Every finding on record at Sunset Health Care Center

Based on observation, interview, and record review, facility staff failed to propel four (Resident #3, #7, #24, and #111) out of six residents in a wheelchair in a manner to ensure resident safety. The facility census was 114. 1. Review of the facility's policies showed staff did not provide a policy for wheelchair safety. 2. Review of Resident #3's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 05/14/25, showed staff assessed the resident as: -Cognitively impaired; -Required partial to moderate assistance for ambulation greater than 50 feet; -No wheelchair. Observation on 05/28/25 at 9:11 A.M., showed Licensed Practical Nurse (LPN) E propelled from the 200 secured unit to the 100 hallway to the scale, weigh the resident, and return the resident to the 200 hallway. The wheelchair did not have leg pedals in place and the bottom of the resident's feet slid on the floor. During an interview on 05/28/25 at 9:22 A.M., LPN E said he/she borrowed a wheelchair to take the resident to get weighed. The wheelchair did not have foot pedals. He/She said he/she knows it was a hazard but was just trying to get the resident's weight. 3. Review of Resident #7's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Required supervision to touch for wheelchair locomotion 50 feet with two turns; -Required partial to moderate assistance for wheelchair locomotion greater than 150 feet. Observation on 05/30/25 at 10:33 A.M., showed the Laundry Supervisor propelled the resident down a ramp connected the north end of the building to the south in a wheelchair without foot pedals on the wheelchair. The bottom of the residents feet touched the floor. During an interview on 05/30/25 at 10:37 A.M., the Laundry Supervisor said he/she didn't realize the pedals were not on the wheelchair when he/she pushed the resident. He/She said if the resident couldn't control their legs to stay up then he/she could have got hurt. 4. Review of Resident #24's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively impaired; -Required supervision to touch to propel his/her wheelchair 150 feet. Observation on 05/28/25 at 10:43 A.M., showed activity aide G propelled the resident from the north activity room to the 100 hall nurse station without pedals on the wheelchair. Observation showed the right tennis shoe drug under the chair. During an interview on 05/28/25 at 1:37 P.M., the activity aide said he/she is new and has not had wheelchair training. He/She said he/she did have a resident plant their feet one time but they did not get hurt or come out of the chair. He/She said he/she knows if the resident cannot hold up his/her feet then he/she would stop pushing the resident and have them pick up their feet. 5. Review of Resident 111's admission MDS, dated [DATE], showed staff assessed the resident as: -Moderate Cognitive impairment; -Manual wheelchair; -Substantial/maximal assist from staff to wheel 50 feet with two turns. Observation on 05/28/25 at 8:57 A.M., showed Certified Nurse Assistant (CNA) L propelled the resident down the hallway into the resident's room without foot pedals on wheelchair. The resident's feet could be heard dragging on the ground. Observation on 05/28/25 at 1:36 P.M., showed CNA L propelled the resident down the hallway from dining room to resident's room. The resident's feet could be heard dragging on the ground. Observation on 05/29/25 at 10:52 A.M. CNA L propelled the resident from the resident's room to dining room without foot pedals on wheelchair. The resident's feet could be heard dragging on the ground. During an interview on 05/29/25 at 1:22 P.M., CNA L said he/she is unsure where resident's foot pedals are. He/She said he/she has not been told to make sure residents have foot pedals before pushing them. He/She said pushing residents without foot pedals is a risk of resident putting feet down and falling forward out of wheelchair. 6. During an interview on 05/29/25 at 1:10 P.M., LPN M said residents should not be pushed in wheelchair without foot pedals. He/She said he/she is unsure where residents foot pedals are currently, but every resident should have foot pedals for their wheelchair. He/She said the resident could put their feet down and fall forward out of wheelchair. During an interview on 05/30/25 at 02:00 P.M., the Director of Nursing (DON) said residents should have foot pedals on wheelchair when being pushed by staff. He/She said not having foot pedals while pushing is a risk the resident could get their feet caught and fall out of wheelchair and hit their head. He/She said he/she is unaware if facility does official training on wheelchairs and foot pedals. During an interview on 05/30/25 at 02:33 P.M., the administrator said if staff are pushing resident they should have foot pedals on wheelchair. He/She said resident could catch their foot on something and flip out of wheelchair and cause injury. He/She said any department can push residents if they are trained correctly on doing so. He/She said he/she is unsure if there is training for wheelchairs and foot pedals, but it is stressed a lot that residents need foot pedals on wheelchairs when being pushed.

Based on interview and record review, facility staff failed to purchase a surety bond in an amount sufficient to assure security of all resident funds the facility holds. The facility census was 114. 1. Review of the resident's trust fund account for July 2024 through April 2025, showed an average monthly balance of $199,493.16, which required a surety bond of $300,000.00. Review of the Department of Health and Senior Services (DHSS) database, showed the facility has an approved non-cancelable Escrow Agreement Account in the amount of $250,000.00. During an interview on 05/28/25 at 1:42 P.M., the business office manager (BOM) said he/she is responsible for resident funds and ensuring the bond is sufficient. He/She said he/she is aware their bond needs to be increased. He/She said they have had several changes that have made their monthly balance increase, and he/she noticed it was getting close to the bond amount. During an interview on 05/29/25 at 12:57 P.M., the administrator said the BOM is responsible for resident funds and ensuring the surety bond is sufficient. He/She said he/she was not aware that they did not have a high enough bond. He/She said they were looking at the average monthly balances and thought they had enough.

Based on observation, interview and record review, facility staff failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections when staff failed to complete hand hygiene between glove changes during wound care for three residents (Resident #4, #28,and #216) of three sampled residents with wounds and when staff failed to ensure the two-step purified protein derivative (PPD) (skin test for TB) was completed in accordance with their policy and on file for three employees (Certified nurse aide (CNA) N, Maintenance assistant, and Housekeeper O) out of ten employee files reviewed. The facility census was 114. 1. Review of the facility's Standard Precautions policy, dated October 2022, showed the policy did not contain direction or guidance for hand hygiene between glove changes. Review of the facility's Hand Hygiene policy, dated April 2022, showed staff are directed to perform hand hygiene before and after applying/removing gloves. Review of the facility's Wound Management policy, dated November 2022, showed the policy did not contain direction of guidance on when to perform hand hygiene. 2. Review of Resident #4's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 05/14/25, showed staff assessed the resident as: -Cognitively intact; -Presence of an unhealed Stage IV (full-thickness skin and tissue loss) pressure injury; -Received pressure ulcer care; -Diagnosis of artery disease. Observation on 05/29/25 at 10:35 A.M., showed the wound nurse completed wound care for the resident. Observation showed the wound nurse applied gloves, removed the residents soiled dressing, removed his/her gloves and did not perform hand hygiene before he/she applied clean gloves. He/She cleaned the residents wound, removed his/her gloves and did not perform hand hygiene before he/she replaced the gloves. 3. Review of Resident #28's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Presence of two unhealed Stage IV pressure injury; -Received pressure ulcer care; -Diagnosis of paraplegia (loss of feeling in lower body). Observation on 05/29/25 at 10:48 A.M., showed the wound nurse applied clean gloves, removed the residents soiled dressing, removed his/her gloves and did not perform hand hygiene before he/she replaced the gloves. He/She cleaned the residents wound, removed his/her gloves and did not perform hand hygiene before he/she replaced the gloves. 4. Review of Resident #216's admission MDS, dated [DATE] showed staff assessed the resident as: -Cognitively intact; -Three unstageable (damage to skin and tissue cannot be confirmed) pressure ulcers; -Diagnosis of peripheral vascular disease (a condition where narrowed or blocked blood vessels restrict blood flow to the limbs, most commonly the legs and feet). Observation on 05/29/25 at 11:28 A.M., showed the wound nurse went into the resident's room to perform wound care. He/She removed the residents covers and bandage, he/she removed his/her gloves and did not perform hand hygiene before he/she replaced the gloves. He/She cleaned the residents wound, removed his/her gloves and did not perform hand hygiene before he/she replaced the gloves. He/She applied the resident's treatment, removed his/her gloves and did not perform hand hygiene before he/she replaced the gloves. He/She removed the residents left lower leg dressing, removed his/her gloves and did not perform hand hygiene before he/she replaced the gloves. He/She applied the residents treatment, removed his/her gloves and did not perform hand hygiene before he/she replaced the gloves. 5. During an interview on 05/30/29 at 10:23 A.M., the wound nurse said hand hygiene should be performed before and after wound care and not between glove changes. He/She said the treatment cart had a sanitizer pump attached to it, but he/she cannot take the cart into the room so he/she does not have quick access to hand sanitizer. He/She said the facility does have small bottles that could be used to sanitize between glove changes but did not use or carry them, but could. There is an infection control risk to not cleaning hands between glove changes but didn't have proximity to the sanitizer to do it during wound care. During an interview on 05/30/29 at 2:00 P.M., the Director of Nursing (DON) said hand hygiene should always be performed between glove changes during wound care. He/She said the wound nurse was really nervous being observed but should still have washed or sanitized because there could be something infectious on the gloves. He/She said the facility is correcting the concern. During an interview on 05/30/25 at 02:32 P.M. the administrator said hands should be washed or sanitized between glove changes to keep germs or bacteria from being spread. 6. Review of the facility's Employment Policies and Procedures, undated, showed staff are directed as follows: -State law requries that skilled and/or residential facilities employees undergo a physical examination, a two (2) step TB test, and an annual TB test thereafter; -The first TB test must be completed on or before the day an employee attends orientation; -The second TB test must be conducted within the first three (3) weeks of employment. 7. Review of CNA N's employee file showed: -Hire date of 01/14/24; -The file did not contain documentation the first and second PPD were administered. 8. Review of maintenance assistant's employee file showed: -Hire date of 04/03/24; -The file did not contain documentation the first and second PPD were administered. 9. Review of Housekeeper O's employee file showed: -Hire date of 07/05/24; -The file did not contain documentation the first and second PPD were administered. 10. During an interview on 05/29/25 at 9:19 A.M., the DON said the Assistant Director of Nursing (ADON) was responsible for ensuring staff TBs are completed timely and tracked. He/She said staff should receive a two-step upon hire and then once annually. He/She said he/she was not aware there were staff members without completed TB documentation. During an interview on 05/29/25 at 12:57 P.M., the Administrator said it is the responsibility of the ADON to ensure two-step staff TBs are completed upon hire. He/She said he/she was not aware staff TB's were not getting completed and said the ADON might have failed to keep completed documentation.

Based on observation, interview and record review, facility staff failed to develop and implement a person-centered comprehensive care plan for four (Resident #19, #28, #47, #91 and #109) of twelve sampled residents. The facility census was 114. 1. Review of the facility's Comprehensive Person-Centered Care Plan (CCP) policy, dated October 2019, showed: -Each resident will have a person-centered plan of care to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team (IDT) will provide care; -All disciplines will collaborate to develop a plan of care that meets residents' needs, preferences and goals; -CCP contains services provided, preferences, ability and goals for admission, desired outcomes, and care level guidelines; -The CCP can be reviewed and/or revised at quarterly intervals in conjunction with the completion of the Minimum Data Set (MDS), a federally mandated assessment tool, quarterly, significant change, and annual assessments per the Resident Assessment Instrument (RAI) manual, a manual used for completion of MDS assessments; -Upon a significant change in condition, the CCP will be updated if applicable. 2. Review of Resident #19's Annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 04/23/25, showed staff assessed the resident as: -Cognitively impaired; -No behaviors or rejection of care; -Impaired mobility on one upper extremity; -Dependent on staff for care; -Diagnosis of dementia and difficulty swallowing. Review of the resident's Physician Order Sheet (POS), dated May 2025, showed an order for an abdominal binder to be worn at all times except during hygiene and water flushes after feeding tube placement. Review of the resident's care plan, dated 04/29/25, showed the care plan did not contain direction or guidance for use and care of the abdominal binder. Observation on 05/28/25 at 10:24 A.M., showed Licensed Practical Nurse (LPN) E unfasten an abdominal binder, administer a water bolus through a feeding tube, and refasten an abdominal binder on the resident. During an interview on 05/28/25 at 10:24 A.M., the LPN said the resident wears the abdominal binder for the safety of the device. He/She said he/she did not know what the care plan said regarding the binder. During an interview on 05/30/25 at 11:08 A.M., the MDS nurse A said he/she is responsible to update the care plans to include adding the abdominal binder. He/She said it was an oversight. 3. Review of Resident #28's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Functionally limited in range of motion to both lower extremities; -Used a wheelchair; -No restraints; -Diagnosis of paraplegia (loss of sensation in lower legs and abdomen). Review of the resident's care plan, dated 05/28/25, showed the care plan did not contain direction or guidance for use of a gait belt to position the residents legs on the wheelchair. Observation on 05/27/25 at 1:35 P.M., showed the resident up in a motorized wheelchair. His/her legs were secured to the leg rests with a gait belt around his/her shins. During an interview on 05/27/25 at 1:35 P.M., the resident said the wheelchair is not his/her normal wheelchair. His/Her wheelchair is not available right now so he/she uses the motorized one and has trouble keeping his/her legs up on it. His/Her family member tried to purchase other options but those options did not work and so the staff are trying the belt on his/her legs to keep them on the chair. During an interview on 05/30/25 at 11:08 A.M., MDS nurse A said he/she is responsible to update the care plans to include adding the belt use for the resident. He/She said it was an oversight. 4. Review of Resident #47's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Diagnosis of Dementia. Review of the resident's care plan, dated 04/17/25, showed the care plan did not contain direction or guidance for Dementia. During an interview on 05/30/25 at 12:55 P.M., MDS nurse B said he/she is responsible to update the care plans to include Dementia Care. He/She said it's important to include on care plan so staff know how to take care of resident. He/She thought it was on the care plan. 5. Review of Resident 91's admission MDS, dated [DATE], showed staff assessed the resident as: -Moderate cognitive impairment; -Indwelling catheter; -Diagnosis of Chronic Kidney Disease. Review of the resident's care plan, last revised 05/27/25, showed the care plan did not contain direction or guidance in regards to the residents catheter. Observation on 05/28/25 at 10:00 A.M., showed the resident in his/her recliner with their catheter bag hooked on the side of the bed. During an interview on 05/28/25 at 10:01 A.M., the resident said he/she admitted to the facility with the catheter. During an interview on 05/30/25 at 12:55 P.M., MDS nurse B said he/she is responsible to update the care plans to include catheters. He/She said it's important to include on care plan so staff know how to take care of resident. He/She thought it was on the care plan. 6. Review of Resident #109's admission MDS, dated [DATE], showed staff assessed the resident as: -Moderate Cognitive impairment; -Very important to do favorite activities and listen to music; -Somewhat important to have books, newspapers, and magazines to read, to do things with groups of people, go outside and get fresh air, and participate in religious services; -Diagnosis of Alzheimer's disease and Dementia. Review of the resident's care plan, dated 05/14/25, showed the care plan did not contain direction or guidance for activity preferences. During an interview on 05/30/25 at 12:55 P.M., MDS nurse B said he/she is responsible to update the care plans to include activity preferences. He/She said its important to include on care plan so staff know how to take care of resident. 7. During an interview on 05/30/25 at 11:08 A.M., MDS nurse A said he/she is responsible to update the care plans with significant changes, changes in care needs, quarterly and annually on the 100 and 200 hallway residents. He/She said he/she finds out about care need changes in morning meeting and communication with staff and/or family members. He/She said the care plans should tell staff how to care for a resident. During an interview on 05/30/25 at 2:00 P.M., the Director of Nursing (DON) said care plan should cover resident care, catheters, falls and fall interventions, activities, restraints, and wheelchairs. The care plans should tell staff how to care for the residents and are the responsibility of the MDS nurses to keep updated. During an interview on 05/30/25 at 02:32 P.M., the administrator said care plans are individualized for each resident to include diets, preferences, showers, behaviors, catheters, and falls. He/She said the MDS Coordinator updated the care plans. He/She says they have care plan update meetings after morning meetings each day. He/She said care plans are important so staff know how to care for each resident.

Based on observation, interview, and record review, facility staff failed to provide an ongoing program of activities designed to meet residents' interests, for the residents who reside on a secured unit. The facility census was 114. 1. Review of the facility's policy titled, Activities, dated 09/14/23, showed: -Facility is to provide an ongoing program to support residents in their choice of activities based on their comprehensive evaluation, care plan, and preferences; -Facility-Sponsored group, individual, and dependent activities will be designed to meet the interest of and support the physical, mental, and psychosocial well-being of each resident, as well as encourage both independence and interaction within the facility; -Each resident's interest and needs will be evaluated on a routine basis; -Special considerations will be made for developing meaningful activities for residents with dementia and/or special needs, these include, but are not limited to the following: -Residents exhibit unusual amounts of energy or pacing; -Residents who exhibit behaviors that require a less stimulating environment to discontinue behaviors not welcomes by others sharing their social space; -Residents who have withdrawn from previous activity interest/customary routines, and isolates self in their room most of the day; -Residents who excessively seek attention from staff and/or peers; -Residents who have delusional and hallucinatory behaviors that are stressful to themselves; -The facility will consider accommodations in schedules, supplies, and timing in order to optimize a resident's ability to participate in an activity of choice. 2. Observation on 05/27/25 at 2:33 P.M., showed the May 2025 Activity Calendar on the dinning room door of 300 hall secured unit. Review of the activity calendar showed: -On 05/27/25: 10:00 A.M., One on one time and 1:30 P.M., Music Making; -On 05/28/25: 10:00 A.M., Church Service and 1:30 P.M., Bingo; -On 05/29/25: 10:00 A.M., Tennis and 1:30 P.M., Happy Birthday; -On 05/30/25: 10:00 A.M., Leisure Program and 1:30 P.M., Manicure and Movie. Observation on 05/27/25 at 2:33 P.M., showed a Leisure Program paper posted in 300 secured unit hallway. The Paper showed the following: -Monday: [NAME] Games; -Wednesday: Art project; -Friday: Food Day. Observation on 05/27/25 at 02:03 P.M., showed the 300 hall did not have the music making activity. Observation showed multiple residents remained in their room or paced up and down hallway. Observation on 05/28/25 at 10:25 A.M., showed the 300 hall did not have the church service activity. Observation showed multiple residents remained in their room or paced up and down hallway. Observation on 05/28/25 at 1:33 P.M., showed the 300 hall did not have the Bingo activity. Six residents sat in the dining room and multiple residents remained in their room. Observation on 05/29/25 at 10:44 A.M., showed the 300 hall did not have the tennis activity. Observation showed multiple residents remained in their room or paced up and down hallway. During an interview on 05/29/25 at 01:22 P.M., Certified Nurse Aide (CNA) L said activities are only done Monday, Wednesday, and Friday on the 300 hall secured unit about 10 A.M He/She said some residents get invited to go out of secured unit in main dinning room for activities, but they don't always invite every resident. He/She said sometimes activities will bring coloring pages on unit, but nothing hands on for activities usually. During an interview on 05/30/25 at 11:53 A.M., the activities director said they go down three times a week and do Leisure program with the residents on secured unit. He/She said some residents can come out of secured unit into main dinning room for activities. He/She said if the CNA's have time they could help with activities. During an interview on 05/30/25 at 2:00 P.M., the Director of Nursing (DON) said there are some activities on the secured units, but probably not daily. He/She said its hard to get everyone in activities because of the size of the facility and could use more help with activities. He/She said three times a week is not appropriate for activities on the secured units.

Based on interview and record review, the facility staff failed to keep Resident #2 from striking Resident #1 twice to the chest. The facility census was 114. The administrator was notified on 3/27/25 of past Non-Compliance, which occurred on 3/22/25 when Resident #1 struck Resident #2 to the chest twice. Staff immediately separated the residents, assessed the residents, notified the resident's physician, moved Resident #1 to a different hallway, put Resident #2 on one on one, and in-serviced nursing staff on abuse and neglect. Staff corrected the deficient practice on 3/25/25. 1. Review of the facility's Abuse prevention policy, dated 10/21/22, showed abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, mental anguish, or emotional distress. This includes the deprivation by an individual, including a caretaker of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Abuse may be resident to resident, staff to resident, family to resident, or visitor to resident. Review of the facility's investigation, dated 3/23/25, showed Resident #1 wandered the hallway and came across the doorway of Resident #2. Resident #2 reached out and struck Resident #1 with a closed fist. Staff immediately separated the residents and while redirecting Resident #1 to the dining room, Resident #2 came around staff and struck Resident #1 again twice with a closed fist to the chest. Resident #2 was placed on one on one surveillance and Resident #1 was moved to a different locked unit with a longer hallway. All necessary parties were contacted, Labs were obtained on Resident #2 to rule out any chemical imbalances, Resident #2 had medication changes, care plans were updated, and all staff were in-serviced on abuse and neglect and the seven principles for effective verbal intervention. Review of Resident #1's Minimum Data Set (MDS), a federally mandated assessment tool, dated 3/7/25, showed staff assessed the resident as: -Moderate cognition impairment; -Short and long term memory problems; -Diagnoses of Alzheimer's and Dementia. Review of the resident's care plan, dated 3/24/25, showed staff assessed the resident with impaired cognitive function/dementia or impaired thought processes. Diagnosis of Alzheimer's. Staff were directed to move the resident from 300 hall to 200 hall. The resident is often noted to wander throughout the lockdown units, in and out of others rooms, redirect when this is noted to a common area or back to his room. Review of the nurses notes, dated 3/22/25 at 4:15 P.M., Licensed Practical Nurse (LPN) C documented Certified Medication Technician (CMT) A stated the resident had wandered into another resident's room, other resident got upset and hit resident in chest with closed fist. Director of Nursing (DON) notified of recent altercation. DON gave orders to moved resident to different hallway after altercation. Review of Resident #2's MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Short term memory problems; -Diagnoses of Huntington's disease (condition in which nerve cells in the brain break down over time) and Psychotic disorder with delusions. Review of the resident's care plan, dated 3/24/25, showed staff documented the resident has a history of aggression against other. Staff were directed to have the resident one on one with the social worker three times per week indefinitely, resident is to remain on 15 minute checks indefinitely due to aggression to other resident and accusations against staff, and attempt to keep resident in sight with two staff members on the unit at all times. Review of the residents nurses notes, dated 3/22/25 at 4:15 P.M., showed LPN C charted recent altercation with another resident. This nurse was called down to unit because resident was witnessed to hit another resident in the chest. Resident stated, I don't want him in my room. DON notified of recent altercation. Resident remains one on one and with 15 minute checks. Will continue to monitor during shift. During an interview on 3/27/25 at 10:40 A.M., CMT A said he/she didn't witness the altercation but was made aware by CNA B. He/She said CNA B and hospitality aide D immediately separated the residents and took Resident #1 to his room. He/She said at this time he/she went to tell the charge nurse what had happened. When he/she was telling the charge nurse what happened hospitality aide D stepped off the hall to inform them Resident #2 had struck Resident #1 again through CNA B and hospitality aide D. He/She said he/she and the charge nurse went back on the unit so the nurse could assess the residents and notify the DON. He/She said he/she was inserviced 3/22/25 over abuse and neglect and dealing with resident's with behaviors. During an interview on 3/27/25 at 10:50 A.M., CNA B said he/she was in the hallway when Resident #1 walked by Resident #2's door. Resident #2 reached out and hit Resident #1 with a closed fist. He/She said he/she and hospitality aide D immediately separated the residents and took Resident #1 to his/her room after he/she had notified the CMT. He/She said they took Resident #1 to his/her room so the nurse could assess him/her but he/she started to become agitated. He/She said he/she and hospitality aide D walked with Resident #1 toward the dining room. He/She said Resident #2 had stayed in his/her room but came out as they were going into the dining room. He/She said Resident #2 pushed him/her and again struck Resident #1. The CNA said he/she took Resident #1 back to his/her room for the nurse to assess and hospitality aide D went to notify the nurse of the second strike. He/She said he/she was inserviced on 3/22/25 over abuse and neglect and resident behaviors. During an interview on 3/27/25 at 11:03 A.M., LPN C said CMT A came to him/her and reported Resident #2 had stuck Resident #1. The LPN said they went to the unit and it was reported by hospitality aide D, Resident #2 had struck Resident #1 again between him/her and CNA B. He/She contacted the DON who instructed staff to move Resident #1 to 200 hall and put Resident #2 one on one. He/She said he/she assessed Resident #1 and Resident #2 refused his/her assessment. He/She said he/she was inserviced on 3/22/25 on abuse and neglect and deescalating resident to resident altercations. During an interview on 3/27/25 at 11:22 A.M., CNA E said Resident #2 had struck Resident #1 twice. He/She said Resident #2 was put one on one and Resident #1 was moved to a different hallway. He/She said he/she was inserviced on 3/22/25 on abuse and neglect and what to do when residents become combative. During an interview on 3/27/25 at 11:52 A.M., the DON said he/she was made aware of the altercations by LPN C. He/She instructed staff to stay one on one with Resident #2 and to move Resident #1 to 200 hallway. He/She said inservice over abuse and neglect and the seven principles for effective verbal intervention starting on 3/22/25 and finished on 3/25/25. During an interview on 3/27/25 at 12:03 P.M., the administrator said he/she was notified by the DON about the altercation between Resident #1 and Resident #2. He/She said an investigation was started and the resident's were separated, Resident #1 was moved to a new hallway and Resident #2 was put one on one with staff. He/She said the DON called all necessary parties and received orders for medication changes for Resident #2. He/She said all staff were inserviced on abuse and neglect and the seven principles for effective verbal intervention. MO00251529

Based on interview and record review, facility staff failed to provide an appropriate emergency discharge notice when staff failed to have an appropriate location to transfer one resident (Resident #2) to when he/she was ready to discharge from the hospital. The facility census was 114. 1. Review of the facility's Discharge and Transfer - Involuntary Policy, reviewed 10/07/2021, showed transfer and discharge includes movement of a resident to a bed outside of the facility whether that bed is in the same physical plant to not. The facility must permit each resident to remain in the facility and not transfer or discharge the resident from the facility unless specific criteria are met. The facility will provide sufficient orientation to residents to ensure a safe and orderly transfer or discharge from the facility including an opportunity to to participate in the decision of where to transfer. 2. Review of Resident #1's facesheet, dated 4/3/25, showed the resident admitted to the facility on [DATE]. Review of the residents progress notes, dated 3/27/2025, at 4:42 P.M., showed staff documented they spoke with the residents guardian in regard to a notice of immediate discharge of the resident related to aggressive behavior toward another resident. Review of the resident's Immediate Discharge Notice, dated 3/27/25, showed staff documented the resident would discharge to the local hospital. During an interview on 4/3/25 at 10:03 A.M., the administrator said the resident is too aggressive to continue to be at the facility and he/she knows it is an issue with the placement of discharge at the hospital but he/she has to keep the other residents in the facility safe and can not allow the resident to return. During an interview on 4/3/25 at 10:13 A.M., the residents guardian said the facility has issued an emergency discharge to the local hospital and that is not a long term safe placement for the resident. The guardian said he/she has started the appeals process but the facility will not allow the resident to return and because of his/her extreme diagnoses no one will take the resident. MO00251810

Based on interview and record review, the facility staff failed to designate a person to serve as the Director of Food and Nutrition Services with the appropriate qualifications, when the facility did not employ a qualified dietitian or other clinically qualified nutrition professional full-time. The census was 107. 1. Review of the dietary supervisor's (DS) personnel records, showed a hire date of 6/13/23 and promoted to the dietary supervisor on 10/22/23. Review showed the records did not contain documentation of prior dietary manager experience in a long-term care facility and certification or other education required for the director of nutritional services position. Review showed the DS had a course start date of 11/02/23 in an on-line Nutrition and Foodservice Professional Training Program. Review showed the DS had an estimated program completion date of 11/01/24. During an interview on 1/03/24 at 2:02 P.M., the DS said he/she needed to be a Certified Dietary Manager (CDM) to hold the DS position. The DS said he/she was taking classes and had finished lesson one of 17 lessons. The DS said he/she had experience working at fast food restaurants but he/she never had ServSafe (food safety training) or other food service related training. The DS said he/she did not know of any qualified nutritional professional staff working full time in the facility. The DS said the Registered Dietitian (RD) comes to the facility monthly. During an interview on 1/04/24 at 12:51 P.M., the administrator said the facility policy was to allow the DS one year to get CDM certification. The administrator said he/she did not know the DS had to be a CDM on hire if there were no other full time staff that met regulatory requirements. The administrator said the RD comes to the facility monthly. He/She said the facility's retired DS also works on an as needed basis to help the new DS. The administrator said the retired DS does not work full time hours at the facility. The administrator said he/she spoke to the active DS about training progress two weeks ago and the DS said he/she was on track. The administrator did not provide a written policy.

Based on observation, interview and record review, the facility staff failed to serve food in accordance with the nutritionally calculated menus and standardized recipes. Facility staff also failed to record substitutions made to the menus. The census was 107. 1. Review of the facility's Menu Alternates and Substitutions policy, reviewed 11/27/23, showed the policy did not contain guidance related to substitutions for preplanned menu items. Review of the facility's Menu Substitution Form showed the last documented food substitution was dated 11-23. 2. Review of the facility Week 1, Day 4 lunch menu, reviewed 5/30/23, showed the menu directed staff to provide residents who receive pureed meals with a #8 (four ounces) scoop of smothered steak, two ounce ladle of brown gravy, #10 (3.2 ounces) scoop pureed green beans, #20 (1.6 ounces) scoop of pureed wheat dinner roll or bread, and a #10 scoop of pureed fruit cup. Review of Week 1, Day 4 recipes showed pureed bread may be prepared separately or if added to meat or vegetables, increase serving size to a #6 (5.33 ounces) scoop. Observation on 1/03/24 at 11:41 A.M., showed staff served residents who received pureed meals a #8 scoop of pureed smothered steak and a #8 scoop of pureed pumpkin pie. Observation showed the residents did not receive pureed rolls or bread. During an interview on 1/03/24 at 12:03 P.M. Cook D said there was bread mixed in with the meat. During an interview on 1/03/24 at 12:05 the Dietary Supervisor (DS) said he/she added six slices of thick sliced bread to roughly 20 salisbury steaks and some gravy. The DS said he/she prepared the meat this way because this is how he/she was taught by the last DS. The DS said he/she did not count how many beef patties he/she pureed. The DS said the pumpkin pie was left over from Thanksgiving and he/she didn't want to throw it away. The DS he/she did not know the correct serving size for pumpkin pie since it is not on this menu rotation. 3. Review of the facility (Week 1, Day 4) dinner menu, reviewed 5/30/23, showed the menu directed staff to provide residents fried chicken [NAME], macaroni and tomatoes. Observation on 1/03/24 at 4:10 P.M., showed staff served breaded chicken patties and macaroni and cheese. 4. Review of the facility (Week 1, Day 5) lunch menu, reviewed 5/30/23, showed the menu directed staff to provide residents cashew chicken and an egg roll. Observation on 1/04/24 showed staff served breaded chicken patties and a slice of bread. During an interview on 1/04/24 at 10:58 A.M., the DS said the facility did not have the ingredients to make cashew chicken. The DS said the facility food vendor did not have egg rolls, so he/she gave the residents a slice of bread instead. The DS said he/she had never discussed food substitutions with the facility's dietitian. The DS said he/she did not know why menu substitutions were not documented. During an interview on 1/04/24 at 12:51 P.M., the administrator said menu substitutions have to be with a like item such as veggie-veggie, starch-starch. The administrator said he/she was not sure if there was documentation of menu substitutions. The administrator said the dietitian should be informed of substitutions. He/She said a slice of bread was probably not a suitable substitute for an egg roll. The administrator said dietary staff should follow recipes.

Based on observation, interview and record review, facility staff failed to maintain kitchen equipment and surfaces in a clean sanitary manner to prevent the potential for cross-contamination. Facility staff failed to perform hand hygiene as often as necessary, using approved techniques, to prevent cross-contamination. Facility staff failed to sanitize kitchen wares in a manner to prevent contamination, and to store dishwares in a manner to prevent cross-contamination when staff stacked dishwares together wet. Facility staff failed to ensure hair/beard coverings remained in place during the preparation of resident meals to prevent the potential for food contamination. The facility census was 107. 1. Review of the facility's Nutritional Services Sanitation policy, reviewed 11/27/23, showed: -Personnel shall be responsible for daily, weekly and monthly cleaning assignments as determined by the Dietary Manager and/or his/her designee; -Equipment shall be cleaned, sanitized, delimed, etc. in accordance with manufacturer recommendations; -Exhaust systems and hoods shall be clean, operational and maintained in good repair; -Cleaning of equipment condensers, lights, vents/fans, ceiling, ice machine, etc., shall be completed by the maintenance department. Review of the facility's Daily Kitchen Checklist, dated 11/23, showed staff were directed to clean and properly store dishes, pots, pans and utensils after each meal and snack and to clean, sanitize and cover slicer. Review of the facility's Weekly Kitchen Checklist, dated 11/23, showed staff were directed to: -Clean exhaust and hoods; -Clean all freezers and refrigerators, interior and exterior; -Polish all stainless steel surfaces; -Clean pantries, shelves and food canisters. Observation on 1/02/24 at 10:51 A.M., of the kitchen showed: -The floor with food, plates, bread, sugar and salt packets; -A large amount of buildup and crumbs on two toasters; -Staff coats and purses stored on the top shelf of the food storage racks in the dry storage area. Observation on 1/03/24, between 9:32 A.M. and 2:52 P.M., of the kitchen showed: -Metal dish storage shelving had an accumulation of grease, dust and food particles; -Dishes facing up on the storage shelving had unidentifiable particles on surfaces; -Two deep white plates on the storage shelves had dried food debris; -Meat slicer was covered with a plastic bag and had an accumulation of food particles around the blade; -Refrigerator doors and lower vent louvres were visibly soiled; -Eindow air conditioner seals and top of unit were visibly soiled with dirt and dead insects; -Silver fire extinguisher had an accumulation of grease on top; -An accumulation of grease and dead insects on the light covers inside the range hood; -An accumulation of grease and dust on three camera covers and the blue wiring leading to the cameras. Observation on 1/03/24, between 9:32 A.M. and 2:52 P.M., showed the kitchen did not contain a cleaning checklists. During an interview on 1/03/24 at 2:16 P.M., Cook D said he/she used the meat slicer two days ago and wiped it down after using. Cook D said he/she did not take the slicer apart to clean it. During an interview on 1/03/24 at 2:02 P.M., the Dietary Supervisor (DS) said he/she was responsible for kitchen cleanliness which included the window air conditioner. The DS said he/she did not have time to print cleaning checklists for the month of January. The DS said maintenance is responsible for cleaning the fire extinguishers and cameras. During an interview on 1/04/24 at 12:51 P.M., the administrator said all kitchen staff were responsible for kitchen cleanliness. The administrator said maintenance staff should clean the fire extinguishers and cameras in the kitchen. The administrator said dishes should be stored face down. 2. Review of the facility's Nutritional Services Hand Hygiene policy, reviewed 11/27/23, showed personnel shall clean their hands and wrist area for at least 20 seconds in a designated handwashing sink and dry hands with a single use towel then turn off faucet with a single use towel. Personnel shall wash their hands after handling soiled equipment, when changing tasks, after engaging in any activity or task which contaminates hands. Observation on 1/03/24 at 10:13 A.M., showed the DS washed his/her hands, turned off the faucet with his/her wet hands and then dried his/her hands with paper towels. Observation on 1/03/24 at 10:44 A.M., showed Dietary Aide (DA) E pre-washed dirty dishes, put his/her hands under the running water for approximately three seconds, removed clean dishes from the clean side of the mechanical dishwasher, placed the clean dishes on drying shelves. DA E did not wash his/her hands after he/she pre-washed dirty dishes or before he/she touched the cliean dishes. DA E pre-washed additional dirty dishes, removed clean dishes from the mechanical dishwasher racks and did not wash his/her hands between tasks. During an interview on 1/03/24 at 10:49 A.M., DA E said he/she washed his/her hands for probably 10 seconds. DA E said he/she should wash hands when going from dirty to clean dishes. Observation on 1/04/24 at 10:38 A.M., showed DA F unloaded soiled trays/dishes from the food tray hall cart, loaded dirty dishes to the dish machine racks, loaded clean items to the drying shelves and did not wash his/her hands between tasks. During an interview on 1/04/24 at 10:47 A.M., DA F said we're supposed to wash between dirty and clean but he/she just forgot. During an interview on 1/04/24 at 10:49 A.M., the DS said staff are expected to wash hands when going from a dirty task to a clean task. The DS said handwashing should take 20 seconds and the water should be turned off with a paper towel. 3. Review of the facility's Nutritional Services Sanitation policy, reviewed 11/27/23, showed the equipment shall be cleaned, sanitized, delimed, etc. in accordance with manufacturer recommendations. Detergents and sanitizers shall be used in correct dilutions consistent with Federal and state guidelines and ordinances governing food service; Review of the sanitizer directions for use showed, apply use solution to dinner ware and food utensils by immersion. Treated surfaces must remain wet for 60 seconds. Observation on 1/03/24 10:11 A.M., showed the DS hand washed a food processor blade and bowl, hosed off the blade and bowl with sanitizer from the three-compartment sink, then immediately assembled and used the food processor to puree green beans for the lunch meal. During an interview on 1/03/24 at 10:21 A.M., the DS said clean items should soak in sanitizer for one minute. The DS said he/she didn't have time to wait for the blade and bowl to soak so technically it wasn't sanitized. During an interview on 1/04/24 at 12:51 P.M., the administrator said kitchen wares should be submerged in sanitizer for the time listed on the product label. The administrator said hosing an item off is not sanitizing it. 4. Observation on 1/02/24 at 10:51A.M., of the kitchen showed a metal storage rack contained wet, stacked dishes. Observation on 1/03/24 between 9:56 A.M., of the kitchen showed -three stacks of steam table pans were stacked wet. During an interview on 1/03/24 at 9:58 A.M., the DS said dishes and pans should not be stacked when wet. During an interview on 1/04/24 at 12:51 P.M., the administrator said pans should not be stacked wet. 5. Review of the facility's Nutritional Services Personal Hygiene and Appearance policy, reviewed 8/28/23, showed hair nets or hair coverings shall be worn while in the kitchen or storage areas. Facial hair, except eyebrows, shall be covered with a hair net or beard cover. Observation on 1/03/24 at 10:11 A.M., showed the DS did not have the required hair covering on while he/she pureed green beans for the lunch meal. During an interview on 1/03/24 at 10:15 A.M., the DS said the facility had a policy for hair covers and he/she should be wearing a cover. The DS said he/she did not know where to locate the hair covers. During an interview on 1/04/24 at 12:51 P.M., the administrator said all kitchen staff are responsible for wearing appropriate hair coverings.

Based on interview and record review, facility staff failed to designate one or more individuals with specialized training in Infection Prevention and Control (IPC) as the Infection Preventionist (IP) for the facility's infection prevention and control program. The census was 107. 1. Review of the facility's policies showed staff did not provide a policy for specialized training for the Infection Preventionist. During an interview on 01/05/24 at 10:15 A.M., the Director of Nursing (DON) said they do not currently have a certified IP. The Assistant Director of Nursing (ADON) is currently acting as the IP and their Regional Corporate Nurse (RNC), who is a certified IP, and himself/herself oversee IPC. He/She said he/she is not certified. He/She said it is the facility's plan the ADON is going to be the IP and the facility's wound nurse is going to be the backup IP after they both become certified. He/She said their last IP stepped down from the position in August and they have not had anyone else in that role. During an interview on 01/05/24 at 10:18 A.M., the ADON said he/she is not certified yet. He/She said he/she just took over this new position about a month ago and has not started the program yet. He/She said he/she does the IPC and the facility's RNC and DON look it over. During an interview on 01/05/24 at 10:56 A.M., the RNC said he/she is IP certified. He/She said the facility's IP stepped down from the position in August 2023. He/She said he/she had been the acting IP until the ADON started his/her position. He/She said now he/she oversees the ADON until he/she gets certified. He/She said they are also having the facility's wound nurse get certified so he/she can act as backup IP. During an interview on 01/05/23 at 2:45 P.M., the Administrator said she is aware the role of IP has to be at least part time. The previous IP left about two or three months ago and the plan is to have ADON start the certification process, but as of right now she is not currently certified.

Based on observation, interview and record review, facility staff failed to provide residents with a dignified environment when staff did not keep residents' personal information private, allowed one resident (Resident #72) to wear the same soiled clothes for three days, left one resident (Resident #30) exposed, did not speak in a dignified manner for one resident (Resident #12) and changed the residents' smoking times for two residents (Resident #76 and #102) for staff convenience. The facility census was 107. 1. Review of the facility's Residents' [NAME] of Rights, showed staff are to treat residents with dignity and respect and are to keep residents' personal information private. 2. Observation on 01/03/24 at 11:40 A.M., Licensed Practical Nurse (LPN) K stood in the dining room with Certified Nursing Assistant (CNA) L and discussed an incident between two residents. Eight residents sat in the dining room and could hear the discussion. Observation on 01/03/24 at 12:00 P.M., LPN K and CNA L stood in the dining room and discussed the residents who needed their weights taken that day. Twelve residents sat in the dining room and could hear the residents' private information. Observation on 01/04/24 at 1:57 P.M., a group of staff stood in the unit hall talking about a resident's condition in front of a different resident. Observation on 01/04/24 at 1:59 P.M., Certified Medication Technician I (CMT) began to weigh residents in the hall where other residents could see and hear. Observation on 01/04/24 at 2:03 P.M., CMT I continued to weigh residents and called out their weight to another staff to record. During an interview on 01/05/24 at 2:02 P.M., the Director of Nurses (DON) said he/she expects staff to take residents to a private location to weigh them. He/She said he/she did not know this occurred. During an interview on 01/05/24 at 2:26 P.M., the administrator said he/she expects staff to be discreet with residents' private information. He/She said he/she did not this occurred. 3. Review of Resident #72's Minimum Data Set (MDS) dated [DATE], showed staff assessed the resident as follows: -Diagnoses of anxiety, depression and arthritis; -Moderate cognitive impairment -Required partial to moderate staff assistance with dressing. Observation on 01/03/24 at 12:30 P.M., showed the resident walked around the unit with a hole in his/her right sock, a brown stain on his/her left sleeve of his/her shirt and a large stain on his/her sweatpants. Observation on 01/04/24 at 12:59 P.M., showed the resident walked around the unit in the same soiled clothes he/she wore the day before. Observation on 01/05/24 at 9:38 A.M., the resident continued to wear the same soiled sweatpants from the previous two days. During an interview on 01/05/24 at 2:00 P.M., CMT O said staff do not change residents' clothes after every meal if their clothes are soiled unless thee resident is going to go off the unit to an activity. He/She said, It's rough keeping up back here. During an interview on 01/05/24 at 2:14 P.M., the DON said he/she expects staff to wash the residents' faces and change their clothes if needed. During an interview on 01/05/24 at 2:26 P.M., the administrator said he/she expects staff to change the residents' clothing after every meal when soiled. 4. Review of Resident #12's quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severely cognitively impaired; -Diagnoses of Diabetes, Aphasia, Cerebral palsy (group of disorders that affect a person's ability to move and maintain balance and posture) and Seizures. Observation on 01/03/24 at 3:15 P.M., showed CNA H and CMT I entered the resident's room to provide peri care. CNA H said even though they bathe him/her three times a week he/she is still funky smelling. CMT I said It's not pleasant. Observation showed the resident's room mate was in the room. During an interview on 01/05/24 at 2:02 P.M., the DON said staff should absolutely not comment if residents have an odor because it is offensive and is a dignity issue. He/She said if someone did that to him/her, he/she would feel terrible. He/She said he/she does not know the situation of why staff made comments but it does not matter, it shouldn't be done. During an interview on 01/05/24 at 2:26 P.M., the administrator said it is never acceptable for staff to talk negatively in front of a resident because it takes their dignity. He/She said he/she would obviously not like it if someone talked about his/her body odor. During an interview on 01/08/24 at 1:55 P.M., CNA H said it is inappropriate for staff to make negative comments to or around other residents about a resident's body odor because it could be considered abuse. He/She said he/she would be mad if people were talking about his/her body odor, especially in front of other people. He/She said staff tend to get frustrated at other staff and start talking crap because they have not completed their jobs and it causes issues, he/she thinks this is why someone may complain about a resident's state. During an interview on 01/08/24 at 2:19 P.M., CMT I said staff should never discuss care in front of other residents because of Health Insurance Portability and Accountability Act. He/She said he/she would not feel good if someone called him/her stinky or funky. He/She said staff did not think clearly if they made comments about someone's odor, that conversation should always be in private on how to fix an issue or to encourage a resident to shower. 5. Review of Resident #30's quarterly MDS, dated [DATE], showed staff assessed the resident as: -Required maximum assistance for bed mobility; -Moderately cognitively impaired; -Multiple Sclerosis (long-lasting (chronic) disease of the central nervous system), Anxiety (feeling of uneasiness or dread), Depression, and Psychotic Disorder (mental disorder characterized by a disconnection from reality). Observation on 01/02/24 at 2:22 P.M., showed the resident in his/her bed with his/her genitals exposed. Observation showed the resident's door open where staff, residents and visitors could view the resident. Observation on 01/02/24 at 2:25 P.M., showed the resident in his/her bed with his/her peri-area exposed. Observation showed the resident's door open where staff and residents could view the resident. Observation showed LPN J walked by and did not stop or assist the resident to cover himself/herself. Observation on 01/02/24 at 2:26 P.M., showed the resident in his/her bed with his/her peri-area exposed. Observation showed the resident's door open where staff and residents could view the resident. Observation showed the staffing coordinator walked by and did not stop or assist the resident to cover himself/herself. Observation on 01/02/24 at 2:31 P.M., showed the resident in his/her bed with his/her peri-area exposed. Observation showed the resident's door open where staff and residents could view the resident. Observation showed LPN C walked by and did not stop or assist the resident to cover himself/herself. Observation on 01/03/24 at 2:49 P.M., showed the resident in his/her bed with his/her peri-area exposed. Observation showed the resident's door open where staff, residents and visitors could view the resident. Observation on 01/03/24 at 2:51 P.M., showed the resident in his/her bed with his/her peri-area exposed. Observation showed the resident's door open where staff and residents could view the resident. Observation showed CNA H walked by and did not stop or assist the resident to cover himself/herself. Observation on 01/03/24 at 3:00 P.M., showed the resident in his/her bed with his/her genitals peri-area. Observation showed the resident's door open where staff and residents could view the resident. Observation showed another resident walked past the resident's room. Observation on 01/03/24 at 3:02 P.M., showed the resident in his/her bed with his/her peri-area exposed. Observation showed the resident's door open where staff and residents could view the resident. Observation showed CNA H and CMT I walked in the resident's room and did not assist the resident to cover himself/herself. Observation showed CMT H and CMT I left the room and did not assist the resident to cover himself/herself. During an interview on 01/05/24 at 1:22 P.M., LPN C said if staff see a resident is exposed and noticeable from the hallway they cover the resident up, staff should always try and maintain residents' dignity. During an interview on 01/05/24 at 2:02 P.M., the DON said residents should be covered and not exposed because it is a dignity issue. He/She said if he/she were exposed to everyone in the halls, he/she would be humiliated. During an interview on 01/05/24 at 2:26 P.M., the administrator said all resident should be covered up or the curtain closed if they are exposed, it is for their privacy and dignity. During an interview on 01/08/23 at 1:55 P.M., CNA H said residents that are exposed should be covered up and their door shut for privacy. He/She said staff may not have covered the resident up because they were in a hurry. He/She said if people saw him/her exposed he/she would be uncomfortable and mad. During an interview on 01/08/24 at 2:19 P.M., CMT I said if a resident is exposed staff should cover the resident and close the curtain. He/She said if he/she was exposed he/she would not feel good about it, very uncomfortable. He/She said he/she has no idea why a resident was left exposed because that should never happen. 6. Review of the facility's Smoking Protocol, last reviewed 10/25/22 showed smoking is only permitted in designated smoking areas with reasonable smoking times to be designated by the facility. Observation on 01/02/24 at 2:30 P.M., showed the posted smoking schedule on the 400 hall across from the nurse's station contained smoking times as follows: -8:30 A.M; -12:30 P.M; -3:30 P.M. 7. Review of Resident #76's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Independent with eating and personal hygiene. Review of the resident care plan, revised 12/15/22 showed staff did not document the residents smoke breaks. During an interview on 01/02/24 at 3:17 P.M., the resident said he/she does not like that their last cigarette break is at 3:30 P.M. and they do not receive another one until 8:30 A.M. the next day but he/she doesn't have a choice. He/She said it is what it is, cause that's what they say. 8. Review of Resident #102's Quarterly MDS, dated , showed staff assessed the resident as follows: -Cognitively intact; -Partial to Moderate assist with eating and personal hygiene; -Impairment to both sided of lower extremity; -Uses wheelchair for mobility. Review of the resident's care plan, revised 12/20/2023, showed staff documened the resident may attend supervised smoke sessions three times per day, weather permitting, smoke breaks may be canceled by activities, administration, nursing or social services, all smoking materials must be kept in activities or at south nurses station. During an interview on 01/03/23 at 12:20 P.M., the resident said Our last smoke break of the day is at 3:30 P.M., and I don't like it. He/She said waiting until 8:30 A.M. the next morning is hard. The resident said his/her understanding is it is that way because there is no staff to take them out in the evening. The resident said I am almost [AGE] years old I should be able to decide when I want to smoke. 9. During an interview on 01/02/24 at 2:45 P.M., the activities director said his/her department does all the smoke breaks because all residents must be supervised. He/She said he/she leaves at 5:00 P.M. and there are no other staff to take the residents out to smoke. He/She said he/she is not here on nights to know if it causes an issue but could see behaviors being worse due to time between smoke breaks. During an interview 01/05/24 2:09 P.M., the administrator said a lot of residents don't have enough money to have another smoke break. 6:00 P.M. use to be their last, but finding staff to supervise the 6:00 P.M. smoke break is hard. He/She said he/she does not know if residents were consulted with before the last smoke break was removed. 39644 43024

Based on observation, interview and record review, facility staff failed to accurately complete entrapment assessments, bedrail assessments, obtain physician orders, obtain consents for the use of bed rails for four residents (Resident #4, #30, #69 and #102). The facility census was 107. 1. Review of facility's policies showed staff did not provide a bed rail policy. 2. Review of Resident #4's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 09/01/23, showed staff assessed the resident as: -Cognitively intact; -Diagnoses of Parkinson's (progressive disorder that affects the nervous system and the parts of the body controlled by the nerves) and Epilepsy (a seizure disorder); -Required full dependence for bed mobility; -Bed rails not used. Review of the resident's medical record showed the record did not contain documentation staff completed: -Entrapment assessment; -Bedrail assessment; -Obtained consent; -Obtained physicians orders. Observation on 01/02/24 at 2:52 P.M., showed the resident in bed with the bilateral bed rails in the upright position. Observation on 01/04/24 at 8:44 A.M., showed the resident in bed with the bilateral bed rails in the upright position. 3. Review of Resident #30's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Moderately cognitively impaired; -Diagnoses of Aphasia (loss of ability to understand or express speech, caused by brain damage), Stroke (when something blocks blood supply to part of the brain or when a blood vessel in the brain bursts), Hemiplegia (paralysis of one side of the body), Multiple Sclerosis (long-lasting (chronic) disease of the central nervous system; -Required maximum assistance for bed mobility; -Bed rails not in use. Review of the resident's medical record showed the record did not contain documentation staff completed: -Entrapment assessment; -Bedrail assessment; -Obtained consent. Observation on 11/02/24 at 9:42 A.M., showed the resident in bed with the left bed rail in the upright position. Observation on 11/03/24 at 2:49 P.M., showed the resident in bed with the left bed rail in the upright position. 4. Review of Resident #69's Quarterly MDS, dated [DATE], showed staff assessed the residents as: -Cognitively intact; -Diagnoses of Traumatic Brain Injury (TBI - injury that affects how the brain works); -Required partial assistance for bed mobility; -Bed rails not used. Review of the resident's medical record showed the record did not contain documentation staff completed: -Entrapment assessment; -Bedrail assessment; -Obtained consent; -Obtained physicians orders. Observation on 01/03/24 at 2:49 P.M., showed the resident in bed with bilateral bed rails in the upright position. 5. Review of Resident #102's Admission MDS, dated [DATE], showed staff assessed the residents as: -Cognitively intact; -Required maximum assistance for bed mobility; -Bed rails not used. Review of the resident's medical record showed the record did not contain documentation staff completed: -Entrapment assessment; -Bedrail assessment; -Obtained consent; -Obtained physicians orders Observation on 01/02/24 at 3:12 P.M., showed the resident in bed with the right bed rail in the upright position. Observation on 01/04/24 at 8:43 P.M., showed the resident in bed with the right bed rail in the upright position. 6. During an interview on 01/04/24 at 1:09 P.M., the Director of Nursing (DON) said he/she did not realize assistive devices needed to be treated like bed rails because they are not. During an interview on 01/05/24 at 1:18 P.M., the Maintenance Director said his/her department inspects bed rails either weekly or monthly. He/She said a program they utilize called [NAME] (a maintenance notification system) and it alerts staff when the assessments are due. He/She said he/she does not have any entrapement assessments because he/she just took over the department. During an interview on 01/05/24 at 2:06 P.M., the DON said he/she believes assessments and entrapment assessments need to be done quarterly, and must have consents and orders to utilize bed rails but he/she has not completed them because he/she did not consider them a bedrail. During an interview on 01/05/24 at 2:31 P.M., the administrator said they do not utilize bed rails and did not think assistive devices were considered bed rails. He/She said he/she is unsure what regulation requirements are for bedrails.

Based on observation, interview, and record review, facility staff failed to destroy medications in a timely manner for five current residents (Resident #41, #56, #81, #89, #92) and three discharged residents (Resident #463, #464, and #465). The facility census was 107. 1. Review of the facility's Disposal of Medications and Medication-Related Supplies policy, Revised [DATE], showed all discontinued medication will be immediately removed form the resident's active medication and stored in separate locked area for up to 90 days or as required by applicable law, and then destroyed by a manner in accordance with applicable state and federal laws. 2. Observation on [DATE] at 12:50 P.M., showed a storage closet at end of 400 hallway contained two pink basins with 33 total medication cards, one large ziplock bag with 16 medication cards, and a large plastic tub with 89 medication cards. During an interview on [DATE] at 12:50 P.M., the Director of Nursing (DON) said him/her and the Assistant Director of Nursing (ADON) destroy expired/discontinued medications together. He/She said they just haven't had time to destroy these medications in the closet yet but they should have been destroyed. The DON said he/she was not sure what the policy said regarding medication destruction. 3. Observation on [DATE] at 1:35 P.M., showed the closet contained a medication card with five capsules of Cephalexin (Antibiotic) 500 milligrams (mg) with an order date of [DATE] for Resident #41. 4. Observation on [DATE] at 1:35 P.M., showed the closet contained the following medications for Resident #56: -One vial of Ipratropium-Albuterol (to treat respiratory symptoms) with an order date of [DATE]; -19 tablets of Lactinex (dietary supplement) chewable tablets with an order date of [DATE]; -Nine tablets of Famotidine (antacid) 20 milligram with an order date of [DATE]; -25 tablets Primidone (Anticonvulsant) of 50 mg with an order date of [DATE]; -210 tablets of Primidone 50 mg with an order date of [DATE]; -11 tablets of Myrbetriq ER (to treat overactive bladder) 50 mg with an order date of [DATE]; -31 capsules of Topiramate (anti-epileptic drugs) 100 mg with an order date of [DATE]; -Six tablets of 2 mg Bumetanide (diuretic) with an order date of [DATE]; -86 capsules of 300 mg Gabapentin (anticonvulsant) with an order date of [DATE]; -15 tablets of Melcoxicam (anti-inflammatory) 15 mg with an order date of [DATE]; -48 tablets of Pramipexole (Parkinson's Disease) 1.5 mg of with an order date of [DATE]; -30 capsules of Duloxetine HCL (Antidepressant) 60 mg of with an order date of [DATE]; -28 tab of Aripiprazole (Antipsychotic) 5 mg of with an order date of[DATE]; -27 tabs of Quetiapine Fumarate (Antipsychotic) 50 mg with an order date of [DATE]. 5. Observation on [DATE] at 1:35 P.M., showed the closet contained a medication card with 12 tablets of Ciprofloxacin 500 mg with an order date of [DATE] for Resident #81. 6. Observation on [DATE] at 1:35 P.M., showed the closet contained three capsules of Doxycycl HYC (Antibiotic) 100 mg with an order date of [DATE] and 14 capsules of Cephalexin 500 mg with an order date of [DATE] for Resident #89. 7. Observation on [DATE] at 1:35 P.M., showed the closet contained a medication card with three capsules of 100 mg Doxycycl HYC (Antibiotic) with an order date of [DATE] for Resident #92. 8. Observation on [DATE] at 1:35 P.M., showed the closet contained the following medications for Resident #463: -26 tablets of Clozapine (Antipsychotic) 25 mg with an order date of [DATE]; -28 tablets of Clozapine 25 mg with an order date of [DATE]; -Three tabs of Clozapine 50 mg with an order date of [DATE]. 9. Observation on [DATE] at 1:35 P.M., showed the closet contained the following medications for Resident #464: -Two tablets of Doxycycline (Antibiotic) 100 mg with an order date of [DATE]; -28 tabs of Metronidazole (Antibiotic) 250 mg with an order date of [DATE]; -Nine tabs Metronidazole of 250 mg with an order date of [DATE]. 10. Observation on [DATE] at 1:35 P.M., showed the closet conatined a medication card with 14 capsules NitrofurantoiN (antibiotic) of 100 mg with an order date of [DATE] for Resident #465. During an interview on [DATE] at 2:45 P.M., the Administrator said it is the responsibility of the DON to destroy the expired and discontinued medication. She said the medications in the closet should have been be taken care of sooner, however it has just been crazy with staffing lately. 47193

Based on interview and record review, facility staff failed to document communication between the facility and their hospice provider for three (Resident #4, #5 and #102) out of five sampled residents who received hospice services. The facility census was 107. 1. Review of the facility's Hospice Services Agreement, dated 05/03/2023, showed hospice will prepare and maintain complete medical records for hospice patients receiving services in accordance with this agreement and will include all treatments, progress notes, authorizations, physicians orders and other pertinent information. Review showed copies of all documents of services provided by hospice will be filed and maintained in the medical record. 2. Review of Resident's #4's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 09/01/23, showed: -Recived hospice services; -A condition or disease that may result in a life expectancy of less than six months. Review of the facility matrix list, dated 01/02/24, showed staff identiied the resident received hospice services. Review of the resident's progress notes, dated December 2023 and January 2024, showed the record did not contain documentation of hospice staff visits. Review of the facility's hospice binder, undated, showed the record did not contain documentation of communication between the facility and the hospice provider. 3. Review of Resident's #5's MDS, dated [DATE], showed: -Recived hospice services; -A condition or disease that may result in a life expectancy of less than six months. Review of the facility matrix list, dated 01/05/24, showed the resident received hospice services. Review of the resident's progress notes, dated December 2023 and January 2024, showed the record did not contain documentation of hospice staff visits. Review of the facility's hospice binder, undated, showed the record did not contain documentation of communication between the facility and the hospice provider. 4. Review of Resident #102's Admission MDS, dated [DATE], showed staff assessed the resident as: -Recived hospice services; -A condition or disease that may result in a life expectancy of less than six months. Review of the facility matrix list, dated on 01/05/24, showed the resident received hospice services. Review of the resident's progress notes, December 2023 and January 2024, showed the record did not contain documentation of hospice staff visits. Review of the facility's hospice binder, undated, showed the record did not contain documentation of communication between the facility and the hospice provider. 5. During an interview on 01/04/24 at 1:24 P.M., Licensed Practical Nurse (LPN) G said communication with hospice is verbal. He/She said there was a book but he/she is not sure where it is. During an interview on 01/05/24 at 1:26 P.M., LPN C said the nurses have the hospice nurses phone numbers to call or text but he/she is unsure what the system is if visits are documented somewhere, there is no charting system. During an interview on 1/05/24 at 2:04 P.M., the director of nursing (DON) said staff communicate through phone calls and text with the hospice staff but there is no place they document their visits. During an interview on 1/05/24 at 2:30 P.M., the administrator said the communication with hospice verbal, hospice staff do not have access to the facility's electronic health records. He/She said there is a hospice binder, but the communication is nurse to nurse. He/She was not aware of what the hospice contract says for communication.

Based on interview and record review, the facility staff failed to provide refunds of personal funds to residents from the facility operating account in a timely manner for four (Resident #361, #362, #371, and #373) discharged from the facility. The facility census was 107. 1. Review of the Facility's Resident Trust Fund policy, undated, showed: -The facility is required to maintain the resident trust account balance as a positive account at all times; -Any account that reflects a negative balance must be addressed immediately to the administrator and Treasury Analyst, to be resolved immediately; -An internal audit of the resident trust will be completed on a quarterly basis by the corporate office. 2. Review of the facility's maintained Accounts Receivable Report from 01/01/23 through 01/03/24, showed the following residents with personal funds held in the facility operating account: Resident Amount Held in Operating Account discharge date #361 $1,350.00 05/02/23 #362 $2,085.00 04/21/23 #371 $1,500.00 01/22/23 #373 $1,580.00 02/24/23 Total $6,515.00 During an interview on 01/03/24 at 10:28 A.M., the Business Office Manager (BOM) said he/she is responsible to send a Third Party Liability (TPL) request to the regional office every thirty days on accounts that need refunds and the regional office pays those refunds within 30 days of receipt but may take up to 60 days. He/She said if the resident is a private pay resident, estate information is needed and attached to the TPL before sending it up for refund. The BOM said he/she has not had time to send in all the TPL requests as he/she should have but would need to investigate which ones were late. During an interview on 01/03/24 at 2:24 P.M., the administrator said refund requests are sent to the regional office within 30 days by the BOM. He/She is aware of some refunds but not all and would need to ask the BOM why some have not been done. During an interview on 01/04/24 at 09:35 A.M., the regional BOM said he/she expects the facility BOM to submit a TPL within 30 days of resident discharging from the facility. He/She cannot answer why the facility has not sent requests for Resident's #361 and #362 but would expect him/her to do so timely so refunds may be issued. The Regional BOM said TPL requests were sent timely to the office for review for Resident #371 and #373 but have not been refunded and would investigate why. During an interview on 1/11/24 at 10:19 A.M., the Administrator said the Regional BOM is responsible to make sure the refund requests are submitted timely.

Based on interview and record review, facility staff failed to notify the Ombudsman (a resident advocate who provides support and assistance with problems and/or complaints regarding the facility) of resident transfers to the hospital for four sampled residents (Resident #39, #56, #58 and #92). The facility census was 107. 1. Review of the facility's Discharge/Transfer-Involuntary Policy, last review 10/07/21, showed the policy did not include direction for staff to notify the ombudsman for resident discharge or transfer. 2. Review of an email dated, 01/02/23 at 1:42 P.M., from the Long Term Care Ombudsman Program Director showed the facility does not send him/her monthly notifications of discharged or transferred residents. 3. Review of Resident #39's medical record showed the resident transferred to the hospital on 12/29/23 and readmitted to the facility on [DATE]. Review showed the medical record did not contain documentation staff notified the Ombudsman of the resident's transfer to the hospital. 4. Review of Resident #56's medical record showed the resident transferred to the hospital on 12/10/23 and readmitted to the facility on [DATE]. Review showed the record did not contain documentation staff notified the Ombudsman of the resident's transfer to the hospital. 5. Review of Resident #58's medical record showed the resident transferred to the hospital on 12/17/23 and readmitted to the facility on [DATE]. Review showed the record did not contain documentation staff notified the Ombudsman of the resident's transfer to the hospital. 6. Review of Resident #92's medical record showed the resident transferred to the hospital on 12/21/23 and readmitted to the facility on [DATE]. Review showed the record did not contain documentation staff notified the Ombudsman of the resident's transfer to the hospital. 7. During an interview on 01/05/23 at 1:10 P.M., the Social Services Director (SSD) said he/she has not been sending the transfer or discharge information to the Ombudsman. During an interview on 01/05/24 at 2:45 P.M., the Administrator said the facility does not have a policy but is aware the regulation says it is to be sent every month. The Administrator said she was not aware it was not being done.

Based on observation, interview, and record review, facility staff failed to post required nurse staffing information to include the facility name, resident census, total number of staff and total actual hours worked by both licensed and unlicensed nursing staff directly responsible for resident care, per shift on a daily basis. The facility census was 107. 1. Review of the facility's policies showed the facility did not have a policy for staffing and scheduling Postings. Observation on 01/02/22 at 10:30 A.M., showed staff did not post the required nurse staffing information to include the total number of staff and the actual hours worked by both licensed and unlicensed nursing staff directly responsible for resident care, per shift by the front entrance. Observation on 01/03/22 at 1:33 P.M., showed staff did not post the required nurse staffing information to include the total number of staff and the actual hours worked by both licensed and unlicensed nursing staff directly responsible for resident care, per shift by the front entrance. Observation on 01/04/22 at 8:40 A.M., showed staff did not post the required nurse staffing information to include the total number of staff and the actual hours worked by both licensed and unlicensed nursing staff directly responsible for resident care, per shift by the front entrance. Observation on 01/05/22 at 9:33 A.M., showed staff did not post the required nurse staffing information to include the total number of staff and the actual hours worked by both licensed and unlicensed nursing staff directly responsible for resident care, per shift by the front entrance. During an interview on 01/05/24 at 1:25 P.M., Licensed Practical Nurse (LPN) C said he/she is not sure who is responsible for posting the daily nursing staff postings but they are only located up at the front entrance of the building. He/She has not seen them posted on the locked units or any other halls. During an interview on 01/05/24 at 2:01 P.M., the Director of Nursing (DON) said medical records is responsible for changing the nurse staffing posts daily for shifts and human resources is responsible if medical records is out of the office. He/She said it is only posted at the front of the building as you enter. During an interview on 01/05/24 at 2:24 P.M., the Administrator said the nurse staffing postings are right outside the front office. He/She said medical records is responsible for changing it daily but is out of the office this week. He/She said human resources is the back up person for posting the daily schedule but forgot.

Based on observation and nterview, facility staff failed to provide meals that were served at a safe and appetizing temperature for three sampled residents (Resident #1, Resident #2, and Resident #3). The facility census was 110. 1. Observation on 10/20/23 at 11:59 A.M., showed the internal temperature of the chicken tenders for Resident #1 measured 95 F upon service to the resident. During an interview on 10/20/23 at 11:01 A.M., Resident #1 said the meals served were cold. Observation on 10/20/23 at 12:14 P.M. showed the internal temperature of the chicken tenders for Resident #2 measured 99 F upon service to the resident. During an interview on 10/20/23 at 11:12 A.M., Resident #2 said meals were cold every time they were served. Observation on 10/20/23 at 12:18 P.M. showed the internal temperature of the chicken tenders for Resident #3 measured 97 F upon service to to the resident. 2. During an interview on 10/20/23 at 12:25 P.M., the cook said he/she did not know the minimum temperature hot food should be when it arrives to a resident. During an interview on 10/20/23 at 12:26 P.M., the dietary manager said he/she did not know the minimum temperature hot food should be when it arrives to a resident. During an interview on 10/20/23 at 12:44 P.M., the director of nursing (DON) said he/she expected dietary staff to meet requirements for proper food temperatures when serving residents. MO00225802

Based on observation, interview and record review, the facility staff failed to appropriately sanitize manually and mechanically washed dishes to prevent cross-contamination. The facility census was 109. 1. Review of the facility's Sanitation-Warewashing policy, dated 04/01/16, showed: -Dinnerware and supplies shall be washed and sanitized according to food safety practices and regulatory guidelines as follows: 1. All dinnerware, utensils, preparation and service supplies shall be washed and sanitized in the pot sink and/or through use of commercially approved dish machine. 4. Test strips shall be available for the pot sink and low temp dish machine sanitizer. Results shall be checked and recorded daily. Observation on 07/06/22 at 10:22 A.M., showed staff washed kitchenware in the three-compartment sink. Observation showed a quaternary ammonium (QUAT) sanitizer used in the third compartment of the sink and kitchenware soaking in the sanitizer. The concentration of the sanitizer measured 100 parts per million (ppm) when measured with a QUAT test kit. Review of the product label for the QUAT sanitizer, showed instruction to use a solution with a 200 ppm concentration of active QUAT to sanitize food contact surfaces. Observation on 07/06/22 at 12:50 P.M., showed a sodium hypochloride (chlorine) sanitizer used in the mechanical dishwasher. The ppm concentration of the sanitizer did not register when tested with a chlorine test kit. The container of sanitizer connected to the dishwasher contained only a small amount of the product. Review of the product label for the chlorine sanitizer, showed the instructions for sanitizing food contact surfaces using mechanical warewashing equipment directed staff to, upon completion of a wash cycle, apply a sanitizing rinse that contained a 100 ppm concentration of available chlorine. The instructions directed staff to test the sanitizer frequently during operation with chlorine test strips to ensure the sanitizer does not drop below a concentration of 50 ppm. Review of the Dish Machine Log posted on the wall, dated 07/01/22 through 07/06/22, showed staff documented the temperature of the dishwasher as okay three times a day and staff did not document the concentration of sanitizer in the dishwasher. Observation on 07/06/22 at 1:20 P.M., showed Dietary Aide (DA) M and DA N washed dishes in the mechanical dishwasher. The ppm concentration of the sanitizer did not register when tested with a chlorine test kit. The container of sanitizer connected to the dishwasher contained only a small amount of the product. During an interview on 07/06/22 at 1:20 P.M., DA M said the staff who wash dishes are responsible to check the concentration of the sanitizer in the dishwasher daily using the chlorine test kit. He/she checked the sanitizer that day at 11:30 A.M. with the test kit stored at the dishwasher and the concentration of the sanitizer measured 125 ppm (a result that cannot be measured with the supplied test kit). The test strip should turn a dark purple when tested and staff are to write it is okay on the log on the wall. He/she had worked in the kitchen since 2017 and no one had ever told him/her to document the actual ppm concentration of the sanitizer. Staff should also check the container of sanitizer each morning to ensure it contains enough sanitizer. The DA said he/she had not checked the container of sanitizer that day. Observation on 07/06/22 at 1:30 P.M., showed DA M used the chlorine test kit stored at the mechanical dishwasher to check the ppm concentration of the sanitizer in the dishwasher. The ppm concentration did not register on the test strip. Further observation showed the DA verified the sanitizer did not register on the test strip. Observation showed DA M did not provide any information to DA N about the lack of sanitizer in the dishwasher and DA N continued to load soiled dishes into the dishwasher. During an interview on 07/06/22 at 1:40 P.M., the Certified Dietary Manager (CDM) said the staff who wash dishes are responsible to check the chemicals in the dishwasher before they wash dishes. Staff should document that the concentration of the sanitizer was okay on the log and he/she does not expect staff to document the ppm measurement. Staff should not continue to wash dishes in the dishwasher if the sanitizer does not register on the machine and he/she thought all staff should know that. During an interview on 07/07/22 at 09:29 A.M., the administrator said whoever does the dishes, should check the sanitizer and test its concentration with a test strip. He/she did not know how often staff check the sanitizer, but they should document the results when tested . He/she found it acceptable for staff to document their test with use of the words pass or okay. The administrator also said if staff test the sanitizer and it does not register the proper concentration, they should not use the machine until they are able to get the correct amount of sanitizer.

Based on observation, interview, and record review, facility staff failed to identify and implement new fall interventions after multiple falls with injury, failed to provide appropriate monitoring while providing assistance with toileting and personal care, and failed to provide appropriate monitoring while using a merriwalker for ambulation for one resident (Resident #12) out of twenty sampled residents. The facility census was 100. 1. Review of the facility's Falls Management Guideline, revised on 7/14/17, showed the following guidance: - When a fall occurs the interdisciplinary team (IDT) will review all resident falls within 24-72 hours at the morning IDT meeting to evaluate circumstances and probable cause for the fall. The IDT shall include the director of nursing (DON), administrator, therapy, nursing leadership if applicable and social services; - The IDT modifies and implements a care plan and treatment approach to minimize repeat falls and risk of injury related to the fall. The care plan will be reviewed and revised as indicated; - Residents that experience actual falls will be reviewed each week during the At-Risk Review Meeting; - The At-Risk Review committee members will review weekly all residents with falls for documentation, compliance, and interventions to determine that interventions are appropriate; - After the At-Risk Review Meeting, the IDT will perform the follow-up items assigned as indicated by the review. 2. Review of the facility's Falling Leaf Policy and Procedure, undated, showed the following guidance: - Objective: To monitor residents with frequent falls more frequently and update interventions after each fall; - All falls are to be addressed in the care plan; - All falls are to be investigated to determine the cause, log the fall and remove cause of fall, if possible. If the cause cannot be removed, revise the care plan to further address risks, and document findings; - If a resident falls twice in one month, they will be put on the falling leaf program; - Once the resident is on the falling leaf program, a green dot will be put on the spine of the medical record and will be charted on every shift; - All documentation will include all intervention attempts and what interventions are not working; - The fall team will address all new falls, and anyone on the falling leaf program, during their weekly meeting, so that new interventions can be addressed; - No one may be removed from the falling leaf program without the advice of the fall team. 3. Review of Resident #12's occupational therapy progress note, dated 1/23/17, showed the following documentation: - Start of care 12/26/17 and end of care 1/23/17; - Resident utilizing merriwalker with staff to meals. Review of the resident's nursing notes, showed staff documented the following: - 12/23/16 at 2:15 A.M.: The resident called staff to bedroom and reported to this nurse, I fell , and stated he/she was attempting to take self to the bathroom. Gait is very unsteady and erratic. 2 small skin tears to the back of scalp present, measuring 0.5 x 0.1, bright red, bleeding present. No other injuries observed and assisted with personal care and helped to bed with call light in reach; - 12/24/16 at 11:40 A.M.: The resident had a fall in his/her room today on day shift that was not seen by staff. The resident was found in his/her room with blood at the bathroom door and on the floor. Resident hit his/her head and has a 3 x 0.2 laceration to the back side of the head. Continue to monitor resident for signs and symptoms of pain and discomfort; - 12/25/16 at 1:30 P.M.: The resident sitting on floor in his/her bathroom between the toilet and wall, with no apparent injuries. Will continue to monitor; - 12/25/16 at 4:00 P.M.: The resident in dining room attempted to stand and lost his/her balance and fell forward hitting his/her head on the table. Has a tiny laceration to right eye brow with immediate edema (swelling) and black eye. Denies any pain or discomfort and will continue to monitor; - 12/31/16 at 6:25 A.M.: The nurse was called to hall by a certified nursing assistant (CNA) with reports of resident fall and bleeding all over the place. Nurse on the hall from night and day shift were with the resident. Resident said that he/she fell going to the bathroom. Sent to hospital for evaluation; - 12/31/16 at 8:44 A.M.: The resident called from room and was sitting on the floor in doorway of his/her room. Large amount of blood on his/her face. Has 2 lacerations to back of his/her head and stated I was trying to go to the bathroom. Resident sent to hospital for evaluation; - 12/31/16 at 11:00 A.M.: The resident returned from the hospital with 8 staples to two lacerations to back of head; - 1/4/17 at 3:01 A.M.: The resident ambulated self to toilet and fell . Knot noted above left eyebrow; - 1/5/17 at 10:00 A.M.: The resident was sitting on the toilet, CNA turned away for a moment to get the resident's pants. Resident attempted to stand and fell backwards hitting the back of his/her head. Laceration between 2 older lacerations with staples. The resident upset because I fell . Transferred to hospital for evaluation; - 1/5/17 at 2:53 P.M.: Resident returned from the hospital. Resident continues to attempt to transfer self, but will sit as long as someone is sitting next to him/her. Has additional 6 staples to back of his/her head, between 2 previous lacerations; - 1/6/17 at 7:27 P.M.: Staff aide called writer to room, resident sitting on bathroom floor facing the toilet with blood around on the floor and on resident's hands and face. Aide states he/she left resident on the toilet to go get linens to provide care and when he/she returned, resident was sitting on the floor bleeding. Resident states he/she slid off the toilet seat. Denies hitting head or any injuries but nose was noted to be bleeding; Review of the resident's plan of care, showed staff added the following interventions on 1/18/17: - Add to falling leaf program; - Do not leave alone in bathroom related to increased fall risk; - If falls, assess when, where, and why. Review of the resident's nursing notes, showed staff documented the following: - 1/29/17 at 7:09 P.M.: At 6:00 P.M. the resident noted to be sitting on his/her buttocks on the floor in his/her room. Blood noted on floor beside mat and to posterior head. Has laceration approx. 1 inch in length gaps with movement. Resident trying to get up unassisted. Resident sent to hospital for evaluation; - 2/2/17 at 2:35 A.M.: Writer heard a loud noise coming from the residents room and when writer entered the room, resident was climbing back into his/her bed. When writer asked if he/she needed something, resident answered writer but unclear tone. Resident's room mate informed writer that the resident had fallen on the floor. Resident without any injuries; - 2/11/17 at 6:22 P.M.: Resident self transferred to bathroom and to merriwalker. States I need a Band-Aid, and when asked for what the resident said he/she hit his/her head on doorway. Continues to get up without assist and also refuses to use call light; - 3/2/17 at 1:44 P.M.: Resident frequently gets up to ambulate without assist and propels self in merriwalker; - 3/7/17 at 9:00 P.M.: Resident was up in merriwalker talking on phone with family in dining room. Nurse responded to loud noise and resident yelling for help and resident was found sitting below merriwalker. Appears to have released security bar and strap and fell out. Resident admits he/she hit his/her head with bloody drainage from previous injury area on back of head. Resident stayed one one one for approx. one hour after fall. Attempted to more self transfers after fall without calling for assist. Resident reminded several times and given a call light; - 3/9/17 at 6:10 P.M.: Resident up ad lib in merriwalker. Review of the Resident #12's quarterly minimum data set (MDS), a federally mandated assessment tool, dated 4/7/17, showed staff assessed the resident as follows: - [DIAGNOSES REDACTED]. - Cognition intact; - Independent with transfers; - Required extensive assistance of one staff with walking in room, personal hygiene, and with toileting; - Required supervision and set up only with walking around corridor and locomotion on and off the unit; - Used a walker; - Used anti-psychotic medications over the past seven days from the review period; - Had two or more falls without injury and had two or more falls with injury. Review of the resident's nursing notes, showed staff documented the following: - 4/18/17 at 7:40 P.M.: Resident was ambulating unassisted in merriwalker and lost balance, tipping merriwalker over into roommate's bed. No injuries observed; - 4/27/17 at 12:51 A.M.: Resident transferred self from bed to toilet without calling for assist and found sitting on buttocks at base of toilet. No injury noted and resident instructed to use call light if assist is needed; - 4/21/17 at 5:56 P.M.: Resident up ad lib in merriwalker and often ambulates with bar open and ambulates without walker at times. The resident will ram his/her merriwalker into doors if roommate is being cared for and he/she wants in the room; - 5/1/17 at 9:35 P.M.: The resident uses merriwalker for mobility, able to get self in/out of it without difficulty. Assistance times one given as needed; - 5/2/17 at 7:19 P.M.: Resident ad lib in merriwalker. Often refuses to close bar of merriwalker or to have strap fastened. Today resident was noted to be climbing over strap to get out of merriwalker; - 5/3/17 at 1:30 A.M.: Called into resident's room by medication technician on hall who had been requested to enter resident's room. Had heard movement in resident's room upon going to doorway and saw resident sitting on buttocks. This nurse observed resident on buttocks on floor near bathroom doorway. Resident explained he/she was unable to keep walking and fell on to buttocks bumping left arm; - 5/4/17 at 9:58 A.M.: Resident had unseen fall this morning around 7:40 A.M. Writer found resident sitting on roommate's bed saying he/she fell when trying to go to the bathroom. Laceration to the right temple noted, measuring 1.5 centimeters (cm) x 0.1 cm x 0.1 cm, with slight swelling noted to site and scant amount of bleeding to wound; - 5/4/17 at 4:53 P.M.: Resident had a non-injury fall at 4:15 P.M. He/She was attempting to get up from dining chair too fast, grabbed at merriwalker, merriwalker begun to move causing resident to slide to floor. This nurse witnessed but was unable to get to resident fast enough. Resident reminded to seek assistance for transfers; - 5/4/17 at 11:33 P.M.: Reported that resident fell earlier this shift. Lacerations noted to right eyebrow, with small amount of bleeding noted; - 5/6/17 at 7:03 P.M.: Resident continues to step over strap in merriwalker when fastened; - 5/7/17 at 6:49 P.M.: Self reported fall at 1:20 P.M. Resident was in merriwalker in hallway yelling, I need to go to the hospital, I'm bleeding, call the ambulance. Resident refused to open mouth fully as can be inspected, small laceration to inner lower lip with possible broken tooth. Unknown what resident hit her lip on, two small drops of blood noted on middle of bathroom floor. Resident reminded to ask for assist with all transfers, strap fastened on merriwalker, resident lifts leg over strap each time; - 5/9/17 at 10:38 P.M.: Resident up in merriwalker ad lib. Refuses to use strap on merriwalker and when fastened the resident will step over strap and ambulate without it; - 5/19/17 at 4:24 P.M.: Uses merriwalker but refuses to use strap on walker, when fastened, resident will step over strap, increasing risk of falls. Self transfers frequently even with reminders to use call light; - 5/22/17 at 10:28 P.M.: While returning from toilet, CNA let go of the resident for a few seconds to grab a washcloth and the resident fell back and hit his/her head against the wall. There was slight bleeding from a previous scab near back-left off head; - 5/26/17 at 2:45 A.M.: Nurses aid heard noise from resident's room and found resident sitting up in bed with helmet on the floor next to the bed. Resident explained he/she fell , then got back into bed. No injuries noted; - 6/7/17 at 7:00 P.M.: Called to resident's room and observed him/her on buttocks in doorway of his/her room. Small amount of blood on left hip/mouth, very small scrape noted. Resident said he/she scraped it there after. Easily transferred back into merriwalker, due to resident was in it before fall; Review of the resident's plan of care, showed staff added the following interventions: -On 6/7/17-Offer to assistance to dining room for snacks. -On 6/14/17-Anticipate needs by offering to toilet every two hours. Review of the resident's fall risk assessment, dated 6/28/17, showed staff assessed the resident at high risk for falls. Review of the resident's plan of care, dated 7/7/17, showed staff identified the following care needs: - Resident is at risk for falls related to personal history of falls and [DIAGNOSES REDACTED]. - Utilized a low bed with mattress beside bed on the floor and one against the wall; - Required one assist with transfers; - Required assistance with ambulation in room; - Resident was impulsive, did not always wait for assistance with activities of daily living; - Utilized a merriwalker (ambulation device) and one assist for all long distance ambulation out of room and off unit. Must have staff member with him/her for all ambulation in merriwalker, should be used for ambulation only and do not leave the resident alone in the merriwalker; - Remove merriwalker from the resident when not in use so he/she doesn't try to get in on own and the resident is capable of removing self from merriwalker. Review of the residents quarterly MDS, dated [DATE], showed staff assessed the resident as follows: - [DIAGNOSES REDACTED]. - Cognition intact - Independent with transfers and toileting; - Independent with walking in room and walking around corridor; - Independent with locomotion on the unit (moving between locations in bedroom); - Independent with locomotion off the unit (moving between dining room, hallway, and other areas on same floor); - Required extensive assistance of one staff with personal hygiene; - Used a walker; - Used anti-psychotic medications over the past seven days from the review period; - Had one fall without injury. Review of the resident's nursing notes, showed staff documented the following: - 7/27/17 at 7:07 P.M.: Resident was in dining room sitting at a table, when another resident grabbed from his/her tray and the resident stood up quickly, losing his/her balance and fell to the floor; - 7/29/17 at 1:57 P.M.: Resident up ad lib in merriwalker as normal; - 8/15/17 at 1:51 A.M.: CNA alerted this writer there was a noise and he/she went to investigate and saw the resident exiting room with blood on his/her face. Resident was assisted to chair and noted to have a laceration above the right eye. Resident sent to hospital for evaluation; - 8/15/17 at 5:54 A.M.: The resident returned to facility and assisted to bed. Resident educated on asking for help before getting up. 17 stitches above right eye; Review of the resident's plan of care showed staff added the following interventions on 8/15/17: - The resident often gets up into merriwalker without securing strap, please ensure strap is secured; - Self reported fall on 8/15/17; - Found resident on floor in bathroom with laceration to left side. Review of the resident's nursing notes, showed staff documented the following: - 8/16/17 at 4:20 P.M.: Resident ambulates using merriwalker and often doesn't close bar when ambulating; - 8/17/17 at 2:15 A.M.: Called to resident's room and observed resident on floor by bathroom doorway. Had self ambulated without required assistance. Resident's gait very unsteady due to Huntington's. Resident had blood running down face. Cleaned it up and observed a deep laceration to his/her left forehead above eyebrow. Sent to hospital for evaluation; - 8/17/17 at 9:51 A.M.: Returned to facility with a fractured humerous. Assisted into merriwalker and taken to dining room. Sutures to left eyebrow noted, sling to left arm intact. After meal resident took self back to room and into bathroom, took arm out of sling to use bathroom, then called for assist to put sling back on correctly. Resident reminded not to get up without assist; Review of the resident's plan of care showed staff added the following on 8/18/17: - Came out of room on 8/18/17 with blood on face, sent to emergency room (ER), returned with 17 stitches above right eye. Remind resident to wait for assist with transfers. Review of the resident's nursing notes, showed staff documented the following: - 8/23/17 at 3:00 P.M.: Resident was going to bathroom unassisted and fell to floor on the way back to room. No injury noted; - 8/27/17 at 6:57 P.M.: At 5:15 P.M., resident noted to be sitting on floor at edge of his/her fall mat, with blood noted to right eyebrow. Resident states I went to bathroom. Observation on 9/8/18 at 9:10 A.M., showed the resident standing up in his/her room and ambulating without staff assistance or staff monitoring. During an interview on 9/7/17 at 6:04 P.M., certified medication technician (CMT) E said he/she feels like sometimes the secured unit has enough staff and sometimes they do not. CMT E said the resident is really impulsive, will not ask staff to help when he/she needs it, and has poor safety awareness. The CMT said the resident's fall interventions include having a low bed, fall mat, and staff will keep the resident's door open because the resident will sometimes ask for assistance if he/she sees staff. The CMT said the resident no longer uses the merriwalker because he/she fractured his/her arm and had the arm in a sling. During an interview on 9/8/17 at 2:06 P.M., CNA C said the resident is very stubborn. The CNA said when staff assist the resident with personal care and toileting, staff have to stay right with the resident or he/she will get up and walk. The CNA said he/she does not recall if the staff were re-educated or provided an in-service related to times the resident fell when staff assisted him/her. The CNA said the resident was very independent in the merriwalker, but no longer uses it because he/she fractured his/her arm and had his/her arm in sling. The CNA said in the dining room, if he/she was busy feeding somebody, the resident would get up on his/her own and get into his/her merriwalker and go. The CNA said while in the merriwalker, the resident would often unfasten the strap and not have the bar down, and has had falls while using the merriwalker. CNA C said he/she does not recall the resident specifically being on fifteen or thirty minute checks after any of his/her falls, but said all of the residents in the secured unit are on thirty minute checks. The CNA said if the resident sees him/her walk by his/her room, the resident will ask for him/her to get him/her up. The CNA said he/she does not think the secured unit has enough staff to complete thirty minute checks on the residents. CNA C said the night shift is especially understaffed and at times a CNA will work by himself/herself because the charge nurse covers both the 100 and 200 hall. The CNA said typically one CNA and one charge nurse works in the unit during the day shift. During an interview on 9/8/17 at 2:33 P.M., registered nurse (RN) D said the resident is very impulsive due to a [DIAGNOSES REDACTED]. The RN said the resident's gait is unsteady and when he/she used a merriwalker, the resident would unfasten the strap or try to climb over the bar, and this resulted in a couple of falls. The RN said the resident had a helmet at one time but the resident refused to wear the helmet and would take it off. The RN said staff tries to anticipate the residents needs, will encourage to use his/her call light, and will try to monitor closely. The RN said he/she feels the facility does not provide enough staff to work in the secured unit and said he/she feels like it has gotten worse since the secured unit now has four residents diagnosed with [REDACTED]. The RN said he/she does not remember receiving an in-service or re-education related to the residents falls. During an interview on 9/8/17 at 3:19 P.M., the DON said when a resident falls, he/she expects staff to assess the resident, start neuro checks, complete an incident report, and call the residents doctor and responsible party. The DON said if a resident has more than two falls in one month, the resident is placed on the falling leaf program, and staff are expected to monitor the resident more closely and to document on the resident every shift. The DON said the risk team meets every week and goes over various topics, including falls. The DON said he/she would expect staff to attempt a new fall intervention and to document whether the fall intervention was effective or not. He/She said the resident is very impulsive, unsteady, does not wait for staff assistance, and would not wear his/her helmet. The DON said the resident could get in and out of the merriwalker, would release the strap, and step over the merriwalker. The DON said he/she would expect staff to stay with the resident when the resident is on the toilet, and said he/she believes a nurse provided the CNA's with re-education after the falls involving the CNA's, but was not sure if it was documented. The DON said the residents fall interventions include having a low bed, fall mat, tries to educate to use call light, and for staff to frequently check the resident, which should be every thirty minutes. During an interview on 9/15/17 at 9:52 A.M., licensed practical nurse (LPN)/charge nurse I said the resident would at times remove the merriwalker strap while in it. The LPN said the resident would get into the merriwalker without staff realizing it and would not hook up the strap, and said staff had tried putting the walker in the residents room, hallway, and dining room, but the resident would just ambulate without anyway. The LPN said when the resident was first admitted , staff would give the resident privacy while on the toilet, but after the resident fell , staff were supposed to monitor the resident more closely. He/She said the resident used to have a bed alarm and knew it didn't work well, but was unsure why. LPN I said he/she does not think the facility provides enough staff to work on the secured unit. During an interview on 9/15/17 at 10:06 A.M., the assistant director of nursing (ADON) said the resident stopped using the merriwalker after he/she had a fall with fracture last month, but thinks the resident is again using the walker. The ADON said when using the walker, the resident would at times remove the strap and said the resident would get into the walker while he/she was in his/her room. He/She said they thought about moving the merriwalker after of the residents line of sight, but were concerned the resident would ambulate anyway without the walker. The ADON said the resident uses the merriwalker for general ambulation throughout the unit and used it most of the time while up; not just for ambulating long distances. The ADON said staff should be monitoring the resident while in the merriwalker. He/She said the resident tried using a wheelchair but he/she would not lock the it and fall while transferring to the wheelchair. The ADON said the resident is on the falling leaf program and the CNA's should of been completing thirty minute checks on the resident at all times. He/She said the fall interventions staff has discussed and implemented on a low bed, fall mat, merriwalker, medication reviews, monitoring, and therapy.

Based on observation, interview, and record review the facility staff failed to implement interventions and follow orders to prevent one resident (Resident #9) from losing a significant amount of weight. The facility census was 88. 1. Review of the facility's Properly Weighing Residents policy, undated, showed the purpose of the policy is to obtain accurate weights and monitor weight losses and gains. The policy showed staff are directed as follows: -Specific employees will be trained to get accurate weights on residents; -Weekly weights are to be recorded in the Medication Administration Record [REDACTED] -Any resident who loses 5% in one month will be weighed weekly for four weeks; -Residents with a 5% loss will be re-weighed to double check weight; -Director of Nurses (DON) or Assistant Director of Nurses (ADON) and the Dietary Manager (DM) will be immediately notified so action weight problem can be addressed; -If a resident gains or loses five pounds, re-weigh the resident immediately, if accurate start weight loss protocol; -If weekly weights are stable after four weeks, weekly weights will be discontinued; -Any resident unable to stand alone will be weighed in a shower chair or hoyer lift scale to ensure accurate weights. 2. Review of the facility's Undesirable Weight Loss policy, undated, showed the purpose of the policy is to keep residents from adverse effects of weight loss. Additional review showed the facility staff are directed as follows: - Weight loss of 5% in one month or 10% in six months is considered significant and cause for multidisciplinary action; -When a weight loss is found the resident will be placed on weekly weights for two weeks and offered an enhanced fortified diet; -After two weeks of continued weight loss the registered dietician (RD) will be notified for further direction; -Interventions for undesirable weight loss will be based on consideration of resident choice, nutrition and hydration needs, functional factors that inhibit eating, environmental factors that may inhibit appetite or desire to participate in meals, chewing and swallowing abnormalities/diet modification, medication side effects, the use of supplementation and/or feeding tubes, and end of life decisions/advanced directives. X. Review of the facility's Fortified Enhanced Power (FEP) Food Protocol, dated 2011, showed dining services are encouraged to develop an individualized plan of care when additional calories and/or protein are needed to meet nutritional needs. Review showed health care communities that utilize "fortified foods" diet orders as an option are to utilize the FEP protocol. Review showed the RD or DM assesses the individual to determine the amount of calories and/or protein, the resident requires in their diet. Additional review showed FEP foods include, but are not limited to the following: -Cheesy eggs; -Fortified hot chocolate; -Fortified milk shakes; -Fortified soup; -Juice shakes; -Orange Creamsicle; -Power potatoes (from instant potatoes); -Power potatoes; -Super cereal; -Super pudding. X. Review of Resident #9's Minimum Data Set (MDS), a federally mandated assessment instrument, dated 6/29/14, showed staff assessed the resident as: -Short and long term memory loss; -Weight 145 pounds, mechanically altered diet and therapeutic diet; -Required to be cued to eat. -Weight loss of 5% or more in the past one month or 10% or more in the last six months; -Not on a physician-prescribed weight-loss regimen. Review of the resident's plan of care dated 3/25/14, showed the Dietary Supervisor (DS) documented a "10% weight loss or more within 180 days." Further review of the resident's plan of care, dated 6/26/14, showed the following information for nutrition: -Assist to feed in the small dining room with tray set up; -Give a pureed fortified diet with nectar thick liquids offering alternates and snacks between meals; -Encourage to have meals in 200 dining room to promote socialization and for better supervision; -Monitor food intake and weights; -Consult with Registered Dietician on 03/25/14 and 06/26/14; -Resident refuses to eat or drink anything but water on some occasions; -Complains of pain either teeth or stomach aches; -All staff offer health shakes at anytime -DS documented resident "lost over 10% of weight within 180 days consult with the RD again this month." Review of the resident's admission weight on 12/14/13, showed staff documented the resident's weight at 183 pounds (lbs.). Review of the residents monthly weights showed: -December 2013-183 lbs., admission weight; -January 2014-178 lbs, 2.73% weight loss in 30 days; -February 2014-174 lbs, 4.92% weight loss; -March 2014-160 lbs, 12.57% weight loss in 90 days; -April 2014-157 lbs, 14.21% weight loss; -May 2014-148 lbs, 19.13% weight loss; -June 2014-145 lbs, 20.77% weight loss in 180 days; -July 2014-150 lbs, 18% weight loss. Review of the 200 hall weekly weight report did not contain weekly weights for the months of May 2014 and June 2014. Observation on 07/17/14, showed RA N weighed the resident. The Restorative Aide (RA) said the resident's weight showed 148 lbs. (19.13% loss in seven months). Review of the resident's MAR, dated 07/2014, did not contain documentation of weekly weights. Review of the resident's Treatment Administration Record (TAR), dated 07/2014, did not contain documentation of weekly weights. Review of the resident's Physician order [REDACTED]. Review of the physician progress notes [REDACTED]. Review of the DM notes, dated 3/25/14, showed the DM documented: -Resident lost more than 10% of weight in 120 days since admission; -Weight four months ago 183 pounds now 160 pounds; -Will not eat due to teeth hurt; -3/05/14 resident was put on [MEDICATION NAME] so far not helping continues to not eat; -Resident saw a dentist and has nine teeth that need to come out and he/she has another dentist appointment; -Resident complains of stomach pain; -Resident is on pureed diet with thickened liquids. Review of the DM progress notes, dated 4/03/14, showed the DM documented the following: -Resident refused to eat at times; -Consult the RD; -Diet changed to fortified diet; -Continue health shakes, super cereal and mashed potatoes. Review of the DM progress note, dated 6/26/14, showed DM documented the following: -Resident lost 10% of weight actually more than 10% within 180 days; -Resident refuses to get up and eat for breakfast or lunch; -Times have been changed to later hours to see if this would help which it did not; -Resident said he/she will eat when he/she goes home, the daughter said "that ain't never going to happen"; -Averaged less than 50% for most meals; -Continue on with pureed diet with nectar thick liquids and fortified foods and still on the list for RD weight loss. Review of the RD notes, dated 6/27/14, showed he/she documented the resident is to receive 2 cal 60 milliliters (ml) between meals. The POS, dated 07/2014, showed it did not contain the RD recommendation for 2 cal 60 ml between meals. Observation on 7/15/14 at 5:15 P.M., showed the resident did not eat his/her evening meal. The staff did not assist or encourage the resident with his/her meal and did not offer health shakes as directed in the plan of care. Observation on 7/16/14 at 12:00 P.M., showed the resident did not eat his/her noon meal. The staff did not assist or encourage the resident with his/her meal and did not offer health shakes as directed in the plan of care. Observation on 7/16/14 at 5:30 P.M., showed the resident did not eat his/her evening meal. The staff did not assist or encourage the resident with his/her meal and did not offer health shakes as directed in the plan of care. Observation on 7/17/14 at 5:50 A.M., showed the resident with his/her head down on the dining room table and eyes closed. Staff did not offer the resident a snack or a health shake as directed in the plan of care. X. During an interview on 7/16/14 at 1:00 P.M., Licensed Practical Nurse (LPN) F said a resident receives a health shake if dietary delivers them. The LPN also said health shakes are not kept on the medication cart. X. During an interview on 07/17/14 at 10:55 A.M., The DM said the resident continues to lose weight and now lost over 10% in 180 days. He/she said health shakes go to the units on the the drink cart at mealtimes. He/She also said the addition of health shakes constitutes a fortified diet. The DM said he/she could not find the resident's recent weights. X. During an interview on 07/17/14 at 11:15 A.M., the DON said if a resident has a three to five pound weight loss, the RA is to re-weigh the resident. The DON said a resident with a weight loss has his/her weight checked weekly for four weeks. After two weeks, if the resident is still losing weight, the RD will be notified to do an evaluation and the physician will get involved. The DON said the physician will see residents every two months and is not called all the time. X. During an interview on 7/17/14 at 10:10 A.M., LPN P said he/she was not sure if the RD comes in every 30 days. He/She also said weekly weights are started by the unit secretary and are done on Sundays and are to be kept in the MAR. He/she said certified nursing aides (CNAs), RAs, and the unit secretary gather weights. He/she also said the staff do not have a meeting that concerns weight loss. X. During an interview on 7/17/14 at 10:56 A.M., RA N said the RAs obtain weekly weights for assigned halls. He/She also said Resident #9 was not on the list for weekly weights in May 2014. The RA also said the charge nurses are given a copy of the weekly weights every week. He/She said he/she could not find the weekly weight list from June 2014.