Every finding on record at Sundale Nursing Home

Based on observation, staff interview and and record review, the facility failed to implement a resident's care plan by failing to use both floor mats for Resident #79 with a a history of falls. Resident identifier: #79. Facility Census: 91. Findings included: a) Resident #79 On 05/27/26 at 12:31 PM, observed a fall mat against the air unit, a fall mat on the resident's right side of bed and the absence of a fall mat on the left side of resident's bed. At 12:32 PM Occupational Therapy Assistant (OTA) #164 was asked about the mat and went to find a nurse. He returned without nurse and observed fall mat leaning against heating/air unit and reported that usually it meant she has an order for it and he would put it back down on the left side of her bed. OTA #164 reported that he would report to the nurse. Review of resident's physician orders dated 11/11/25 stated bed side mats (low profile) on floor- at all times while in bed. Review of the care plan revealed, pages 7-8. Focus- Resident #79 is at risk for serious injury related to history of falls, impaired mobility, incontinence, diagnosis of Cerebrovascular Accident with R-sided hemiplegia, arthritis, etc. Approaches- Low profile mats on floor beside bed. Date initiated: 11/11/25.

Based on Observations and Staff interviews, the facility failed to store food in accordance with professional standards for food safety. The first floor south nutrition room had five (5) Glucerna drinks that were expired. This was a random opportunity for discovery during the normal Long Term Survey Process, that had the potential to effect more then a limited number of residents. Facility Census: 91. a) During the facility walkthrough and inspection of the nutrition areas on 05/27/26 at approximately 10:45 AM, five (5) expired Glucerna supplements were found in the first-floor south wing resident nutrition room. They expired on 01/03/26 and remained in the cabinet accessible to residents.During a interview with Social Worker #148 on 05/27/26 at approximately 11:15 AM, they confirmed the supplements were expired and then discarded them.

Based on record review and staff interview, the facility failed to ensure Quality assessment and assurance (QAA) meetings were completed at minimum quarterly. This failed practice has the potential to affect more than a minimal number of residents residing in the long term care facility. Facility Census: 91Findings included: a) Record review completed on 06/03/26 revealed the QAA meeting for Quarter Two (2) was held on 10/29/25 along with the Quarter Three (3) meeting. During an interview on 06/03/26 at approximately 11:30 AM the Administrator stated they normally hold meetings the month following the end of the quarter to discuss all items for that quarter. However, the Doctor was unable to attend the scheduled meeting for Quarter Two (2) so they combined both the Quarter Two (2) and Quarter Three (3) meetings. This confirms there was no meeting during the second quarter.

Based on interview and record review, the facility failed to document voice grievances (such as those about treatment, care, management of funds, lost clothing, or violation of rights) and maintain evidence of the result of all grievances for no less than 3 years from the date the grievance decision was issued. This has the potential to affect, more than a limited number of Residents. Facility census: 85. Findings Included: Record review of the facility's policy titled, Resident and Family Grievances, showed: --The grievance official is responsible for overseeing the grievance process: receiving and tracking grievances through their conclusion. --Evidence demonstrating the results of all grievances will be maintained for a period of no less than 3 years from the issuance of the grievance decision. A grievance log will be maintained for each calendar year. a) Grievance Process A record review on 01/08/25 of grievances revealed no grievance forms or logs were filled out for the last two years. During an interview with the Social Services Director (SSD) on 01/08/25 at 2:22 PM SSD states that the facility has not had any grievances in the last two years, and they do not keep a list of concerns. She continued to say that the facility lets each department take care of any complaint made at that department. During an interview with the Administrator on 01/08/25 at approximately 2:50 PM, she stated that the residents or representative has to say they want to file a formal grievance before they would write the concern / grievance on a formal grievance form. She stated that she feels that care, treatment, medication issues, lost personal items or perceived rudeness is just an informal complaint, and the facility does not log them or consider them a grievance.

Based on observation, record review, and staff interview, the facility failed to ensure accurate weights were obtained for three (3) out of three (3) residents sampled for weight loss. Failure to monitor and investigate significant changes in resident's weight status places the residents at risk for an incorrect assessment or diagnosis of impaired nutrition or hydration status. Further, this failed practice potentially prevented the interdisciplinary team from accurately developing and implementing interventions to stabilize or improve the resident's nutritional status before complications arose. Resident Identifiers: Residents #24, #53 and #78. Facility Census:85. The findings included: a) Resident #24 During a review of Resident #24's weights on 01/09/25 at approximately 9:18 AM, the following values were revealed: 10/1/2024 21:28 175.9 Lbs 11/1/2024 23:28 175.9 Lbs 12/1/2024 20:35 177.2 Lbs 1/8/2025 19:29 160.4 Lbs Based on these records, the resident experienced a weight loss of 16.8 pounds, (9.4% of body weight), over a period of 37 days, between 12/01/24 and 01/08/25. A review of Resident #24's care plan revealed the following: PROBLEM: [Resident] has the potential for decreased fluid status, AEB constipation, hx of UTI, and intake less than 75%. Limited fluid preferences. Family provides beverage of choice (Mountain Dew) Date initiated: 11/13/2018 Revision: 09/19/2024 APPROACHES/TASKS: Encourage the resident to drink fluids of choice with and between meals Date initiated: 11/13/2018 Revision: 09/10/2020 Monitor/document/report PRN any s/sx of dehydration: decreased or no urine output. Concentrated urine. Strong odor. Tenting skin. Cracked lips. Furrowed tongue. New onset confusion. Dizziness. Fever. Thirst. Recent/sudden weight loss. Dry/sunken eyes. Date initiated: 03/18/2021 Offer fluids when giving medication Date initiated: 11/13/2018 Provide supplements as ordered by MD Date initiated: 04/09/2024 Record review on 01/13/25 at 11:35 AM revealed no documentation that the nurse was aware of the weight loss. b) Resident #53 During the record review of Resident #53's weights on 01/07/25 at approximately 3:15 PM, the following values were seen: 3/1/2024 06:33 208.1 Lbs 3/12/2024 18:23 202.6 Lbs 4/1/2024 06:12 217.3 Lbs 4/2/2024 15:07 213.5 Lbs This record shows that Resident #53 experienced a weight loss of 5.5 pounds in 11 days, between 03/01/24 and 03/12/24. In addition, the resident also experienced a significant weight gain of 14.7 pounds (6.76% of body weight), over a period of 19 days, between 03/12/24 and 04/01/24 Ongoing record review revealed a nutritional assessment and dietitian note on 03/29/24 that stated the following: Resident's significant change nutritional assessment completed. NKFA. Weight reflects significant weight gain over past one month. Resident was admitted to hospice. Resident has her own teeth was some missing. She eats all meals in her room per her request. Diuretic therapy; weight fluctuations may occur with diuretic therapy. The record review showed that the resident was prescribed Spironolactone once daily. However, there was no documentation that the weight gain was investigated, or that the physician was notified. Further, clinical evidence has shown that dehydration and weight loss, not weight gain, are associated with diuretic therapy. c) Resident #78 Record review on 01/07/25 at approximately 1:45 PM revealed the following: 12/23/2024 06:29 147.8 Lbs 12/24/2024 06:13 147.4 Lbs 12/25/2024 11:49 161.0 Lbs 12/26/2024 06:03 161.0 Lbs This weight record revealed that Resident #78 gained 13.6 pounds (9.22% of her body weight), in one (1) day, between 12/24/24 and 12/25/24. Record review also reveals that the resident lost 11.8 pounds (7.39% of her body weight) in one (1) day between 12/22/24 and 12/23/24. Further record review revealed a dietitian's note on 01/02/25 which stated the following: [Resident's] plan of care reviewed and updated. CW is 161.7 lbs. with a BMI of 26.9. CW reflects significant weight loss of 6.9% over past 1 month, 8.0% over past 3 months and weight gain of 10.2% over past 6 months. Will alert MD of significant weight changes via weight change stamp. Diet is Regular with PO intakes over past week as noted: 2 meals @ 0-25%, 9 meals @ 26-50%, 5 meals @ 51-75%, 3 meals @ 76-100%. She eats breakfast and supper in her room and in fine dining for lunch and supper. Dietary is providing 3780 cc which exceeds her estimated fluid needs of 2059 cc, calculated using his adjusted weight of 151 lbs. @ 30 cc/kg. Dx. of Depression may affect PO intakes. Dx. of Edema. Will continue with current goals and approaches, review plan of care quarterly. On 01/13/25 at approximately 1:54 PM, Registered Nurse (RN) #80 and Nursing Assistant (NA) #24 were observed weighing Resident #78 with the aid of a Hoyer lift. The resident was seated in a wheelchair with a blue sling underneath her. RN #80 first zeroed the scale on the Hoyer lift, and then lowered it so that NA #24 could attach the sling to the lift bar. Once the sling was securely attached, the resident was hoisted up and moved away from the wheelchair, ensuring that her extremities were protected during the process. Once hoisted, the resident was weighed, and her weight was recorded as 164.6 pounds. She was then carefully transferred and lowered into her bed. The sling was removed, and the resident was made comfortable. When questioned about the resident's weight, RN #80 explained that she would deduct the weight of the blue sling from the recorded weight to determine the resident's actual weight. Upon being asked about the sling's weight, RN #80 stated it was 2.2 pounds. She mentioned that she had found this information in the manufacturer's manual. The Centers for Medicare Services (CMS) interpretative guidelines suggest the following parameters for evaluating the significance of unplanned and undesired weight loss: Interval Significant Loss Severe Loss 1 month 5% Greater than 5% 3 months 7.5% Greater than 7.5% 6 months 10% Greater than 10% On 01/08/25 at 1:15 PM, the Quality Assurance Trainer (QA Trainer) #104 presented the facility's protocols for staff training, including weight monitoring. A review of the training protocol revealed that if weights varied by five (5) pounds from a previous weight, the nurse was to be notified. During an interview with QA Trainer #104 on 01/14/25 at 10:55 AM, he stated that the staff were required to notify the nurse on duty of a weight change of five (5) pounds or over. The Director of Nursing (DON) was interviewed on 01/13/25 at 10:45 AM and notified of the significant weight changes. DON confirmed that the significant and severe changes in weight were due to the staff's inaccurate weighing of residents. She further stated that the residents should have been re-weighed when the discrepancies were noted. The QA Trainer #104 stated during the interview on 01/14/25 at 10:55 AM that all the scales were checked monthly to ensure all facility scales were calibrated correctly. In addition, he stated that he did not think the problem of having inconsistent weights was with the scales but with the weighing techniques of the staff. He further stated that based on the survey findings, he was creating a training program for the staff to ensure that they weighed residents accurately.

Based on record review and interview, the facility failed to notify the physician of a resident's significant change in weight, and failed to ensure that the physician conducted a medical evaluation of a resident with a sudden significant change in weight. As a result, the residents were not evaluated to determine the cause for the sudden change in body weight. This placed the resident at risk for serious harm or death. Resident Identifiers: Resident #24, #53, and #78. Facility Census: 85. Findings Included: a) Resident #24 During a review of Resident #24's weights on 01/09/25 at approximately 9:18 AM, the following values were revealed: -10/1/2024 21:28 175.9 Lbs -11/1/2024 23:28 175.9 Lbs -12/1/2024 20:35 177.2 Lbs -01/8/2025 19:29 160.4 Lbs Based on these records, the resident experienced a weight loss of 16.8 pounds, (9.4% of body weight), over a period of 37 days, between 12/01/24 and 01/08/25. A review of Resident #24's care plan revealed the following: PROBLEM: [Resident] has the potential for decreased fluid status, AEB constipation, hx of UTI, and intake less than 75%. Limited fluid preferences. Family provides beverage of choice (Mountain Dew) Date initiated: 11/13/2018 Revision: 09/19/2024 APPROACHES/TASKS: -Encourage the resident to drink fluids of choice with and between meals Date initiated: 11/13/2018 Revision: 09/10/2020 -Monitor/document/report PRN any s/sx of dehydration: decreased or no urine output. Concentrated urine. Strong odor. Tenting skin. Cracked lips. Furrowed tongue. New onset confusion. Dizziness. Fever. Thirst. Recent/sudden weight loss. Dry/sunken eyes. Date initiated: 03/18/2021 Offer fluids when giving medication Date initiated: 11/13/2018 Provide supplements as ordered by MD Date initiated: 04/09/2024 Record review on 01/13/25 at 11:35 AM revealed no documentation that the nurse was aware of the weight loss, or that the physician had been notified. b) Resident #53 During the record review of Resident #53's weights on 01/07/25 at approximately 3:15 PM, the following values were seen: -03/01/2024 06:33 208.1 Lbs -3/12/2024 18:23 202.6 Lbs -04/01/2024 06:12 217.3 Lbs -04/02/2024 15:07 213.5 Lbs This record shows that Resident #53 experienced a weight loss of 5.5 pounds in 11 days, between 03/01/24 and 03/12/24. In addition, the resident also experienced a significant weight gain of 14.7 pounds (6.76% of body weight), over a period of 19 days, between 03/12/24 and 04/01/24 Ongoing record review revealed a nutritional assessment and dietitian note on 03/29/24 that stated the following: Resident's significant change nutritional assessment completed. NKFA (No known food allergies). Weight reflects significant weight gain over past one month. Resident was admitted to hospice. Resident has her own teeth was some missing. She eats all meals in her room per her request. Diuretic therapy; weight fluctuations may occur with diuretic therapy. The record review showed that the resident was prescribed Spironolactone once daily. However, clinical evidence has shown that dehydration and weight loss, not weight gain, are associated with diuretic therapy. Record review revealed no documentation that the weight gain was investigated, or that the physician was notified. c) Resident #78 Record review on 01/07/25 at approximately 1:45 PM revealed the following: 12/23/2024 06:29 147.8 Lbs 12/24/2024 06:13 147.4 Lbs 12/25/2024 11:49 161.0 Lbs 12/26/2024 06:03 161.0 Lbs This weight record revealed that Resident #78 gained 13.6 pounds (9.22% of her body weight), in one (1) day, between 12/24/24 and 12/25/24. Record review also reveals that the resident lost 11.8 pounds (7.39% of her body weight) in one (1) day between 12/22/24 and 12/23/24. Further record review revealed a dietitian's note on 01/02/25 which stated the following: [Resident's] plan of care reviewed and updated. CW is 161.7 lbs. with a BMI of 26.9. CW reflects significant weight loss of 6.9% over past 1 month, 8.0% over past 3 months and weight gain of 10.2% over past 6 months. Will alert MD of significant weight changes via weight change stamp. Diet is Regular with PO intakes over past week as noted: 2 meals @ 0-25%, 9 meals @ 26-50%, 5 meals @ 51-75%, 3 meals @ 76-100%. She eats breakfast and supper in her room and in fine dining for lunch and supper. Dietary is providing 3780 cc which exceeds her estimated fluid needs of 2059 cc, calculated using his adjusted weight of 151 lbs. @ 30 cc/kg. Dx. of Depression may affect PO intakes. Dx. of Edema. Will continue with current goals and approaches, review plan of care quarterly. Once again, record review revealed no documentation that the physician was notified of the sudden changes in body weight. The Centers for Medicare Services (CMS) interpretative guidelines suggest the following parameters for evaluating the significance of unplanned and undesired weight loss: Interval Significant Loss Severe Loss 1 month 5% Greater than 5% 3 months 7.5% Greater than 7.5% 6 months 10% Greater than 10% On 01/08/25 at 1:15 PM, the Quality Assurance Trainer (QA Trainer) #104 presented the facility's protocols for staff training, including weight monitoring. A review of the training protocol revealed that if weights varied by five (5) pounds from a previous weight, the nurse was to be notified. During an interview with QA Trainer #104 on 01/14/25, at 10:55 AM, he stated that staff were required to notify the on-duty nurse of any weight change of five pounds or more. The Director of Nursing (DON) was interviewed on 01/13/25 at 10:45 AM and notified of the significant weight changes. DON confirmed that the significant and severe changes in weight were due to the staff's inaccurate weighing of residents. She further stated that the residents should have been re-weighed when the discrepancies were noted. The QA Trainer #104 stated during the interview on 01/14/25 at 10:55 AM that all the scales were checked monthly to ensure all facility scales were calibrated correctly. In addition, he stated that he did not think the problem of having inconsistent weights was with the scales but with the weighing techniques of the staff. He further stated that based on the survey findings, he was creating a training program for the staff to ensure that they weighed residents accurately.

Based on observation and staff interviews, the facility failed to store food in a safe sanitary manner in regard to storing medical ice packs in the freezer in the residents pantry. This has the potential to affect a limited number of residents. Facility census: 85. Findings Included: a) Two South Resident Pantry During the tour on 01/08/25 at 9:20 AM to the Resident pantry, two (2) medical Ice packs were observed stored in resident freezer. An interview, on 01/08/25 at 9:20 AM, with the Dietary Manager confirmed the medical ice packs should not be stored with resident food.

Based on medical record review and staff interview, the facility failed to provide evidence that the long-term care Ombudsman was sent a copy of the written Notice of Transfer for acute hospital transfers. This was true for two (2) out of two (2) residents reviewed for hospitalization s during the long-term care survey process. Resident identifiers: #28 and #4. Facility census: 85. Findings included: a) Resident #28 A record review, completed on 01/14/25 at 9:26 AM, revealed that Resident #28 had been transferred to the hospital on 09/28/24. Although the Notice of Transfer/Discharge was given to the resident at the time of transfer, there was no evidence that the facility had sent a copy of the notice to the long-term care Ombudsman. During an interview on 01/14/25 at 11:19 AM, the Director of Social Services stated that she had not yet sent a notification to the long-term care Ombudsman. She stated, We do a log, I am way behind on my log. We try to do it no less than yearly. b) Resident 4 Medical Record review on 01/14/25 revealed resident #4 was discharged to the hospital on 09/29/24 and 11/30/24. Subsequent review of Resident #4's medical record showed it did not contain documentation that the Notice of Transfer or Discharge was provided to the Ombudsman. On 01/14/25 at 11:26 AM during an interview the Social Worker verified, there was no evidence that the Notice of Transfer or Discharge was sent to the Ombudsmen for the discharges on 09/29/24 or 11/30/24. She stated that she was behind on the Transfer or Discharge log. 43340

Based on record review and staff interviews, the facility failed to identify Major Depressive disorder on Preadmission Screening and Resident Review (PASARR). This was found true for one (1) of three (3) residents reviewed during the long-term care survey process. Resident identifier: Resident #53. Facility Census: 85 Findings included: a) Resident #53 A record review conducted on 01/07/25, at approximately 11:45 AM for Resident #53 revealed that the PASARR completed on 03/18/24 did not include any diagnoses of Mental Disorder (MD) or Intellectual Disability (ID). Record reviews also indicated that Resident #53 had been diagnosed with Major Depressive Disorder (MDD) on 11/26/24. Further record review revealed no updated PASARR that captured the MDD diagnosis. During an interview, with the Director of Nursing (DON), on 01/09/24 at approximately 10:55 AM, she confirmed that the PASARR did not reflect the new diagnosis of Major Depressive Disorder. She further stated that she would notify Social Services of the deficiency. On 01/13/24 at approximately 12:12 PM, during an interview with the Director of Social Services (DSS) #15, she confirmed that the PASARR and Care Plan had not been updated to reflect the new diagnosis.

Based on record review and staff interview, the facility failed to ensure that the Resident had a person-centered, comprehensive care plan, developed and implemented to meet his / her preferences and goals, and address the resident's medical, physical, mental, and psychosocial needs. This practice affected one (1) of nine (9) residents' care plans reviewed during the Long-Term Care Survey Process (LTCSP). This failure to ensure that the comprehensive care plan was developed to ensure the residents' highest practicable well-being placed the resident at risk of not receiving services that would meet their desires or needs. Resident Identifier: Resident #53. Facility Census: 85. Findings included: a) Resident #53 During a review of Resident #53's current diagnoses performed on 01/07/25 at approximately 11:45 AM, revealed that the resident had been diagnosed with Major Depressive Disorder (MDD) on 11/26/24. Continued review revealed the resident's current care plan did reflect specific interventions to address the symptoms and management of MDD. The care plan, however, did address interventions for the management of the symptoms of the medications prescribed for MDD. The review of Resident #53's Care Plan on 01/07/25 revealed the following: PSYCHOTROPIC - (Resident name) is at risk for side effects/complications from psychotropic medication use. Ordered trazodone for MDD, Seroquel for psychosis, and Depakote for psychosis. Has tearfulness, difficulty sleeping, hallucinations, paranoia, delusions, agitation, etc. She is a hospice patient with terminal dx (diagnosis) of HTN (high blood pressure), Heart Disease with HF (heart failure). Date Initiated: 01/17/2024 Revision on: 11/26/2024 On 01/09/25 at 2:06 PM, the Director of Nursing (DON) confirmed the care plan addressed the side effects and complications of the psychotropic medications prescribed for MDD, but did not specifically address the needs of a resident with MDD. She stated that Social Services would know more about the diagnosis. During an interview with the Director of Social Services (DSS) #15, on 01/13/25 at approximately 12:12 PM, she confirmed that the Care Plan had not been updated to reflect and address the diagnosis of MDD.

Based on record review, and staff interview, the facility failed to follow physician orders related to administration of pain medication. This was true for one (1) of three (3) residents reviewed for pain during the annual long-term care survey process. Resident identifier: #2. Facility census: 85. Findings included: a) Resident #2 A record review was completed on 01/08/25 at 7:00 PM. The record review demonstrated that Resident #2 had the following physician order: Hydrocodone-Acetaminaphen oral tablet 5-325 MG. Give 1 tablet by mouth every 6 hours as needed for pain related to pain, for severe pain (7-10). Review of the December 2024 and January 2025 Medication Administration Records (MARs) revealed the following dates the medication was administered outside the physician's parameters for severe pain. December 2024 -12/10/24 Pain Level of 6 -12/11/24 Pain Level of 3 -12/25/24 Pain Level of 3 January 2025 -12/06/26 Pain Level of 3 During an interview on 01/09/25 at 8:56 AM, the Director of Nursing (DON) acknowledged the medication was administered outside of the parameters set in the physician's order for severe pain ranked 7 - 10. She recognized it was the same nurse who had made the error and stated that the nurse would be re-educated and disciplined.

Based on record review and staff interview, the facility failed to complete a comprehensive social services assessment in its entirety for Resident #35. This was a random opportunity for discovery. Resident identifier: #35. Facility census: 85. Findings included: a) Resident #35 During a record review, on 01/13/25 at 11:29 AM, it was identified that the following questions were left unanswered on the comprehensive social services assessment, dated 06/25/24. Question 12: Date capacity determined by MD Question 13: Competency (Guardian, Conservator, or Both) Question 14: Current Pain Medications Further record review revealed: -The most recent physician determination of capacity was on 05/22/24 -Resident #35 had both a court appointed legal guardian and a conservator effective 01/28/13 -Resident #35 was ordered Tramadol pain medication, an order that began on 07/20/23. During an interview, on 01/13/25 at 2:15 PM, the Director of Social Services acknowledged the questions were left blank and were unanswered.

Based on observation, record review, and staff interview, the facility failed to develop and/or implement a care plan regarding fall prevention interventions for Resident #38 and #9. Resident Identifiers: #38 and #9. Facility Census: 85. Findings Included: a) Resident #38 On 01/03/24 at 10:07 AM, a record review was completed for Resident #38. The review found the fall prevention interventions on the care plan had not been implemented. An observation of Resident #38's wheelchair found no anti-roll backs were in place. Nurse Aide (NA) #104 confirmed the anti-roll backs were not in place. The resident was found to have multiple falls throughout the stay at the facility. On 01/03/24 at 10:15 AM, the record review found an additional fall prevention intervention of check q (every) 30 minute checks to ensure toileting and ADL (activities of daily living) needs were met. However, the documentation only found shift (every eight (8) hours) notes which were identified with a check mark under the tasks tab. There was no 30 minute documentation found to verify the checks were completed. On 01/03/24 at 10:45 AM, an interview was held with the Director of Nursing (DON). The DON stated, the staff documents every shift .if they charted every 30 minutes .they would be charting all day. No further information was obtained during the survey process. b) Resident #9 On 01/03/24 at 10:20 AM, a record review was completed for Resident #9. The review found a fall prevention intervention on the care plan had not been implemented. The fall prevention intervention was check q hour for toileting and ADL needs. The resident was found to have multiple falls throughout the stay at the facility. However, the documentation only found shift (every eight (8) hours) notes which were identified with a check mark under the tasks tab. There was no hourly documentation found to verify the checks were completed. On 01/03/24 at 10:45 AM, an interview was held with the Director of Nursing (DON). The DON stated, the staff documents every shift .if they charted every hour .they would be charting all day. No further information was obtained during the survey process.

Based on record review and staff interview the facility failed to revise a careplan related to a significant weight loss and to include supplements. This was a random opportunity for discovery. Resident identifier # 81. Facility census 85. Findings included: a) Resident #81 During a record review on 01/02/24 at 1:00 PM of Resident #81's orders, it revealed Resident #81 was ordered Ensure Plus one time a day for significant weight loss on 12/19/23 During a record review on 01/02/24 at 1:15 PM of Resident #81's dietary care plan it read Resident #81 was a significant weight gain at 3 and 6 months, revised on 10/17/23. There is no mention of supplements. During an interview on 01/03/24 at 9:30 AM wit the Director of Nursing (DON), she stated, I don't feel its necessary to add the supplement to the care plan if they are on a regular diet, our dietary manager updates the dietary careplan's. During and interview on 01/03/24 at 9:45 AM the Dietary Manager stated, The supplement for resident #81 is not in the care plan. I am the one that adds those to careplan and I missed that one.

Based on observation, record review, and staff interview, the facility failed to follow the physician's orders regarding fall prevention interventions for Resident #38 and #9. Resident Identifiers: #38 and #9. Facility Census: 85. Findings Included: a) Resident #38 On 01/03/24 at 10:07 AM, a record review was completed for Resident #38. The review found the physician's orders for the fall prevention interventions were not being followed . An observation of Resident #38's wheelchair found no anti-roll backs were in place. Nurse Aide (NA) #104 confirmed the anti-roll backs were not in place. The resident was found to have multiple falls throughout the stay at the facility. On 01/03/24 at 10:15 AM, the record review found an additional physician's order for a fall prevention intervention of check q (every) 30 minute checks to ensure toileting and ADL (activities of daily living) needs were met. However, the documentation only found shift (every eight (8) hours) notes which were identified with a check mark under the tasks tab. There was no 30 minute documentation found to verify the checks were completed. On 01/03/24 at 10:45 AM, an interview was held with the Director of Nursing (DON). The DON stated, the staff documents every shift .if they charted every 30 minutes .they would be charting all day. No further information was obtained during the survey process. b) Resident #9 On 01/03/24 at 10:20 AM, a record review was completed for Resident #9. The review found the physician's order for a fall prevention intervention was not being followed. The fall prevention intervention was check q hour for toileting and ADL needs. The resident was found to have multiple falls throughout the stay at the facility. However, the documentation only found shift (every eight (8) hours) notes which were identified with a check mark under the tasks tab. There was no hourly documentation found to verify the checks were completed. On 01/03/24 at 10:45 AM, an interview was held with the Director of Nursing (DON). The DON stated, the staff documents every shift .if they charted every hour .they would be charting all day. No further information was obtained during the survey process.

Based on observation, staff interview, and facility policy the facility failed to serve house snacks in a sanitary manor, by serving snacks off of a cart which included dirty dishes. This was a random opportunity for discovery. This failed practice was true for two (2) of two (2) residents. Resident identifiers #9 and #16. Facility census 85. Findings included: a) Resident #9 During an observation on 01/03/24 at 10:00 AM Dietary Aide Employee #52 was putting house snacks at the nurses station from cart that was covered in dirty dishes which she had collected on her way down the hall. During an interview on 01/03/24 at 10:02 AM with Dietary Aide employee #52, she stated, This is how I do it. During an interview on 01/03/24 at 10:16 AM with Dietary Manager she stated, No this is not how it is done. She knows better than to do it that way. During a review on 01/02/24 at 10:30 AM of the facilities policy titled, (facilities name) Nursing Home Nourishment Policy, it reads {When Dietary Personnel delivering nourishments, all food items must be kept clean and free from cross contamination of soiled dishes. No dirty dishes should be placed on cart used to deliver nourishments.}

Based on observation and record review, the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. A medication cart and a treatment cart were unlocked with no one in attendance. These were random opportunities for discovery that had the potential to affect residents who were able to access the carts. Resident identifiers: #34, #73, #60, #21, #54, #78, #38, #135, #8, #81, #72, #76, #9. Facility census: 84. Findings included: a) Medication cart On 02/21/23 at 8:28 AM, the medication cart in the 100 hallway was noted to be unlocked. No staff member was present. Licensed Practical Nurse (LPN) #13, who was administering medications, came out of a resident room and verified the medication cart was unlocked. According to information provided by the facility, the following residents were known to wander around the facility: #34, #73, #60, #21, #54, #78, #38, #135, #8, #81, #72, #76, and #9. b) Treatment Cart On 02/21/23 at 10:28 AM, the treatment cart was observed unlocked and unattended by staff. On 02/21/23 at 10:30 AM, Registered Nurse (RN) #126 confirmed the treatment cart was left unlocked and unattended. RN #126 stated, I'm sorry. On 02/21/22 at approximately 12:30 PM, the Director of Nursing (DON) was notified and confirmed the treatment cart should be locked at all times when left unattended. No further information was obtained during the long-term survey process. 45173

Based on observation and staff interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. During the kitchen tour it was discovered dry food bins had not been dated when filled. This had the potential to affect any resident receiving nourishment from the kitchen. Facility census: 84. Findings included: a) Kitchen tour During the kitchen tour on 02/20/23 at 11:43 AM, it was discovered the flour, sugar and rice bins had not been dated when they were filled last. In an interview with the Dietary Manager (DM) on 02/20/23 at 11:50 AM, verified the flour, sugar and rice bins had not been dated when refilled.

Based on medical record review and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. Resident hand hygiene was not performed before the noon meal. This was a random opportunity for discovery. Resident identifiers: #38, #284, #45, #73. Facility census: 84. Findings included: a) Resident hand hygiene On 02/21/23 at 11:17 PM, the surveyor arrived on the 2 South hallway to observe the noon meal pass. Resident #45 and Resident #284 were sitting at a table at the nursing desk. At 11:20 PM, Resident #38 was brought to the table via wheelchair. At 11:51 AM, Resident #73 was brought to the table via wheelchair. On 02/21/23 at 11:37 AM, Employee #72 was observed delivering a meal tray to Resident #254 who was dining in her room. Hand hygiene was not offered to Resident #254. At 11:41 AM, tray delivery was began by Restorative Aide (RA) #72 to the residents seated at the table at the nursing desk. Resident #284 received a tray at 11:41 AM. Resident #45 received a tray at 11:43 AM. Resident #38 received a tray at 11:47 AM. Resident #73 received a tray at 11:51 AM. None of the residents were offered hand hygiene before beginning their meals. During an interview on 02/21/23, RA #72 stated Resident #38 had received hand hygiene because she had been toileted before being taken to the table. Employee #72 did not offer any information regarding hand hygiene for the remaining residents. No further information was provided through the completion of the survey.

Based on record review and staff interview, the facility failed to complete an accurate Minimum Data Set (MDS) assessment for a resident. This deficient practice was found for one (1) of 20 resident MDS assessments reviewed during the Long Term Care Survey Process. Resident identifier: #60. Facility census: 84. Findings included: a) Resident #60 During a medical record review on 02/21/23 for Resident #60 revealed the significant change MDS completed on 01/12/23 was not coded correctly for a fall on 01/01/23. In an interview with the MDS Coordinator #25 on 02/22/23 at 9:25 AM, verified the fall on 01/01/23 was not coded correctly in Section J for falls.

Based on observation, staff interview and record review the facility failed to ensure that timely care and services were provided for two (R10 and R14) of a total of nineteen residents. R14 did not receive timely treatment for [REDACTED]. Findings include: a) Resident #14 R14 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The facility assessed R14 as being interviewable. A review of the Nurse ' s Notes indicated the following: 04/30/12 at 5:00am: Resident lost balance when CNA (Certified Nursing Assistant) transferring from BSC (bedside commode) to W/C (wheelchair). CNA lowered (resident) to floor. 04/30/12 at 10:30am: Resident insisting on taking her shoes off to use the restroom this am. Tried to explain to resident that her socks alone were too slippery. She took her shoe off herself. As she was transferring herself she tried to sit herself on the floor. 04/30/12 at 3:00pm: Has large swollen area in outer left ankle. She said she bumped it on chair during transfer. Dr. (doctor) ordered x-ray. 04/30/12 at 5:00pm: X-ray at bedside to do x-ray. 04/30/12 (no time documented): X-ray results of left ankle. There is no evidence for fracture; mild lateral soft tissue swelling is identified. 05/01/12 at 3:00am: Swelling noted to left ankle. Resident refused to stand to transfer to BSC and refuses to use bed pan. Several incontinence episodes this shift. 05/01/12 at 12:00pm: Bruising to left foot. Will monitor. 05/02/12 at 2:00am: Mild swelling in left ankle. 05/02/12 at 3:00am: Resident continues to refuse to stand up and refuses to use bed pan. Several incontinence episodes and refuses to be changed. 05/02/12 at 9:00pm: Resident alert with pleasant confusion at times - attention seeking most of shift. Bruising and small amount of swelling to left ankle. Resident c/o (complains of) pain in left ankle upon weight bearing/ambulation. 05/03/12 at 3:00am: Follow-up to fall with injury to left ankle. Area swollen with bruising present. Resident continues to c/o pain in left lower extremity upon ambulation/weight bearing activity. 05/03/12 3:00-11:00pm shift: Resident confused at times and physically abusive to staff. Resident hit staff several times while staff attempted to get resident up for dinner. 05/08/12 at 2:30pm: Mobile Imaging called. Resident has questionable fx (fracture) to left foot. MD called, order obtained to send to ER. A review of the " Physician order [REDACTED]. 04/30/12: Left outer ankle x-ray order for large raised area. 05/01/12: " May be WB (weight bearing) " 05/03/12: Repeat left ankle x-ray on 05/08/12. Ice ankle 20 minutes three times a day. A review of x-ray reports indicated the following: 04/30/12: History: Bumped outer ankle/swollen, painful to touch. Bony structures left ankle are intact. There is no evidence for fracture. Mild lateral soft tissue swelling is identified. 05/08/12: History: Pain, swelling, S/P (status [REDACTED]. Indication: Pain and swelling after trauma. Comparison is made to study of 04/30/12. A non-displaced fracture is possible with this appearance. This was present on prior study of 04/30/12, but is better seen on today ' s study due to technique. A review of the " Incident Report-Investigation of Unit " form indicated the following: 04/30/12 at 5:00am: " I (CNA) was assisting resident from BSC to W/C and her left leg gave our and I assisted her to the floor and she was saying her ankle was hurting, but then after she got it straightened out she said it felt better. " R14 was interviewed on 06/06/12 at 7:40am. R14 stated " Yes, I had a fall, my foot got twisted and I ended up under the bed. " During an interview conducted with the Director of Nursing (DON) on 06/07/12 at 11:00am, the DON could not explain why further investigation was not conducted on the statement made by the CNA who witnessed the fall on 04/30/12. The DON could not explain what the CNA meant by " straightened out " . The DON acknowledged that the physician was not notified that R14 was refusing to stand, was having an increase in incontinence episodes or displaying behaviors when staff attempted to ambulate the resident. . The DON could not explain why R14 ' s statement and the investigation about this statement were not documented on the " Risk Management Accident/Incident (A/I) Report. " b) Resident #10 R10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the Physician order [REDACTED]. On 05/17/12, an order was written to: " Apply gauze padding to right great toe " . During an observation of a dressing change to R10 ' s right heel wound the following was observed on 06/07/12 at 10:30 am: Licensed Practical Nurse (LPN) 64 applied normal saline to the wound and patted it dry. Silver alginate was applied to the wound then covered with gauze and Kling. During an interview with the Wound Nurse (LPN54) on 06/07/12 at 12:00pm, she stated " The order reads to clean the wound with soap and water; I don ' t know why the nurse used normal saline. " .