Every finding on record at Smith Center Health and Rehab

The facility had a census of 37 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to provide the services of a full-time Certified Dietary Manager for the 37 residents who resided in the facility and received their meals from the kitchen. This placed the residents at risk for inadequate nutrition. Findings included: - On 04/14/25 at 09:00 AM, observation dietary staff in the kitchen preparing the breakfast meal. On 04/14/25 at 09:10 AM, Dietary Staff BB verified she was not a Certified Dietary Manager. Dietary Staff BB stated the facility had one resident with a pureed diet. On 04/16/25 at 01:00 PM, Administrative Staff A verified Dietary Staff BB was not certified. The facility's Food Service Staffing dated 10/2024, documented that the community will employ sufficient staff with the appropriate competencies and skills to carry out the food and nutrition services function. The qualified Dietitian would help oversee clinical nutrition and dietary services in the facility. The policy documented that if the Dietitian was not full-time, the community would employ another qualified nutritional professional to serve as the Dietary Manager. The person must meet one of the following qualifications: A) A certified Dietary Manager, b) A certified food service manager, c) Have similar certification in food service management and safety from a national certifying body, d) Has an associate's or higher degree in food services management or in hospitality, if the course study includes food service or restaurant management from an accredited institution or higher degree, e) Has two or more years of experience in the position of dietary manager in a nursing facility setting and has completed a course of study in food safety management, by no later than October 1, 2023, that includes topics integral to managing dietary operations including, but not limited to, foodborne illnesses, sanitization procedures, and food purchasing/receiving; and f) meets the state-established standards if applicable. The Dietary Manager would receive frequently scheduled consultations from a qualified dietician.

The facility had a census of 37 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to store food by professional standards for food service safety in the nourishment refrigerator located in the south hall. The facility failed to cover two fluorescent light fixtures in one of one dining room. This placed the residents, who received their food items from the south nourishment refrigerator/freezer, at risk for foodborne illness. This also placed the residents who ate in the facility's dining room at risk of getting foreign objects in their meals. Findings included: - On 04/14/25 at 09:00 AM in the south hall resident nourishment freezer revealed the following: 1. A frozen banquet salisbury meal with an expiration date of 12/24. 2. Two frozen Michelina's fettuccini [NAME] meals with an expiration date of 12/24. 3. A Michelina fettuccine alfredo with chicken and broccoli frozen meal with an expiration date of 12/24. 4. An undated to when opened 8 ounce (oz) package of Butterfinger unwrapped minis. 5. A 7.6 oz package of unwrapped Reese's minis with an expiration date of 03/25. The refrigerator contained the following: 1. An unlabeled, undated blue plastic container with meat. 2. A box with four, 8 oz cans of Glucerna rich chocolate drink with an expiration date of [DATE]. 3. Three 4 oz containers of Dannon creamy vanilla pudding with expiration 04/09/24. 4. A 4oz container of cherry gelatin without an expiration date of 04/09/24. On 04/14/25 at 09:05 AM, Licensed Nurse LN G verified the above findings and discarded the above food items. LN G stated the night shift nursing staff were responsible for checking the nourishment refrigerator/freezer food items. On 04/16/25 at 11:50 AM, Administrative Nurse D stated night shift nursing staff were responsible for checking food items in the south hall nourishment refrigerator/freezer. Administrative Nurse D stated residents' food items should be dated and have the resident's name on them. The facility's Food Safety Requirements Policy, revised 10/24, documented that all foods stored in the refrigerator or freezer would be covered, labeled, and dated. All foods and beverages belonging to residents must be labeled with the resident's name, the item, and the use by date. Expiration dates on unopened food would be observed, and used by dates indicated once the food is opened. 27168 - On 04/14/25 at 12:00 PM, during dining observation revealed the following: Two overhead fluorescent light fixtures, with two light bulbs in each fixture, approximately six inches by five feet located directly above two of the tables in the dining room. The covers were missing and exposed the fluorescent bulbs. On 04/14/24 at 02:00 PM, Maintenance Staff U verified the two overhead fluorescent lights in the dining room, the bulbs were not encapsulated with a plastic covering and they lacked a cover for the light fixtures. The facility's Supervision, Maintenance Services policy, dated October 2024, documented maintenance services shall be under the direct supervision of the Administrator. The policy documented the day-to-day maintenance operation is under the supervision of the Maintenance Department and he/she is responsible for scheduling preventative maintenance service. The policy documented the duties and responsibilities of the Maintenance Director are outlined in his/her job description.

The facility had a census of 37 residents. The sample included 13 residents, with five residents reviewed for immunizations, Resident (R) 4, R6, R11, R18, and R25, to include pneumococcal (a disease that refers to a range of illnesses that affect various parts of the body and are caused by infection) vaccinations. Based on record review and interviews, the facility failed to offer, or obtain an informed declination or a physician-documented contraindication for the pneumococcal PCV20 vaccination per the latest guidance from the Centers for Disease Control and Prevention (CDC). This placed the residents at risk for pneumococcal infection and related complications. Findings included: - Review of R4, R6, R11, R18, and R25 clinical medical records lacked evidence the facility or the resident representative received or signed a consent to receive or informed declination for the pneumococcal vaccine PCV20. Review of R4's electronic health record revealed the resident was admitted to the facility on [DATE]. R6 had not been offered or received a pneumococcal PCV20 vaccine since admission. Review of R6's electronic health record revealed the resident was admitted to the facility on [DATE]. R6 had not been offered or received a pneumococcal PCV20 vaccine since admission. Review of R11's electronic health record revealed the resident was admitted to the facility on [DATE]. R11 had not been offered or received a pneumococcal PVC20 vaccine since admission. Review of R18's electronic health record revealed the resident was admitted to the facility on [DATE]. R18 had not been offered or received a pneumococcal PCV20 vaccine since admission. Review of R25's electronic health record revealed the resident was admitted to the facility on [DATE]. R25 had not been offered or received a pneumococcal PCV20 vaccine since admission. On 04/15/25 at 11:20 AM, Administrative Nurse E stated residents are offered the pneumonia vaccines on admission and as indicated. Administrative Nurse E said the facility would sign a consent or declination for receiving the vaccine. Administrative Nurse E verified that every resident in the building had not been reviewed to determine if they were eligible to receive the PVC20 vaccine or not. Administrative Nurse E verified they did not have a definitive system in place to determine who was eligible, if they were eligible had been offered or declined the vaccinations, and if it was something they had recently been working on. On 04/15/25 at 11:00 AM, Administrative Nurse D verified the facility lacked a system in place to identify which residents were eligible for which pneumococcal vaccination. Administrative Nurse D stated they did not have a system in place to identify if the resident was eligible for the PCV20 pneumococcal vaccine. The facility's Pneumococcal Vaccine policy dated February 2025 documented all residents were offered pneumococcal vaccines to aid in the prevention of pneumococcal infections. Prior to or upon admission, residents are assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, are offered the vaccine series unless medically contraindicated or the resident has already been vaccinated. Assessment of pneumococcal vaccination status were conducted within five working days of the resident's admission if not conducted prior to admission. Before receiving a pneumococcal vaccine, the resident or legal representative receives information and education regarding the benefits and potential side effects of the pneumococcal vaccine. Pneumococcal vaccines are administered to residents per the facilities physician approved pneumococcal vaccination protocol. Residents/representatives have the right to refuse vaccinations. If refused, appropriate information is documented in the resident per physician-approved pneumococcal vaccination protocol. Administration of the pneumococcal vaccines were made in accordance with the current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination.

The facility had a census of 37 residents. The sample included 13 residents, with three residents reviewed for the Center for Medicare and Medicaid Services (CMS) Beneficiary Liability notices. Based on record review and interview, the facility failed to provide the correct CMS Form 10055, Advanced Beneficiary Notice (ABN), to the resident or their representative for Residents (R)15, R21, and R140. This placed the residents at risk for uninformed decisions regarding skilled services. Findings included: - The Medicare ABN form informed the beneficiaries Medicare may not pay for future skilled therapy and did not provide an estimated cost to continue their services. The form included options for the beneficiary to (1) receive specified services listed, and bill Medicare for an official decision on payment. I understand if Medicare does not pay, I will be responsible for payment, but can appeal to Medicare. (2) receive therapy listed, but do not bill Medicare, I am responsible for payment for payment of services. (3) I do not want the listed services. The facility's Medicare ABN form staff provided to R15 (or their representative) was CMS-R-131 when the resident's skilled services ended on 02/13/25. The facility's Medicare ABN form staff provided to R21 (or their representative) was form CMS-R-131 when the resident's skilled services ended on 10/14/24. The facility's Medicare ABN form staff provided to R140 (or their representative) was form CMS-R-131 when the resident's skilled services ended on 01/08/25. On 04/15/25 at 02:02 PM, Administrative Nurse F stated she did not realize she had provided the families with the incorrect CMS (ABN) form. The facility's Beneficiary Notices Policy, revised 08/24, documented for part A items and services; the facility should use the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) form CMS 10055.

The facility had a census of 37 residents. The sample included 13 residents. Based on interview and record review, the facility failed to notify the State Long-term Care Ombudsman (LTCO) of Resident (R)18's discharge to the hospital. This placed R18 at risk for impaired rights. Findings included: - R18's Electronic Health Record (EHR) revealed diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion) with behavioral disturbance, delusional disorder (untrue persistent belief or perception held by a person although evidence shows it was untrue), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R18's Quarterly Minimum Data Set (MDS), dated [DATE], recorded R18 had severe cognitive impairment (problems with thinking, learning, remembering, and using judgment). The MDS recorded she required extensive staff assistance with transfers and activities of daily living (ADL). The MDS documented the resident ambulated with a walker and wheelchair and received antianxiety (a class of medications that calm and relax people), antidepressant (a class of medications used to treat mood disorders), and antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medications. The Care Area Assessment (CAA), dated 07/08/24, recorded R18 required total assistance with ADLs and mobility, and often refused to stand with assistance. The CAA documented the resident was at risk for falls due to weakness and poor safety awareness. The CAA documented the resident had delusions and behaviors that included refusal of care. R18's Care Plan, dated 03/04/25, recorded R18 required extensive staff assistance with most ADL care. R18's plan of care documented R18 had a diagnosis of impaired cognitive function due to dementia and delirium and directed staff to anticipate and meet the resident's needs be sure the call light was within reach and staff would encourage the resident to use it for assistance as needed. The care plan documented staff would encourage the resident to use appropriate footwear when ambulating had a personal safety alarm on and was functioning properly after providing care for the resident. On 12/07/24 at 03:45 PM the Nurses Notes documented staff heard a walker fall over and went to the dining room and found the resident lying under the table, on her stomach. The walker was noted to be tipped over several feet away from R18. The resident was alert and denied hitting her head. The nurse was notified and assessed R18 and noted her left leg was bent and unable to extend without severe pain in the left hip. The staff applied a blanket to keep R18 warm and notified emergency medical services, the physician, and the resident's family. At 03:55 PM the ambulance arrived and transported R18 to the hospital at 04:08 PM. On 12/07/24 at 06:10 PM the Nurses Notes documented R18 transferred to an out-of-town hospital after she was diagnosed with a fractured left hip. On 12/12/24 at 10:57 AM the Nurse's Notes documented R18 returned to the facility per facility staff. The resident entered the facility in a wheelchair and two staff assistance. Observation revealed the resident was alert and cooperative with assessment and care. The notes documented staff placed a chair alarm in the chair due to fall risk. R18's clinical record lacked documentation/evidence the staff notified the LTCO of R18's discharge from the facility. On 04/16/25 at 12:00 PM, Social Service X stated she just started the position in December 2024 and was not aware she needed to send the Ombudsman notification of residents who were discharged to the hospital, as she had just sent the Ombudsman notification of residents who discharged home. Social Service X verified she will now send the Ombudsman a list of the residents discharged to the hospital. On 04/16/25 at 01:00 PM, Administrative Staff A stated they did not have any notification to the Ombudsman regarding R18's discharge. The facility's Admission, Transfer, and Discharge, policy, dated April 2025, documented the community has established transfer and discharge criteria based upon applicable federal requirements. The community would provide a resident and/or the resident's representative within 30 days, a written notice of an impending transfer or discharge when specific criteria have not been reached. Transfer refers to the movement of a resident from a bed in one certified facility to a bed in another certified facility when the resident expects to return to the original facility. The policy documented the transfer or discharge information would be documented in the resident's chart, including: a. The verbal and/or written notices supplied: b. The discharge care plan. c. Documented discussions with the resident and if appropriate their representative. d. Recommended details. i. Discharge planning, and if necessary ii. Arrangements for post-discharge care. e. Send a copy to the State Long Term Care Ombudsman, note in the record.

The facility had a census of 37 residents. The sample included 13 residents. Based on observation, interview, and record review, the facility failed to label Resident (R)6 and R23s' insulin (a hormone that lowers the level of glucose in the blood) flex pens with a started/opened date or a use by date. This deficient practice placed the affected residents at risk for ineffective medications. Findings included: - On [DATE] at 08:35 AM, observation of the facility's South Hall medication cart revealed the following: R6's Tresiba (long-acting insulin) flex pen was not labeled with an open or expired date. R23's Tresiba flex pen was not labeled with an open or expired date. On [DATE] at 08:40 AM, Administrative Nurse D verified the nurses should label and date the insulin flex pens with the date opened. Medlineplus.gov directs open, unrefrigerated Tresiba can be used within 56 days; after that time, they must be discarded. The facility's Storage of Medication policy, dated [DATE], documented the facility would store all drugs and biologicals in a safe, secure, and orderly manner. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed per state regulation. Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing.

The facility had a census of 37 residents. Based on observation, interview, and record review, the facility failed to submit complete and accurate staffing information through Payroll Based Journaling (PBJ) as required. This deficient practice placed the residents at risk for unidentified and ongoing inadequate nurse staffing. Findings included: - The PBJ report provided by the Centers for Medicare & Medicaid Services (CMS) for Fiscal Year (FY) 2024 Quarter 3 and 4 indicated the facility had excessively low weekend nurse staffing Review of the facility's weekend nursing schedules for the above Quarters revealed the facility had adequate staffing. On 04/16/25 at 11:55 PM, Administrative Nurse D verified the facility had not submitted the correct information for weekend nursing staffing and stated Administrative Staff B was responsible for submitting the PBJ information. The facility's Nursing Services Policy, revised 04/2025, documented the facility utilized the PBJ to report the following: a. Report RN hours b. Licensed nursing coverage 24 hours/day c. Weekend staffing d. Star rating for the survey; and e. Reporting per guidelines

The facility identified a census of 35 residents with three residents reviewed for accidents. Based on record review, observation, and interview, the facility failed to provide a safe environment free from preventable accidents for Resident (R) 1. On 01/15/25 at approximately 09:20 AM, Certified Nurse Aide (CNA) M and CNA N transferred R1 from his wheelchair to his recliner using a Hoyer (total body mechanical lift) lift. The CNAs used the lift to suspend R1 into the air due to limited space in R1's room. CNA M turned around to position R1's recliner for R1 to sit in, turned back around to assist R1 into the recliner, and the right top lift sling strap dislodged and R1 slid out of the lift sling onto the floor. R1 hit the right side of his head and came to rest on his right side. The facility transferred R1 to the hospital where they diagnosed the resident with a fractured neck. This deficient practice placed R1 at risk for death, injury, pain, and a decrease in daily function. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of atrial fibrillation (rapid, irregular heartbeat), abnormalities of gait and mobility, muscle weakness, repeated falls, and dysphagia (difficulty swallowing). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status score of six, which indicated severely impaired cognition. The MDS documented R1 had bilateral upper extremity impairment and bilateral lower extremity impairment. The MDS documented R1 required substantial staff assistance for eating, bathing, upper body dressing, and personal hygiene. The MDS documented R1 was dependent on staff for oral hygiene, toileting, lower body dressing, bed mobility, and transfer. The MDS documented R1 had not had any falls during the assessment period. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 08/07/24, documented R1 had a BIMS score of 7, which indicated severely impaired cognition, had a history of false beliefs and delusions, and vivid scary dreams. The Functional Abilities CAA, dated 08/07/24, documented R1 required two staff assistance with his Activities of Daily Living (ADLs) to maintain safety. The CAA documented a full mechanical lift was utilized to transfer R1 as he was unable to bear his weight. The Falls CAA, dated 08/07/24, documented R1 as at risk for falls due to poor balance, weakness, and variable mentation. The Care Plan documented R1 required up to total assistance of one to two staff for bed mobility, transfers, dressing, grooming, hygiene, toileting, and bathing. (06/11/24) The care plan directed staff R1 required assistance with obtaining the correct utensils when eating and getting food onto the fork or spoon when R1 had difficulty and required a divided plate with large-handled utensils. (07/14/23) The care plan documented R1 as a fall risk and directed staff R1 was non-ambulatory and required a full lift for transfer, ensure R1 had on appropriate footwear when ambulating or mobilizing in his wheelchair, and R1 required a safe environment. (09/12/19) The Fall Risk Evaluation, dated 10/18/23, documented R1 had a fall risk score of 10, which indicated R1as a high fall risk. The EMR lacked a more recent Fall Risk Evaluation. The undated Facility Incident Report, documented on 01/15/25 at approximately 09:20 AM, CNA M, and CNA N transferred R1 from his wheelchair to his recliner using a Hoyer mechanical lift. The CNAs used the lift to suspend R1 into the air due to limited space in R1's room. CNA M turned around to position R1's recliner, for R1 to sit in, and then turned back around to assist R1 into the recliner and R1 slid out of the lift sling onto the floor. The right top lift sling strap had come unhooked from the lift cradle. R1 fell to the floor hitting the right side of his head and came to rest on his right side. CNA M called for nurse assistance in R1's room. Licensed Nurse (LN) G entered R1's room and observed R1 on the floor with his head next to the foot of his bed lying almost perpendicular to the bed on his right side. Administrative Nurse D reported to R1's room and assisted LN G in assessing R1 for obvious signs of injury. R1 denied pain during the initial assessment, pupils were reactive, and R1 was unable to complete a full neuro check due to R1's position. Due to the severity of the fall, R1 was not moved. R1 was given a pillow for comfort and an ice pack for the hematoma (collection of blood trapped in the tissues of the skin or in an organ, resulting from trauma) on the right side of his head. R1 initially denied pain, but began to complain of head, neck, and shoulder pain while on the floor. The Hoyer lift was in the room with three of the straps on the sling still attached to the lift and the right top sling was unhooked. The correct Hoyer sling had been used. LN H arrived to R1's room and was directed to call Emergency Medical Services (EMS) to send R1 to the local hospital for evaluation. EMS was notified at 09:25 AM and arrived at the facility at 09:30 AM and R1 left via ambulance. R1's son was notified of the fall and transported to the hospital at 09:45 AM. Upon investigation, staff reported the Hoyer lift sling straps had come unhooked from the Hoyer lift before while it was in use, but staff had not reported it to administration because it had not resulted in any injury CNA M's Notarized Witness Statement, dated 01/15/25, documented CNA N and CNA M transferred R1 from his wheelchair to go to his recliner. After lifting R1 with the lift, CNA M stated she turned to pull out R1's recliner from the wall and when she turned back around R1 was falling from the sling. The sling had come unhooked from the lift and R1 fell to his right side then slid the rest of the way out. CNA M called over the walkie for a nurse. CNA N's Notarized Witness Statement, dated 01/15/25, documented at approximately 09:20 AM, CNA M and CNA N transferred R1 from his wheelchair to his recliner. After lifting R1, CNA M turned around to pull the recliner from the wall and CNA N stated she was starting to move the lift towards the recliner and R1 started to fall out of his sling. CNA N stated she tried to catch R1, but he had already landed on the floor on his right side and then slid the rest of the way out. LN G's Notarized Witness Statement, dated 01/15/25, documented LN G heard the page for a nurse to respond to R1's room. LN G entered R1's room at approximately 09:20 AM and R1 was lying on the floor nearly perpendicular to his bed with his head toward the foot of the bed on his right side. CNA M and CNA N were present in R1's room. CNA M and CNA N stated they were transferring R1 with the full lift and while R1 was suspended in the air, staff were adjusting the wheelchair out of the path of the transfer, and CNA M turned to move the recliner forward and turned back around and R1 was falling to the floor. R1 landed on his head on the floor according to CNAs report. The full lift remained in R1's room and three of the lift sling straps remained attached to the lift and the front right side sling strap was no longer connected to the lift. CNA M and CNA N stated the right front lift strap came off of the hook during the transfer and caused R1 to slide out of the suspended sling and fall to the ground. LN G assessed R1 and asked R1 if he was okay and R1 replied, Yes, I think so. R1 denied pain at that time. CNA M sat on the floor beside R1. LN G assessed R1's head and noted a fluid-filled hematoma to the right center top of the head. A small amount of bleeding was noted from a pinpoint area to the top of the resident's head/forehead. Administrative Nurse D and LN H entered the resident's room. Administrative Nurse D instructed LN J to call for the ambulance and notify the emergency room , R1's primary care provider, and R1's responsible party. R1 left with EMS by ambulance on a scoop board. The Radiology Report, dated 01/15/25, documented R1 sustained an acute type II odontoid process (neck) fracture without significant displacement. The Discharge Instructions, dated 01/16/25, documented R1's diagnoses were neck fracture and urinary tract infection. The discharge instructions directed R1 to wear the C-collar (medical device to prevent movement of the neck) for six to eight weeks. A follow-up appointment was scheduled for 02/04/25. The Discharge Summary, dated 01/16/25, documented R1 was a [AGE] year-old male who admitted to the hospital after sustaining a neck fracture after a fall from a Hoyer lift. R1 hit his forehead on the floor when he fell , which resulted in a hematoma to his forehead and neck fracture. R1's case was discussed with neurosurgery who recommended C-collar placement for six to eight weeks to allow for healing. R1 admitted to the hospital overnight for pain control and to ensure he tolerated the C-collar. The neurosurgeon stated at R1's age he could refuse the C-collar as long as R1's family understood the risks of an unstable neck fracture and the potential for a spinal cord injury without the C-collar. Given R1's age, and previous status at the nursing home, R1's prognosis was noted to be guarded. If R1 continued to decline it would be appropriate for comfort care measures at the nursing home. On 01/21/25 at 10:45 AM R1 laid in bed with his eyes closed. The head of the bed was up at 40 degrees. R1 wore a C-Collar around his neck. R1's chin continually dropped below the chin holder of the C-collar, and LN I placed her hand on R1's forehead pushed his head up and replaced the C-collar under R1's chin. R1 had a large purple bruise on his right temple. R1 did not open his eyes or respond verbally. On 01/21/25 at 10:45 AM, LN I stated R1 was running a temperature and she called his doctor to report the findings. LN I stated she felt like R1 had stasis pneumonia as his lungs were course. LN I stated no CNA had ever reported to her the straps on the Hoyer lift would come off intermittently, otherwise the facility would not have been using that Hoyer lift. LN I stated after R1 came back with the C-collar there was no way he could eat normal food, so the facility had speech therapy consult and they changed R1's diet to pureed with nectar consistency fluids and R1 was a full assist for eating and drinking. LN I stated right after R1 came back she gave him a drink of water through a straw, R1 was so very thirsty, kept drinking, and then ended up coughing. LN I thought R1 aspirated at that time. On 01/21/25 at 11:00 AM, CNA M stated she and CNA N went into R1's room to get him from his wheelchair to his recliner after breakfast. CNA M stated they lifted R1 into the air and CNA N removed the wheelchair while CNA M positioned R1's recliner away from the wall so he could be sat down. When CNA M turned around, R1 was falling from the lift sling. CNA M stated she hated that Hoyer lift because the lift sling hooks would come off of the Hoyer attachments. CNA M stated she reported this finding to the administration but was told to just watch the straps. On 01/21/25 at 11:15 AM, Administrative Nurse D stated R1's fall was completely preventable if the CNAs reported the lift sling straps were coming off during transfers. Administrative Nurse D stated the CNAs reported another time that the straps came off and it was when a resident was barely off the bed and the lower strap came unhooked and dropped the resident's leg about two inches to the bed. Administrative Nurse D stated the Hoyer lift had been removed from the facility and was inaccessible to staff. The facility rented another Hoyer lift from a medical equipment provider. The facility educated all current staff to notify administration when equipment was not working properly. The facility educated all current staff on how to use the new lift safely and lift use competencies were completed for all current staff. The facility's Accidents Policy, revised 08/2022, documented our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes, Quality Assurance reviews of safety and incident/accident reports, and facility-wide commitment to safety at all levels of the organization including staff, residents and families. Employees shall be trained and in serviced on potential hazards and how to identify and report accident hazards and try to prevent avoidable accidents. The facility's Safe Lifting and Movement of Residents Policy, revised 10/2009, documented in order to protect the safety and well-being of staff and residents and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. Staff responsible for direct resident care will be trained in the use of manual and mechanical lifting devices. Mechanical lifting devices shall be used for heavy lifting, including lifting and moving residents when necessary. Staff will be observed for competency in using mechanical lifts periodically for adherence to policies and procedures regarding use of equipment and safe lifting techniques. Maintenance Staff shall perform routine checks and maintenance of equipment used for lifting to ensure that it remains in good working order. All equipment design and use will meet or exceed guidelines and regulations concerning resident safety. The facility failed to provide a safe environment free from preventable accidents for R1. This deficient practice placed R1 at risk for death, injury, pain, and a decrease in daily function. On 01/21/25 at 12:20 PM, Administrative Staff A and Administrative Nurse D were provided the IJ template and notified the facility failed to provide a safe environment free from preventable accidents for R1. The facility identified and implemented immediate corrective actions, which were completed on 01/15/25 and prior to the start of the survey on 01/21/25 and included: the Hoyer lift was removed from use and could no longer be accessed by staff. A new lift was rented from a medical equipment company, education was provided to current nursing staff on how to use the new lift, current staff were educated on the need to notify administration when equipment is not working properly, and Total Mechanical Lift competency was completed for all current nursing staff. The corrective actions were verified on-site on 01/21/25 at 11:30 AM. Due to the corrective action completed before the onsite survey, the citation was deemed past noncompliance at a J scope and severity.

The facility had a census of 36 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to store and administer medications in a safe manner for one of two medication carts and the facility failed to discard an expired bottle of melatonin (supplement used to treat sleeping problems) in one of two medication rooms. This placed the residents at risk to receive expired supplements and medication errors. Findings included: - On 08/02/23 at 07:28 AM, observation during medication administration revealed Resident (R) 28 entered the dining room. Licensed Nurse (LN) G opened the top drawer of her medication cart where R28 and R12s' medications were set up in medication cups with each resident's initials on the two separate cups. On 08/02/23 at 07:28 AM, LN G stated when she comes in to work in the morning, she pre-sets the residents medications who she know would be in the dining room at 07:00 AM. On 08/02/23 at 08:32 AM, LN G stated she should not set up residents medications ahead of time. On 08/02/23 at 08:37 AM, Administrative Nurse D stated staff should not set medications up prior to administering them; they should pop them out of the card then immediately administer to the residents. The facility's Administering oral Medications Policy, dated 05/22, instructed staff to follow the following procedure when administering residents medications: Staff should verify that there is a physician's medication order for this procedure. review the resident's care plan to assess for any special needs of the resident. assemble the equipment, wash hands, arrange supplies in the medication room or move the medication cart outside the resident's room place the Medication Administration Record (MAR) within easy viewing distance. unlock the medication cart. select the drug from the unit dose drawer or stock supply. check the label on the medication and confirm the medication name and dose with MAR . Check the expiration date on the medication. return any expire medication to the pharmacy. check the medication dose. recheck to confirm the proper dose. prepare the correct dose of medication, confirm identity of the resident explain the procedure to the resident place medications on the bedside table or tray then administer the medications. The facility failed to administer and store medications in a safe manner, placing the residents at risk for receiving the wrong medications. - On 08/02/23 at 09:40 AM, observation in the medication room revealed a bottle of melatonin, 1 milligram (mg) with expiration date 06/2023. On 08/02/23 at 09:41, Licensed Nurse (LN) N verified the above observation, discarded the medication, and stated the night shift was responsible for checking expiration dates on medications in the medication room. LN Nstated the pharmacist came to the facility on ce a month and checked the carts. On 08/02/23 at 2:00 PM, Administrative Nurse D stated night shift staff should check expiration dates on medications in the medication room and discard all expired medications. The facility's Storage of Medications Policy, dated 05/22 documented the facility should not use discontinued, outdated, or deteriorated drugs or biologicals, all such drugs should be returned to the dispensing pharmacy or destroyed. The facility failed to discard or destroy an expired bottle of melatonin. This placed the residents at risk for receiving an expired/ineffective dose.

The facility had a census of 36 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to store food in accordance with professional standards for food service safety for the residents who resided in the facility and received food from the nutrition refrigerator, when staff failed to label and date food items kept in the nutrition refrigerator. The facility staff failed to assess and record freezer temperatures for the nutrition freezer. This placed the affected residents at risk for foodborne illness. Findings included: - On 08/01/23 at 09:53 AM, observation revealed the following in the nutrition refrigerator: An unlabeled, undated box of chicken alfredo meal, Two unlabeled, undated 15.5-ounce jars of salsa. An unlabeled, undated deli meat sandwich. A sticky brown substance in the refrigerator door in the small compartment on the left upper corner, approximately four inches (in) x two in. The refrigerator trays had numerous areas of a blackish substance which varied in size. The freezer lacked a thermometer and lacked evidenced staff measured the freezer temperature for August 2023. The July 2023 temperature logs for the nutrition refrigerator/freezer lacked evidence staff measures freezer temperatures. On 08/01/23 at 10:00 AM, Administrative Nurse D verified the above finding and stated nursing staff should be checking and recording temperatures in the nutrition freezer. On 08/01/23 at 02:00 PM, Certified Dietary Manager (CDM) BB verified the lack of a freezer log for July 2023 and stated nursing was responsible for checking and recording the temperatures in the nutrition freezer. The facility's Refrigerators and Freezers Policy, dated 10/22, documented monthly tracking sheets for all refrigerators and freezers would be posted to record temperatures. All food should be appropriately labeled and dated to ensure proper rotation by expiration dates. received dates (dates of delivery) would be marked on cases and on individual items removed from cases for storage. The facility failed to store food in accordance with professional standards for food service safety. This placed the affected residents at risk for receiving foodborne illness.

The facility had a census of 36 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to ensure the number of nursing (licensed and unlicensed) staff and actual hours worked was posted for all four days of the onsite survey. Findings included: - On 08/01/23 (Tuesday) at 09:00 AM, observation revealed the daily nursing staff numbers and hours was not posted in the facility. On 08/02/23 (Wednesday) at 08:00 AM, observation revealed the daily nursing staff numbers and hours was not posted in the facility. On 08/03/23 (Thursday) at 08:00 AM, observation revealed the daily nursing staff numbers and hours was not posted in the facility. On 08/07/23 (Monday) at 08:30 AM, observation revealed the daily nursing staff numbers and hours was not posted in the facility. On 08/07/23 at 08:58 AM, Licensed Nurse (LN) G stated the daily staffing schedule was in a notebook at the front desk . On 08/07/23 at 10:09 AM, Administrative Nurse D verified the daily staffing schedule was not posted and stated it was kept in a green binder at the front desk, cooperate told her the regulation changed and the facility had to put each shift in the notebook. The facility's Posted Direct Care Daily Staffing Numbers Policy, dated 11/22, documented at the beginning of each shift, the number of licensed Nurses and the number of unlicensed nursing personal directly responsible for the resident care would be posted in prominent location (accessible to residents and visitors) and in a clear and readable form. The facility failed to ensure the daily staff nursing staff numbers and actual hours worked was posted for all four days of the onsite survey.

The facility had a census of 43 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to distribute and serve food in accordance with professional standards for food service safety in one of one facility kitchen. This placed the 43 residents who received food from the facility kitchen at risk for foodborne illness. Findings included: - On 02/10/22 at 09:45 AM, observation revealed the following: The outer layer of wood peeling from eight under counter cupboards, two upper cabinets by the eyewash station, and nine drawers. The shelf above the stove had sticky gray substance. Missing mopboard, approximately 18 inches (in), below the three sink and approximately 4 feet (ft) by the steam table. On 02/10/22 at 09:45 AM, Dietary Staff (DS) BB verified the above findings. The facility's Sanitization policy, revised December 2021, documented all kitchens, kitchen areas and dining areas should be kept clean. The food services manager would be responsible for scheduling staff for regular cleaning of kitchen and dining areas. The facility failed to distribute and serve food in accordance with professional standards for food service safety in one of one facility kitchen. This placed the 43 residents who received food from the facility kitchen at risk for foodborne illness.

The facility had a census of 43 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to maintain an environment free of accident hazards for two of two shower/whirlpool rooms when the facility failed to adequately secure harmful chemicals. This placed five cognitively impaired, independently mobile residents residing in the facility at risk for harm or injury related to avoidable hazards. Findings included: - On 02/09/22 at 08:40 AM, observation revealed the west shower room with an unlocked cabinet. The cabinet contained a quart spray bottle of Peroxide Multi surface cleaner and disinfectant and a quart spray bottle of lemon scented disinfectant. Both spray bottles labels documented, Hazardous to humans do not ingest, can cause eye irritation. On 02/09/22 at 08:50 AM, observation revealed the north whirlpool room with an unlocked cabinet. The cabinet contained two quart spray bottles of Bio Enzymatic Odor Eliminator and one quart spray bottle of Peroxide Multi surface cleaner and disinfectant. The three bottles labels documented, Hazardous to humans do not ingest, can cause eye irritation. On 02/09/22 at 08:50 AM, Administrative Staff A verified the west shower room and north whirlpool room cabinets should be locked at all times. On 02/09/22 at 9:05 AM, Administrative Nurse D verified the west shower room and north whirlpool room cabinets contained chemicals and should be locked at all times. Administrative Nurse D verified a total of five cognitively impaired independently mobile residents resided in the facility. The facility's Cleaning, Disinfecting and Storage of Chemicals policy, dated May 2021, documented it is the intent of the facility to keep all chemicals out of reach of cognitively impaired residents. All chemicals should be stored in a locked cabinet. The facility failed to adequately secure harmful chemicals in two of two shower/whirlpool rooms, placing the cognitively impaired independently mobile residents at risk for injury.

The facility had a census of 43 residents. The sample included 12 residents, with one reviewed for change of condition. Based on observation, record review, and interview, the facility failed to notify Resident (R) 140's representative when staff ripped off his loose toenail during a transfer. This placed R140 at risk for uninformed treatment decisions and/or delayed wound care treatments. Findings included: - R140's Electronic Medical Record (EMR) documented R140 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R140's Quarterly Minimum Data Set, (MDS) dated [DATE], documented the resident had short- and long-term memory problems and severe impaired cognition. The MDS documented R140 required total staff assistance with locomotion off unit and extensive staff assistance with the rest of his activities of daily livings (ADLs). The MDS documented R140 had no skin issues. R140's [CONDITION(S)]/[CONDITION(S)] Care Plan, revised on 12/30/21, documented the resident had a stroke which affected his left side and required extensive staff assistance with ADLs. R140's Skin Inspection Care Plan, revised on 12/30/21, instructed staff to check his nail length, trim, clean them on bath day as necessary, and report any changes to the nurse. The Nurses Note, dated 02/02/22 at 07:02 AM, documented R140's left great toenail was loose, very thick and discolored, and ripped off while staff transferred him to the wheelchair for his shower. The Nurses Note documented R140's left great toenail bed was bloody and staff applied pressure, cleansed it with wound cleanser, wrapped the toe in gauze, and secured it with tape. Review of R140's EMR lacked documentation R140's representative was notified of the incident. On 02/10/22 at 01:17 PM, observation revealed Licensed Nurse (LN) G entered R140's room and told him she was going to change the dressing on his left great toenail. LN G washed her hands, applied gloves, removed the dressing. The wound bed was red with no bleeding. There was bruising at the tip of the resident's toe. LN G removed and discarded her gloves, applied new gloves, and cleansed the wound area with normal saline on a 4 x 4 gauze pad. R140 jerked his foot away. LN G removed and discarded her gloves, applied new gloves, squeezed [MEDICATION(S)] (topical antibiotic) ointment onto the wound, applied a [MEDICATION(S)] (non stick dressing) pad, wrapped the great toe with gauze, and secured it with tape. On 02/16/22 at 01:24 PM, LN H verified lack of documentation in R140's EMR regarding notification of R140's representative in regards to the incident where his toenail was ripped off. On 02/16/22 at 01:58 PM, Administrative Nurse D verified R140's representative had not been notified of the incident where his toenail was ripped off during a transfer. Administrative Nurse D stated it happened around shift change and both nurses thought the other one had notified the representative, but neither had contacted R140's representative. The facility's Change in a Resident's Condition or Status policy, revised on May 2021, documented the facility staff should promptly notify the resident, his or her attending physician and resident representative of changes in the resident's medical/mental condition and/or status. The facility failed to notify R140's representative when staff ripped off his toenail during a transfer. This placed R140 at risk for uninformed treatment decisions and/or delayed wound care treatments.

The facility had a census of 44 residents. The sample included three residents, with three reviewed for abuse. Based on observation, record review, and interview, the facility failed to assess Resident (R) 1 (a cognitively intact resident) after she alleged Certified Nurse Aide (CNA) M touched her inappropriately. R1 reported the allegation to the Director of Nursing (DON), who failed to thoroughly investigate the incident and failed to suspend CNA M for almost three hours after the allegation (after finishing his shift), which allowed CNA M to care for R1 again and care for other residents in the facility. The facility's failure placed R1 in immediate jeopardy. Findings investigation: - R1's Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had intact cognition, required extensive assistance of two staff for toileting and personal hygiene, and depended on two staff for transfers. The Activities of Daily Living (ADL) Care Area Assessment (CAA), dated 12/20/20, documented the resident required extensive to total assistance with cares due to her [CONDITION(S)] (MS-a chronic, progressive disease involving damage to the sheaths of nerve cells in the brain and spinal cord)). The CAA further documented the resident occasionally incontinent and staff toileted the resident as needed. The Bladder Incontinence Care Plan, dated 04/07/21, recorded the resident as occasionally incontinent of bladder related to poor mobility and poor bladder control due to her MS, and directed staff to assist the resident as needed to toilet or commode with a full lift and two staff. The Facility Investigation, dated 06/01/21, documented the resident reported the agency nightshift nurse aide touched her inappropriately during peri-care (cleaning of the private areas). The investigation documented facility staff contacted the nurse aide's employer and advised the aide could not come back to the facility until the investigation was completed. On 06/15/21 at 09:30 AM, Administrative Nurse D stated she worked the night of the alleged incident with CNA M (06/01/21). Administrative Nurse D stated at approximately 03:15 AM the resident asked to talk to her. R1 stated that CNA M inappropriately touched her during peri care and he would not stop doing peri care until she slapped his hand away. Administrative Nurse D stated she told the resident CNA M would not go into her room alone the rest of his shift. Administrative Nurse D stated she asked CNA M if anything happened during cares and he stated the resident made inappropriate sexual comments about some candy that was shaped like male genitalia, but he ignored her. Administrative Nurse D stated she did not have the nurse aide write a statement. Administrative Nurse D stated she did not send CNA M home because there was no-one else to call to come in to replace him. Administrative Nurse D stated the resident's peri area was not red, but did not do an actual body assessment on the resident and did not chart the incident. Review of the facility's investigation lacked any witness statements. On 6/15/21 at 10:00 AM, R1 stated the nurse aide wiped her weird and that it made her feel uncomfortable. R1 stated there had been no penetration but CNA M would not stop wiping her until she told him that was enough. R1 stated CNA M told her he would be back later to finish up but never came back into her room alone again. On 6/15/21 at 04:30 PM, Administrative Staff A stated after investigating the incident, the facility felt the abuse was unsubstantiated as the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Administrative Staff A stated she decided to have the nurse aide not come back to work at the facility because it would make the resident uncomfortable. The facility's Abuse Investigations policy, dated November 2107, documented reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management. Residents will be protected from further abuse, neglect, exploitation or mistreatment while the investigation is in process. Should an incident or suspected incident of resident abuse, mistreatment, misappropriation, neglect or injury of unknown source be reported, the Administrator, or his/her designee, will appoint a member of management to investigate the alleged incident. The individual conducting the investigation will, as a minimum: a. Review the completed documentation forms; b. Review the resident's medical record to determine events leading up to the incident; c. Interview the person(s) reporting the incident; d. Interview any witnesses to the incident; e. Interview the resident (as medically appropriate); f. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; g. Interview the residents' roommate, family members, and visitors, as able or as appropriate to the situation; h. Review all events leading up to the alleged incident. Witness reports will be obtained in writing. Witnesses will be required to sign and date such reports. Employees of the facility who have been accused of resident abuse will be suspended pending investigation. The facility failed to assess R1 after she alleged CNA M touched her inappropriately. R1 reported the allegation to the DON, who failed to thoroughly investigate the incident and failed to immediately suspend CNA M. The facility's failure placed R1 in immediate jeopardy. The facility implemented in-service education for all staff regarding Abuse, Neglect, and Exploitation on 06/01/21-06/02/21. This deficient practice was identified as past non-compliance and corrected on 06/02/21.

The facility had a census of 44 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to follow droplet isolation precautions to prevent the development and transmission of communicable diseases and infection for two isolation rooms on two of four halls. Findings included: On 08/04/20 at 01:45 PM, observation revealed Social Service Staff (SSS) X in droplet isolation room on South Hall with gown not closed in back and exited room rolling up gown into hallway. SSS X then stopped in hallway and asked the housekeeper who took the trash can out of the resident's room. Further observation revealed the housekeeper provided a trash bag, and SSS X placed the soiled gown into the bag. SSS X walked down the hall to the front entrance and placed the bag in the biohazard room. On 08/04/20 at 02:30 PM, observation revealed the nurse stood outside the doorway of the isolation room in South Hall with droplet sign on door talking to staff with the back of the gown open and loose around the neck in front. On 08/04/20 at 03:12 PM, observation revealed Isolation room with droplet sign on East Hall and door wide open. Further observation revealed Activity Staff (AS) Z in room with isolation gown over her arms up to shoulders, back of gown open, face shield and mask, and no gloves. AS Z sat on resident's bed writing on an orange envelope on resident's bedside table. On 08/06/20 at 08:38 AM, observation revealed isolation room with droplet sign on South Hall, door open, and resident ate breakfast seated in chair in room. On 08/04/20 at 04:20 PM, SSS X verified she left a droplet isolation room with her soiled gown, placed it into a bag while in the hallway, and walked down the hall to the front entrance to place the bag in the biohazard room. On 08/06/20 at 08:40 AM Administrative Nurse (AN) D stated prior to entering isolation rooms staff were required to sanitize hands, put on their gowns, gloves, masks and could wear face shield if they were coughing prior to entering room. AN D stated prior to exiting isolation rooms staff should remove gowns, gloves and masks inside of room and discard in room. AN D verified the doors of isolation rooms should remain closed and gowns should cover staff's clothing. On 08/06/20 at 11:29 AM, Licensed Nurse (LN) I verified resident's in isolation precautions for droplet should have their door closed, the gowns should cover the staff's body and be closed in the back. LN I verified staff had not followed correct procedure and training needed to be completed. The facility's Isolation-Categories of Transmission-Based precautions Policy, dated January 2020, stated Transmission-Based Precautions should be used when caring for residents who are documented or suspected to have communicable diseases or infections that can be transmitted to others. Droplet Precautions should be used for anyone who is documented or suspected to be infected with microorganisms transmitted by droplets (larger than five microns) (a micron is a unit of length equal to one millionth of a meter) that can be generated by the individual coughing, sneezing, talking, or by the performance of procedures such as suctioning. The room door should be closed, the resident kept in the room, staff must wear approved respiratory protection when entering the room, staff should wear a gown (clean, nonsterile) for all interactions that may involve contact with the resident or potentially contaminated items in the resident's environment. The gown must be removed and hand hygiene performed before leaving the resident's environment. After removing the gown, the staff should not allow clothing to contact potentially contaminated environmental surfaces. The facility failed to follow droplet isolation precautions to prevent the development and transmission of communicable diseases and infection for two isolation rooms on two of four halls, placing residents and staff at risk of development and transmission of communicable diseases and infection.

The facility had a census of 44 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to provide a safe, clean, comfortable and homelike environment on two of four halls in the facility. Findings included: - On 08/03/20 at 10:10 AM, observation during initial tour revealed the following: Fluorescent light coverings above the north nurse's station contained numerous bugs. West Hall room [ROOM NUMBER] had multiple scratches and chunks out of the dry wall, approximately three inches by six inches, on the wall by a resident's bed and two unfilled holes. The front entrance nurse's station, outside the administrator's office, with approximately 10 feet (ft) x four ft area of buckled carpet. On 08/06/20 at 08:36 AM, during the environmental tour, Maintenance Staff (MS) U verified the above findings and stated the facility had plans to replace the carpet, but they had been put on hold because of the pandemic (outbreak of disease) and restriction on visitors. MS U stated if staff had any concerns, they were to place them in the notebook at the West nurse's station and he was unaware of the scratches and chunks out of the dry wall. The facility's Supervision, Maintenance policy, dated January 2020, documented the day to day maintenance operation is under the supervision of the maintenance director. The policy documented the administrator is responsible for the overall supervision of the maintenance department. The maintenance director is responsible for scheduling preventative maintenance service. The facility failed to provide a safe, clean environment, placing the residents at risk for accidents and an unclean environment.

The facility had a census of 44 residents. The sample included 12 residents. Based on observation and interview, the facility failed to maintain medication storage in a safe manner for one of two medication carts. Findings included: - On 08/03/20 at 11:17 AM, during initial tour, one medication cart found unlocked, and unattended by staff, at the north nurses station area. The cart contained medication cards, bottles, various dispensing containers from a pharmacy, and stock medications. The cart also contained over the counter and prescription medications, not limited to: [MEDICATION NAME], used to treat minor aches and pains, and reduce fever multivitamins, used as a dietary supplement magnesium oxide, used for magnesium deficiency stool softeners aspirin, used to treat pain, fever, headache, and inflammation iron, used to treat red blood cells that enable them to carry oxygen folic acid, a vitamin used to treat certain type of [MEDICAL CONDITION] (condition without enough healthy red blood cells to carry adequate oxygen to body tissues) [MEDICATION NAME], used as a laxative (used to help increase stool motility, bulk and frequency) [MEDICATION NAME], treats heartburn, a damaged esophagus, stomach ulcers and gastroespohageal reflux disease (back flow of stomach contents to the esophagus) [MEDICATION NAME], used to treat fever and mild to severe pain [MEDICATION NAME], used as laxative [MEDICATION NAME], used to treat fever and pain milk of magnesium, used as a laxative [MEDICATION NAME], used to treat pain and itching [MEDICATION NAME], used for [MEDICAL CONDITION] (inability to sleep) alendronate-used to treat and prevent [MEDICAL CONDITION] (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk) [MEDICATION NAME], to treat diarrhea (loose, watery stools that occur more frequently than usual) [MEDICATION NAME], to treat pain, itching, and swelling by many skin diseases [MEDICATION NAME], to treat swelling caused by heat, liver and kidney disease apexiban, to prevent blood clots [MEDICATION NAME], used to treat depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness), [MEDICAL CONDITION] (anxiety disorder characterized by recurrent and persistent thoughts, ideas and feelings of obsessions severe to cause marked distress, consume considerable time or significantly interfere with the resident's occupational, social or interpersonal functioning) and posttraumatic stress disorder ( psychiatric disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress, such as natural disaster, military combat, serious automobile accident, airplane crash or physical torture), and panic attacks [MEDICATION NAME] inhaler, used to prevent and treat difficulty breathing [MEDICATION NAME] inhaler, used to treat [MEDICAL CONDITION] various eye drops On 08/03/20 at 11:17 am, Licensed Nurse (LN) H, verified the cart should have been locked. On 08/06/2020 at 01:38 PM, Administrative Nurse D verified the medication cart should be locked if unattended. The facility's Storage of Medication policy, dated January 2020, documented the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. The compartments (including, but not limited to drawers, cabinets, rooms, refrigerators, carts and boxes) containing drugs and biologicals shall be locked when not in use, and trays or cart to transport such items shall not be left unattended if open or otherwise potentially available to others. The facility failed to maintain and secure medications in a safe manner, placing eight cognitively impaired, independently mobile residents at risk for medication accessibility and ingestion.

The facility had a census of 44 residents. The sample included 12 residents. Based on record review and interview, the facility failed to notify the physician for one unsampled resident Resident (R) 45's decreased oxygen saturation level. Findings included: - R45's Physician order [REDACTED]. fibrosis (a lung disease that occurs when lung tissue becomes damaged and scarred), and interstitial lung disease (disorder that causes progressive scarring of lung tissue). The Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had moderately impaired cognition, required extensive assistance of one staff for Activities of Daily Living (ADLs), used oxygen, and received occupational, physical, and respiratory therapy. The ADL Care Area Assessment (CAA), dated 04/19/20, documented the resident required assistance with ADL's due to shortness of breath, wore oxygen, and at risk for further decline. The [MEDICAL CONDITION] Care Plan, dated 06/09/20, documented the resident had [MEDICAL CONDITION] and readmitted to the facility on [DATE] for exacerbation of [MEDICAL CONDITION]. The care plan directed staff to monitor, document, and report to the medical doctor any signs or symptoms of congestive heart (shortness of breath upon exertion, cool skin, cough, weakness, crackles and wheezes upon listening to lung sounds, weakness, fatigue, lethargy, increased heart rate, and disorientation) and the resident received oxygen therapy at 5 liters continuously and 6 liters with activity. The POS, dated 06/09/20, directed staff to provide the resident oxygen therapy at 5 liters via nasal cannula, increase to 6 liters with activity, and may use oxygen mask for short time to help with shortness of air symptoms to keep oxygen levels above 90%. The orders directed staff to administer [MEDICATION NAME] sulfate nebulizer solution (breathing treatment) four times a day and every four hours, as needed, for shortness of breath. The Treatment Administration and Vital Sign Record, dated 06/14/20, recorded the following breathing treatments without follow-up assessment: 06:35 AM, oxygen saturation of 98% prior to treatment 11:04 AM, oxygen saturation of 95% prior to treatment 04:26 PM, oxygen saturation of 94% prior to treatment 08:25 PM, oxygen saturation of 81% prior to treatment The Nurse's Note, dated 06/14/20 at 08:25 PM, recorded treatment given as ordered, oxygen on at 6 liters via cannula, saturation at 81% and the resident rested in bed and voiced no complaints at that time. The Nurse's Note, dated 06/14/20 at 11:05 PM, recorded the resident lying on the floor in the doorway of the bathroom, prone (chest down, back up) with face turned to her left, no signs of circulation or respirations noted, and Do Not Resuscitate (DNR) on file. Review of R45's medical record lacked documentation staff notified the physician of R45's decreased oxygen saturation at 08:25 PM, or that staff further assessed the resident's condition. On 06/06/20 at 01:38 PM, Administrative Nurse D stated nursing staff should have reassessed R45's oxygen saturation levels and notified the physician if the saturation remained low. The facility's Change in Resident 's Condition or Status policy, dated January 2020, documented the Nurse Supervisor/Charge Nurse will notify the attending physician or on-call physician and resident's representative of a significant change in the resident's physical, mental, or psychosocial status in either life threatening conditions or clinical complications. The facility failed to notify R45's physician of the residents decrease in oxygen saturation, placing the resident at risk for further decline.

The facility had a census of 44 residents. The sample included 12 residents with three reviewed for behaviors. Based on observation, record review, and interview, the facility failed to address behaviors and the use of a leg immobilizer on the care plan for one of three sampled residents, Resident (R) 7. Findings included: - R7's Quarterly/Medicare 5-Day Minimum Data Set (MDS), dated [DATE], documented the resident had moderately impaired decision making skills and required extensive staff assistance with bed mobility, dressing, toileting, and personal hygiene. The assessment documented the resident had other behaviors daily, surgical wound care, and a nonsurgical dressing. The Behavior Care Area Assessment (CAA), dated 05/18/20, documented the resident moaned loudly and cried, staff contributed this more to discomfort and sadness then behavior. The CAA documented the resident was at risk for mood concerns related to pain and current condition. The Mood Care Plan, dated 07/23/20, documented the resident had a mood problem due to amputation of partial foot then above the knee due to complications. The care plan directed staff to assist the resident, family, and caregivers to identify and reinforce strengths, and positive coping skills. The care plan failed to document the resident's behavior of removing the dressings on her left [MEDICAL CONDITION] (BKA). The Skin Impairment Care Plan, dated 07/23/20, directed staff to monitor the resident's surgical wound for signs and symptoms of infection, notify the physician as needed, orient the resident as needed to the care regiment, current medical needs and interventions. The care plan failed to document the resident had a full leg immobilizer (a brace to keep the leg straight and immobile). The physician's orders [REDACTED]. The physician's orders [REDACTED]. The physician's orders [REDACTED]. The physician's orders [REDACTED]. The physician's orders [REDACTED]. The physician's orders [REDACTED]. The physician's orders [REDACTED]. The physician's orders [REDACTED]. The physician's orders [REDACTED]. when resident removed the dressing. (The order was obtained after this surveyor asked to see the order.) The physician's orders [REDACTED]. The order directed staff to cover the wound bed with 4 x 4's, silver alginate (a dressing that absorbs exudates and forms a gel-like covering over the wound), cover with Abdominal (ABD) gauze pad (absorbs drainage from wounds and roll gauze, then cover with an ACE bandage. The Nurse's Note, dated 07/20/20 at 02:48 PM, documented the facility readmitted the resident to skilled care after she had a BKA of the left leg. The note further documented the resident had a full leg immobilizor and an ACE wrap over her wound that was to remain in place until her physician appointment on 07/23/2020. The Nurse's Note, dated 07/24/20 at 06:40 PM, documented the resident pushed the leg immobilizer and dressing off four times during day shift. The note further documented staff applied loose fitting tubi grip (elastic bandage intended to aid recovery of an injured limb) over the wound and reapplied the leg immobilzer. The note documented the physician ordered a decrease in the resident's [MEDICATION NAME] to one tablet every eight hours as needed. The Nurse's Note, dated 07/29/20 at 08:40 PM, documented the resident removed the immobilizer and tried to remove the dressing. The note further documented staff readjusted the dressing, applied the immobilizer, and explained to the resident the immobilizer wound keep the dressing and wrap into place. The resident denied removing the immobilizer. The Nurse's Note, dated 07/30/20 at 12:01 PM, documented the resident pulled off the immobilizer and the dressing from her left leg stump. The note further documented staff covered the wound with ABD gauze pad, 4 x 4 gauze pad, secured the dressing with kling wrap, and reapplied the immobilizer. Staff asked the resident to leave the immobilizer and dressing on. The Nurse's Note, dated 07/31/20 at 09:00 PM, documented the resident removed the ace wrap to her dressing twice since 08:00 PM, and when staff checked on the resident, the dressing was completely off. The resident stated she did not remove the dressing. The Nurse's Note, dated 08/02/20 at 12:30 AM, documented staff reapplied the dressing of three ABD pads, a 4 x 4 gauze, and covered it with kling gauze, tape, and wrapped with an ACE wrap. The Nurse's Note, dated 08/02/20 at 05:41 PM, documented staff contacted the emergency room (ER)regarding the resident's pain and behaviors. The resident continued to cry out and removed the dressing off of her left leg wound. The note further documented the physician increased the resident's pain [MEDICATION NAME] to 20 mcg/hr every week, placed an additional 10 mcg/hr patch that day and directed staff replace both patches on 08/07/20. The Nurse's Note, dated 08/03/20 at 12:45 AM, documented the resident removed her wound dressing and staff reapplied the dressing. On 08/03/20 at 03:43 PM, observation revealed the resident in her recliner, footrest in the up position, resident's dressing loose and appeared the resident had pulled on the gauze wrap. Further observation revealed no leg immobilizer on the resident's left leg. On 08/04/20 at 01:13 PM, observation revealed the resident in her recliner, footrest in the up position, left leg immobilizer in place. On 08/05/20 at 01:28 PM, observation revealed the resident in her recliner, no dressing to her left leg wound, and a 4 x 4 with dried blood still stuck to the wound. On 08/05/20 01:45 PM, observation revealed Licensed Nurse (LN) H placed a bed pad under the resident left leg stump, cleansed the wound with wound cleanser, applied a 4 x 4 and ABD pad, wrapped the dressing with an ACE wrap, and applied the immobilizer to the resident's left leg. On 08/04/20 at 10:45 AM, LN G stated the resident frequently removed the dressing and staff had to redress the wound. LN G verified there was not an order from the physician to redress the wound. On 08/04/20 at 1:31 PM, Certified Nurse Aide (CNA) P stated the resident frequently removed the bandage on the wound and did not like when staff put the immobilizer on. On 08/04/20 at 03:00 PM, CNA Q stated staff tried to check on her more often and when the resident removed the bandage they told the nurse so the wound could be redressed. On 08/05/20 at 01:34 PM, LN H stated the resident removed the bandage multiple times a day and would say she didn't take it off. On 08/06/20 at 11:37 AM, Administrative Nurse D verified the resident's behaviors of removing the dressing and the leg immobilizer should have been on the care plan. The facility's Comprehensive Assessment, policy, dated January 2020, documented a comprehensive care plan would be developed within 14 days, and the comprehensive assessment would be used to develop, review and revise the resident's comprehensive care plan. The facility failed to identify and address R7's behaviors and the use of a leg immobilizer on her care plan, placing the resident at risk for inappropriate care.

The facility had a census of 26 residents. The sample included 3 residents. Based on observation, record review and interview the facility failed to provide an environment that was free from accident hazards for 1 of 3 sampled residents reviewed for accidents who sustained a burn from a space heater.(#1) Findings included: - Resident #1 ' s signed physician orders, dated 5/1/14-5/30/14, indicated the resident had [DIAGNOSES REDACTED]. impaired blood flow to your brain). The 4/23/14 quarterly (MDS) Minimum Data Set 3.0 assessment indicated the resident required extensive assistance with (ADLs) Activities of Daily Living and had moderately impaired cognition with a (BIMS) Brief Interview for Mental Status score of 8. The MDS indicated the resident had impairment on his/her upper extremity on one side and impairment on both sides of his/her lower extremities. The 4/23/14 care plan instructed the staff to question unrealistic or dangerous decisions and to ensure the resident would not experience injury related to poor decision making and poor short term memory. The care plan instructed the staff to monitor independent transfers and report unsafe practices, and to provide assistance of 1-2 staff with transfers and toileting. Review of the care plan revealed no mention of an electrical space heater in the resident's room due to his/her complaints of being cold. The weekly wound record for the resident revealed the following: On 4/25/14 the resident had no documentation in regards to a burn. On 5/4/14 the resident had a 6 (cm) centimeter long by 3 cm wide burn area, with redness and blistered skin on the back of his/her right arm above his/her elbow. On 5/9/14 the resident had a "superficial burn" that remained the same size as above. On 5/16/14 the resident had a burn area to the back of his/her right arm above his/her elbow with 2 small, 1 cm, open areas with pink skin surrounding the open areas. On 5/23/14 the burn area was healed. (19 days after acquiring the burn) The 5/4/14 at 6:00 AM, nurse's note indicated an aide had reported to the nurse the resident had a red blistered area to the back of his/her right arm just above the elbow. The note indicated the nurse assessed the resident and the area had a broken blister over the red area measuring 6 cm long by 3 cm wide. The note indicated the resident had a personal heater a few inches from his/her recliner and the nurse removed the heater from his/her room. The 5/4/14 at 10:27 AM, nurse's note indicated the nurse notified the hospital emergency department of the resident's burn. (4 hours after the aide reported the resident's burn to the nurse) The 5/4/14 at 10:31 AM, nurse's note indicated the wound on the back of the resident's right arm measured 9 cm long by 3 cm wide. (an increase in size from 6 cm to 9 cm long.) The 5/4/14 at 1:30 PM, nurse's note indicated the nurse received an order from the nurse practitioner to administer Keflex (a medication used to treat infections caused by bacteria) 500 (mg) milligram, three times a day, for 10 days, and to debride (to remove all materials that may promote infection and impede healing) the area, wash with soap and water, cover with a sterile Vaseline dressing, and follow up in the clinic in 3 or 4 days if the area had no improvement. Review of the medical record revealed no documentation the staff provided first aide, or and intervention to the resident's burn from 6 AM until 1:30 PM. (7 1/2 hours) The 5/4/14 at 1:54PM, nurse's note indicated the nurse notified the nurse practitioner the resident already received Zithromax (an antibiotic) and the nurse practitioner cancelled the order for Keflex. The 5/4/14 at 8:25 PM, nurse's note indicated the nurse changed the resident's dressing to the burn above his/her elbow and the area was mostly debrided, with a blister in the center of the wound. The nurse's note indicated the nurse applied a sterile Vaseline gauze to the burn, covered the area with a telfa dressing, and secured the dressing with mefix fabric tape. The nurse's note further indicated an aide reported the area on the resident's right arm was present at bedtime on 5/3/14. The medical record revealed no documentation a nurse assessed the area on 5/3/14. The 5/10/14 at 1:19 PM, nurse's note indicated the burn area on the resident's right arm had bright red and white areas and no drainage. The note indicated when the nurse cleansed the wound and a little bit of the white slough (dead tissue separating from living tissue) came off, and the nurse applied a sterile Vaseline gauze, a telfa dressing, and secured the dressing with mefix tape. The 5/11/14 at 12:04 PM nurse's note indicated the staff faxed the nurse practitioner to inquire about continuing the current treatment to the burn area twice a day. The 5/13/14 at 10:10 AM nurse's note indicated the nurse received an order from the nurse practitioner to change the resident's treatment to the burn area on his/her right arm to bacitracin (a medication used to prevent minor infections caused by small cuts, scrapes, or burns) twice a day and cover the area with a dressing until healed. The 5/15/14 at 8:55 PM nurse's note indicated the burn on the resident's right upper arm had two, round open areas, 1 cm in diameter, with a white center and the skin surrounding the open area was pink. On 6/2/14 at 4:10 PM, observation revealed the resident's right upper arm, above the elbow, had 2 small raised pea size white areas of scar tissue, surrounded by slightly pink tissue. On 6/3/14 at 8:07 AM, observation revealed the facility's space heater, used for the resident at the time of the incident, stored in an empty resident room. Observation revealed the heating device was a Sunbeam model SH 1500 enclosed inside a wooden device, with 4 rolling wheels on the bottom, that stood approximately 18 inches from the floor and was approximately 14 inches wide. Further observation revealed approximately 2 inches from the top of the wooden device a metal strip, approximately 12 inches long and 2 inches wide, where the air flow blew out of the device. The product information indicated it produced an output of room temperature plus 120 degrees. No safety information was listed. On 6/3/14 at 9:29 AM, observation revealed Administrative Nurse A turned on the heating device, and with the device on and air flowing through the metal strip, he/she obtained the temperature of the metal strip at 195 degrees at 9:30 AM. (1 minute after turning the heating device on). Observation revealed Administrative Nurse A turned off the heating device, no air flow through the metal strip, the temperature of the metal strip was 189.7. On 6/3/14 at 10:48 AM, observation revealed Nurse B illustrated how the resident sat in the recliner and where the staff usually positioned the heating device. Observation revealed Nurse B sat in the resident's recliner, and he/she explained the staff placed the heating device on the right side of the recliner, with the air flow towards the resident's right side, approximately 4 inches from the recliner. Observation revealed Nurse B illustrated the resident leaned to the right in his/her recliner when sleeping toward the device. On 6/2/14 at 11:00 AM, Nurse F stated the resident had a space heater in his/ her room for a long time prior to the burn incident. Nurse F verified the resident was confused and would move the heating device closer to him/her. Nurse F stated he/she moved the heating device away from the resident when it was too close. On 6/2/14 at 1:30 PM Administrative Nurse A stated he/she called the corporative office and they reported the facility was not to have a space heater in the building. Administrative Nurse A stated the facility did not have a policy for space heaters but the administrator was making a policy at this time. On 6/2/14 at 4:00 PM, Nurse Aide C stated the resident had a heating device in his/her room and he/she frequently moved it closer to him/her by pulling on the cord of the heating device when seated in his/her recliner. On 6/3/14 at 8:06 AM, Maintenance Staff D stated the resident had the heating device for a long time and stated the device was not supposed to get hot on the surface but the metal strip would get hot. On 6/3/14 at 9:20 AM, Administrative Nurse A stated the resident moved the heating device closer to himself/herself and the heating device should never have been in his/her room. On 6/3/14 at 10:14 AM, Nurse Aide E reported the resident moved the heating device closer to him/her by placing his/her hands on the heating device, and rolling it towards him/herself. On 6/11/14 at 12:00 PM, Medical Staff G stated the resident had some dementia that decreased his/her cognition. Medical Staff G stated when the burn was first reported to him/her, staff gave the impression the resident brushed up against a heating device and received a small burn to his/her upper right arm. Medical Staff G further stated the staff did not mention the burn when he/she was in the facility making rounds, so he/she did not see the burn. The 6/2013 facility burn policy instructed the staff to apply cold to the burn, immerse affected extremity in ice water for 10 minutes, apply cool towels, cover the burn with a sterile dressing or any clean cloth, do decrease pain by preventing air from contacting the injured surface and to notify the physician and follow orders. The facility failed to provide an environment that was free from accident hazards, to prevent an avoidable burn by a space heater to cognitively impaired, dependent Resident #1's right arm.

The facility had a census of 32 residents. The sample included 19 residents. Based on observation, record review, and interview, the facility failed to ensure acceptable nutritional parameters, such as body weight, were maintained for 1 sampled resident. (#30) Findings included: - Resident #30's quarterly (MDS) Minimum Data Set 3.0 assessment, dated 10/8/12, revealed the resident had short and long term memory problems and severely impaired decision making abilities. The MDS further indicated the resident required extensive assistance of 1 staff for eating. Continued MDS review indicated the resident had weight loss greater than 5% in the previous month or 10% in the previous 6 months, received a therapeutic diet, and antipsychotic, antianxiety, and antidepressant medications. The 10/19/12 care plan instructed the staff to encourage the resident to consume a well balanced 2000 calorie American Diabetic Association diet, provide assistance with eating at mealtime snacks between meals, and to follow the Registered Dietician's recommendations. The care plan also instructed the staff to assist the resident with eating and provide a supplemental shake if he/she left 25% or more of his/her meal uneaten. The 10/8/12 Mini Nutritional Assessment indicated the resident had a moderate decrease in food intake with a weight loss greater then 6.6. pounds in the past 3 months. Review of the Registered Dietician's notes revealed the following: The 8/2/12 Registered Dietician's note indicated the resident was status [REDACTED]. The resident was receiving multiple supplements due to weight loss after his/her [MEDICAL CONDITION] but his/her weight was stable at this time. The note also indicated the resident required less assistance with meals at this time. Interventions in place included monitoring weekly weights, meal intake, laboratory results, and if the resident's weight remained stable, greater than 170 pounds, at the next check, then staff was to gradually reduce the additional calories the resident received. The 10/11/12 Registered Dietician's note indicated the resident continued to receive multiple supplements due to weight loss and his/her weight had continued to decline since his [MEDICAL CONDITION] even though staff assist him/her at mealtimes. The dietician's note indicated the resident had an unintentional weight loss related to decline in condition as evidenced by: post [MEDICAL CONDITION], fluctuating intake but presently better since his/her hospitalization ; confusion and agitation; decreasing weight parameters and medication changes. Interventions that were placed at this time included: increased calories at meals using low or no carbohydrate sources, food as desired, weekly weights, monitoring of weights, laboratory tests, meal intakes, and preferences. The 11/1/12 Registered Dietician's note indicated the resident received multiple supplements and would eat seconds at times with breakfast being the meal with the best intake. The note further indicated the resident's gained 5% in 1 week and the staff were to continue the current diet and supplements. The 11/19/12 Dietary communication note indicated the resident received house supplements with meals and between meals and received 1 1/2 portions of proteins at meals. Review of the Meal Intake Record revealed the following: The August 2012 meal intake record revealed the resident ate less than 50% of his/her meal on 2 days at lunch time. The September 2012 meal intake record revealed the resident ate less than 50% of his/her meal on 5 days at breakfast and 1 day at supper. The October 2012 meal intake record revealed the resident ate less than 50% of his/her meal on 5 days at breakfast, 8 days for lunch, and 3 days for supper. The 8/2/12 Pharmacy Consultation Report indicated the Pharmacists recommended re-evaluation of the resident's continued use of [MEDICATION NAME]. The Nurse Practitioner responded the resident was having no side effects and the [MEDICATION NAME] aided in increasing the resident's appetite due to weight loss. The 9/26/12 Physician's Progress Note indicated the resident had been seen by the nurse practitioner and that his/her weight was stable at 163 pounds. The 10/5/12 Nurse's note indicated the staff notified the physician of the resident's weight was 159 pounds, down from 163 pounds the previous week. The note further indicated the resident continued to receive house shakes for meals and between meals and remained on [MEDICATION NAME] 15 (mg) milligrams, by mouth, every night. Review of the Resident's Weight Record revealed the following: 6/11/12 - 198 pounds (readmission from the hospital) 7/2/12 - 175 pounds (23# weight loss, 11.6 percent in 3 weeks) 7/16/12 - 168 pounds (30# weight loss, 15.1 percent in 5 weeks) 7/23/12 - 171 pounds 8/2/12 - 172 pounds 8/5/12 - 170 pounds 8/13/12 - 169 pounds 8/22/12 - 168 pounds 9/2/12 - 166 pounds 9/12/12 - 165 pounds 9/16/12 - 163 pounds 9/25/12 - 159 pounds 10/9/12 - 158 pounds 10/16/12 - 166 pounds 10/21/12 - 160 pounds 10/29/12 - 158 pounds 11/5/12 - 154 pounds 11/11/12 - 152 pounds 11/19/12 - 153 pounds (45 pounds/22.7 percent weight loss in 5 months, weight loss greater than 10 percent in 6 months indicates severe weight loss). Review of the medical record revealed the last note by the dietician, dated 11/1/12, indicated the resident had the most intake at the breakfast meal and the October weights revealed the resident weighed between 158 - 166 pounds. Review of the medical record revealed no further assessment or note from the dietician or physician although the resident continued to lose weight weekly from 10/29/12 - 158 pounds to 11/19/12 - 153 pounds. ( a continued weight loss of 5 pounds in 21 days or an additional 3.16% weight loss.) On 11/27/12 at 12:10 PM, observation revealed the resident seated in his/her wheelchair at the dining room table. The staff placed the resident's meal on a tray in front of him/her and he/she made no attempts to pick up silverware or to eat. Nurse Aide BN assisted the resident to eat one bite of his/her meal which consisted of mashed potatoes and gravy, green beans, chicken fried steak and applesauce. At 12:36 PM observation revealed the resident had a fork in his/her right hand attempting to stab the bread with the fork but makes no attempt to pick up the bread. At 12:40 PM observation revealed Nurse Aide J approach the resident and Nurse Aide N indicated he/she had attempted to feed the resident but the resident had refused and he/she had made no further attempts to encourage or assist the resident with his/her meal. Nurse Aide J removed the resident from the dining room table and no further attempts were made to encourage or assist the resident to eat his/her meal. At 12:49 PM observation revealed Nurse Aide N propelled the resident him his/her wheelchair to his/her room, attached the call light to the resident's clothes and left the resident alone in his/her room. Observation revealed the staff encouraged or assisted the resident one time and after the resident refused to eat the staff did not prepatent to encourage or assist the resident to eat or offer him/her a supplement as outlined in the plan of care. On 11/28/12 at 1:35 PM, Nurse Aide T stated that if a resident does not eat well at meals, then the staff try to encourage them, assist them and offer them substitutes. Nurse aide T verified at times the resident eats independently and at other times the staff must assist him/her with the meal. On 11/28/12 at 2:56 PM, Administrative Nurse H verified the resident has had weight loss and an overall decline in independence in his/her activities of daily living. On 11/29/12 at 11:39 AM, Nurse S verified the resident received supplements. Nurse S further verified the staff notified the physician's office anytime a resident lost 2 pounds or more. On 12/3/12 at 11:00 AM, Administrative Nurse B verified the staff assist the resident to eat and if the resident does not eat more than 25% the staff are to provide the resident a nutritional supplement. Administrative B further verified the visiting physicians and practitioners are shown a flowsheet of vital signs, including weights, when they make visits. On 12/3/12 at 4:45 PM, physician office staff R verified the nursing facility staff routinely called or notified the doctors office with any significant weight loss. Office Staff R further verified the resident is seen by rotating physicians when they make rounds at the nursing facility. On 12/10/12 at 2:15 PM administrative nurse B verified the staff did not document the amount of the nutritional supplement the resident consumed each time it was offered to him/her. The facility's Weight Monitoring Program Policy, undated, revealed the following: In the event of a patterned or significant, unintended weight loss of 5 percent in 30 days, 7.5 percent in 90 days, or 10 percent in 180 days, the following interventions will be carried out: 1) Notification of attending physician and family member/responsible party by nursing staff. The facility's Policy and Process Program for significant weight change diet indicated the facility would provide more food at "best consumed meal" and provide house supplements. The undated Standing Orders for Weight Change indicated if a resident's weight loss is persistent, consider possible physician referral/appetite stimulant. The facility failed to ensure Resident #30 maintained acceptable nutritional parameters, such as body weight. The facility failed to ensure staff provided encouragement, or assistance at mealtimes, provided substitutes or supplements and the record lacked evidence to show the facility reassessed the resident who continued to lose weight.