 3/29/22 at 8:32 a.m., staff member H stated the resident was actively dying, and was not eating or drinking. She stated it was probably a failure to thrive. Staff member L stated she had just given the resident [MEDICATION(S)] for her dry heaves. During an interview on 3/29/22 at 11:00 a.m., staff member A stated the facility was waiting for a decision from resident #4's family regarding putting the resident on 'comfort measures.' This surveyor stated resident #4 did not appear to be comfortable now, and staff member A replied, We don't want our residents to be miserable. During an observation on 3/29/22 at 11:30 a.m., resident #4 did not eat any lunch. She had water at her bedside and was lying in bed. Her lunch tray was on the meal cart outside her room, and it was observed all the food remained on the plate, uneaten. During an interview and observation on 3/30/22 at 11:10 a.m., resident #4 was lying in bed with her meal tray on her bedside table. She stated she needed help sitting up. Staff member K came into the room, and stated she had just sat the resident up, but she layed back down. She stated she did not know why the resident could not eat, but it was very sad to watch. Staff member K stated the resident had a few bites of lunch, and then had a very small emesis. Resident #4 stated, Just help me. Review of resident #4's Significant Change MDS, dated [DATE], showed a severe weight loss of 20 pounds, a 14 percent loss in two months, from 136 pounds to 106 pounds. The MDS showed the resident had frequent moderate pain that interfered with her sleep and daily activities. Resident #4 did not receive scheduled pain medication. A review of resident #4's medical record failed to show if the facility attempted to verify through testing if resident #4's verbal responses were accurate, due to her dementia, confusion, mental decline, and severe cognitive deficits. A review of the resident's current care plan showed she had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The pain care plan showed the resident may have increased anxiety or agitation when attempting to express needs, such as pain. The care plan goal was for the resident to have tolerable pain, but the plan did not identify what the resident's level of tolerance was for pain. Staff were to watch her expressions and provide PRN pain meds if needed, and she complained of pain more at HS (night). It was unclear per the care plan what staff were to specifically monitor for when considering pain as a contributing factor for the residents agitation/confusion, or anxiety. Review of resident #4's care area assessment for pain, dated 2/24/22, showed the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Watch for cues; Resident may not be able to verbalize. The assessment did not show staff what non-pharmacological interventions to use, or what cues indicated the resident was in pain. A review of resident #4's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The notes showed the resident's medication list included acetaminophen as needed, but when it was documented in the medical record the resident was exhibiting agitation/anxiety, it was unclear if pain was assessed or an intervention offered for pain, each time. Review of resident #4's electronic health record did not show continued evaluations for possible pain or how it may have hindered the resident's daily routine. Review of resident #4's Nursing Progress notes showed: 1/10/22 - Resident continues on [MEDICATION(S)] for [CONDITION(S)], staff try and inform her she needs to eat and drink plenty of water while taking her antibiotic without much success. Resident will sometimes say Not on that black thing referring to her bedside table. Nursing have tried to get her a different colored table to set her food on without success. We will put her food down, and she will just get up and walk away. The resident was noted to be only able to stay in bed 2 to 3 minutes and would then get up, and not easily redirected. [MEDICATION(S)], for pain, was attempted for a one week trial, which was unsuccessful, and shortly after discontinued. 1/20/22 - Resident appears exhausted, leaning onto the wall and glass windows, running walker into things. 1/31/22 - [MEDICATION(S)] 8 mg was ordered for sleep. It was decreased to 2 mg after 1 week because she was sleeping during the day. 1/31/22 - The resident does not have a good appetite. She refused breakfast and supper. She accepted a couple sips of water without issue. Will continue to offer food she may enjoy. 2/2/22 - Resident has been eating poorly and spending most of her time in bed. When self (this nurse) has worked, I try to get her to eat some mashed potatoes or some soft foods along with her pills. She is not weepy, just in bed and sleeping a lot. This is a change in comparison to several weeks ago, she was walking around the clock. 2/4/22 - The resident has not had a bowel movement in 6 days, and was given a rectal suppository. The resident was found on the floor between the wall and toilet. She stated she hit her head. When the staff started to stand her, she became unresponsive. The note did not include follow-up on the cause of the lack of a bowel movement for 6 days or a medical evaluation for the unresponsive episode when standing. 2/7/22 - Resident #4 was physically assessed by the physician. Resident was able to communicate, answer questions, and respond. Discussion was had about her diet and appetite being poor. Staff offer to assist her with meals without success. She does receive supplements, but again hit or miss if she drinks them on her own or accepts assistance. Orders to discontinue [MEDICATION(S)]. Orders to try [MEDICATION(S)] 2.5 mg PO at night for one week to see if it will help her appetite. The lack of meal intake for food/fluids was noted to be causing difficulty with her bowel movements. 2/11/22 - Resident has been refusing to eat. Encourage resident to eat. Resident continues to refuse to eat. She says she is just not hungry. The note showed the physician ordered a trial of [MEDICATION(S)] 5 mg at bedtime for one week, as a trial, to increase her appetite. The facility was pending the arrival of the medication. 2/18/22 - Resident has been eating better since the initiation of her [MEDICATION(S)]. She ate 100 percent of her evening meal tonight and said she 'ate it with her fingers.' 3/7/22 - Orders to increase [MEDICATION(S)] to 5 mg BID. The facility was unable to obtain the medication timely, which resulted in an extended delay in treatment (refer to note on 2/7/22). The medication was to be given one hour before the resident's meals. 3/12/22 - Resident lies in bed all shift, able to reposition self but refuses to get out of bed. Resident is withdrawn. Resident's appetite has not increased with the change of [MEDICATION(S)] BID. 3/15/22 - Resident #4 was spending most of the day in bed with her eyes closed. Staff noted she denied pain and discomfort, but failed to show if the resident was assessed for pain if she was unable to verbalize appropriately or understand if she was in pain. 3/17/22 - Resident is eating approximately 25 percent of her meals at this time. 3/23/22 - Resident does have a poor appetite and does drink water, but probably not enough. Will encourage some food and drink this evening. She did not eat any supper. 3/24/22 - Reported by CNA that when she attempted to feed resident at lunch time resident dry heaved and refused to eat lunch. At dinner time CNA gave 2 sips of fluid to resident. A few minutes later staff heard a dry heave noise from the day room. CNA went to check, and resident was dry heaving. Writer asked resident if she felt like throwing up she said yes. [MEDICATION(S)] given. Resident continues with minimal intake. Resident encouraged to eat and drink but she says she does not feel well. Resident does not answer when asked why she does not feel well. 3/28/22 - Resident is lethargic, weak and not eating or drinking well. Has been incontinent of urine. Needs assist with all cares. The resident was unable to take her medication in the morning. The physician was contacted, and ordered the [MEDICATION(S)] from BID (twice a day) to QHS (at bedtime/night). 3/29/22 - Resident is lethargic, not eating or drinking well. Will take sips of water when offered. Has nausea which is relieved with the [MEDICATION(S)]. Unable to walk to the bathroom, has been incontinent of urine. Very flat affect. 3/30/22 - Staff reported resident was dry heaving on and off through the evening. [MEDICATION(S)] order currently is every 12 hours as needed. Physician was notified. Orders for [MEDICATION(S)] patch and increase [MEDICATION(S)] frequency to every 8 hours as needed. Review of resident #4's physician visit note, dated 2/7/22, showed her diminished appetitite was concerning, as it does complicate her weight loss. An SSRI may be considered as there might be some depression going on. This may also stimulate her appetite. Review of resident #4's nutrition note, dated 2/9/22, showed a 16 percent weight loss in 60 days. Receives a supplement 1X/day. Intake has been poor - averaging 14 percent. Will increase supplement to tid with meals and switch to a juice type supplement, since it is reported that she does not like milk. Snacks to be offered between meals. Dietary to fortify food to make it calorie dense. No other nutritional interventions were in place prior to the severe weight loss, or documentation for the effectiveness of the interventions. Review of resident #4's physician visit note, dated 3/13/22, showed her weight loss was concerning. She was encouraged to eat. There may be some underlying depression going on as well. This will need to be monitored. Review of resident #4's Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of resident #4's POLST, dated 12/2021, showed the resident would choose to have IV fluids for hydration. During an interview on 3/30/22 at 1:44 p.m., staff member E stated she did not make meal rounds for palatability or acceptance of the meals. She looked at the CNA Care Tracker to monitor intake. Staff member F stated the CNAs provide the supplements, and she also used the Care Tracker to monitor supplement intake. Review of resident #4's medical record showed no nursing assessment for dehydration, and no followup on the resident's mood and underlying depression. The medical record did not include information provided to resident #4 for risks related to not eating or drinking, if she no longer wanted to live, or if she understood her medical status and decline. The [MEDICATION(S)] was not increased from twice a day to three times per day for her nauseausness until the second day of the survey. Review of resident #4's Care Area Assessment, from a Significant Change MDS, dated [DATE], showed nursing should be assessing for signs and symptoms of dehydration; dry mucos membranes, tenting in skin, thirst, labs, and altered mental status. During an interview on 3/30/22 at 4:10 p.m., staff member A stated they were still waiting for a decision from the family (multiple members) if end of life care for resident #4 would be appropriate. She stated nursing would then ensure the resident was 'comfortable.' She stated there had been no communication from the nursing staff that resident #4 was coughing or choking on food and fluids. Review of the resident #4's fall history, included in the resident's nursing notes, physician notes, fall investigation notes, and IDT notes, showed resident #4 had repeated falls, to include a head injury, being unresponsive after a fall without adequate f/u on the cause, continued nausea/vomiting, agitation, anxiety, loss in ADL abilities, and ongoing decline in her overall health status. Refer to F689 - Accidents and Hazards, for resident #4's fall information. It was unclear through review of the resident #4's medical record what caused the resident's continued decline in health status after her admission, due to the lack of information, testing, root cause analysis, or assessments, showing the facility was proactive in an attempt to identify the contributing factors of the health decline for the resident with dementia.

Based on observation, interview, and record review, the facility failed to directly monitor intake of meals and meal satisfaction; and failed to provide alternatives to the meals to prevent a severe weight loss of 15 percent for 1 (#23) and failed to assess and evaluate the inability to eat and drink with a severe weight loss of 14 percent in 2 months for 1 (#4) of 5 sampled residents. Findings include: 1. During an observation and interview on 3/30/22 at 11:10 a.m., resident #23 was seated in her room with her lunch meal. She stated, I will not eat any of that, it's not appealing. And that bread, why would I eat that, it has nothing on it, no meat or anything. The resident received mechanical soft Chow mein over rice. The Chow mein had no texture and was a pale beige/pink color. The resident was asked if she would like the kitchen to provide her with the alternate. She stated she had tried that too many times, and it never worked out. She said she finally wrote a note to the kitchen about her Ensure, and she now got the Ensure in a bottle. She stated her weight was going down. During an interview on 3/30/22 at 11:15 a.m., staff member E was asked if she had observed the mechanical soft Chow mein. She said she had not. During an observation and interview of resident #23 on 3/30/22 at 11:20 a.m., the staff delivered a ground ham sandwich and a bowl of soup. Resident #23 ate half of the sandwich and soup. She stated the soup was an improvement. Review of resident #23's Quarterly MDS, with an ARD of 8/19/21, showed a weight of 112 pounds. Review of resident #23's Quarterly MDS, with an ARD of 2/7/22, showed a weight of 95 pounds, a severe weight loss of 15 percent in six months. During an interview on 3/30/22 at 1:30 p.m., staff members A and B stated they were not aware of resident #23's food concerns. Staff member A stated the resident always said she was just 'too full.' During an interview on 3/30/22 at 1:45 p.m., staff member E stated she was not aware resident #23 had concerns about the palatibility of her meals. Staff member E stated she did receive the resident's note regarding her Ensure. Staff member E stated she did not make meal rounds for palatability or acceptance of the meals. She looked at the CNA Care Tracker to monitor intake. She stated the dietitian was in the facility doing assessments twice a month. Review of resident #23's Resident Profile Report did not include a weight loss problem. It did include a nutrition note, dated 2/23/22. The note showed the resident was eating an average of 38 percent per day, and was offered supplements 6X/day, and a Lemon Lime pop 6X/day for added calories. No likes or dislikes were included. During an interview on 3/30/22 at 1:45 p.m., staff member F stated the CNAs provide the supplements, and staff member F also used the Care Tracker to monitor supplement intake. Review of resident #23's Weights Detailed Entry Report, dated 3/28/22, showed the resident's weight continued to decline at 91.7 pounds. 2. During an observation on 3/29/22 at 11:30 a.m., resident #4 did not eat any lunch. She had water at her bedside and was lying in bed. Her lunch tray was on the meal cart outside her room with no food observed to be eaten on the plate. During an interview and observation on 3/30/22 at 11:10 a.m., resident #4 was lying in bed with her meal tray on her bedside table. She stated she needed help sitting up. Staff member K came into the room, and stated she had just sat the resident up, but she layed back down. She stated she did not know why the resident could not eat, but it was very sad to watch. Staff member K stated the resident had a few bites of lunch, and then had a very small emesis. Resident #4 stated, Just help me. Review of resident #4's Significant Change MDS, dated [DATE], showed a severe weight loss of 20 pounds, a 14 percent loss in two months, from 136 pounds to 106 pounds. Review of resident #4's nursing progress notes showed: 1/31/22 - The resident does not have a good appetite. She refused breakfast and supper. She accepted a couple sips of water without issue. Will continue to offer food she may enjoy. 2/2/22 - Resident has been eating poorly and spending most of her time in bed. When self (this nurse) has worked, I try to get her to eat some mashed potatoes or some soft foods along with her pills. She is not weepy, just in bed and sleeping a lot. This is a change in comparison to several weeks ago, she was walking around the clock. 2/7/22 - Resident #4 was physically assessed by the physician. Resident was able to communicate, answer questions, and respond. Discussion was had about her diet and appetite being poor. Staff offer to assist her with meals without success. She does receive supplements, but again hit or miss if she drinks them on her own or accepts assistance. Orders to discontinue [MEDICATION(S)]. Orders to try [MEDICATION(S)] 2.5 mg PO at night for one week to see if it will help her appetite. 2/11/22 - Resident has been refusing to eat. Encourage resident to eat. Resident continues to refuse to eat. She says she is just not hungry. 2/18/22 - Resident has been eating better since the initiation of her [MEDICATION(S)]. She ate 100 percent of her evening meal tonight and said she 'ate it with her fingers.' 3/7/22 - Orders to increase [MEDICATION(S)] to 5 mg BID. 3/12/22 - Resident lies in bed all shift, able to reposition self but refuses to get out of bed. Resident is withdrawn. Resident's appetite has not increased with the change of [MEDICATION(S)] BID, although it was noted to be increasing on 2/18/22. 3/17/22 - Resident is eating approximately 25 percent of her meals at this time. 3/23/22 - Resident does have a poor appetite and does drink water, but probably not enough. Will encourage some food and drink this evening. She did not eat any supper. 3/24/22 - Reported by CNA that when she attempted to feed resident at lunch time resident dry heaved and refused to eat lunch. At dinner time CNA gave 2 sips of fluid to resident. A few minutes later staff heard a dry heave noise from the day room. CNA went to check, and resident was dry heaving. Writer asked resident if she felt like throwing up she said yes. [MEDICATION(S)] given. Resident continues with minimal intake. Resident encouraged to eat and drink but she says she does not feel well. Resident does not answer when asked why she does not feel well. 3/28/22 - Resident is lethargic, weak and not eating or drinking well. Has been incontinent of urine. Needs assist with all cares. 3/29/22 - Resident is lethargic, not eating or drinking well. Will take sips of water when offered. Has nausea which is relieved with the [MEDICATION(S)]. Unable to walk to the bathroom, has been incontinent of urine. Very flat affect. 3/30/22 - Staff reported resident was dry heaving on and off through the evening. [MEDICATION(S)] order currently is every 12 hours as needed. Physician was notified. Orders for [MEDICATION(S)] patch and increase [MEDICATION(S)] frequency to every 8 hours as needed. Review of resident #4's physician visit note, dated 2/7/22, showed her diminished appetitite was concerning, as it does complicate her weight loss. An SSRI may be considered as there might be some depression going on. This may also stimulate her appetite. Review of resident #4's nutrition note, dated 2/9/22, showed a 16 percent weight loss in 60 days. Receives a supplement 1X/day. Intake has been poor - averaging 14 percent. Will increase supplement to tid with meals and switch to a juice type supplement, since it is reported that she does not like milk. Snacks to be offered between meals. Dietary to fortify food to make it calorie dense. No other nutritional interventions were in place prior to the severe weight loss, or documentation for the effectiveness of the interventions. During an interview on 3/30/22 at 3:45 p.m., staff member C stated the QAPI committee performed performance improvement projects on weight loss issues, and the dietician or dietary supervisor looked at the palatability and acceptance of meals given to residents. She stated she would expect the DON to monitor food issues locally and bring it to QAPI if she needed help solving an issue. Staff member C also stated resident #23's weight loss was not on the QAPI agenda at this point, but the facility's provider was following her closely and the committee was aware of the issue.

Based on observation, record review and interview, the facility failed to ensure adequate nutritional intake, eating assistance, adequate nutrition for wound healing and appropriate evaluations and interventions for 4 (#s 2, 3 7, and 8) of 13 sampled residents with severe weight loss. Findings include: 1. Resident # 2 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of the significant change MDS, with the ARD of 4/12/15, showed resident #2 had signs and symptoms of a [MEDICAL CONDITION], and was mostly dependent on staff for activities of daily living. Resident #2's incontinence had increased, and she had coughing/choking, and difficulty swallowing. Resident #2 had a 26 % weight loss (39 pounds) in 6 months, which is a severe weight loss. The weight loss was coded as a physician prescribed weight loss. The resident also had a significant decline in her cognition and was bed-bound. Review of the NH progress note dated 3/3/15, showed the resident was not taking in real food, just sips of supplements, 7up and water. She was very weak and not able to sit up on the commode. Review of the NH progress note, dated 3/5/15, reflected the resident choked on the liquids. Review of the NH progress note dated 3/10/15, reflected the resident was not eating well. Coughs with drinking and taking pills. Review of the NH progress note dated 3/12/15, showed the resident coughed with each bite and drink of fluids. Review of the NH progress note dated 3/27/15, reflected the resident was eating small amount at meals - soups, cereal, Jell-O and was drinking her supplements. Review of the NH progress note, dated 3/31/15, reflected the MD had been in for a visit. Resident has declined over past several months. Resident has eaten poorly and weight loss has occurred. She is taking supplements, and meals are hit and miss. No changes at this time in her order. Review of the MD visit note, dated 3/31/15, showed the resident's complaints were remaining the same. There were no nursing concerns. Will make no changes. Review of the NH progress note, dated 4/18/15, reflected the dietary department asked to have the lactose restriction removed due to comfort care status and weight loss. Review of the MD visit note, dated 5/26/15, reflected the resident was getting along fairly well. She had actually gained 6 pounds. She continues to have the same complaints of abdominal distress. I notice she has been drinking diet sodas and in view of the fact the calories have been an issue for her, I think she should have regular sodas if she is going to drink soda at all. Review of the care plan review/recapitulation of care, dated 4/22/15, reflected diet is still low lactose. The resident prefers soups and Jello and soft foods. She struggles some with swallowing medications and liquids. She refuses consistency changes in food or fluids. She receives 1 supplement/day plus others if she allows. She has had a severe weight loss. She prefers comfort cares at this time. Review of the quarterly nutrition note, dated 4/17/15, reflected the severe weight loss the past quarter. Intake of meals reported to be fair to good. Resident will complain to nursing often of not feeling well. She was put on comfort care. Supplement offered 1x/day. Goal: no further weight loss. During an observation on 6/17/15 at 8:10 a.m., resident #2 was in her bed. Her breakfast tray was sitting on a cart outside her room. The tray was covered, no lids removed and the silverware still wrapped up. During an interview on 6/17/15 at 8:15 a.m., staff member O, CNA, stated the resident did not want to eat breakfast because she was sick. During an interview on 6/18/15 at 7:10 a.m., staff member B, dietary manager, stated she would do the nutritional notes and assessments for residents, and the RD would review them. The facility was unable to provide evidence of a swallow evaluation, assessment of the cause of the weight loss, or other interventions to prevent a severe weight loss. 2. Resident #3 was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. Record review of the care plan showed the interventions for the significant decline in status for resident #3 included the foley catheter, wound care, and a turn assist mattress. No interventions were implemented for the severe weight loss, swallowing difficulties, decline in mood, and activities of daily living. Review of the MD note, dated 3/4/14, reflected resident #3's weight had unfortunately been gradually going up. With her weight gain, she is obviously going to have more respiratory problems, and I explained that to her. I think that she should be formally placed on a diet, 1200-calorie diet to get started with. Review of a nutritional note dated 3/18/14, reflected the resident is now on a 1200 kcal low salt diet. She feeds self, and intakes average 97% overall. Review of a dietary quarterly review note dated 1/4/15, reflected a 22 pound severe weight loss in one quarter. A stage II pressure ulcer was reported and [MEDICATION NAME], a protein supplement, was added one time daily to aid in healing. The facility did not provide evidence that any other interventions were implemented after this severe weight loss, or an assessment of the continued need for the significant caloric restriction. Review of the NH progress noted dated 3/22/15, reflected the facility was trying pureed food, and resident #3 was eating better with less concern over choking, but still had poor appetite. Review of the dietary progress note, dated 3/25/15, reflected the RD recommended the diet be changed to Regular-Pureed, related to poor intake, skin breakdown and large weight loss. Review of the current Physician orders [REDACTED]. Review of the MD note dated 3/31/15, reflected the resident is generally a little better. She has developed a small sore on her buttock and she in in bed more often now. Review of a NH progress note dated 4/2/15, showed the resident continued to be weak, and staff is feeding her. She only takes a few bites and coughs with each bite. Review of the MD note dated 4/3/15, reflected a substantial decline over the last few months. She has known advanced [MEDICAL CONDITION] fibrosis; however, her oxygenation has stayed fairly good. We have not been able to find another significant chronic underlying infection or problem. Review of the MD note dated 4/10/15, reflected the resident has had significant urinary incontinence over the last few months. With her chronic disease, she has had significant anorexia and is starting to lose considerable amount of weight. This has caused her to be bed-bound, and she now has developed some sacral sores. During an observation on 6/16/15 at 8:47 a.m. resident #3 was sleeping in bed, with an untouched breakfast tray beside her. During an observation on 6/16/15 at 5:20 p.m., resident #3 was in her bed with a tray in front of her. She was calling out, and attempting to drink one of her liquids. During an interview on 6/17/15 at 8:00 a.m., when asked about resident #3's ability to feed herself, staff member O, CNA, stated mostly we set the resident up and she does what she can. If we have time, we help her. During observation of breakfast and lunch on 6/16/15 and 6/17/15, resident #3 was not provided any assistance with her meals. Review of the dietary progress notes showed resident #3's [MEDICATION NAME] level on 1/14/15 was within normal limits at 3.6. On 4/29/15, the [MEDICATION NAME] was low at 2.7. Review of the significant change MDS, with the ARD of 4/6/15, showed resident #3 continued to have difficulty swallowing. Resident #3's weight loss continued through June with another 10 pound loss. During an interview on 6/17/15 at 5:50 p.m., a family member stated she is at the end of her journey. 3. Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the dietary notes from 9/2014 through 6/2015 reflected the following: -9/16/14: regular diet, [MEDICATION NAME] low at 3.3, weight decreased 5 lbs in one month and weight decreased 22 lbs in six months; -10/8/14: weight down 14 lbs. [MEDICATION NAME] 3.3 (low), protein needs 93 grams and protein snack added one time daily; -12/23/14: regular diet, requests smaller portions, one supplement per day, weight increase of 14 lbs in one month and weight decreased 6 lbs in 6 months. No nutritional concerns at this time-continue with current plan; -1/14/15: weight up 7 lbs. Regular diet. No new labs. Once daily supplement related to low [MEDICATION NAME]; -3/20/15: regular diet. One supplement daily. Weight decreased 20 lbs in one month. No changes at this time. Will adjust plan if severe weight loss continues; -4/29/15: weight up 2 lbs. Regular diet usually fair to good. No new labs. History of low [MEDICATION NAME] in 6/2014. Supplement one time daily for added protein. Continue with current plan; -6/16/15: receives 1500 Kcal diet. Requests small amounts. One supplement daily. Weight is 198 lbs. Weight decreased 18 lbs in one month and 16 lbs in six months. Will follow and adjust plan as needed. Review of the care plan for resident #7 reflected the following for nutrition: -Regular diet. Small portions. 1500 Kcal; -Honor food preferences; -Observe food/fluid intake. Monitor weight. Report significant changes; -Daily estimated nutritional needs: Kcal = 2100; Protein = 93 grams per day; 1 supplement per day for increased protein. Review of the physician progress notes [REDACTED]. Review of a progress note, dated 2/17/15, reflected the physician recommended a 1500 calorie diet for the resident. Review of a physician note, dated 3/17/15 reflected family concerns regarding physical problems and the physician reflected a lack of physical capacity. Review of a physician note, dated 5/12/15, reflected progressive weakness in the resident's legs. Review of the MDS, with an ARD of 3/23/15 reflected declining cognitive ability (section C0500) and increased depression (section D0200 and 0300). Section J0300 reflected the resident was experiencing moderate pain frequently with effect on sleep and activities. Review of the facility Philosophy of Nutritional Care reflected the following: -The dietary professional will participate in the monitoring and evaluation of quality and appropriateness of nutritional care; -dietary restrictions may impair adequate nutrition and lead to further decline in nutritional status. During an interview on 6/17/15 at 2:00 p.m., staff member B, dietary manager, stated the resident was on a physician prescribed diet, but the severe weight loss had not been addressed. Staff member B stated the resident was on a one time daily supplement. 4. Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of resident #8's care plan under eating habits reflected the resident was a total assist for feeding. The dietary section of the care plan reflected staff to assist with meals, no feeding tube per POLST and family wished no supplements be offered. Review of the dietary notes from 8/2014 through 6/2015 reflected the following: -8/19/14: receives regular diet. Gets distracted easily and requires more prompting at meal time. Meal intakes average 65%. Weight decreased 4 lbs in one month. No feeding tube per POLST. Continue with current nutrition plan; -quarterly review (not dated): down 3 lbs. Intake fair to good. Receives afternoon snack. Staff to encourage her at meals, to keep eating, when she becomes distracted. Goal: no further weight loss; -11/20/14: receives regular diet. Meal intakes average 68%. Offered a snack in the afternoon. Weight decreased 6 lbs in one month and 8 lbs in six months. Continue with current nutritional plan; -12/10/14: Intakes mostly fair. Hemoglobin 7.7 (critically low). Small open area to coccyx. Staff reports resident refuses supplements, so dietary will fortify foods; -2/23/15: regular diet. Meal intakes average 67%. Foods are fortified. Offered afternoon snack. Severe weight loss; weight decreased 10 lbs in one month, 19 lbs in three months and 25 lbs in six months. Recent UTI. Family has requested no treatment for [REDACTED]. Continues to become weaker-is fed, and uses wheel chair now; -3/11/15: weight down 12 lbs in three months. Resident is being fed by staff. Intake is good at breakfast and lunch and fair at supper. No supplements per family wishes. Continue with fortified foods. Goal: no further weight loss; -5/18/15: regular diet with fortified foods. Feeds self with prompting. Meal intakes average 68%. Offered a snack in the afternoon. Hemoglobin 7.5 (critically low). No change in weight this month; decreased 15 lbs in six months. No supplements per family wishes. No feeding tube per POLST. Continue with current plan; -6/10/15: Meal intake fair to good at breakfast and noon, poor to refusing at supper. Afternoon snack being offered. Dietary to offer bedtime snack. Goal: no further weight loss. Review of the Doctor Progress Visits sheets for 8/2014 through 5/2015 reflected the following: -8/5/14: Often refuses going to meals, may not eat what is brought to her. May sit and look at her plate and tell you she has eaten; -11/8/14: spends more and more time in room; -3/17/15: allows staff to feed her. Supplements offered, she does not always take them. Review of the physician progress notes [REDACTED]. Review of a note dated 11/18/14 gave mention to the resident's decline, some weight loss and she sometimes does not eat supper. The progress notes did not reflect recommendations to prevent further weight loss. During an observation on 6/16/15 at 12:05 p.m., resident #8's lunch meal was on the table, however the resident had returned to her room. No food on the plate had been eaten. At 1:00 p.m., the resident was seated, in a recliner, in her room with her eyes closed. During an interview on 6/16/15 at 12:10 p.m., staff member F, CNA stated the resident usually eats a really good breakfast. During an interview on 6/17/15 at 9:00 a.m., staff member B, dietary manager, stated supplements were not offered to resident #8 because the family requested no supplements. Staff member B stated the family wanted nature to take its course.

Based on observation, interview, and record review, the facility failed to provide the necessary care and services to maintain the highest practicable physical, mental and psychosocial well-being for 2 (#s 3 and 7) of 13 sampled residents. Specifically, the facility failed to assist and provide residents with adequate food intake, turning and repositioning while in bed, prevent new and worsening pressure ulcers and weight loss, and a decline in ADLs from minimal assist to dependent bed-bound status. Findings include: 1. Resident #3 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of the annual MDS, with the ARD of 12/12/14, reflected the resident was cognitively intact, had minimal depression, was independent in most activities of daily living, did not have pressure ulcers, or swallowing difficulties, and was continent of bowel and bladder. Review of the significant change MDS, with the ARD of 4/6/15, reflected the resident had moderately impaired cognition, signs and symptoms of [MEDICAL CONDITION], mild depression, worsening in behaviors, extensive to dependent assist for all activites of daily living, three pressure ulcers, swallowing difficulties, and a physician prescribed severe weight loss. Review of the MD note dated 3/4/14, reflected resident #3's weight had unfortunately been gradually going up. With her weight gain, she is obviously going to have more respiratory problems, and I explained that to her. I think that she should be formally placed on a diet, 1200-calorie diet to get started with. Review of a nutritional note, dated 3/18/14 reflected the resident is now on a 1200 kcal low salt diet. She feeds self, and intakes average 97% overall. Review of a dietary quarterly review note, dated 1/4/15, reflected a 22 pound severe weight loss in one quarter. A stage II pressure ulcer was reported and [MEDICATION NAME], a protein supplement, was added one time daily to aid in healing. Review of the NH progress note, dated 3/2/15, showed resident is pale and seems weaker. Review of the NH progress note, dated 3/10/15, reflected [MEDICATION NAME] given at 3:30 P.M., per her request but continues to be demanding/needy and has not rested much. Review of the NH progress note, dated 3/11/15, reflected resident has multiple functional, mood and mentation changes. Is weaker generally and 2 assist to bedside commode. Review of the NH progress note, dated 3/11/15, reflected resident #3's sons were concerned with the decline of their mom as far as weight loss and weakness. The weight loss was a plan but she has lost 9 pounds in one month. Appetite has been fair to good on a 1200 calorie diet. Message was sent do Dr. (name) regarding weight loss. Review of the NH progress note, dated 3/17/15 reflected the doctor checked resident in relation to message sent about change in condition. Tests were ordered and are being completed. Review of the nursing home weight record reflected resident#3's weight was 182.6 pounds in July, 2016. In January, 2015, her weight was recorded at 152 pounds. In March, 2015, the resident's weight was recorded at 134.5 pounds - a 48 pound weight loss in 9 months. Review of a nutritional note, dated 3/20/15, reflected the resident feeds herself and eats meals in the dining room. She has experienced a server weight loss, 40 pounds in 6 months. She has a couple of open areas on her buttocks. Will reinstate [MEDICATION NAME] to help with healing. Much of weight loss was planned fluid and weight loss, but recently due to poor appetite and not feeling well/swallowing problems. Will request change in calories if weight loss continues. Review of the NH progress noted dated 3/22/15 reflected the facility was trying pureed food, and resident #3 was eating better with less concern over choking, but still had a poor appetite. Review of the dietary progress note dated 3/25/15 reflected the RD recommended the diet be changed to Regular-Pureed, related to poor intake, skin breakdown and large weight loss. Review of the current physician orders [REDACTED]. Review of the NH progress note dated 3/31/15, reflected the MD was in to see the resident and reported on an open area on the buttock. We have her lying in bed majority of time, due to open area. Review of the MD note reflected the resident was generally a little better. She has developed a small sore on her buttock and she is in bed more often now. Review of the NH note, dated 4/2/15, reflected The resident's condition was discussed today at MDS meeting. Will give her this week for assessing, new MDS will be due 4/13/15. Review of a NH progress note dated 4/2/15, showed the resident continued to be weak, and staff is feeding her. She only takes a few bites and coughs with each bite. Review of the MD note, dated 4/3/15, reflected a substantial decline over the last few months. She has known advanced [MEDICAL CONDITION] fibrosis; however, her oxygenation has stayed fairly good. We have not been able to find another significant chronic underlying infection or problem. Review of the MD note, dated 4/10/15, reflected the resident has had significant urinary incontinence over the last few months. With her chronic disease, she has had significant anorexia and is starting to lose considerable amount of weight. This has caused her to be bed-bound, and she now has developed some sacral sores. Review of the NH progress note, dated 4/4/15, reflected the resident had 5/6 spots on her coccyx that are opened, reddened and oozing. these sores are stage 2. The aides were informed to keep the patient off of this area as best as possible and turn her every 2 hours. Review of the NH progress notes, dated 4/5/15, reflected the resident was now on [MEDICATION NAME] 1 gm per day for a UTI. Review of the NH progress note dated 4/8/15 reflected an order for [REDACTED]. Review of the Care Plan Review / Update / Recapitulation of Care for resident #3 reflected (name)'s strength and activity have declined due to her appetite being poor, which is causing the weakness and weight loss - not very interested in nursing home activities since admit. She is oriented and making own choices as to staying in bed and desire to eat. Review of the care plan showed the interventions for the significant decline in status for resident #3 included the Foley catheter, wound care, and a turn assist mattress. No interventions were implemented for the severe weight loss, swallowing difficulties, decline in mood, and activities of daily living. The facility could not provide evidence of an assessment or interventions regarding the decline in the resident's mood for possible depression. During an interview on 6/18/15 at 10 a.m., staff member A, DON, stated that she realized the facility only looked at resident #3's anxiety. Staff member I, unit manager stated she could see the depression. During an interview on 6/19/15 at 7:30 a.m., staff member B, dietary manager, stated the facility had not been having many swallow evaluations because the contracted speech pathologist used a radiology study, and the facility was no longer able to accommodate this type of procedure. Record review of the doctor progress visits by nursing, dated 6//9/15, reflected, failing - almost wonder if the [MEDICATION NAME] is too much. Very sleepy, can't feed self. Record review of the MD visit dated 6/9/15 reflected, The patient continues a gradual decline and is now having to be fed. Have recommended that we cut back on her routine [MEDICATION NAME] to 0.25 bid routinely and then use 0.25 prn. She has a real tendency to lay on her back, and as long as they keep her on her sides it is better; however, with her nutritional status and her incontinence, this makes care difficult. During an observation on 6/16/15 at 8:47 a.m. resident #3 was sleeping in bed, with an untouched breakfast tray beside her. During an observation on 6/16/15 at 2:00 p.m., resident #3's eyes were caked with green matter. During an observation on 6/16/15 at 5:20 p.m., resident #3 was in her bed with the tray in front of her. She was calling out, and attempting to drink one of her liquids. During an interview on 6/17/15 at 8:00 a.m., when asked about resident #3's ability to feed herself, staff member O, CNA, stated mostly we set the resident up and she does what she can. If we have time, we help her. The current MDS with the ARD of 4/6/15 reflected resident #3 required extensive assistance for eating. During an observation on 6/17/15 at 5:45 p.m., the resident was being fed some soup by her son. During an observation of skin care on 6/17/15 at 10:30 a.m., staff member K, LPN, noted the resident to have new tunneling, an area of bleeding, a possible fungal infection, and a new pressure area on the leg. The tunneling area was restaged to a stage IV pressure ulcer and the doctor was notified. A current weight was requested for June, and resident #3 was weighed by staff members L and M on 6/6/15 at 3:30 p.m. She weighed 116 pounds, a 66 pound weight loss in one year. 2. Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS with an ARD of 3/23/15 reflected declining cognitive ability (section C0500) and increased depression (section D0200 and 0300) and disorganized thinking. Section J0300 reflected the resident was experiencing moderate pain frequently with effect on sleep and activities. Section G0400 reflected a decline in range of motion from impairment on one side of upper extremities to impairment on both sides Review of the dietary notes from 9/2014 through 6/2015 reflected the following: -9/16/14 regular diet, [MEDICATION NAME] low at 3.3, weight decreased 5 lbs in one month and weight decreased 22 lbs in six months; -10/8/14 weight down 14 lbs. [MEDICATION NAME] 3.3 (low), protein needs 93 grams and protein snack added one time daily; -12/23/14 regular diet, requests smaller portions, one supplement per day, weight increase of 14 lbs in one month and weight decreased 6 lbs in 6 months. No nutritional concerns at this time, continue with current plan; -1/14/15 weight up 7 lbs. Regular diet. No new labs. Once daily supplement related to low [MEDICATION NAME]; -3/20/15 regular diet. One supplement daily. Weight decreased 20 lbs in one month. No changes at this time. Will adjust plan if severe weight loss continues; -4/29/15 weight up 2 lbs. Regular diet usually fair to good. No new labs. History of low [MEDICATION NAME] in 6/2014. Supplement one time daily for added protein. Continue with current plan; -6/16/15 receives 1500 Kcal diet. Requests small amounts. One supplement daily. Weight is 198 lbs. Weight decreased 18 lbs in one month and 16 lbs in six months. Will follow and adjust plan as needed. Review of the care plan, dated 3/2015, for resident #7 reflected the following for nutrition: -Regular diet. Small portions. 1500 Kcal; -Honor food preferences; -Observe food/fluid intake. Monitor weight. Report significant changes; -Daily estimated nutritional needs: Kcal = 2100; Protein = 93 grams per day; 1 supplement per day for increased protein. Review of a progress note, dated 2/17/15, reflected the physician recommended a 1500 calorie diet for the resident. Review of a physician note, dated 3/17/15 reflected family concerns regarding physical problems and the physician reflected a lack of physical capacity and is a set up for pressure ulcers on his heels. Review of a physician note, dated 5/12/15, reflected progressive weakness in the resident's legs and requires a maxi lift assist. During an interview on 6/17/15 at 2:00 p.m., staff member B, dietary manager, stated the resident was on a physician prescribed diet, but the severe weight loss had not been addressed. Staff member B stated the resident was on a one time daily supplement. Review of the physician progress notes [REDACTED].