Every finding on record at The Blossoms at White Hall Rehab & Nursing Center

Based on record review and staff interview, the facility failed to ensure staff members who performed cardiopulmonary resuscitation (CPR) maintained an active and verified provider-level CPR certification for two Certified Nursing Assistant (CNA)s #1 and #4 of two CNAs reviewed. The findings include: Review of Resident #1's Physician's Orders revealed Resident #1 had diagnoses that included chronic combined congestive heart failure, chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea. The Physician's Orders revealed the following: -Admit to [hospice name] with diagnosis of COPD with an order date of [DATE]. -BIPAP (Bilevel positive airway pressure) to be applied every night with settings preset by respiratory at back up rate-at bedtime with an order date of [DATE]. -O2 (Oxygen): O2 at 3 L (liters)/(per) min (minute) via nasal cannula as needed every shift, maintain O2 saturation above 92 percent. The order date was [DATE]. Review of Resident #1's annual Minimum Data Set (MDS) with an Assessment Reference Date of [DATE] revealed a Brief Interview for Mental Status score of 15, which indicated Resident #1 was cognitively intact. This MDS also revealed Resident #1 had shortness of breath or trouble breathing when sitting at rest and when lying flat. Resident #1 also received respiratory treatments which included oxygen therapy and a non-invasive mechanical ventilator while a resident. Review of Resident #1's Care Plan revealed the following: -A focus problem of altered respiratory status/difficulty breathing related to CHF and COPD with an initiated date of [DATE]. Interventions included BIPAP/CPAP (continuous positive airway pressure) Settings per MD (Medical Doctor)orders with an initiated of [DATE]. -A focus problem of CPR measures are to be performed (FULL CODE STATUS) ([DATE]) . I need you to initiate CPR if you find me pulseless or breathless and continue CPR until paramedics arrive to take over, initiated date [DATE]. Review of Resident #1's Progress Notes revealed: - On [DATE] at 10:33 PM, Resident #1 was sent to the ER (emergency room). -On [DATE] at 12:25 AM, indicated at 7:58 PM a power outage occurred and Resident #1's oxygen concentrator was replaced with an emergency E-tank located in the room. This note indicated Resident #1 was stable, but anxious regarding the power loss and reassurance was provided. The note indicated at 8:30 PM, Licensed Practical Nurse (LPN) #2 conducted safety rounds in Resident #1's room and this resident was found lying in bed, holding an oxygen mask, unresponsive to verbal and tactile stimuli, pulseless and apneic (cessation of breath). LPN #2 called a code blue at 8:31 PM and Resident #1's code status was verified as full code. At 8:32 PM a crash cart was brought to Resident #1's room and CPR was immediately initiated. A local ambulance service was on-site [for a separate call], assisted the facility staff and assumed resuscitation efforts. At 9:15 PM, Resident #1 was transported to a local hospital. This note indicated at 9:40 PM, Resident #1's family was notified of the event, that the resident had been transported to the local hospital and the facility had been notified by the local hospital that Resident #1 had expired. During an interview on [DATE] at 2:21 PM, CNA #1 stated she performed chest compressions on Resident #1 and CNA #4 performed rescue breaths on Resident #1 using an [name brand manual resuscitator] bag. CNA #1 stated she thought she was CPR certified but that she had not had a CPR class in the last couple of years. She stated she did not have her CPR card or a picture of it. She was asked if a staff member told her to start CPR and she stated someone stated, Start CPR but she did not know who this staff member was. She stated she had never performed CPR prior to [DATE] with Resident #1. She was asked prior to her starting CPR if she had to take over chest compressions for another staff member and she stated she did not. She stated, Me and [CNA #3] turned [Resident #1] over a little and I jumped up there and started CPR. During an interview on [DATE] at 3:00 PM, LPN #2 stated she was CPR certified, and she did perform CPR on Resident #1 on [DATE] during the code but she did not start CPR. She stated she thought a nurse started CPR, but the room was dark and she was not sure who that may have been. She stated there were CNAs coming in the room also, and everyone including the CNAs, participated in CPR on Resident #1 at some point,. During an interview on [DATE] at 4:30 PM, the Administrator stated CNAs were not required to be CPR certified when she was asked to provide CPR certification for CNAs #1 and #4. The Administrator stated if exhaustion has set in and the nurse needs relief, then CNAs are allowed to perform CPR in their facility. She stated she was not familiar with the federal regulations to indicated if staff could perform CPR without certification. The Administrator stated she would need to look at the federal regulation before answering if CPR could be performed under nurse supervision. The Administrator was asked to provide a policy on CPR to the surveyor. During a telephone interview on [DATE] at 10:25 AM, CNA #4 stated she did see CNA #1 performing CPR on Resident #1. CNA #4indicated CNA #1 was doing chest compression, and the two breaths. She stated they would switch out when one of the team members became tired. CNA #4 stated she was CPR certified, but she did not know where her card was and she did not provide a copy to the facility because no one asked for it. CNA #4 was asked to email a copy of the CPR card to this surveyor. This surveyor provided a work email for CNA #4 to send the document to, and CNA #4 confirmed she received the email address. As of 5:00 PM on [DATE], CNA #4 had not provided a copy of her CPR certification to this surveyor. A review of a basic life support document with an issue date of [DATE] revealed Licensed Practical Nurse (LPN) #2 had successfully completed the cognitive and skills evaluations in accordance with the curriculum of the American Heart Association Basic Life Support (CPR and AED (automated external defibrillator) Program. The document had a renew by date of 07/2028. Review of a Cardiopulmonary Resuscitation policy, dated as revised 04/2025, indicated obtain and /or maintain American Heart Association certification in basic life support (BLS)/ Cardiopulmonary Resuscitation (CPR) for key clinical staff members who will direct resuscitative efforts, including non-licensed personnel. This policy indicated licensed nurses should maintain current CPR certification for healthcare providers.

Based on interview and record review, the facility failed to ensure respiratory care and services were provided in accordance with the prescribed Physician's Orders for one (Resident #1) of one resident reviewed. The findings include: Review of Resident #1's Physician's Orders revealed Resident #1 had diagnoses that included chronic combined congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea. The Physician's Orders revealed the following: -Admit to [hospice name] with diagnosis of COPD with an order date of [DATE]. -BIPAP (Bilevel positive airway pressure) to be applied every night with settings preset by respiratory at back up rate-at bedtime with an order date of [DATE]. -O2 (Oxygen): O2 at 3 L (liters)/(per) min (minute) via nasal cannula as needed every shift, maintain O2 saturation above 92 percent. The order date was [DATE]. Review of Resident #1's annual Minimum Data Set (MDS) with an Assessment Reference Date of [DATE] revealed a Brief Interview for Mental Status score of 15, which indicated Resident #1 was cognitively intact. This MDS also revealed Resident #1 had shortness of breath or trouble breathing when sitting at rest and when lying flat. Resident #1 also received respiratory treatments which included oxygen therapy and a non-invasive mechanical ventilator while a resident. Review of Resident #1's care plan revealed the following: - A focus problem that indicated Resident #1 had panic attacks about going to the doctor and running out of oxygen. The problem indicated Resident #1 was on a BIPAP device most of the day even though education was provided on the risks versus benefits. Interventions included assist me to develop more appropriate methods of coping and interacting. - A focus problem of oxygen therapy related to CHF, ineffective gas exchange. Interventions included oxygen settings: O2 via nasal prongs at 3L as needed, humidified as needed, with a date initiated of [DATE]. The focus problem also indicated to provide reassurance and allay anxiety: have an agreed-on method for the resident to call for assistance and stay with the resident during episodes of respiratory distress. -A focus problem of altered respiratory status/difficulty breathing related to CHF and COPD with an initiated date of [DATE]. Interventions included BIPAP/CPAP (continuous positive airway pressure) Settings per MD (Medical Doctor) orders with an initiated of [DATE]. Review of the Oxygen Saturations Summary for Resident #1 revealed on [DATE] at 4:04 PM Resident #1's value was 97.0 % and the method was BiPAP. There was no documentation after this date and time that indicated Resident #1's oxygen saturation. Review of Resident #1's Progress Notes revealed: - On [DATE] at 10:33 PM, Resident #1 was sent to the ER (emergency room). -On [DATE] at 12:25 AM, indicated at 7:58 PM a power outage occurred and Resident #1's oxygen concentrator was replaced with an emergency E-tank located in the room. This note indicated Resident #1 was stable, but anxious regarding the power loss and reassurance was provided. The note indicated at 8:30 PM, Licensed Practical Nurse (LPN) #2 conducted safety rounds in Resident #1's room and this resident was found lying in bed, holding an oxygen mask, unresponsive to verbal and tactile stimuli, pulseless and apneic (cessation of breath). LPN #2 called a code blue at 8:31 PM and Resident #1's code status was verified as full code. At 8:32 PM a crash cart was brought to Resident #1's room and CPR was immediately initiated. A local ambulance service was on-site [for a separate call], assisted the facility staff and assumed resuscitation efforts. At 9:15 PM, Resident #1 was transported to a local hospital. This note indicated at 9:40 PM, Resident #1's family was notified of the event, that the resident had been transported to the local hospital During an interview on [DATE] at 3:00 PM, LPN #2 stated that on [DATE] during her shift, Resident #1 was using a CPAP machine connected to oxygen and wore the CPAP device continuously. She stated after the power outage she went to Resident #1's room and Resident #1 stated, I need my CPAP machine. What's wrong? LPN #2 stated she told Resident #1 about the power outage, and Resident #1 had been anxious at that time. LPN #2 stated the E-tank was full because she had to open the E-tank with a wrench and the dial indicated full when she turned the E-tank on. She stated she placed Resident #1 on an E-tank at three liters per minute (LPM) via nasal cannula and Resident #1 verbalized not feeling any oxygen coming through the cannula. She stated she increased the flow rate of oxygen to four LPM without speaking to a medical provider. LPN #2 stated Resident #1's oxygen saturation was 96 percent (%) when she checked, but she did not document this observation anywhere. She stated she left the room to monitor another hall and when she made it back to Resident #1's room, Resident #1 did not respond. She stated she entered Resident #1's room and found the resident with no pulse, no breath sounds and no response to a sternal rub of the resident's chest. She stated she then called a code blue [to indicate a medical emergency]. During a follow-up interview on [DATE] at 10:51 AM, LPN #2 stated she did not know what the facility's emergency plan was regarding a power outage and she had not received any education/training on emergency preparedness at this facility. She stated the facility did not have an emergency plan for which indicated what to do for a resident who used a BIPAP device when there was a power outage. She stated the facility did not have anything but an E-tank for Resident #1. She confirmed she had checked Resident #1's oxygen level which was 96% but she did not document this anywhere. She also confirmed she did increase Resident #1's oxygen to four liters and had not called the provider because she could not locate her cellphone, and the facility phones were not working due to the power outage. LPN #2 stated she had not asked another staff member to call the provider. She stated increasing the flow rate of oxygen for a resident without a provider's order was not in her scope of practice. She stated she did not call 911 because emergency personnel were in the facility for another matter. During an interview on [DATE] at 1:57 PM, the Director of Nursing (DON) stated she did not see a physician's order that indicated Resident #1 could use the BIPAP device during the day and as needed and this was more of the resident's preference. She stated the medical provider was aware that the resident used the BIPAP device more than the prescribed order. She stated the facility did not have any written instructions which guided nurses on what to do if the emergency generator did not come on for a resident who used a BIPAP device. She stated the only thing the nurses could have done was to supply Resident #1 with oxygen. She stated the facility does not have standing orders and nurses should not adjust a resident's oxygen flow rate without a physician's order. The DON stated the facility's emergency preparedness did not have a protocol that instructed nurses on what to do in the event of a power outage when the generator does not come on. She stated the facility did not have an emergency plan for a Resident who used a BIPAP device and the generator did not come on after a power outage. The DON stated the nurse should have called the provider to see if he had any suggestions as COPD patients do not take [a lot of] oxygen well. During an interview on [DATE] at 5:02 PM, the Medical Director stated he was aware that Resident #1 used the BIPAP device more than just at bedtime. He stated he had spoken to Resident #1 a few days prior about hospice and this was the last he had spoken to Resident #1. He stated he did not remember if the staff had asked him about obtaining an order for Resident #1 to use the BIPAP device more than at bedtime. He stated Resident #1 had become more dependent on the BIPAP device and had become more anxious. He stated that it was hard to tell if three to four liters of oxygen was sufficient for Resident #1 since the BIPAP device was used more than at bedtime. He stated Resident #1 could get by with it [oxygen] during the times he saw Resident #1. He was asked if the nurse should have increased the oxygen flow rate from three to four liters for Resident #1, who had a diagnosis of COPD, without consulting him or another provider and he stated, I don't know. That depends on what [Resident #1] looks like, and what was happening. I didn't see [Resident #1] any during that time, that weekend or before the event itself. Review of an Oxygen Administration -Resident policy, with a revised date of [DATE], indicated the purpose of the procedure was to provide guidelines for safe oxygen administration. This policy indicated for preparation, to verify that there is a physician's order and review the physician's order or facility protocol for oxygen administration.

Based on observation, interview, and record review, the facility failed to ensure a call light was kept in reach to ensure a resident had a means to call for assistance for 1 (Resident #296) of 1 resident sampled for accommodation of needs. The findings are: Review of the Medical Diagnosis Screen indicated Resident #296 had diagnoses which included anxiety disorder, schizophrenia, muscle weakness wasting and atrophy, and abnormality of gait. The annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/01/2024, indicated Resident #296's vision was highly impaired. The MDS indicated a Brief Interview of Mental Status (BIMS) of 12, which indicated moderate cognitive impairment. The MDS also indicated Resident #296 rejected care daily, was independent with toileting, was continent of bladder and bowel, and ambulated short distances without assistance. Review of Resident #296's Care Plan with an initiated date of 10/17/2023, indicated the resident was blind, and that staff were to ensure the call light was within reach and to respond to needs promptly. On 04/14/25 at 9:12 AM, Resident #296 was observed in their room sitting in a recliner. Resident #296's call light was lying on the floor in front of the recliner. When asked if the resident could reach the call light, Resident #296 stated No, where is it? Resident #296 confirmed experiencing blindness and was unable to locate call light. The call light was observed again on the floor at 11:48 AM, and again when checked at 3:24 PM. On 04/15/25 at 8:25 AM, Resident #296 was observed sitting in the recliner in their room with the call light lying on the floor in front of the recliner, out of reach of the resident. During an interview, on 04/15/2025 at 8:30 AM, Licensed Practical Nurse (LPN) #15 confirmed Resident #296 had impaired vision and that the call light should be placed in reach of the resident so that the resident could use it to call for assistance when needed.

Based on observation, record review, and interview, the facility failed to ensure incontinent care was provided in a timely fashion and in accordance with the resident ' s needs for one (Resident #247) of one sampled resident dependent on facility staff for incontinent care. The findings are: Review of a Medical Diagnosis report revealed Resident #247 was admitted to the facility with diagnoses that included a fracture in the lower part of the upper left arm bone, a fracture in the upper part of the upper left arm bone, and obesity class 3, with body mass index 45.0 - 49.9, adult. Review of a Baseline Care Plan for admitted d 04/10/2025, indicated the resident could easily communicate with staff, was cognitively intact and required maximal assistance for toileting hygiene. The health conditions section indicated that the resident was always incontinent of bowel and bladder. The functional abilities section for mobility indicated the resident was dependent to roll left and right in bed. Review of a Care Plan assessment dated [DATE], indicated the resident required staff assistance times two for incontinent/perineal care. On 04/14/25 at 10:36 AM, a review of Resident #247 ' s Wound Evaluation, dated 04/10/2025, indicated the resident had a pre-admission stage 2 pressure injury at the sacrum. On 04/14/25 at 9:04 AM, Resident #247 was interviewed and reported incontinence of bowel and bladder. Resident #247 stated a request to receive incontinent care was made to two different staff members within the last twenty minutes. On 04/14/25 at 9:37 AM, Resident #247 verified staff had not provided incontinent care. The room had a foul odor. On 04/14/25 at 10:48 AM, Resident #247 verified staff had not provided incontinent care. The room had a foul odor. On 04/14/2025 from 9:04 AM until 11:22 AM, this surveyor remained in the hallway within view of Resident #247's room and no staff were observed entering the room during that time to assist the resident. On 04/14/25 at 11:22 AM, Certified Nursing Assistant (CNA) #1 and CNA #2 knocked on the resident's door, announced themselves, and entered Resident #247's room. On 04/14/2025 at 11:26 AM, this surveyor knocked on Resident #247's door, announced self, and with Resident #247 ' s permission, entered the room. Resident #247 was observed lying in bed in a hospital gown. The resident's left arm was in a full plastic arm brace, and a purple bruise about the size of a sheet of copy paper was on the resident's left flank/shoulder areas. The resident's brief was down, exposing the brief was over half full of loose stool. CNA #1 had on gloves, no gown, and was standing on the left side of the resident handing CNA #2 cleaning wipes. She used the cleaning wipes several times each and tucked the used wipes into the soiled brief between the resident's legs. CNA #1 was observed multiple times to reach into her jacket pockets for gloves. She was observed touching both curtains in the room, dispensing cleaning wipes and providing perineal care with dirty gloves on her hands. She was not observed using hand sanitizer at any time in the room or during perineal care. During perineal care CNA #1 removed her gloves and went outside of the room. CNA #1 came back into the resident's room, reached into her jacket pocket again for gloves to wear. CNA #2 had gloves on, no gown and was standing on the right side of the resident. She used the cleaning wipes several times each and tucked the used wipes into the soiled brief between the resident's legs. She changed gloves multiple times. She was not observed performing hand hygiene at any time in the room during perineal care. On 04/14/2025 at 11:42 AM, CNA #1 and CNA #2 were placing a clean brief on Resident #247. Before the brief was fastened, this surveyor asked CNA #2 and CNA #1 if the resident's perineal care was completed, and each CNA indicated the perineal care was complete. This surveyor requested one of the CNAs to please take a cleaning wipe and wipe down one side of the resident's groin. The Director of Nursing (DON) peered over the resident and asked, did we not get it all? CNA #1 obtained a cleaning wipe and wiped down the side of the resident's groin with a large amount of fecal material being present on the wipe. The DON left the resident's room. Within 5 minutes the Restorative CNA knocked on the door, announced self and entered the room. The Restorative CNA had on a gown, used hand sanitizer located by the door and put on gloves. She then assisted with perineal care. CNA #1, CNA #2 and Restorative CNA continued cleaning the resident's groin area utilizing over a half bag of wipes to finish cleaning the resident after CNA #1 and CNA #2 stated they were finished providing perineal care. On 04/14/2025 at 12:00 PM, upon the completion of incontinent care, CNA #1 and CNA #2 verified the only hand sanitizer in the room was next to the door on the opposite side of the room. CNA #1 and CNA #2 confirmed they did not utilize any hand sanitizer during the incontinent care. On 04/14/25 at 12:12 PM, the Restorative CNA was interviewed and indicated it was important for the resident to receive proper incontinence care to avoid cross contamination and prevent urinary tract infections. The Restorative CNA reported gloves should be changed and hands sanitized between each clean and dirty task. On 04/14/25 at 12:16 PM, CNA #1 was interviewed and indicated it was important for a resident to receive proper incontinent care to keep the resident from getting a bacterial infection or having skin problems. She reported the process for incontinent care included gathering supplies, knocking on the door, greeting the resident, explaining the care, and providing proper incontinent care. CNA #1 stated during incontinent care, hand sanitizing should take place when changing gloves and every time the gloves are dirty. She indicated she did not wash her hands, nor sanitize her hands at any time during incontinent care provided to Resident #247 today. On 04/14/25 at 12:17 PM, CNA #2 was interviewed and indicated it was important for a resident to receive proper incontinent care to prevent infection and prevent skin breakdown. She indicated each cleaning wipe should be used for one wipe and then disposed. She stated proper incontinent care would provide the resident with thoroughly cleansed skin. CNA #2 indicated hand sanitizer should be used every time gloves were removed, and verified she did not use hand sanitizer while providing incontinent care for Resident #247 today. On 04/14/25 at 3:38 PM, the DON was interviewed and indicated it was important to promptly and thoroughly clean the perineal area during incontinent care to prevent infection and to protect the skin. The DON reported the incontinent care provided by CNA #1 and CNA #2 to Resident #247 did not meet her expectation of incontinent care. She verified she was in the room during incontinent care and observed that CNA #1 and CNA #2 did not change gloves when indicated, did not sanitize hands and did not provide proper incontinent care. On 04/17/25 at 2:59 PM, the Administrator verbally verified the facility did not have a policy for incontinent care. On 04/14/2025 at 2:59 PM, the Administrator was asked to provide documentation of a facility hand washing policy. No hand washing policy was provided.

Based on record review and interview, the facility failed to ensure a resident was re-assessed for safe smoking behaviors before being allowed to smoke after the admission smoking evaluation indicated the resident did not smoke for 1 (Resident #91) of 1 sampled resident reviewed for smoking. The findings are: On 04/14/2025, the Administrator provided a list of residents who use tobacco products and Resident #91's name was listed on the document. Review of an admission Minimum Data Set with an Assessment Reference Date of 03/04/2025, revealed the resident had a brief interview for mental status score of 07, which indicated Resident #91 had moderate cognitive impairment and did not use tobacco products. Review of an Admission/Readmission Nursing Evaluations Packet with an effective date of 02/27/2025, revealed Resident #91 did not use smoking/tobacco/nicotine products and the smoking evaluation was stopped. Review of the Progress Notes revealed the following: -A Nursing Note dated 02/27/2025 at 4:41 PM, which indicated Resident #91 was admitted to the facility by way of an emergency medical service. -A Medication Administration Note, dated 02/28/2025 at 7:46 AM, which indicated a nicotine patch 24 hour 14 milligrams per 24 hours (14GM/24HR), apply 1 patch on the skin (transdermally) one time a day for nicotine, remove per schedule and the note indicated the medication was not available. - A Medication Administration Note dated 03/01/2025 at 5:19 AM, Nicotine Patch 24-hour 14 MG/24HR. The resident refused the medication. - A Progress Note/ H and P (History and Physical) by the APRN (Advance Practice Registered Nurse), dated 03/23/2025 at 11:00 PM, revealed a date of service of 03/24/2025, and indicated Resident #91 was in the dayroom at the time of the visit. The note indicated Resident #91 wanted to smoke a cigarette. The note indicated the APRN checked on the resident later and the resident was sitting in front of a door to go out to smoke at 11:30 AM. - A Progress Note/ H and P by the APRN, dated 03/24/2025 at 11:00 PM, revealed a date of service of 03/25/2025, and indicated Resident #91 was sitting up in a wheelchair in the resident's room getting ready to go outside and smoke. - A Weight Note dated 04/04/2025 at 1:56 PM, revealed the nicotine patch had been discontinued because the resident was smoking. Review of the April 2025 Electronic Medication Administration Record (eMAR) revealed the nicotine patch 24-hour 14 MG/24HR apply 1 patch transdermally [on the skin] one time a day for Nicotine and remove per schedule with a start date 02/28/2025 at 6:00 AM, had a discontinued date of 04/04/2025. Review of an Admission/Readmission Nursing Evaluation packet 02/27/2025, revealed Resident #91 did not use smoking/tobacco/nicotine products. Review of the Care Plan Report dated 3/25/2025, revealed Resident #91 had a behavior problem related to at times Resident #91refused to wear a smoking apron when smoking initiated on 04/15/2025. Review of a Smoking/Nicotine Devices form, dated 4/15/25, indicated Resident #91 had a score of 6, which a score of 10 or greater should be considered at risk and needs supervision when smoking. The form indicated the resident smoked cigarettes, morning, afternoon and evening and required supervision, including retrieval. On 04/17/25 at 9:02 AM, Resident #91 was seen walking in the hall by the dining room with a walker waiting to go outside to smoke. At 9:06 AM, an unidentified female staff member went out the door on hall 600 with this resident and two other residents. She handed Resident #91 a cigarette and lit the cigarette. Resident #91 was observed with a lit cigarette to the resident's mouth and white smoke coming from the resident's mouth. On 04/17/2025 at 4:02 PM, during an interview with the Director of Nursing (DON) and the Administrator, the DON stated the nurse completed the smoking assessment for residents on admit, quarterly, and as needed. The Administrator stated she would need to check if a resident was allowed to smoke before being assessed for smoking behaviors. On 04/17/2025 at 5:41 PM, the Administrator and DON were asked if residents were assessed before being given smoking privileges. The Administrator stated residents had the right to smoke. The Administrator stated residents were assessed on admission, quarterly, and as needed. Review of a Smoking Policy, not dated, and located in the admission packet provided by the administrator on 04/14/2025, indicated the purpose was to determine if a resident was an independent smoker or an at-risk smoker before the resident exercised the privilege to smoke while residing in the facility and to establish guidelines for all residents that desired to smoke at the facility. The policy also indicated residents will be assessed for safe smoking behavior prior to smoking at the facility. On 04/17/2025 the Administrator provided a Smoking Policy, not dated and stated the smoking policy was revised Friday, 04/11/2025. The smoking policy was reviewed and indicated the resident would be evaluated on admission to determine if the resident was a smoker or non-smoker. The policy indicated that staff would consult with the attending physician and DON to determine if safety restrictions needed to be placed on a resident's smoking privileges based on the smoking assessment and the resident's ability to smoke would be re-evaluated as determined by staff.

Based on observation, record review, and interview, it was determined the facility failed to ensure staff changed gloves and performed proper hand hygiene during incontinent care for 1 (Resident #247) of 1 sampled resident reviewed for incontinent care. The findings are: Review of a Medical Diagnosis report indicated Resident #247 was admitted with diagnoses that included a fracture in the lower part of the upper left arm bone, and a fracture in the upper part of the upper left arm bone, and obesity class 3, with body mass index of 45.0 - 49.9, adult. Review of a Baseline Care Plan for admitted d 04/10/2025, indicated Resident #247 could easily communicate with staff, was cognitively intact and required maximal assistance for toileting hygiene. The health conditions section indicated Resident #247 was always incontinent of bowel and bladder. The functional abilities for mobility section indicated Resident #247 was dependent to roll left and right in bed. Review of a Care Plan assessment dated [DATE], indicated Resident #247 required staff assistance times two for incontinent/perineal care. On 04/14/25 at 10:36 AM, review of Resident #247 ' s Wound Evaluation report dated 04/10/2025, indicated the resident had a pre-admission, stage 2 pressure injury at the sacrum. On 04/14/2025 at 10:36 AM, review of Resident #247 ' s Order Summary dated 04/11/2025, indicated to follow Enhanced Barrier Precautions (EBP). On 04/14/25 at 9:04 AM, Resident #247 was interviewed and reported incontinence of bowel and bladder and stated a request to receive incontinent care was made to 2 different staff members within the last 20 minutes. A sign on the resident's door indicated Enhanced Barrier Precautions (EBP). On 04/14/25 at 11:22 AM, Certified Nursing Assistant (CNA) #1 and CNA #2 knocked on Resident #247's door, announced themselves and entered the resident ' s room without Personal Protective Equipment (PPE). On 04/14/2025 at 11:26 AM, this surveyor knocked on Resident #247's door, announced self, and with Resident #247s permission, entered the room. Resident #247 was observed lying in bed in a hospital gown. The resident's left arm was in a full plastic arm brace, and a purple bruise about the size of a sheet of copy paper was on the resident's left flank/shoulder areas. The resident's brief was down, exposing the brief over half full of loose bowel. CNA #1 had on gloves, no gown, and was standing on the left side of the resident handing CNA #2 cleaning wipes. She used the cleaning wipes several times each and tucked the used wipes into the soiled brief between the resident's legs. CNA #1 was observed multiple times to reach into her jacket pockets for gloves. She was observed touching both curtains in the room, dispensing cleaning wipes and providing perineal care with dirty gloves on her hands. She was not observed using hand sanitizer at any time in the room during perineal care. During perineal care, CNA #1 removed her gloves and went outside of the room. CNA #1 came back into Resident #247's room, reached into her jacket pocket again for gloves to wear. CNA #2 had gloves on, no gown and was standing on the right side of the resident. She used the cleaning wipes several times each and tucked the used wipes into the soiled brief between the resident's legs. She changed gloves a few times. She was not observed to sanitize hands at any time in the room during perineal care. The Director of Nurses (DON) knocked on the door, announced self, entered the room and indicated to the CNAs they should have gowns on while providing care, stating the resident had a wound. CNA #1 and CNA #2 went to resident's door with the DON and discussed what PPE should be utilized for a resident on EBP. CNA #1, CNA #2 and the DON donned gowns and then continued with perineal care. The DON went into the resident's bathroom to wash her hands, donned gloves, and began to assist with resident care. The DON was observed to tuck the soiled brief under the resident. Using the same gloves the DON was observed holding the resident's left arm brace to offer support during repositioning. On 04/14/2025 at 12:00 PM, upon the completion of incontinent care, CNA #1 and CNA #2 verified the only hand sanitizer in the room was next to the door on the opposite side of the room. CNA #1 and CNA #2 confirmed they did not utilize any hand sanitizer during the incontinent care. On 04/14/25 at 12:12 PM, the Restorative CNA was interviewed and reported gloves should be changed and hands sanitized between each clean and dirty task. On 04/14/25 at 12:16 PM, CNA #1 was interviewed and stated during incontinent care, hand sanitizing should take place when changing gloves and every time the gloves are dirty. She indicated she did not wash her hands, nor sanitize her hands at any time during incontinence care provided to Resident #247 today. On 04/14/25 at 12:17 PM, CNA #2 was interviewed and indicated each cleaning wipe should be used for one wipe and then disposed of. CNA #2 indicated hand sanitizer should be used every time gloves are removed. She verified she did not use hand sanitizer while providing incontinent care for Resident #247 today. On 04/14/25 at 3:38 PM, the DON was interviewed and verified she was in the room during incontinent care and observed CNA #1 and CNA #2 did not change gloves when indicated, did not sanitize hands, and did not provide proper incontinent care. The DON indicated the CNAs and nurses had been in-serviced for EBP including which PPE is required. She confirmed that staff with gloves on who have touched a dirty brief should not touch a resident's arm brace with the same dirty gloves. On 04/17/25 at 2:59 PM, the Administrator provided handwritten documentation that the facility did not have a policy for enhanced barrier precautions (EBP) and verbally verified the facility did not have a policy for incontinent care. On 04/14/2025 at 2:59 PM, the Administrator was asked to provide documentation of a facility hand washing policy. No hand washing policy was provided.

Based on observations and interview, the facility failed to ensure deep fryer was free of debris to prevent potential cross contamination, food items stored in the freezer or refrigerator were sealed, covered and dated, expired food items were promptly removed /discarded by the expiration or use by dates, and foods were dated as when received to ensure first in and first out usage to prevent the potential for food borne illness, Dish washing air vent was cleaned, wall tiles were free of paint peelings, baseboard were free of missing and replaced, deep fryer and ice machine were free of dirt, rust, and grease and 1 of 2 ice machines was maintained in clean and sanitary condition to prevent food and beverage contamination, staff washed their hands between dirty and clean tasks and before handling clean equipment to minimize the potential for contaminating food items for residents who received meals from 1 of 1kitchen. This failed practice had the potential to affect 77 residents who received meals from the kitchen (total census 78), The findings are: On [DATE] at 08:03 AM The ice machine in a room on 500 Hall had brown stains on the panel of the ice machine. The surveyor asked the Dietary Surveyor to wipe the panel of the ice machine. She used a tissue to wipe the panel inside of the ice machine which had a brown residue on it that had easily transferred from the ice machine onto the tissue. The surveyor asked Dietary Supervisor to describe the residue found inside the ice machine that showed on the tissue. Who uses the ice machine from the machine and how often do you clean it? He stated, That's the ice the CNAs) Certified Nursing Assistants) use to fill the water pitchers in the resident's rooms. On [DATE] at 10:26 AM on initial kitchen rounds the following concerns were noted: At 10:27 AM there was a coffee machine with paper towels on the right side of it soaked in a brown liquid and brown drops of liquid on the top of two tier stand the coffee machine was resting on. There was an Elite brand deep fryer that had small tan colored particles on the insides of it and floating on top of a dark brown liquid inside of it. At 10:29 AM there was a white upright refrigerator that had an open box that contained 26 sausage patties inside of a plastic bag that was tied off but there was no open date written on the plastic. The paints on the wall above the food preparation counter were peeling, exposing the cement. On [DATE] at 08:52 AM A bottle of vitamin -D water with an expiration date of [DATE] was on a shelf in the refrigerator in the medication room on the 500 Hall. There was no name on the bottle to identify whom it belongs to. There was no received or opened date on it. On [DATE] at 08:53 AM The following observations were made in the freezer in the medication room on the 500 Hall: A package of beef burger slides on a shelf in the freezer was discolored. There was no received date or name to identify whom it belongs to on the package. The surveyor asked the Dietary Employee to describe the appearance of the food content. She stated, It has freezer burn. b. Two of 2 boxes of hot pockets were in the freezer. There was no received date or name on it. c. An opened box of cinnamon sticks was in the freezer. The box was not covered or sealed. There was no name on the box. On [DATE] at 09:09 AM The following observations were made in the kitchen: a. The ceiling tiles in the dish washing machine peeling, exposing the cement. b. The air vent in dish washing has stains on it. c. The baseboard where a rack that contained clean bowls were kept on the left side of the door entrance leading to the dish washing was missing. The areas where the tiles were missing had brown stains and dirt on them. On [DATE] at 11:06 AM The oil in the deep fryer was covered with food crumbs. The surveyor asked the Dietary Supervisor how often they clean deep fryer and when was the last time they used it? She stated, They clean it every Monday and it was used on Friday. On [DATE] 11:07 AM The closed cabinet below the deep fryer had four pallets that were attached to the deep fryer. All four pallets had grease build up on them. The bottom of the deep fryer had grease on it. The surveyor asked the Dietary Supervisor how often they cleaned the bottom of the deep fryer. She stated, We clean it every week. On [DATE] at 11:00 AM Dietary Employee (DE) #1 picked up a pan that contained food and placed it in pan of hot was on stove. She turned off the faucet with her bare hand. Contaminating her hands, without washing her hands, she picked up a clean blade with and attached it to the base of the blender to be used in pureeing food items to be served to the residents on pureed diets. At 11:09 AM When (DE) #1 was about to place food items into a blender to puree. The surveyor immediately asked the (DE) #1 what should you have done after touching dirty objects and before handling clean equipment? She stated, I should have washed my hands. On [DATE] at 08:09 AM The following observations were made in the refrigerator in the medication room on the 100 Hall: a. The A-8 fl ounce box was on a shelf in the refrigerator with an expiration date of ,d+[DATE]. b. A 8 fl ounce box Nepro was on a shelf in the refrigerator with an expiration dated ,d+[DATE]. c. A gallon of water on a shelf in the refrigerator had an expiration date of ,d+[DATE]. A facility policy titled Hand washing Documented When to wash hands. A. When entering the kitchen at the start of a shift. b. After handling soiled equipment or utensils. c. During food preparation, as often as necessary to remove soil or contamination and to prevent cross contamination when changing tasks. 37925

Based on observation and interview, the facility failed to ensure that pureed food items were blended to a smooth, lump free consistency to minimize the risk of choking or other complications for those residents who required pureed diets for 1 of 1 meal observed. The failed practice had the potential to affect 4 residents who received pureed diets, as documented on the list Dietary Supervisor provided by the Food Service Supervisor on 02/06/2024 The findings are: On 02/05/24 at 10:45 AM Dietary Employee (DE) #1 placed 6 servings of pork loins into a blender, added its juice and pureed. At 10::50 AM (DE) #1 poured the pureed pork loins into a pan. She covered the pan with foil and placed it in a pan of hot water on the stove. The consistency of the pureed pork [NAME] was gritty and not smooth. 2. On 02/05/24 at 10:58 AM (DE) #1 used #8 scoop to place 7 servings of white rice into a blender, added sauce and pureed into a pan. At 11:00 AM She covered the pan with foil and placed it in a pan of hot water on the stove. The consistency of the pureed rice was gritty and not smooth. 3. On 02/05/24 at 11:11 AM Dietary Employee (DE) #1 used a-4-ounce spoon to place 8 servings of vegetables blend into a blender and pureed. She poured the pureed vegetables into a pan. She covered the pan with foil and placed it in a pan of hot water on the stove. The consistency of the pureed vegetables was not smooth. There were pieces of carrots visible in the mixture. 4. 02/05/24 1:15 PM The surveyor asked Dietary Supervisor to describe the pureed food items served to the residents on pureed diets. She stated, Pureed meat looks like mechanical soft meat. Pureed vegetables still have pieces of carrots in them. Pureed rice was thick with a little lump in it.

Based on observation, record review and interview, the facility failed to ensure the medication error rate was less than 5 percent (%)for 1 (Resident #14) of 3 (Residents #14, #16 and #183) residents observed during the medication pass. The medication error rate was 14.81% based on observation of 27 medications administered and 4 errors detected. The findings are: Resident #14 had a diagnosis of Dysphagia Following Nontraumatic Subarachnoid Hemorrhage. a. The February 2024 Physician's Orders documented the orders for: 1. Amiodarone 200 mg (milligrams) give 1 tablet via (by way of) PEG (Percutaneous Endoscopic Gastrostomy) Tube-01/08/2024 2. Hydroxyzine 25 mg give 1 tablet via PEG Tube-02/05/2024 3. Metoprolol Succinate ER (Extended Release) 24 Hour Sprinkle give 1 capsule via PEG Tube-02/01/2024 4. Protonix Delayed Release 40 mg give 1 tablet via PEG-Tube- 02/01/2024 (DO NOT CRUSH) b. On 2/7/24 at 8:23 AM, LPN #4 crushed two pills, opened the capsule and mixed Protonix whole in pudding and administered the medications to resident #14 by mouth. c. On 2/7/24 at 11:34 AM LPN #4 was asked, How long have you been working here as a nurse? and she stated, Since May 2023. She was asked, What do you do before administering medications to a resident? She stated, I check the MAR [Medication Administration Rate]. d. A Medication Administration and General Guidelines Policy provided by the Administrator on 2/8/24 at 11:16 AM documented, . Procedure . 2. Medications are administered in accordance with written orders of the attending physician . Checklist for completing proper steps in the administration of medications . Adheres to the 6 Rights of Medication Administration: . 2) Right Route .

Based on observation, record review and interview, the facility failed to ensure a humidifier bottle was changed per the Physician's orders and that Oxygen was administered at the prescribed flow rate to decrease the potential for Respiratory complications for 1 (Resident #63) of 3 (Residents #2, #19 and #63) sampled residents who had a Physician's order for Oxygen (O2) as documented on a listed provided by the Administrator on 2/7/24 at 11:13 AM. The findings are: 1. Resident #63 had diagnoses of Acute Respiratory Failure with Hypoxia, Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation and Chronic Diastolic (Congestive) Heart Failure. a. A Physicians' Orders dated 9/35/23 documented, .O2 at (2) L/min [liters per minute] via [by way of] (nasal cannula) as needed for SOB [shortness of breath] . Change humidifier bottle once weekly on (Sunday) during the (night) shift and PRN [as needed] . b. A Modification of Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/28/23 documented the resident received O2 while a resident. c. A Care Plan with a completion date of 12/11/23 had no documentation regarding O2 therapy for resident #63. d. On 02/04/24 at 12:33 PM resident #59 was lying in bed and receiving O2 at 2 liters/minute (l/m) by way of a nasal cannula. The humidifier bottle was dated 1/26/24 and was empty at this time. e. On 02/04/24 at 2:00 PM resident #59 was lying in bed with eyes closed. O2 was in use at 2 l/m by way of a nasal cannula. The humidifier bottle was dated 1/26/24 and was empty at this time. f. On 02/06/24 at 10:38 AM resident #59 was lying in bed with eyes closed and O2 was in use by way of nasal cannula and the concentrator was set at 2.5 l/m. h. On 02/07/24 at 9:34 AM resident #59 was lying in bed, awake and O2 was in use by way on nasal cannula at 2.5 l/m at this time. i. On 2/8/24 at 1:45 PM resident #59 was in bed with the head of bed up and O2 was in use by way of nasal cannula at 2.5 l/m. j. On 2/8/24 at 1:48 PM Registered Nurse (RN) #1 was asked to go to resident #59's room with this Surveyor. She was asked, Will you look at the concentrator and tell me what the Oxygen is set on? She stated, It looks like the tip of the ball is at 2.5 but her order is for 2. She reached down and turned the O2 flow rate to 2 l/m. k. An Oxygen Administration-Resident policy provided by the Administrator on 2/7/24 at 11:13 AM documented, . The purpose of this procedure is to provide guidelines for safe oxygen administration . 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration . 48630

Based on observation, record review and interview, the facility failed to ensure personal hygiene and nail care were routinely maintained and all areas of the skin were cleansed during incontinent care to promote good grooming and personal hygiene for 1 (Resident #53) of x (Residents #53 .) sampled residents who required staff assistance for shaving, 2 (Residents #53 and #59) of x (Residents #53, #59 ) sampled residents who required staff assistance with nail care and 1 (Residents #59) of x (Residents #53 #59 ) sampled residents who were dependent on staff for incontinent care as documented on lists provided by the Administrator on 2/8/24. The findings are: 1. Resident #53 had a diagnosis of Type 2 Diabetes Mellitus with Hypoglycemia Without Coma. a. A Care Plan with a completion date of 1/26/24 documented Resident #53 required extensive assistance with personal hygiene and bathing and to observe the resident for hygiene needs and render as needed each shift, check the resident's fingernail length and trim as needed unless the resident is diabetic and ensure the resident is shaved as needed. It documented the resident has actual impairment to skin integrity related to skin cancer lesions and to keep fingernails short. b. On 02/04/24 at 11:50 AM, Resident #53 was sitting up in a wheelchair (w/c) the fingernails on the right hand were greater than a quarter (1/4) inch in length with jagged edges. The left hand was not visible at this time. There was facial hair on Resident #53's chin, cheeks, and upper lip. c. On 02/05/24 at 2:42 PM, Resident #53 was sitting up in a wheelchair (w/c), awake and the fingernails on both hands were greater than 1/4 inch in length. There was facial hair on Resident #53's chin, cheeks, neck, and upper lip. d. On 02/06/24 at 8:28 AM, Resident #53 was sitting up in a w/c. There was facial hair on Resident 53's chin, cheeks, neck, and upper lip. The fingernails on both hands were greater than 1/4 inch in length. e. On 02/06/24 at 2:54 PM, Certified Nursing Assistant (CNA) #4 was asked to enter Resident #53's room with this surveyor. She was asked, Look at the [Resident #53]'s face and tell me what you see? She stated, Looks like [Resident #53]'s a little scruffy and might need a shave. She was asked, Do you know when [Resident #53]'s bath days are? She stated, I don't know but they have a book up front at the desk. She was asked, Who shaves the residents? She stated, We [CNAs] do. She was asked, Look at both of [Resident #53]'s hands and describe [Resident #53]'s nails for me? She stated, Long [and] there's stuff under them. Some are short and some are long. She was asked, Who provides nail care to the residents? She stated, We do unless they are diabetic. She was asked, Do you know if [Resident #53] ever refused nail care? She stated, I know [Resident #53] has refused [Resident #53] baths so I'd have to say yes. She was asked, Tell me why the resident's fingernails should be trimmed? She stated, For hygiene purposes and to make sure it doesn't get snagged on something or [Resident #53] scratches [Resident #53]. f. A Task sheet provided by the Administrator on 2/7/24 at 11:13 AM documented the resident shower / bathe self on 2/2/24 at 20:18 [8:18 PM] and 2/5/24 at 21:48 [9:48 PM]. g. On 2/8/24 at 1:59 PM the Director of Nursing (DON) was informed that Resident #53 had facial hair. She was asked, Who is responsible for shaving the residents? She stated, Half of the time he will not let us touch him and he refuses his baths. He does not have an electric razor and he can't use the other razors. I've been talking to the family about trying to get him one, but we might have to buy him one. 2. Resident #59 had diagnoses of Cerebral Infarction, Frontal Lobe and Executive Function Deficit and Hemiplegia, Unspecified Affecting Right Dominant Side. a. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/23/24 documented the resident scored 3 (3=severely impaired) on a Staff Assessment for Mental Status (SAMS) and was dependent for toileting hygiene, shower / bathe self and personal hygiene. b. A Care Plan with a completion Date of 1/25/24 documented, . [Resident #59] has potential for complications associated with incontinence of bowel and bladder . Check every two hours and PRN [as needed] for incontinence . I require extensive assist x 2 with .toileting, personal hygiene . If I am incontinent of bowel and bladder . give me incontinent care and change my brief . Observe for my hygiene needs and render as needed each shift and prn . Please check my fingernail . length and trim as needed unless I am diabetic . c. On 02/04/24 at 11:54 AM Resident #59 was in bed and the fingernails on the left hand were greater than 1/4 inch in length and had a brown substance underneath them. d. On 02/05/24 at 3:03 PM Resident #59 was resting supine in bed, awake and her left hand was closed. The fingernails were greater than 1/4 inch in length and there was a dark substance underneath the nails on the left hand. e. On 02/06/24 at 8:31 AM Resident #59 was resting quietly in bed awake, and the fingernails on both hands were greater than a 1/4 inch in length and there was a dark brown substance underneath the fingernails on the left hand. f. On 02/06/24 at 10:53 AM Certified Nursing Assistant (CNA) #4 was asked, Are you familiar with [Resident #59]'s care? She stated, [Resident #59] used to be on 200 hall so I can give you a little bit on [Resident #59]. She was asked, Do you know when [Resident #59] bath days are? She stated, So [Resident #59] bath days are Monday, Wednesday, Friday. She was asked to look at the resident's fingernails on both hands and describe what she saw, and she described [Resident #59] nails as clean and need clipping. She was asked, Who provides nail care to the residents? and she stated, AllCNAs but on their shower days they are supposed to get them cleaned and clipped, unless they are diabetic, and the nurses will do them. She was asked, Why should [Resident #59] nails be trimmed? and she stated, That's like an infection control. Anything can get under them or [Resident #59] could scratch [Resident #59]. She was asked, What could happen to [Resident #59] left hand with long nails? and she stated, A nail could dig in [Resident #59] skin and that could become a problem. She was asked and confirmed that Resident #59 could not open her left hand. h. A Documentation Survey Report for February 2024, provided by the Administrator on 2/7/24 at 11:13 AM documented resident #59 was transferred to the tub / shower on 2/2/24 at 11:17 [AM], 2/4/24 at 9:38 [AM] and 2/5/24 at 21:38 [9:38 PM]. i. On 02/07/24 at 1:38 PM the Director of Nursing (DON) and Surveyor entered Resident #59's room. The DON was asked, Will you ask the Resident to open [Resident #59] left hand for you? The DON picked up the resident's left hand and asked the resident to open it. Resident #59 only mumbled but did not open her hand. The DON stated, [Resident #59] sister wants [Resident #59] to keep the fingernail on [Resident #59] thumb because this is what [Resident #59] uses to scratch [Resident #59] nose with. The DON was asked, What about the other fingernails that are long and up against the palm of [Resident #59] hand? The DON did not respond. j. On 02/08/24 at 1:59 PM the DON was asked, How are the CNA's trained regarding providing care to the residents? She stated, We assign them to another CNA to do orientation with and we try to rotate them on all of the units. The CNAs they are put with are experienced and they tell them what to do. Agency CNAs get a run through. We assume that their company does their training to say they are capable of doing what they say they can do. She was asked, Do you all do any skill check offs with the CNAs? She stated, Yes. We started a peri-care check-off already. She was asked, Who is responsible for trimming the resident's fingernails? She stated, The CNAs are to do them when they are doing baths. k. On 02/08/24 the Administrator stated the facility does not have a policy on ADL care.

Based on record review and interview, the facility failed to ensure care plans were reviewed and revised as least quarterly and / or when residents' care needs changed, as evidenced by failure to revise the plan of care to address limited range of motion in the left hand and the use of Oxygen to ensure staff were aware of the necessary care, assessments and services required for 1 (Resident #59) of 1 (Resident #59) sampled resident who had limited range of motion in the left hand and for 1 (Resident #63) of 1 (Resident #63) sampled resident who used Oxygen. The findings are: 1. Resident #59 had diagnoses of Cerebral [brain] Infarction [death of tissue], Frontal Lobe and Hemiplegia [paralysis], Affecting Right Dominant Side. a. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/23/24 documented Resident #59 scored 3 (3 = severely impaired) on a Staff Assessment for Mental Status (SAMS), had impairment on one side in the upper extremity, received no days in a Restorative Nursing Program and received Occupational Therapy from 2/16/23 to 5/12/23 and Physical Therapy from 4/20/23 to 6/16/23. b. On 02/06/24 at 10:53 AM Certified Nursing Assistant (CNA) #4 was in the room with this surveyor and she was asked, Are you familiar with [Resident #59]'s care? She stated, [Resident #59] used to be on 200 hall so I can give you a little bit on [Resident #59]. She was asked, Is [Resident #59] able to use [Resident #59] left hand? and she stated, No. She was asked, Do you know if [Resident #59] can open it on [Resident #59] own? She stated, [Resident #59] can't open that left hand. She was asked, Do you know when [Resident #59]'s bath days are? She stated, So [Resident #59]'s bath days are Monday, Wednesday, Friday. CNA #4 was unable to as Resident #59 to perform any tasks with the left hand because the resident asked to be left alone. CNA #4 and this surveyor left the room. c. On 02/07/24 at 1:38 PM the Director of Nursing (DON) and Surveyor entered resident #59's room. The DON was asked, Will you ask the resident to open [Resident #59] left hand for you? The DON picked up the resident's left hand and asked the resident to open it. Resident #59 only mumbled but did not open that hand. The DON was asked to open Resident #59's hand. She picked up the resident's left hand and was able to partially open the resident's hand by placing one finger at the top of the resident's closed left hand and pushing her finger downward. The resident started groaning and had facial grimacing. This surveyor advised the DON if this was causing discomfort or pain to the resident, she could stop but she did not. She was asked, What should be done to keep some ROM in [Resident #59]'s left hand since you were able to open it? She stated, I'm going to talk to therapy about evaluating [Resident #59] today. We normally send it out when we do their quarterly MDS. She was asked, What if staff notices a decline in ROM before the quarterly MDS is due? She stated, They tell the nurse, and the nurse will come and tell us. We will then refer her to therapy so they can evaluate her and recommend what type of treatment she may need. d. The Care Plan with a revision date of 1/25/24 did not address resident #59's limited range of motion in the left hand. 2. Resident #63 had diagnoses of Acute Respiratory Failure with Hypoxia, Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation and Chronic Diastolic (Congestive) Heart Failure. a. Physicians' Orders dated 9/25/23 documented, .O2 at (2) L/min [liters per minute] via [by way of] (nasal cannula) as needed for SOB [shortness of breath] . Change humidifier bottle once weekly on (Sunday) during the (night) shift and PRN [as needed] . b. A Modification of Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/28/23 documented the resident received oxygen while a resident. c. A Care Plan with a revision date of 12/11/23 had no documentation regarding oxygen therapy for resident #63.

Based on observation and interview the facility failed to ensure trash was properly contained within 1 of 1 dumpster, to minimize the presence of foul odors and decrease the potential for pest infestation. The failed practice had the potential to affect all the residents who resided in the facility, as documented on the list provided by the Dietary Supervisor on 2/6/2024 at 010:10 AM. The findings are: 1. On 02/06/24 10:10 at the one dumpster used by the facility was located outside approximately 67 feet from the door leading into the kitchen. The dumpster was overflowing with several trash bags on the ground. There was one clear bag that contained incontinent briefs that was hanging down from the door of the dumpster. There were 30 clear bags full of trash on the ground by the dumpster. There was another clear bag behind the dumpster that contained soiled briefs. The surveyor asked the Dietary Supervisor how many of the trash bags were dumped on the ground and was also asked how often the dumpster was emptied. She stated, They come every day expect on weekends. There were 40 bags, because there were some trash bags behind the dumpster. There was a very strong, foul odor in the area around the dumpster. The Dietary Surveyor stated, It smells like pee. 2. On 02/05/24 11:14 AM The door of the dumpster was not closed. There was a clear bag that contained soiled brief trapped under the dumpster. A loose glove, bottle of water and white milky liquid smeared substance were on the ground in front of the dumpster. [NAME] Dietary Manager stated, The waste people came and picked up the trash around 11:00 AM. 3. On 02/06/24 at 07:44 AM The door to the dumpster was not closed. The surveyor asked the maintenance Surveyor to measure the distance from the dumpster to the kitchen door. He did and stated, It was 67 feet.

Based on observation, record review and interview, the facility failed to ensure meals were served at temperatures that were acceptable to the residents to improve palatability and encourage good nutritional intake during 2 of 2 meals observed. The failed practices had the potential to affect 22 residents who received their meal trays in the their rooms on the 100 Hall, 10 residents who received their meal trays in the room on the 200 Hall, 11 residents who received their meal trays on the 300 Hall, 13 residents who received their meal trays in their room on the 400 Hall, 21 residents who received their meat trays in the room on 500 Hall and 4 residents who received their meal trays in their room on 600 Hall, as documented on a list provided by the Dietary Supervisor on 02/06/2024 10:10 AM. The findings are: 1. Resident #284 had diagnoses of Hero sclerotic heart disease of native coronary aorta, without Angina pectoris. The Admission Minimum Data Set (MDS) with and Assessment Reference Date (ARD) of 01/23/2024 documented the resident scored 12 (8-12 indicates moderately impaired) on a Brief Interview for Mental Status (BIMS). a. The Physician Orders, date of 01/25/2024 documented, General mechanical soft texture, thin liquid consistency NAS. b. The Care Plan date of 01/23/2024 documented, . One staff assist with eating . 2. On 02/04/24 at 11:29 AM Resident #284 was asked, Is your hot food hot and your cold food cold when it arrives to your room? R#284 states, My hot food is cold from time to time. 3. On 02/05/24 07:37 AM An unheated cart that contained 22 breakfast meal trays for 100 Hall was delivered by the Certified Nursing Assistant #1. At 07:57 AM immediately after the last resident received their tray in their room on 100 Hall, the temperatures of food items on a test tray from the food were checked and read by the Dietary supervisor were with the following results: a. Milk 47 degrees Fahrenheit. b. Hash brown 110 degrees Fahrenheit. c. Ground sausage with gravy 109 degrees Fahrenheit. d. Scrambled eggs 112 degrees Fahrenheit. e. sausage 99 degrees Fahrenheit. 4. On 02/05/24 at 07:51 AM An unheated cart that contained 13 breakfast meal trays for 400 Hall was delivered by the Certified Nursing Assistant #2 At 08:01 AM immediately after the last resident received their tray in their room on 400 Hall, the temperatures of food items on a test tray from the food were checked and read by the Dietary supervisor were with the following results: a. Milk 44 degrees Fahrenheit. b. Sausage 114 degrees Fahrenheit. 5. On 02/05/24 08:19 AM An unheated cart that contained 25 breakfast meal trays for 500 and 600 Halls was delivered to the 500 Hall by the Certified Nursing Assistant #3. At 08:53 AM immediately after the last resident received their tray in their room on 500 Hall, the temperatures of food items on a test tray from the food were checked and read by the Dietary supervisor were with the following results: a. Milk 51 degrees Fahrenheit. b. Ground sausage with gravy 114 degrees Fahrenheit. c. Scrambled eggs 106 degrees Fahrenheit. d. Hash brown 108 degrees Fahrenheit e. Pureed eggs 109 degrees Fahrenheit. Pureed sausage 106 degrees Fahrenheit. f. Pureed hash brown 101 degrees Fahrenheit. 6. On 02/05/24 12:51 AM An unheated cart that contained 25 meal trays for 500 and 600 Halls was delivered to 500 Hall by the Certified Nursing Assistant #3. At 01:01 AM immediately after the last resident received their tray in their room on 500 Hall, the temperatures of food items on a test tray from the food were checked and read by the Dietary supervisor with the following results: a. Milk 51 degrees Fahrenheit. b. Ground sausage with gravy 114 degrees Fahrenheit. c. Scrambled eggs 106 degrees Fahrenheit. d. Hash brown 108 degrees Fahrenheit.

Based on record review and interview the facility failed to ensure that a self-inflicted incident was reported to the Office of Long-Term Care. This failed practice affected 1 of 1 Residents (R#31). The findings are: a. Review of an Incident and Accident (I&A) form dated 01/12/2024 at 6:41 PM documented Resident #31 sitting in wheelchair with wounds to the abdomen area. Wounds which were self-inflicted with a razor. The razor cap was noted in the resident's lap. a. Review of the Nurse's Notes dated 01/12/2024 at 7:12 PM documented Resident #31 was noted in the dining hall with self-inflicted wounds to abdomen area. Resident was sent to the emergency room for medical observation. c. On 02/07/2024 at 08:30 AM review of the facilities last 3 reportable incidents showed there was not a reported incident report to the Office of Long-Term Care for Resident #31. d. On 02/07/2024 at 03:08 PM during an interview, the Administrator confirmed there was not an I&A reportable completed on the self-inflicted accident.

Based on observation, record review and interview, the facility failed to ensure medications were allowed to flow by gravity through a Percutaneous Endoscopic Gastrostomy (PEG) Tube to decrease the potential for gastric complications for 1 (Resident #16) of 1 (Resident 16) sampled resident whose medications were administered through a PEG Tube. The findings are: 1. Resident #16 had a diagnosis of Dysphagia, Oropharyngeal Phase and Gastrostomy Status. a. February 2024 Physician's Orders documented resident #16 diet was nothing by mouth active 11/04/2023 and may crush meds (medications) and administer together in tap water via (by way of) G (Gastrostomy)-Tube every shift active 11/04/2023. b. On 2/7/24 at 11:10 AM, after preparing the resident's medications, LPN #4 crushed all the meds and placed them in two separate 8 oz (ounce) cups with water. After stirring each cup, she sanitized her hands, put on gloves, placed the pump on hold, checked placement and placed the end of the administration set in a cap. She used a 60 cc syringe, drew up the meds and liquid from the first cup, inserted the syringe into the PEG tube and pushed the medication and liquid through the PEG tube, not allowing it to flow by gravity. She repeated this same step after drawing up the meds from the second cup in the syringe and pushed it through the PEG tube and did not allow it to flow by gravity. c. On 2/7/24 at 11:34 AM LPN #4 was asked, Where did you learn to give meds via PEG Tube? She stated, Here. She was asked, Do you know what the facility's policy is on how to give meds through a tube? She stated, No I don't. She was asked, How long have you been working her as a nurse? She stated, Since May 2023. She was asked, Did anyone show you how to administer meds via PEG TUBE here? She stated, No. d. A Medication Administration through an enteral Tube Policy provided by the Administrator on 2/8/24 at 11:16 AM documented, .The purpose of this procedure is to provide guidelines for the safe administration of medications through an enteral tube . Steps in the Procedure . 20. Administer medication by gravity flow . d. Pour diluted medications into the barrel of the syringe while holding the tubing slightly above the level of insertion. e. Open the clamp and deliver medications slowly .

Based on observation, record review and interview, the facility failed to ensure that interventions that were care planed were utilized to prevent potential accident hazards as possible by continuing to fall for 1 of 1 Resident (#11) 1 sampled resident. The findings are: 1. On 02/04/24 at 12:40 PM, Resident #11 was in bed with a neck brace around her neck. Observed about a 3inch dark purple area under right. eye. Above the left eye was a 2.5 cm raised area surrounded with dark purple color with dried blood over it. Resident #11 stated, I fell a couple weeks ago. A dark purple area below right eye about 3 inches long. Resident stated, I just don't want to bother anyone. I leaned on my table, and it moved with me. I got up and that's all I remember. a. On 02/05/24 at 08:39 AM Resident #11 was lying in the bed with a neck brace around her neck and under both eyes had dark purple areas under them. Raised area above right eye. Observed a bedside table on the right side of the bed. There were no padded tables in the room. b. Review of hospitalization record dated 1/23/24, documented trauma due to fall .injuries included C-6 nondisplaced anterior fracture, MRI demonstrating moderate spinal canal and severe neural foraminal stenosis. C-6 and C-7 and myelopathic signal within the cord at this level all associated acute post trauma hypoxemic, hypercapnic respiratory failure requiring supplemental oxygen (O2). c. On 2/6/24 at 3:30 PM LPN #1 was asked about the fall that occurred on 1/21/24. LPN#1 was asked if she or anyone else had witnessed the fall. LPN#1 stated No we heard a thump. LPN #1 was asked if the interventions from prior falls were in place prior to the fall she stated, I don't know we just took care of the resident. d. On 2/08/24 at 09:27 AM, LPN#2 was asked if she or anyone witnessed the fall for Resident #11. LPN # 2 stated, no I didn't witness the fall, nobody did. I just heard a noise. LPN #2 was asked if she could remember where the bedside table was after the fall. LPN#2 stated the bedside table was on the right side of the bed, and she leaned on it and it rolled with her. The Bed side table wasn't padded, and her bed was in the lowest position. 1. Review of notes in the electronic record (ER) from LPN #2 dated 1/21/24 7:06 PM. This nurse outside res. room, heard a loud crash, this nurse knocked then entered after hearing someone moaning, this nurse observed Resident lying on the floor, face down (blood observed on the floor (staff turned res. over slowly and placed her on the bed) res. has 3 abrasions (#1 over lt (left) eye, #2 on bridge of nose, #3 on tip of nose). staff has asked res. again please put your call light on when you need assistance, res. (resident) stated I don't want to bother anyone. f. On 12/24/23 and again on 1/8/24, documented on the care plan that resident was educated on use of call light. g. On 02/08/24 at 09:23 AM Certified Nurse Aide (CNA) #1 was asked to accompany this Surveyor to Resident #11's room and was asked where the over bed table is located, if there is any table in the room padded and what position her bed is in at this moment. CNA #1 stated, the table is on her right side, no table in the room is padded. The bed is not in the lowest position, it's about waist high. h. On 2/7/24 at 9:28 AM, LPN #2 was asked to accompany this surveyor to Resident #11's room and note where the over bed table is located, if there is any table in the room padded and what position her bed is in at this moment. LPN # 2 stated, the table is on her right side, no table in the room is padded. The bed is not in the lowest position. i. On 2/7/24 at 4:41 PM the Administrator provided a policy titled Accidents and Hazards Policy The facility strives to ensure the resident environment remains as free of accident hazards as is possible and each Resident receives adequate supervision and assistance devices to prevent accidents . 3. The care team shall target interventions to reduce individual risks related to hazards .

Based on observation, record review and interview, the facility failed to ensure services were provided to minimize the potential for further decline in range of motion (ROM) for 1 (Resident #59) of 3 (Residents #16, #31 and #59) sampled residents who had limited range of motion as documented on a list provided by the Administrator on 2/7/24 at 11:13 AM. The findings are: 1. Resident #59 had diagnoses of Cerebral [brain] Infarction [death of tissue], Frontal Lobe and Hemiplegia [paralysis], Affecting Right Dominant Side. a. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/23/24 documented the resident scored 3 (3=severely impaired) on a Staff Assessment for Mental Status (SAMS), had impairment on one side in the upper extremity, received no days in a Restorative Nursing Program and received Occupational Therapy from 2/16/23 to 5/12/23 and Physical Therapy from 4/20/23 to 6/16/23. b. On 02/04/24 at 11:54 AM resident #59 was in bed and the left (L) hand was closed and did not open it when asked by this surveyor. c. On 02/05/24 at 3:03 PM resident #59 was lying on her back in bed, awake and the (L) hand was closed. d. On 02/06/24 at 8:31 AM resident #59 was resting quietly in bed awake and the (L) hand was closed and no hand roll or cushion was noted in that hand or in the room. e. On 02/06/24 at 10:53 AM Certified Nursing Assistant (CNA) #4 was in the room with this surveyor and she was asked, Are you familiar with [Resident #59]'s care? She stated, [Resident #59] used to be on 200 hall so I can give you a little bit on [Resident #59]. She was asked, Is [Resident #59] able to use [Resident #59] left hand? and she stated, No. She was asked, Do you know if [Resident #59] can open it on [Resident #59] own? She stated, [Resident #59] can't open that left hand. She was asked, Do you know when [Resident #59]'s bath days are? She stated, So [Resident #59]'s bath days are Monday, Wednesday, Friday. CNA #4 was unable to ask resident #59 to perform any tasks with the left hand because the resident asked to be left alone. CNA #4 and this surveyor left the room. f. On 02/07/24 at 10:16 AM resident #59 was lying in bed with eyes closed. The left hand was closed. g. On 02/07/24 at 1:23 PM the Director of Nursing (DON) and this Surveyor went to the resident's room. The DON was asked, Can [Resident #59[ open [Resident #59] left hand on [Resident #59]'s own? She stated, I don't know if [Resident #59] still can but [Resident #59] was at one point. She was asked, Has [Resident #59] received any type of restorative or occupational therapy to [Resident #59]'s left hand? She stated, I think when I first got here [Resident #59] was on the skilled services. She was asked, Tell me what your process is for residents who have some ROM remaining to keep them functioning at the same level or better? She stated, So, this is the company process that they go to therapy, and therapy does an assessment and then they recommend restorative or whatever [Resident #59] may need if [Resident #59]'s not at full capacity, then we get the order from the doctor. h. On 02/07/24 01:26 PM the DON was asked to look in the resident's electronic health record (EHR) to see if there is any therapy or restorative notes regarding this resident's left hand. She stated she would get some therapy notes. The DON provided a Physical Therapy Treatment Encounter Note (s) with dates of 6/9/23, 6/12/23 and 6/13/23 that only addressed ROM /PROM (Passive Range of Motion) to the lower extremities. i. On 02/07/24 at 1:38 PM the Director of Nursing (DON) and Surveyor entered resident #59's room. The DON was asked, Will you ask the resident to open [Resident #59] left hand for you? The DON picked up the resident's left hand and asked the resident to open it. Resident #59 only mumbled but did not open that hand. The DON stated, [Resident #59] sister wants [Resident #59] to keep the fingernail on [Resident #59] thumb because this is what [Resident #59] uses to scratch [Resident #59] nose with. The DON was asked, What about the other fingernails that are long and up against the palm of [Resident #59] hand? The DON did not respond. The DON was asked to open resident #59's hand. She picked up the resident's left hand and was able to partially open the resident's hand by placing one finger at the top of the resident's closed left hand and pushing her finger downward. The resident started groaning and had facial grimacing. This surveyor advised the DON if this was causing discomfort or pain to the resident, she could stop but she did not. The DON was asked, Will you take the Q-Tip and swab the inside of [Resident #59]'s hand and show it to me? At 1:45 pm she swabbed the inside of the resident's left hand and showed it to this surveyor. She was asked to smell the swab and describe it? She stated, [Resident #59] has a little odor. She was asked, What should be done to keep some ROM in [Resident #59]'s left hand since you were able to open it? She stated, I'm going to talk to therapy about evaluating [Resident #59] today. We normally send it out when we do their quarterly MDS. She was asked, What if staff notices a decline in ROM before the quarterly MDS is due? She stated, They tell the nurse, and the nurse will come and tell us. We will then refer her to therapy so they can evaluate her and recommend what type of treatment she may need. j. A Restorative Nursing Policy provided by the Administrator on 2/7/24 at 11:13 AM documented, . Policy Statement . The Restorative Nursing Program will include nursing interventions that promote a resident's ability to attain and maintain his/her optimal functional potential . Policy Interpretation and Implementation . 3. The Unit Manager or designee will be responsible for identifying residents with restorative needs, collaborate with the care planning team to establish goals and interventions, supervise activities, and ensure all required documentation is complete. 4. The Unit Manager or designee will be responsible for reviewing clinical assessments, quality assurance monitoring systems, MDS triggers and quality measures data to identify new residents for the program . m. A Mobility and Range of Motion Policy provided by the Administrator on 2/7/24 at 11:13 AM documented, . Policy Statement . 2. Residents with limited range of motion will receive treatment and services to increase and / or prevent a further decrease in ROM .

Based on observation, interview and record review the facility failed to ensure the Minimum Data Set (MDS) was coded accurately to reflect the resident's nutritional status for 1 sampled resident (R#37). The findings are: On 12/27/2023, the resident weighed: a. Per record review, resident #11 weighed 277.4 pounds on 12/27/23. On 01/24/2024, the resident weighed 273.8 pounds which is a -1.30 % Loss.2/05/24 12:PM . On 08/23/2023, the resident weighed 305.6 lbs. On 01/24/2024, the resident weighed 273.8 pounds which is a -10.41 % Loss. b. A Minimum Data Set, dated dated dated [DATE] did not document in section K that there was a weight loss. c. On 2/7/24 at 09:02 AM a Minimum Data Set Coordinator (MDSC) was asked to access resident #37's Minimum Data Set (MDS) in the Electronic Record and look in K section under weight loss. MDSC stated Resident #37 should have been coded for weight loss. Surveyor asked MDSC why is it important for the MDS to be coded correctly. d. On 2/08/24 at 10:22 AM the Director of Nurses (DON) was asked to explain the process of building an MDS. The DON replied, The nurse assesses the resident and inputs the answers in a MDS The Surveyor asked the DON, Should the MDS be coded accurately? The DON replied, Yes. The Surveyor asked, If a resident has lost weight should it be coded on the MDS? The DON confirmed that it should have been coded. e. On 2/7/24 at 10:20 AM, the MDS Consultant provided the section K guidelines pertaining to weight loss coding. Page K-8 K0300 would be coded 2, yes weight change is significant; . According to the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual. It states .Medicare and Medicaid participating LTC (Long-term care) facilities are required to conduct comprehensive, accurate, standardized .

Based on record review and interview the facility failed to notify the Ombudsman required for 1 (Resident #31) of 6 (Residents #11, #14, #31, #59, #64, and #53) sampled residents who were transferred to the hospital in the last month. The findings are: 1. Resident #31 had a diagnosis of Schizophrenia. a. An Incident and Accident (I&A) form dated 01/12/2024 at 6:41 PM documented resident #31 was sitting in a wheelchair with wounds to the abdomen area. The wounds which were self-inflicted with a razor. The razor cap was noted in the resident's lap. b. The Nurse's Notes dated 01/12/2024 at 7:12 PM documented Resident #31 was noted in the dining hall with self-inflicted wounds to abdomen area. Resident #31 was sent to the emergency room for medical observation. c. On 02/06/2024 at 4:14 PM, the Administrator provided a list of residents who were transferred to the hospital from 01/02/2024 to 01/31/2024 with Resident #31 name listed on the list. d. On 02/08/2024 at 09:31 AM, the Social Services Director provided a document titled Emergency Transfers from Facility with a list of residents that was provided to the ombudsman from 01/01/2024 to 01/31/2024. Resident #31's name were not listed on the list. e. On 02/08/2024 at 11:08 AM the Social Services Director (SSD) was asked, On the January 2023 list to the Ombudsman, was Resident #31 included on the list? The SSD replied, I print the Admit/discharge to and from form [named computer system] each day and if the resident is not out after midnight they will not show on that report. So, since Resident #31 was not out after midnight I did not send it to the Ombudsman.

Based on observation, interview and record review, the facility failed to ensure planned interventions to address a significant weight loss were consistently implemented to prevent the potential for continued weight loss for 1 (Residents #4) of 5 ( Residents #1, 3, 4, 7 and 6) case mix residents who had a severe weight loss. The facility also failed to ensure the Registered Dietitian was promptly consulted regarding the planning, management and implementation of interventions to address weight loss; and failed to ensure the RD calculated and documented the residents calorie and protein needs to minimize the potential for further weight loss for 1 (Resident #1) of 5 (Residents #1, 3, 4, 7 and 6) case mix resident who had a significant weight loss. The deficient practices resulted in a pattern of actual harm for Resident #1 and 4 who experienced a significant weight loss and had the potential to cause more than minimal harm for 12 residents in the facility who had a significant weight loss according to the list provided by the Administrator on 1/16/15. The findings are: 1. The facility ' s policy for Nutrition Interventions received from the Administrator on 1/16/15 at 8:45 a.m. documented, "... Policy ... [MEDICATION NAME] committed to assisting patients/residents in maintaining and maximizing nutritional status. Supplemental nutrition will be provided in a manner that maximizes intake of the oral diet before adding other supplementation. When oral diet intake alone is insufficient, supplements will be added in a stepwise manner to achieve the maximum result ... Use fortified foods at meals to provide additional calories and protein for patients/residents unable to meet estimated calories and/or protein needs with current intakes. Increasing the number and types of fortified foods may result in greater acceptance of fortified foods. Approved fortified recipes should be used ... Use other supplements only when the above interventions are ineffective, for individuals needing supplements who refuse med pass or for diabetes with poorly controlled blood sugar. The approved [MEDICATION NAME] should be used when ordering other supplements. 2. Resident #4 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an assessment reference data (ARD) of 11/21/14 documented the resident scored 5 (0-7 indicates severely impaired) per a brief interview for mental status (BIMS), was blind, required extensive assistance for eating, had no weight loss and was not on a physician prescribed weight loss regimen. a. A physician's order [REDACTED]. " b. The facility's annual 2014 Weight Change Comparison sheet received from the Director of Nursing on 1/13/15 documented the following monthly weights: June 2014: 153.0 pounds July 2014: 143.0 pounds August 2014: 140.50 pounds September 2014: 145.50 pounds October 2014: 144.0 pounds November 2014: 132.50 pounds December 2014: 130.0 pounds. January 2015: 129.61 pounds The resident experienced a 6.9 % weight loss between June and July and a severe weight loss of 9.99% weight loss for the past three months between October 2014 and January 2015. c. The care plan dated 9/3/14 documented, "At nutritional risk as receive a mechanically altered/therapeutic diet as ordered by physician. Provide alternates for foods uneaten or unwanted. Assist with tray set up and observe for needed assistance during meal as needed. Serve diet per Dr. (doctors) orders." d. The Nutrition Services Progress Note dated 9/26/14 and signed by the Registered Dietitian (RD) documented, " Resident weight is up to 145.5 pounds, up 7.5 pounds (Plus 5.4 %)x 60 days. His diet RCS (Regular Concentrated Sweet), ground meat with enhanced foods all meals and Glucerna 1 can BID (two times per day). He has fair intake. Needs are 1800 to 2000 calorie, 65 to 75 grams protein and 2000 ml fluid. Continue current plan of care. " e. The October 2014 CNA/RNA (Certified Nurse Assistant/Rehabilitation Nurse Assistant) Care Flow Sheet documented the resident refused 11 out of 31 meals (October 1 through 31). The form documented all three meals were refused on 10/1/14, breakfast and lunch was refused on 10/2/14, lunch was refused on 10/3/14, breakfast was refused on 10/5/14, lunch was refused on 10/8 and 10/10/14, lunch was refused on 10/22/14 and breakfast was refused on 10/28/14. f. The Nutrition Services Progress Note dated 11/14/14 by the RD documented, "Resident current weight is 135.5 pounds, down 10.86 % x 6 months. Diet is RCS, ground meat, enhanced foods all meals and Glucerna 1 can Bid. Would recommend increasing Glucerna to Glucerna 1.5 1 can Tid. There was no documentation in the Nutritional Services Progress Notes that identified the problem of the resident refusing meals. g. On 1/13/15 at 12:21 p.m., Dietary Employee # 2 prepared macaroni and cheese adding approximately one cup of melted cheese sauce from a can, little butter and a carton of whole milk and stated, "That was enhanced macaroni." The macaroni and cheese was not creamy, it was dried. 1/13/15 at 1:39 p.m., all the residents on fortified foods were served regular prepared macaroni and cheese. The facility's recipe for Fortified Cheese Sauce received from the Dietary Manager on 1/14/15 documented, Portion Size: 6 oz. Portions 20. Ingredients: Onion Piquet (small onion half, bay leaf, whole clove) 1, whole milk flour 1 gal (gallon) 8 oz, clarified butter Salt Pepper 8 fl oz (fluid ounces), Shredded Cheese (Cheddar or American) 8 oz. h. On 1/13/15 at 1:20 p.m., during the noon meal, the resident was served ground polish sausage, oven fried potatoes, seasoned cabbage, fruit cocktail, regular macaroni and cheese, 3 slices of bread and cranberry juice. There was no fortified food items served to the resident during or after the meal. The resident ate 50% of the polish sausage, the American fried potatoes, the macaroni and cheese, one slice of bread and drank all the cranberry juice and Hi-C drink. The January 2015 CNA/RNA Flow Sheet documented the resident ate 10% of the lunch meal on 1/13/15. i. On 1/13/15 at 6:30 p.m., the resident was served ground corn dog, macaroni and cheese, English peas, fruit cocktail, 8 ounces (oz) of high protein milk and 4 oz of grape juice. There was no fortified food items served to the resident. The resident was not served Glucerna or any other supplement. The January 2015 CNA/RNA Flow Sheet did not document a % eaten for the evening meal on 1/13/15. j. On 1/14/15 at 8:14 a.m., the resident was served a bowl of super cereal, an 8 oz cup of high protein milk, double portions of scrambled eggs, ground sausage and two biscuits. There was no Glucerna served to the resident with his breakfast meal. The January 2015 CNA/RNA Flow Sheet documented the resident ate 30 % of the breakfast meal on 1/14/15. k. On 1/15/15 at 4:15 p.m., the Dietary Manager was asked about the Glucerna and stated, " They told us to stop using Gluercna. I cannot order Gluercna at all. Nurses suppose to change ordered supplements to house supplements. " At 4:35 p.m., the Dietary Manager was asked, " When the dietician makes a recommendation how do you communicate this to staff? " She stated, "The Dietician and I go over the list and then we give a copy of the recommendations to the Director of Nurses. The Nurses call the physician for orders. " She was asked, "Who is responsible for putting Glucerna on the resident's tray if the resident had an order for [REDACTED]. 3. Resident #1 had [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set with an Assessment Reference date of 11/07/14 documented the resident had severely impaired cognitive skills for daily decision making per a Staff Assessment of Mental Status and received 100% of nutrition via enteral feeding. a. The September 2014 Dietitian Quality Assurance Report dated 9/26/14 documented " ... Recommendations ... gain expected as fluid shifts or [MEDICAL CONDITION] function. Weekly weights to monitor. Will follow ... " b. A Care Plan dated 11/14/14 documented, " ... I require a PEG tube for adequate nutritional intake ... I will not experience adverse effects from placement of a PEG tube ... Dietician to evaluate my current nutritional status ... Weigh me as ordered ... Observe for changes that may indicate worsening of my condition and notify the Physician ... " c. The facility's log titled Weight Change Comparison received from the Director of Nursing on 1/13/15 for the last 7 months documented the following weights: July 2014 - 271 pounds August 2014 - 294 pounds September 2014 - 305.50 pounds October 2014 - 310 pounds November 2014- 327 pounds December 2014 - 246 pounds January 2015 - 232 pounds This was a 5.69 % (14 pound) weight loss for one month between December 2014 and January 2015, a 25.16% (78 pound) weight loss for three months between October 2014 and January 2015 and a total of 14.39 % (39 pounds) weight loss for six months between July 2014 and January 2015. d. The January 2015 Physician order [REDACTED]. e. The January 2015 MAR (Medication Administration Record) documented, "[MEDICATION NAME] 1.5 cal (one) can bolus QID per PE[DEVICE]." f. On 1/14/15 at 4:25 p.m., when the Dietary Manager was asked if she was aware of the weight loss for the resident she stated, "Yes, resident had [MEDICAL CONDITION] on her body and was sent to the Hospital a couple of times, she did notice the weight loss. When asked if the Registered Dietician had been notified she stated, "I called the RD (Registered Dietician) on 12/29/14 she came to the building on Wednesday 12/31/14 and documented in the resident's chart." The Dietary Manager further stated that the RD will leave a report when she visits the facility but she has not read the report or the note in the chart and there were no changes made for the resident's tube feeding. The Dietary Manager was asked if she did any charting she stated, "Yes I do my charting in the computer." The Dietician was notified of the son's request to stop the food trays she stated, "Yes, no new recommendations were made." The Dietary Manager was asked if she could provide the documentation from the Dietician and herself. On 1/15/15 at 9:00 a.m., the Administrator stated that the computer system in facility is new to them and that the Dietary Manager did make entries into the computer but did not press the save button and so none of her notes were saved in the computer and that staff are unable to find notes from Dietician. g. A Nutritional Progress Note dated 1/15/15, no time, documented, " ... RD note - Current weight is 229 pounds. Height is 67 inches. Her weight has fluctuated drastically RT (Related To) [MEDICAL CONDITIONS], June 2014 267.4 (lbs (pounds)), July 2014 267, August 2014 267, September 2014 307.5 (lbs), October 2014 310-335, November 296-335 pounds, December 226.50 to 230 pounds. She was in the Hospital often during the past few months. Her IBW (Ideal Body Weight) is 135 +/- (Plus or Minus) 10%.She is 170% IBW and BMI (Body Mass Index) is 35.8. She is currently NPO (Nothing by Mouth) with 1 can [MEDICATION NAME] 1.5 4 times daily, she had been refusing some of the bolus feedings. She would need 1800-2150 calories (ABW of 160), 70-75g (grams) protein and 2200-2600 ml (Milliliters) fluid ([MEDICAL CONDITION] ).Current feedings provide 1422 calories,60.5 protein and 720 ml of free water. Would recommend trying to add another can of [MEDICATION NAME] 1.5 to provide 1778 calories. She remains on Hospice. Will follow ... " h. On 1/15/15 at 3:21 p.m., during a phone interview, the RD was asked about the resident and stated that she saw (Resident #1) every month when she came to the building and that her notes should be in the chart. She also stated that she did not see the resident in October, she was told that the resident was in the Hospital. She stated that she had asked about the resident in November and December (2014) and was told that she was still in the hospital. She stated that resident's weight had huge fluctuations during the summer, it was up and down and she was aware of this and the resident used to get a tray and this was stopped. She stated the resident used to refuse some bolus feedings. She stated she does not keep a copy of her notes, she always completes a written report and leaves a copy with the Dietary Manager, the Director of Nursing and the Administrator, she documents her interventions for weight loss on the report and gives a verbal report to staff at end of each visit. i. As of 1/15/15 the formula, [MEDICATION NAME] 1.5 bolus feeding three times per day provides a total of 1422 calories. The resident did not meet her caloric needs of 1800 to 2150 per day as calculated by the Registered Dietician to prevent further weight lost.