Every finding on record at The Legacy Midtown Park

Based on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access to the keys for 1 resident (Resident #1) of 5 residents reviewed for pharmacy services. The facility failed to ensure Resident #1's Albuterol (a fast-acting prescription inhaler used as a rescue medication that quickly opens the airways in the lungs to make breathing easier when someone is wheezing, short of breath, or having an asthma attack) was secured in the medication cart. These failures could place residents at risk for compromised unsafe administration, and increased harm to residents.Findings included: Record review of Resident #1's Comprehensive MDS Assessment, dated 05/29/26, reflected she was an [AGE] year-old female, admitted to the facility on [DATE]. She had a BIMS score of 14, which indicated she was cognitively intact. She had diagnoses that included: acute diastolic (congestive) heart failure (the heart can't pump blood as well as it should, causing fatigue, swelling, and shortness of breath.), chronic obstructive pulmonary disease (also referred to as COPD, a long-term lung disease that makes it hard to breathe, often from smoking or long-term exposure to irritants.), and acute respiratory failure (also referred to as ARF, when the lungs are not able to get enough oxygen into the blood). The MDS Assessment reflected Resident #1 was not receiving any respiratory treatments or respiratory therapy. Record review of Resident #1's Care Plan dated 5/28/2026, reflected Resident #1's HOB was to be elevated due to her diagnoses of COPD and ARF. As an intervention, the plan stated to give Resident #1 aerosol (a medicine turned into a fine mist that a person breathes in through a mask or mouthpiece so it goes straight to the lungs) or bronchodilators (a medication that relaxes and opens up the airway in the lungs) medication as ordered and to monitor for any side effects and effectiveness. Record review of Resident #1's active Physician's Orders, dated 06/16/2026, reflected Resident #1 did not have an active order for Albuterol, aerosols, bronchodilators, or to self-administer medications. Record review of Resident #1's EHR on 06/16/2026, reflected that she did not have an assessment completed to determine her ability to self-administer medications. Record review of Resident #1's hospital discharge orders dated 05/27/2026, reflected that she did not have an active order for Albuterol. Record review of Resident #1's hospital Discharge summary dated [DATE], reflected Resident #1 received Albuterol nebulizer treatment twice a day in the hospital. The summary reflected she did not have a prior to hospital admission order for albuterol. During an observation and interview with Resident #1 on 06/16/2026 at 11:40 AM, 2 albuterol inhalers were observed on her nightstand next to her bed. Resident #1 reported she always kept one inhaler at her bedside and the other one with her whenever she would leave the room to go eat or go to physical therapy. She stated she received the inhalers from her doctor but could not recall which doctor. She reported she used the inhalers as needed for shortness of breath or wheezing. Resident #1 could not recall had long she had the inhalers. During an interview with LVN on 06/16/2026 at 11:48 AM, he visually confirmed 2 albuterol inhalers on Resident #1's nightstand. He told Resident #1 the medications would be taken and kept at the nursing station and collected the medications. He reported he did not know how long she had the medications. He reported he completed wound care on Resident #1 earlier in the morning and did not see the medications in her room at that time. He denied ever seeing the medications in her room. He reported he did not know where the medications came from or how Resident #1 obtained them. He stated the medications should not be there. He reported a resident having medications without supervision could lead to risk of overdose, increased heart rate and increased blood pressure. During an interview with the DON on 06/16/2026 at 2:00 PM, she reported she was unaware Resident #1 had the albuterol inhalers in her room. The DON reviewed Resident #1's EHR and stated the Resident had diagnoses that would indicate appropriate for albuterol use. She reported she did not know where the medications came from or how long the resident had them in her room. She reported Resident #1 had not yet had a self-administer assessment to determine her ability to self-administer medications. She reported Resident #1 was not authorized to have medications in her room. She reported the facility policy was that a resident would need to have a physician order as well to self-administer their own medications. The DON reported Resident #1 was admitted to the nursing facility from the hospital. She reported a facility nurse would go over the Resident's hospital discharge summary to review their active medications. The nurse would then contact the facility physician who would input the orders. She stated if a resident was cognitively impaired, self-administering medications would pose multiple risks to the resident. During a subsequent interview with the DON on 06/16/2026 at 2:30 PM, she reported she spoke to LVN about Resident #1's albuterol inhalers. She reported they contacted Resident's physician who gave an order for PRN albuterol inhaler to use in the evening if needed. Record review of the facility's policy for Medication Labeling and Storage, dated 2001, reflected the following: The facility stores all medications and biologicals in locked compartments under proper temperature, humidity, and light controls. Only authorized personnel have access to keys.

Based on observation, interview and record review, the facility failed to ensure that residents who needed respiratory care were provided with such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 3 residents (Resident #6) reviewed for respiratory care. The facility failed on 09/23/2025 to ensure Resident #6's oxygen was administered at the correct setting of 4 liters per minute per physician's orders when Resident's oxygen was set at 1 LPM.This failure could place residents at risk of developing respiratory complications. Findings included:Record review of Resident #6's admission record, dated 09/23/2025, revealed an [AGE] year-old male who admitted to the facility on [DATE] with a primary diagnosis of Pneumonia (infection in one or both lungs). Other diagnoses included Acute and chronic respiratory failure with hypoxia (condition when there is not enough oxygen in the tissues in the body), and Chronic Obstructive Pulmonary Disease (a lung disease that blocks airflow and makes it difficult to breathe). Record review of Resident #6's admission MDS, dated [DATE], revealed a BIMS of 11, indicating moderate cognitive impairment. Record review of Resident #6's care plan, dated 09/01/2025, revealed the following: -The Resident has COPD with intervention of Head of bed elevated while in bed to tolerable/preferred level or out of bed upright in a chair during episodes of difficulty breathing.-The Resident Has altered respiratory status/difficulty breathing r/t COPD, Acute respiratory failure. On Oxygen via nasal cannula with interventions of Monitor for s/sx of respiratory distress and report to MD PRN. and O2 via nasal cannula per physician orders.Record review of Resident #6's Active physician's order summary revealed, O2 at 4 L/min via NC every day and night shift with start date of 09/01/2025.Observation and interview on 09/23/2025 at 3:13 PM revealed Resident #6 lying in bed with nasal cannula on. The oxygen concentrator was on and set at 1 LPM. Resident #6 stated they [staff] had been running it at 4 [LPM]. Resident #6 did not appear to be in respiratory distress. Interview on 09/23/2025 at 4:03 PM, CNA B stated that Resident 6's oxygen was supposed to be set at 2 LPM. She stated she had not checked with the nurse, but when they had another resident on oxygen, the nurse told her to put it on 2 LPM. CNA B stated if oxygen was not at the right setting the resident could have breathing problems. She stated she had not seen Resident #6 have any problems breathing. Observation and interview on 09/23/2025 at 4:23 PM, in Resident #6's room, LVN A stated Resident #6's concentrator was set at 1 LPM. LVN A went to verify the order on the computer and brought the vital sign monitor with her back to the room. Resident #6's oxygen saturation level read 95%. She stated she would check with Therapy about the setting and maybe the knob on the concentrator was bumped. LVN A stated if the setting was incorrect, the risk was the resident could go hypoxic. She said the nurse and everybody else involved in care was responsible for ensuring the setting was correct. She stated the nurses were responsible to monitor and follow the physician order.In a follow up interview on 09/23/2025 at 4:58 PM, CNA B stated she had not changed the setting on the concentrator. She stated when she switched the O2 from the concentrator and turned on the e-tank (portable oxygen cylinder) she would set it for 2 LPM. She stated she was supposed to verify the setting with the nurse. Interview on 09/25/2025 at 4:00 PM, the DON stated her expectation for staff was the setting should be per the physician orders. She stated the licensed nurse was responsible and CNAs were to verify with the licensed nurse what the flow rate should be. The DON said if not followed, the patient could not have adequate oxygen delivery or more. She said it was monitored by the nurse; the order pops up and the licensed nurse observed the correct flow rate.Interview on 09/25/2025 at 4:59 PM, the Administrator stated the nurse was responsible based on the order and to communicate that to the CNA. She said if not followed the resident could desat and have an emergent episode. Record review of the facility policy titled Oxygen Administration undated, revealed: The purpose of this procedure is to provide guidelines for safe oxygen administration.Preparation1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration.Steps in the Procedure.8. Turn on the oxygen. Unless otherwise ordered, start the flow of oxygen at the rate of 2 to 3 liters per minute.

Based on interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury to the administrator of the facility and to other officials to include the State Survey Agency, in accordance with State law through established procedures for 2 of 10 residents (Resident #1 and Resident #2) reviewed for abuse/neglect. 1. The facility failed to report Resident #1's fall with injury to the State Survey Agency, where Resident #1 sustained a fractured hip and blood loss. The incident occurred on 09/21/25 at 9:00 pm and was not reported.2. The facility failed to report Resident #2's fall with injury to the State Survey Agency, where Resident #2 sustained a fractured hip. The incident occurred on 10/05/2025 at 04:08 am and was not reported.These failures could place residents at risk for potential abuse/neglect.The findings include:1. Record review of Resident #1's admission record revealed an [AGE] year-old male who was admitted to the facility on [DATE] and was his own responsible party. Resident #1 had diagnoses which included Unspecified Fracture of Shaft of Right Tibia (break in the main part of the shin bone in the right leg), Unspecified Fall, Pain in Right Knee, Muscle Weakness (Generalized), Other Lack of Coordination, Cognitive Communication Deficit (communication challenge caused by impaired thinking abilities, such as memory, thinking, or problem solving, rather than a language or speech impairment), Muscle Wasting and Atrophy (loss of muscle mass and strength), Acute Kidney Failure (sudden and significant decline in kidney function that leads to inability to remove waste products and excess fluid from the body), Hereditary and Idiopathic Neuropathy (inherited disorders that effect nerves outside the brain and spinal cord), Gout (form of inflammatory arthritis caused by accumulation of uric acid crystals in the joints), and Polyneuropathy (damage or disease nerves in roughly the same areas on both sides of the body, featuring weakness, numbness, and burning pain). Record review of Resident #1's Fall Risk Evaluation, dated 6/19/2025, revealed the resident had 1-2 falls in the past three months, had an ambulation/elimination status of bedbound/incontinent, had gait/balance needs of required use if assistive devices (i.e. cane, wheelchair, walker, furniture), and took 1-2 medications (or medication classes) currently or within the last 7 days of anesthetics, antihistamines, antihypertensives, antiseizures, benzodiazepines, cathartics, diuretics, hypoglycemics, narcotics, psychotropics, sedatives/hypnotics. The Focus revealed Resident #1 was a risk for falls. Interventions were Assist Resident with ambulation and transfers, utilizing therapy recommendations; Determine resident's ability to transfer; Evaluate fall risk on admission and PRN; If fall occurs, alert provider; if fall occurs, initiate frequent neuro and bleeding evaluation per facility protocol; If Resident is a fall risk, initiate fall risk precautions. Record review of Resident #1's Fall Risk Evaluation, dated 9/19/2025, revealed no falls in the past 3 months, ambulation/elimination status was chairbound/continent, no change in condition in last 14 days, gait/balance required the use of assistive devices (i.e. cane, walker, wheelchair, furniture), and took 1-2 medications (or medication classes) currently or within the last 7 days of anesthetics, antihistamines, antihypertensives, antiseizures, benzodiazepines, cathartics, diuretics, hypoglycemics, narcotics, psychotropics, sedatives/hypnotics with a medication change in the last 14 days. The focus revealed Resident #1 was at risk for falls. Interventions were Assist resident with ambulation and transfers, utilizing therapy recommendations; Determine resident's ability to transfer; Evaluate fall risk on admission and PRN; If fall occurs, alert provider; If fall occurs, initiate frequent neuro and bleedingevaluation per facility protocol; If Resident is a fall risk, initiate fall risk precautions.Record review of Resident #1's BIMS, on 9/21/2025, revealed a score of 08, which indicated Moderate Cognitive Impairment.Record review of Resident #1's Progress notes revealed an incident note that was struck through, dated 9/21/2025 at 11:55 PM, by RN A, that stated Note Text : 2100 [9:00 PM]:Heard Resident screaming for Help, Nurse went to pt room, Pt found laying on his on the floor, Assess pt, Pt transferred in bed with Hoyer lift x 3 Assist, ask Pt what Happen Pt stated am trying to Shut the door, Pt A&O x 1, unable to move Right Lower extremity c/o pain PRN Tylenol, administered. Neuro checked initiated, VS Checked WNL, 1050: Nurse went back into Pt room to check on Pt, blood noted in Foley bag, and also from Pt Penis, Dr On call called no answer,2327 [11:27 PM]: Called 911, paramedics In, Pt transported to [local hospital], Family called and Notified, DON Notified. Strike Out Reason: Incorrect Documentation. A Health Status Note entered on 9/21/2025 at 11:55 stated Note Text : 2100 [9:00 PM]: Nurse went into Pt room, Pt observed laying Supine (laying on one's back face upwards) on the floor beside the bed to the right, no call light activated at this time from pt room. Nurse Perform initial assessment, no c/o pain or distress noted, VS checked, pt able to move extremities, no swelling or discoloration noted, extremity equal, log roll pt to check pt head no bump or redness noted, insert Hoyer sling, Pt was transferred into his bed x 3 Assist, pt tolerated well, bed placed in lowest position, call light placed within pt reach, reminded pt to always use his call button, pt verbalize understanding, Neuro Check Initiated, VS Checked BP 138/80,P77,R 20,O2 98,T97.6 and continue 15 x ,2200; Resident Dr on-call notified about Pt fall, [Family Member] called phone not connecting, q30 minutes x 2,2250: Went Back into Pt room to check on Pt Neuro check ongoing, Pt c/o pain F/U complete Head to Toe Assessment done, Assess both extremities, c/o pain to right extremity, Blood Noted to Pt Foley,2327 [11:27 PM]: Paramedics 911 called, Pt sent to ER. At [local hospital], Report given to Paramedics crew, paperwork printed and given to them, [family member] called No Answer 2354 [11:54 PM]: [family member] Called and Notified. DON Notified.Record review of Resident #1's Change in Condition, dated 9/22/2025, revealed signs and symptoms identified were falls and bleeding (other than GI) that began on the night of 9/21/2025. Vital signs were considered normal and taken at 9:23 PM. Review Findings indicated this was a new onset of conditions and the symptoms or signs had gotten worse. The mental status evaluation of Resident #1 revealed increased confusion compared to the resident's baseline that was a persistent change from usual cognitive function. The functional status evaluation described the change as a fall with the fall associated with any suspected serious injury (e.g. fracture) any hip pain, or more than minor pain elsewhere. Genitourinary status evaluation revealed blood in urine described as gross hematuria with pain, fever or other signs of bleeding at other sites. Pain status evaluation revealed Resident #1 had pain and was unable to cognitively rate their pain scale. Pain was musculoskeletal in location and described as marked localized bruising, swelling, or pain over joint or bone, with or without recent fall. Exact location of pain was documented as right trochanter (hip). Date and time clinician notified was documented as 9/21/2025 at 11:34 PM. Resident representative notification was documented to be 9/21/2025 at 11:50 PM.Record review of Resident #1's Care Plan, closed on 10/06/2025, revealed the following significant Focus Areas and Interventions: Focus: The resident is on sedative/hypnotic therapy r/t Insomnia. Interventions: Administer sedative/hypnotic medications as ordered by physician; Monitor/document side effects and effectiveness Q-SHIFT; Monitor/Document/Report PRN for following adverse effects of sedative/hypnotic therapy: daytime drowsiness, confusion, loss of appetite in the morning, increased risk of falls and fractures, dizziness. Date Initiated: 06/20/2025 Focus: The resident has a right tibial fracture r/t Fall, s/p ORIF. Interventions: Anticipate and meet needs. Be sure call light is within reach and respond promptly to all requests for assistance. Follow MD orders for weight bearing status. See MD orders and/or PT treatment plan. Monitor/document/report PRN s/sx of tibial fracture complications: Embolism s/sx (cyanosis, pain, petechiae, increased heart rate [Tachycardia], tachypnea, difficulty breathing [Dyspnea]), Infection at surgical site, Impaired mobility, Unrelieved pain. PT, OT evaluation and treatment per orders. Date Initiated: 06/20/2025 Focus: The resident is at risk for falls r/t deconditioning, right tibial fracture. Interventions: Anticipate and meet the residents' needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Date Initiated: 07/13/2025 Focus: The resident has limited physical mobility r/t Weakness, deconditioning, right tibial fracture. Interventions: The resident is non-weight bearing to RLE X 12 weeks, See physician notes/Therapy updates. Locomotion: The resident uses W/C for locomotion. Provide extensive assist x 1 staff PRN. Date Initiated: 07/13/2025 Focus: The resident has an ADL self-care performance deficit r/t recent right lower extremity surgery. Interventions: Bathing/Showering: The resident requires total assist x 1 staff per facility schedule and as necessary. Bed Mobility: The resident requires extensive assist x 2 staff to turn and reposition in bed as necessary. Bed Mobility: The resident uses an assist bar to maximize independence with turning and repositioning in bed. Dressing: The resident requires total assist x 1 staff. Eating: Provide set up assist x 1 staff to eat. Personal Hygiene: The resident requires total assist x 1 staff with personal hygiene and oral care. Toilet Use: The resident requires total assist x 2 staff for toileting. Transfer: The resident requires extensive assist x 1 staff as necessary. Date Initiated: 07/13/20252. Record review of Resident #2's admission record revealed a [AGE] year-old female who admitted to the facility on [DATE]. Resident #2 had diagnoses which included Urinary Tract Infection (infection caused by bacteria entering the urinary tract [kidneys, ureters, bladder, and urethra]), Chronic Diastolic (Congestive) Heart Failure (condition where the heart muscle becomes stiff and less able to relax between heartbeats, leading to reduced filling of the heart chambers), Pain in Thoracic Spine (pain in the middle back, between the neck and the lower ribs), Muscle Wasting and Atrophy, Other Abnormalities of Gait and Mobility, Other Lack of Coordination, Abnormal Posture, Cognitive Communication Deficit (communication challenge caused by impaired thinking abilities, such as memory, thinking, or problem solving, rather than a language or speech impairment), Muscle Weakness (Generalized), Age-Related Physical Debility, Unspecified Dementia (symptoms of dementia but the specific underlying cause cannot be determined), and Restlessness and Agitation. Record review of Resident #2's admission MDS, dated [DATE], revealed functional limitation in range of motion of both sides upper extremities (shoulder, elbow, wrist, hand), and a wheelchair was normally used for mobility. Functional abilities noted Partial/moderate assistance was needed with oral hygiene, upper body dressing, and personal hygiene. Substantial/maximal assistance was noted to have been needed for shower/bathe self, lower body dressing, and putting on/taking off footwear. Resident #2 was noted to be dependent, where helper did all of the effort, for toileting hygiene. Resident #2 was evaluated to be dependent, where helper did all of the effort, for mobility of roll left and right, sit to lying, lying to sitting on side of the bed, sit to stand, chair/bed-to-chair transfer, toilet transfer, car transfer, walk 10 feet, walk 50 feet with two turns, and walk 150 feet. Resident #2 was noted to have been always incontinent of bladder and frequently incontinent of bowel. Resident #2 was noted to not have had any falls in the last 6 months or have any fractures related to a fall in the past 6 months.Record review of Resident #2's care plan, last updated 9/17/2025, revealed the following significant Focus Areas and Interventions: Focus: The resident is at risk for falls r/t Deconditioning. Interventions: Anticipate and meet the resident's needs; Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Pt evaluate and treat as ordered or PRN. Date Initiated: 09/15/2025Record review of Resident #2's BIMS, on 10/05/2025, revealed a score of 03, which included a severe cognitive impairment. Record review of Resident #2's Progress Note, dated 10/05/2025 at 4:25 AM, by LVN B, revealed during CNA rounds, resident was found on the floor lying on her left side. Resident stated she slipped and fell while attempting to go to the bathroom. Upon assessment, a skin tear was noted on left arm and bruising near left knee. Resident yelled out in pain and complained of pain to the left hip and leg while attempting to assist her with getting up. Resident remained in place on floor for EMS to assist with transfer. EMS and the resident's emergency contact were notified. Record review of Resident #2's SNF/NF to Hospital Transfer Form, dated 10/05/2025, revealed the reason for transfer was a fall, with a most recent pain level of 10 in the left trochanter (hip) location. Resident #2 was listed as capable of making own decisions. Resident #2's usual functional status before acute change in condition was listed as ambulates independently with needs assistance for bathing, dressing, toileting, and transfers. Resident #2 was also listed as continent of bowel and bladder, and alert, oriented, and follows instructions. Resident #2 was listed as a high fall risk. Record review of facility inservices revealed the most recent inservices for: Abuse and Neglect/Resident Rights on 8/13/2025 Gait Belt Use for Safety on 4/17/2025Proof of online course completion provided for Preventing Falls: An Interdisciplinary Approach; Slips, Trips, and Falls Prevention for employees between 1/01/2025 and 10/22/2025. Interview with the Administrator on 10/21/2025 at 1:19 PM revealed the facility process when a resident was found on the ground was for a nurse to assess the resident and begin neuro checks, then to contact the medical doctor and family as soon as possible to let them know what happened. The Administrator stated ongoing monitoring of the resident would happen and if it were determined the resident needed to be sent to the hospital then the incident would be considered a significant change in condition. The Administrator revealed an unwitnessed injury, injury of unknown origin, or serious bodily injury should have been reported and investigated, however, if the facility knew the resident fell or the resident could tell them they fell then the injury was not of an unknown origin. The Administrator stated an unwitnessed fall with a fracture or serious bodily injury was not reported as the facility did not interpret an unwitnessed fall as an unknown source since they knew [the residents] fell. The Administrator stated neglect was if a resident tripped on something or some item that could have been addressed by staff, but there were no obstacles staff saw when entering the rooms of Residents #1 or #2 after they fell. When asked about the blood in the catheter bag of Resident #1, the Administrator deferred to the DON for a nursing viewpoint on how that was known to be from the unwitnessed fall. The Administrator was able to report Resident #1 was sent out to a local hospital for evaluation once blood was observed. The Administrator stated Resident #2's injury was not reported because the known source was the fall as she was found on the floor, and she was able to say that she fell and there were no reported or observed obstacles in the environment that may have caused or contributed to the fall. The Administrator stated she was responsible for reporting incidents of abuse. neglect, exploitation, and injuries of unknown origin, and the DON would report in her absence.Interview with CNA C on 10/21/2025 at 3:35 PM revealed unwitnessed falls were to be reported to the nurses right away, as were any changes in condition like blood being seen in the catheter bag. CNA C stated any suspicion of abuse, neglect, or exploitation, which included unexplained injuries, should be reported immediately to the abuse coordinator for the facility who was the Administrator. Interview on 10/21/2025 at 3:39 PM with LVN D revealed if a resident was found on the ground, the first step was to make sure the resident was safe and call out for help, then the resident was assessed to see if they could move extremities. LVN D stated if the resident had any pain, the doctor was to be called for orders unless it was severe then call 9-1-1 right away. LVN D stated all unwitnessed falls and injuries of unknown origin were reported to the DON and Administrator right away so they could determine if an investigation needed to happen. Interview with the DON on 10/21/2025 at 4:29 PM revealed the expectations of staff when a resident was found after an unwitnessed fall was for a CNA to call out for a nurse, the nurse to assess the resident and try to identify what caused the fall either from resident report or by looking for environmental factors. The DON stated if the resident was not expressing pain, then staff would assist to the bed and monitor for anything remarkable or for a delayed injury to be expressed. The DON stated Resident #1 was sent out to the hospital due to the blood seen in the catheter bag during follow-up checks as the follow-up checks were not remarkable for any injury because of the fall; the assessment of Resident #1 when he was found on the floor did not indicate any dislodging or trauma to the catheter. The DON stated she had limited interactions with Resident #1 during his stay at the facility and did not notice anything remarkable with his memory or ability mentally. The DON stated interactions with Resident #2 were brief and the resident was able to respond appropriately to general inquiries, however, did not have in-depth interactions with her. Resident #2 was sent to the hospital immediately due to expressing pain was severe in her hip. The DON stated the appropriate interventions were in place for both Residents #1 and #2 at the time of their unwitnessed falls. The DON stated unwitnessed falls were discussed with the Administrator and a decision was made on whether an investigation and self-reporting were necessary; the instances of Residents #1 and #2 were not required to be self-reported in their opinions.Record review of the facility's policy Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating revealed: All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/ misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Reporting Allegations to the Administrator and Authorities 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility; e. The resident's attending physician; and f. The facility medical director. 3. Immediately is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury.;

Based on observation, interview and record review, the facility failed to ensure that residents who needed respiratory care were provided with such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 3 residents (Resident #6) reviewed for respiratory care. The facility failed on 09/23/2025 to ensure Resident #6's oxygen was administered at the correct setting of 4 liters per minute per physician's orders when Resident's oxygen was set at 1 LPM.This failure could place residents at risk of developing respiratory complications. Findings included:Record review of Resident #6's admission record, dated 09/23/2025, revealed an [AGE] year-old male who admitted to the facility on [DATE] with a primary diagnosis of Pneumonia (infection in one or both lungs). Other diagnoses included Acute and chronic respiratory failure with hypoxia (condition when there is not enough oxygen in the tissues in the body), and Chronic Obstructive Pulmonary Disease (a lung disease that blocks airflow and makes it difficult to breathe). Record review of Resident #6's admission MDS, dated [DATE], revealed a BIMS of 11, indicating moderate cognitive impairment. Record review of Resident #6's care plan, dated 09/01/2025, revealed the following: -The Resident has COPD with intervention of Head of bed elevated while in bed to tolerable/preferred level or out of bed upright in a chair during episodes of difficulty breathing.-The Resident Has altered respiratory status/difficulty breathing r/t COPD, Acute respiratory failure. On Oxygen via nasal cannula with interventions of Monitor for s/sx of respiratory distress and report to MD PRN. and O2 via nasal cannula per physician orders.Record review of Resident #6's Active physician's order summary revealed, O2 at 4 L/min via NC every day and night shift with start date of 09/01/2025.Observation and interview on 09/23/2025 at 3:13 PM revealed Resident #6 lying in bed with nasal cannula on. The oxygen concentrator was on and set at 1 LPM. Resident #6 stated they [staff] had been running it at 4 [LPM]. Resident #6 did not appear to be in respiratory distress. Interview on 09/23/2025 at 4:03 PM, CNA B stated that Resident 6's oxygen was supposed to be set at 2 LPM. She stated she had not checked with the nurse, but when they had another resident on oxygen, the nurse told her to put it on 2 LPM. CNA B stated if oxygen was not at the right setting the resident could have breathing problems. She stated she had not seen Resident #6 have any problems breathing. Observation and interview on 09/23/2025 at 4:23 PM, in Resident #6's room, LVN A stated Resident #6's concentrator was set at 1 LPM. LVN A went to verify the order on the computer and brought the vital sign monitor with her back to the room. Resident #6's oxygen saturation level read 95%. She stated she would check with Therapy about the setting and maybe the knob on the concentrator was bumped. LVN A stated if the setting was incorrect, the risk was the resident could go hypoxic. She said the nurse and everybody else involved in care was responsible for ensuring the setting was correct. She stated the nurses were responsible to monitor and follow the physician order.In a follow up interview on 09/23/2025 at 4:58 PM, CNA B stated she had not changed the setting on the concentrator. She stated when she switched the O2 from the concentrator and turned on the e-tank (portable oxygen cylinder) she would set it for 2 LPM. She stated she was supposed to verify the setting with the nurse. Interview on 09/25/2025 at 4:00 PM, the DON stated her expectation for staff was the setting should be per the physician orders. She stated the licensed nurse was responsible and CNAs were to verify with the licensed nurse what the flow rate should be. The DON said if not followed, the patient could not have adequate oxygen delivery or more. She said it was monitored by the nurse; the order pops up and the licensed nurse observed the correct flow rate.Interview on 09/25/2025 at 4:59 PM, the Administrator stated the nurse was responsible based on the order and to communicate that to the CNA. She said if not followed the resident could desat and have an emergent episode. Record review of the facility policy titled Oxygen Administration undated, revealed: The purpose of this procedure is to provide guidelines for safe oxygen administration.Preparation1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration.Steps in the Procedure.8. Turn on the oxygen. Unless otherwise ordered, start the flow of oxygen at the rate of 2 to 3 liters per minute.

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety. 1. The facility failed to ensure on [DATE] food items in the refrigerator, freezer and dry storage room , that were not in the original packaging, were labeled. 2. The facility failed to discard items stored in refrigerator, freezers or dry storage on [DATE]. The facility had expired food items from approximately 6 months- 3 days old past the expiration date/best used by date. 3. The facility failed to remove molded fruit from the refrigerator. These failures could place residents at risk for food-borne illness and cross contamination. Findings included: Observations of the walk-in refrigerator on [DATE] at 09:45 AM revealed the following: -22.50 lbs box of corn tortillas opened and there was no expiration date or manufacturer date. - 1 large vacuumed sealed package of an unidentified food item. There was no label of item description or used by or expiration date. - 1 Small bowl with cooked eggs [DATE]-[DATE]. - 1 5lbs cottage cheese unsealed and there was no used by or expiration date. - 1 8fl oz of Lactose free milk opened. There was no used by or expiration date. -1 gallon of blue cheese opened. There was no use by date or manufacturer date. -8 1 lbs clear containers of strawberries with received date [DATE]. 4 of the clear containers contain strawberries with mold. -6 1 lbs clear containers of blueberries. There was no used by date or expiration date. - 1 large bag of approximately 40 carrots. There was no used by date or expiration date. -1 small pan of an unidentified meat with a used by date [DATE]. There was no label of item description. - 1 medium bowl of an unidentified meat. There was no used by date or label of item description. - 1 lbs of roast beef exposed to air. There was no used by date or expiration date. An Interview on [DATE] at 10:15am the Dietary Manager who stated molded items and items that are past the use by or expired by date are thrown away. The expired and molded items were presented to the DM. The DM removed the molded and expired items and had staff discard the items at that time. Observations of the Dry Storage Room on [DATE] at 10:28 AM revealed the following: -1 2lbs bag of crisp rice cereal with best used by date of [DATE]. -1 2lbs bag of crisp rice cereal with best used by date [DATE]. - 1 2lbs corned flakes cereal with best used by date [DATE]. -1 large plastic bin of breadcrumbs dated restocked [DATE]. There was no used by or expiration date. - 1 large plastic bin of flour dated restocked [DATE]. There was no used by or expiration date. -1 larger plastic bin of corn starch dated restocked [DATE]. There was no used by or expiration date. - 2 boxes with ten brown bananas. There was no used by or expiration date. -1 large box of approximately 25 potatoes. There was no used by or expiration date. - 1 large bag of approximately 20 onions. There was no used by or expiration date. -1 25 lbs. long grain parboiled rice was opened. There was no used by or expiration date. - (2) 4.5lbs boxes of black tea dated best by [DATE] and [DATE]. An interview on [DATE] at 9:27am the Dietary Manager who stated the dates on items are the arrival date or opened date. DM stated items without manufacturers dates are dated with the received date. The DM stated if items are opened without a manufactured date, the items are discarded three days from the received date. DM stated flour, breadcrumb, and cornstarch are frequently used. The DM stated those items are restocked every ,d+[DATE] months. The DM stated flour, breadcrumb, and cornstarch usually has a shelf life of one year. Review of the facility's Food Receiving and Storage Policy dated [DATE]: Revision [DATE], reflected Policy Statement: Foods shall be received and stored in a manner that complies with safe food handling practices. Policy Interpretation and Implementation: Dry Food Storage: 4. Dry foods that are stored in bins will be removed from original packaging, labeled, and dated (use by date). Such foods will be rotated using a first in - first out system. Refrigerated/Frozen Storage 1. All foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by date). 7. Refrigerated foods are labeled, dated, and monitored so they are used by their use by date, frozen, or discarded. 8. Frozen foods are maintained at a temperature to keep the food frozen solid. Wrappers of frozen foods must stay intact until thawing. Review of the U.S. FDA Food Code 2022 reflected: Chapter 3 . section ,d+[DATE].11 Compliance and Food Law: . C. Packaged Food shall be labeled as specified in Law, including 21 CFR 101 Food Labeling [* .(b) A food which is subject to the requirements of section 403(k) of the act shall bear labeling, even though such food is not in package form. (c) A statement of artificial flavoring, artificial coloring, or chemical preservative shall be placed on the food or on its container or wrapper, or on any two or all three of these, as may be necessary to render such statement likely to be read by the ordinary person under customary conditions of purchase and use of such food. The specific artificial color used in a food shall be identified on the labeling when so required by regulation in part 74 of this chapter to assure safe conditions of use for the color additive.], 9 CFR 317 Labeling, [*(a) When, in an official establishment, any inspected and passed product is placed in any receptacle or covering constituting an immediate container, there shall be affixed to such container a label .Marking Devices, and Containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under S ,d+[DATE].18. Section ,d+[DATE].12 Food Storage Containers, Identified with Common Name of Food: Except for containers holding FOOD that can be readily and unmistakably recognized such as dry pasta, working containers holding food or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food. Section ,d+[DATE].17 . Commercial processed food: Open and hold cold . B. 1. The day the original container is opened in the food establishment shall be counted as Day 1. 2. The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. C. 2. Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (A) of this section. 3. Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section. Definitions 3. Food Receiving and Storage - When food, food products or beverages are delivered to the nursing home, facility staff must inspect these items for safe transport and quality upon receipt and ensure their proper storage, keeping track of when to discard perishable foods and covering, labeling, and dating all PHF/TCS foods stored in the refrigerator or freezer as indicated. www.fda.gov an *- www.ecfr.gov

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. 1. The facility failed to ensure food items were kept away from potential airborne contaminants (dust and fuzz) on the mixer, knife rack, piping leading to the ice machine, and utility shelving. 2. The facility failed to ensure food items were properly covered and labeled with the contents or date the items were placed in the refrigerator in accordance with professional standards. 3. The facility failed to ensure raw beef was stored away from prepared food in the walk-in refrigerator. These failures could place residents at risk for food contamination and food-borne illness. Findings include: Observation on 07/18/2023 at 9:15 AM in the facility's kitchen refrigerator revealed the following items were not labeled or dated with the date they were placed in the refrigerator: - Rice pudding - Peach cobbler - Chocolate crumb cake - Pecan Pie - Cake In an interview on 07/18/2023 at 9:25 AM, the Kitchen Supervisor identified the rice pudding, peach cobbler, chocolate crumb cake, pecan pie, and cake. She said she was not sure when they were placed in the refrigerator. She stated the items should be labeled so all staff could identify the items and dated with the date they were placed in the refrigerator to ensure freshness and prevent possible food-borne illness. She said the Cook was responsible to ensure all food items were dated and labeled but was not sure which Cook placed the items into the refrigerator. An observation in the facility's walk-in refrigerator revealed a container of raw meat on the top shelf of a tray cart beside containers of prepared fruits and vegetables. The raw meat was covered but not labeled with the contents or the date it was placed there. In an interview on 07/18/2023 at 9:25 AM, the Kitchen Supervisor stated the raw meat should not be on the same shelf as any prepared foods and should be stored on the bottom shelf to minimize the possibility of raw meat juices contaminating other foods. She stated this could cause food borne illness. She said she was not sure who placed the meat on the shelf. She asked the Cook, who denied doing it. The Cook told the Kitchen Supervisor she did not know who placed the raw meat on the shelf and did not know when it was placed there. An Observation on 07/19/2023 at 8:01 AM in the facility's kitchen revealed a large industrial mixer, in the food preparation area, with built up dust and grease on the top and sides, a utility rack with dust and fuzz on the shelving. The utility rack stored clean metal inserts and plate covers. An observation of the ice machine revealed a pipe leading to the filter, next to the opening of the ice machine to be covered with dust and fuzz. A magnetic knife holder attached to the backsplash of the food preparation area was also covered with dust and crumbs. In an interview on 07/19/2023 at 8:10 AM, the Kitchen Supervisor stated the kitchen was cleaned regularly by the dishwashers and a cleaning schedule was in place as a guide. She stated all kitchen equipment should be clean and free of any debris that could contaminate food during preparation. She said the Dietary Manager followed up with the cleaning schedule to ensure it was followed. She stated when the Dietary Manager was not working, it was the Cook's responsibility to follow up. In an interview on 07/19/2023 at 8:20 AM, the Dietary Manager said she expected staff to know food needed to be labeled and dated with the date the item was opened to ensure freshness and prevent the possibility of food born illness. She said the dishwashers were responsible for cleaning kitchen equipment according to the cleaning schedule. She provided a copy of the cleaning schedule. In an interview on 07/20/2023 at 8:05 AM, the Dishwasher stated there was a cleaning schedule for kitchen equipment, but she had been on vacation for three weeks. She said she did not know who was working while she was gone but assumed they would have been responsible for the cleaning during that time. She was unable to say when she last cleaned the mixer, ice machine filter pipe, utility shelf, or knife holder. She said she knew it was important to keep the items clean as dirt and dust could contaminate food items being prepared nearby. In an interview on 07/20/2023 at 9:15 AM, the Administrator said she expected the kitchen staff to follow all food safe handling procedures to prevent food contamination or food born illness. An observation and interview on 07/20/2023 at 8:00 AM with the Kitchen Supervisor revealed a pound cake in the refrigerator that was uncovered and undated. She stated the cake must have been opened last night but was not sure why it was not dated or labeled. She said whoever opend it should have labeled and deted the pound cake. Record review of the cleaning scheduled reflected the mixer was to be cleaned on Tuesdays by the morning Cooks and shelving on Saturdays by the morning cooks. Record review of the facility's in-service records, titled Label, Dates, Temp Logs, dated 04/10/2023, reflected nine staff names which included the Kitchen Supervisor, Cook, and Dishwasher. The in-service reflected Why is it important to label and date food: This helps prevent foodborne disease outbreaks. This practice recommended in the Food and Drug Administration's (FDA) Food Code. They should be marked with a date indicating when the food should be eaten, sold, or thrown away. Record review of the facility's policy titled, Sanitation, dated October 2008 reflected, The food service area shall be maintained in a clean and sanitary manner. All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary .Kitchen and dining room surfaces not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent accumulation of grime. The Food Services Manager will be responsible for scheduling staff for regular cleaning of kitchen and dining areas. Food services staff will be trained to maintain cleanliness throughout their work areas during all tasks, and to clean after each task before proceeding to the next assignment. Record record review of the Federal Drug Administration Food Code dated 2022 section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils revealed (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. 3-305.11 Food Storage. (A) Except as specified in (B) of this section, FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor. (B) FOOD in packages and working containers may be stored less than 15 cm (6 inches) above the floor on case lot handling EQUIPMENT as specified under S 4-204.122. 3-305.14 Food Preparation. During preparation, UNPACKAGED FOOD shall be protected from environmental sources of contamination. 3-307.11 Miscellaneous Sources of Contamination. FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 - 3-306. 3-602.11 Food Labels. (A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. 3-302.12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding FOOD that can be readily and unmistakably recognized such as dry pasta, working containers holding FOOD or FOOD ingredients that are removed from their original packages for use in the FOOD ESTABLISHMENT, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the FOOD. 3-501.17 - Commercially processed food Open and hold cold (B) Except as specified in (E) - (G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: Pf (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; Pf and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer ' s use-by date if the manufacturer determined the use-by date based on FOOD safety.

Based on observation, interview and record review the facility failed to, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls, and to permit only authorized personnel to have access to the keys for one of 3 medication carts (2nd floor medication cart) reviewed for medication storage. MA A failed to ensure all drugs and biologicals were locked inside the medication cart. This failure could place residents at risk of ingestion/exposure to medications not intended for them. Findings included: Observation on 7/19/23 at 7:51 AM revealed MA A set up medications for Resident #8, which included Salonpas Patch. MA A was observed to remove Salonpas Patch from the sealed pouch, MA A dated and initialed the patch and placed the patch on top of the medication cart parked in room [ROOM NUMBER] doorway. MA A was observed to lock the cart, left the Salonpas Patch laying on top of medication cart and entered room [ROOM NUMBER] and administered oral medications to Resident #8. MA A was observed to have her back to the medication cart while she administered medications. Interview with MA A on 7/19/23 at 8:23 AM, MA A stated she left Salonpas Patch on medication cart top while giving Resident #8 morning medications. The Medication-aide stated it was okay to leave the patch on the medication cart top because the patch was not medicine. MA A stated if another resident/someone took patch there would be big trouble. MA A stated she was in-serviced on medication security by the nurses. Interview on 7/20/23 at 9:12 AM with LVN B, she stated medications were never to be left on top of an unattended cart under any circumstance. LVN B stated all medications should be secured inside of the cart and the cart locked before leaving cart. LVN B stated topical patches were medication and should never be left on top of medication cart unattended. LVN B stated the DON/ADON provided in-services related to cart/medication security. LVN B stated failure to secure medications would put others at risk of taking medication not intended for them and could cause severe illness, even death. LVN B stated she had never received any information that patches were not medication and could be left unattended. Interview on 7/20/23 at 9:29 AM with R.N. C stated she would observe staff and in-service them on anything that needed correction/refresher. R.N. C stated it was never okay to leave medications on top of the medication cart unattended. R.N. stated medications left unattended put residents/others at risk for taking substances not prescribed for them and could cause serious illness or death. Interview on 7/20/23 at 11:59 AM, the DON stated medications should never be left unattended. The DON stated she had been in her position such a short time that she had not had the opportunity to provide staff in-services; that was one of her responsibilities. The DON stated all nurses/MA's had been in-serviced on medication security since this incident. The DON stated leaving medications unsecured put residents/others at risk for illness. Interview on 7/20/23 at 12:06 PM, the facility Administrator stated the DON was responsible for in servicing all staff. The Administrator stated medications should always be secured and never left unattended. The Administrator stated unattended medications placed residents/others at risk of illness. Record review of the facility's, undated, current Standards and Guidelines, revealed the following: Storage of Drugs and Biologicals did not specifically address securing all medications inside medication carts. Record review of https://rcni.com/nursing-standard/opinion/expert-advice/medicines-management on 7/26/23 revealed All medicines should be locked away in a treatment room, drug trolley or the patient's bedside locker. Record Review of https://www.google.com/search?q=can+medications+be+left+on+med+cart+top&rlz=1C1GCEB_enUS969US971&oq=can+medications+be+left+on+med+cart+top&aqs=chrome 69i57.17052j0j1&sourceid=chrome&ie=UTF-8 on 7/26/23 revealed Medication carts should never be brought into resident rooms and should instead remain in the doorway with the outward side of the cart inaccessible to passersby. No medication should be kept on the top of the cart.

Based on observation, interview and record review, the facility failed to ensure that a resident who needs respiratory care, was provided such care, consistent with professional standards of practice one (Resident #1) of two oxygen concentrators reviewed for essential equipment. The facility failed to clean the oxygen concentrator for Resident #1. This failure could affect residents by causing inhaling of foreign particles and decreased input of oxygen resulting in increased risk of respiratory infections and cause risk for injury related to broken equipment. Findings included: Review of Resident #1's Quarterly MDS assessment dated [DATE] revealed Resident #1 was a [AGE] year-old male admitted to the facility on [DATE]. The MDS reflected that oxygen was used. The MDS revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's June 2022 physician's orders revealed an order dated for oxygen at 2-3 liters/minute via oxygen mask PRN for SOB/oxygen saturation below 90%. The resident also had an order dated 3/29/21 to change oxygen tubing and clean oxygen concentrator filter every week on Sunday night shift. Review of Resident #1's Care Plan dated 03/20/21 revealed oxygen therapy related to SOB with an intervention to change the oxygen tubing and clean the oxygen concentrator filter every week on Sunday night shift. Observation on 06/20/22 at 8:55 AM revealed Resident #1 was in bed with oxygen in place. The oxygen concentrator had a filter which was visibly dusty (thick layer of greyish white powdery substance) on the back of the machine. Observation and interview on 06/20/22 at 9:45 AM with LVN A revealed Resident #1's oxygen concentrator had a filter which was visibly dusty (thick layer of greyish white powdery substance) on the back of the machine. LVN A stated the filter was dirty, and she stated she needed to clean the filter. LVN A stated the risk of the filter being dirty could cause infection and that was why it needed to be clean. Interview on 06/20/22 at 12:13 PM with LVN B via telephone revealed she worked the night shift on 06/19/22, Sunday, and was responsible for cleaning Resident #1's oxygen concentrator filter however she had not cleaned the filter. She stated she forgets to clean the filter. Interview on 06/20/22 at 10:43 AM with the DON revealed the oxygen concentrator filters should be cleaned but since she had only been employed for two weeks at the facility, she was not certain who or what shift was responsible for ensuring the filters were cleaned. She stated it was her expectation the filters were cleaned weekly, per the policy, in order to decrease the risk of respiratory infections in the facility for those residents requiring oxygen. Interviews with the ADON and ADM were not available. Review of the facility policy titled Oxygen Administration, revised October 2010 reflected: The purpose of this procedure is to provide guidelines for safe oxygen administration. 12. Check the mask, tank .to be sure they are in good working order

Based on record review, interview, and facility policy review, the facility failed to ensure a pneumococcal vaccine was offered to three (Resident #9, Resident #14, and Resident #24) of five residents sampled for immunizations. This had the potential to result in decreased protection from pneumococcal infection. Findings included: A review of the facility's Pneumococcal Vaccine policy and procedure, revised 08/2016, indicated the following: - All residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. - Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. - Assessments of pneumococcal vaccination status will be conducted within five (5) working days of the resident's admission if not conducted prior to admission. 1. A review of an Admission Record revealed the facility admitted Resident #24 to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Immunization Record in the electronic health record (EHR) indicated Resident #24 received [MEDICATION(S)] dose 1 on 06/14/2016. A review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documentation in the EHR to indicate a pneumococcal vaccine was offered to the resident or the resident's representative upon the resident's admission to the facility. There was no documentation the resident's primary care physician had indicated the resident was not a candidate for the second [MEDICATION(S)] dose. 2. A review of an Admission Record revealed the facility admitted Resident #14 on 02/26/2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Immunization Record in the electronic health record (EHR) indicated the resident had received [MEDICATION(S)] dose 1 on 10/01/2020. Further review of the record revealed no documentation in the EHR to indicate a pneumococcal vaccine was offered to the resident or resident's representative upon the resident's admission to the facility. There was no documentation the resident's primary care physician had indicated the resident was not a candidate for the second [MEDICATION(S)] dose. 3. A review of an Admission Record revealed the facility admitted Resident #9 on 04/07/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Immunization Record in the EHR indicated Resident #9 had received [MEDICATION(S)] dose 1 on 05/06/2021. There was no documentation in the EHR to indicate a pneumococcal vaccine was offered to the resident or resident's representative upon the resident's admission to the facility. There was no documentation the resident's primary care physician had indicated the resident was not a candidate for the second [MEDICATION(S)] dose. On 06/09/2022 at 9:54 AM, the Director of Nursing (DON) and Assistant Director of Nursing (ADON) were interviewed. The facility's Pneumococcal Vaccine policy, the Centers for Disease Control and Prevention (CDC) pneumonia vaccine recommendations, and the above information regarding [MEDICATION(S)] dose 1 for Residents #24, #14, and #9 were all reviewed with the DON and ADON. The DON stated no documentation was located to indicate any of the three residents had been offered a second pneumococcal vaccine. She stated there was no documentation the residents' physicians had indicated a second pneumonia vaccine was medically contraindicated for any of the three residents. The DON stated if Residents #24 and #9 had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated the facility's policy and procedure to assess the residents' pneumococcal vaccine status and/or to offer the second pneumococcal vaccine to the residents had not been followed. On 06/09/2022 at 10:38 AM, the Administrator was interviewed. He stated he expected the nursing staff to follow a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Texas Administrative Code TAC §554.1601(e)(2)(A)(ii), Tag 1754. This requirement is not met as evidenced by: For evidence of violation refer to CMS Form 2567 dated 06/09/2022, F883

Based on interviews, record review, and facility policy review, the facility failed to notify the attending physician of a significant change in condition for Resident #20. Specifically, the facility failed to ensure the physician was consulted regarding a severe weight loss for two (Resident #20 and Resident #8) of four residents who were reviewed for weight loss. Findings included: A review of the facility policy titled, Change in Resident's Condition or Status, revised May 2017, revealed: Our facility shall promptly notify the resident, his or her attending physician and representative sponsor of changes in the resident's medical/mental condition and or status. 1. A review of Resident #8's Admission Record revealed the facility admitted the resident on 01/21/2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a discharge Minimum Data Set (MDS) dated [DATE] revealed the resident's weight was 172 pounds and that there was no weight loss of greater than 5% in the past month, nor 10% or more in the last six months. Review of a quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident scored 15 on a Brief Interview for Mental Status (BIMS), which indicated the resident was cognitively intact. The resident required extensive assistance of one person with bed mobility and required only supervision and set-up assistance for eating. The MDS indicated the resident had a weight loss of 5% or more in the last month or 10% or more in the last six months and was not on a physician-prescribed weight loss regimen. As of the assessment date, the resident was five feet/six inches tall, and the resident's most recent weight was 145 pounds. A review of the Care Plan, dated as initiated on 04/08/2022, revealed the resident had unplanned/unexpected weight loss. Interventions included monitoring and recording food intake at each meal, weighing per facility policy/physician orders, and having the dietitian to follow as scheduled and as needed (PRN). A review of the Monthly Weight Report, dated from January 2022 through June 2022, revealed the following weights: - January 2022: 170 pounds - February 2022: 172.6 pounds. - March 2022: 171.8 pounds. - April 2022: 146.2 pounds. - May 2022: no weight documented - June 2022: 130.4 pounds. This represented a severe weight loss of 41.4 pounds, or 24.10% body weight in three months. A review of the Nutrition Progress Notes, dated from March 2022 through June 2022, revealed no progress notes related to nutritional needs, nor recommendations from the Registered Dietitian (RD). A review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . As of 06/08/2022, a review of the Order Summary Report indicated the resident had an order dated 03/14/2022 for a no-added-salt (NAS) regular texture diet. There were no orders for nutritional supplements, nor appetite stimulants. During an interview on 06/08/2022 at 10:25 AM, the restorative aide (RA) indicated she was responsible for obtaining weights for all newly admitted residents, in addition to getting residents' weekly and/or monthly weights. She indicated the nursing staff would inform her of the residents who were newly admitted and of the residents who needed weekly or monthly weights that were due. She stated the nurse told her the names of the residents who needed to be weighed, and she wrote the names down on a list. She indicated she recorded the weights and emailed all of the weights to the charge nurse and Assistant Director of Nursing (ADON), with the 3% and 5% weight changes highlighted. The RA stated the only reason a weight would be missed was if a resident refused, in which case, she would document the refusal in the electronic health record and send an email to the charge nurse. RA stated the ADON would then send all the weights to the RD. She indicated she had not seen the RD in the facility in a long time and could not remember the last time she saw her. The RA stated there was no way to run a report to determine if any weights were missed and, the only way she would know to check would be to look in each resident's electronic medical record. The RA stated Resident #8 refused to be weighed in May 2022 and that there should be an email where she notified the charge nurse about the refusal, as well as the resident's weight loss. The RA provided a copy of an email dated as sent on 05/03/2022 at 2:41 PM, which indicated that Resident #8 refused to be weighed. When the surveyor asked the RA if she reattempted the weight on another date/time in order to get a weight for May 2022, she stated she did reattempt, but did not document that anywhere. She reiterated that all refusals should be documented, and the charge nurse should also be made aware. The RA stated she did not know why there was no documentation, but she also provided the email sent on 04/01/2022 at 2:30 PM, which indicated that Resident #8 refused to be weighed on that date. The RA stated there was no documentation of an email notification related to the weight on 04/05/2022 of 146.2 pounds, which was a 14.90% decline. The RA stated she may have reported it verbally to the charge nurse on duty that day, who was Licensed Vocational Nurse (LVN) E. A review of emails sent between April 2022 and June 2022 by the RA revealed on 06/02/2022, the resident's weight was 130.4, which represented a loss of 15.8 pounds from the 04/05/2022 weight of 146.2 pounds. During an interview on 06/08/2022 at 12:37 PM, LVN E stated the RA was responsible for the weights, but when the RA was not there and there was a new admission, a different Certified Nursing Assistant (CNA) would get the weights. LVN E stated there was a notification on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN E stated the RA did the weights and sent an email to the charge nurse, ADON, and Director of Nursing (DON), and that email was the primary method of notification. She stated there may also be occasions when the RA would tell the nurse verbally. LVN E stated the DON would notify the dietary manager RD, and the physician would be informed. LVN E stated the physician notification should be documented in the electronic medical record but not she was not sure where. LVN E stated the RA did not make her aware of the 14.90% weight loss on 04/05/2022 and stated if she had been made aware, she would have notified the physician and the DON. LVN E also stated Resident #8 was not currently receiving any nutritional supplements. LVN E stated if a resident was losing weight by choice, that should be documented, and the physician should still be informed. During an interview on 06/08/2022 at 1:53 PM, the former Director of Nursing (DON) revealed her last day with the facility was about six weeks ago. The former DON stated all RD recommendations were given to her, and she would send the recommendations to the physician for approval, after which they were entered into the electronic health record. She indicated it was rare that any recommendations were not approved. She indicated physician orders would come in an email, and she would sign off on them. She had a list of orders that she kept. The former DON indicated the physician was aware of Resident #8's weight loss, but she was not sure why there was no documentation that showed the physician was notified. She stated there was ongoing monitoring. During an interview on 06/08/2022 at 2:37 PM, the ADON revealed the former DON received the RD recommendations, notified the physician, and input the orders into the electronic health record. The ADON stated she was not aware of or involved with weight-loss monitoring, nor of how the RD recommendations were followed and monitored. During an interview on 06/08/2022 at 4:03 PM, the alternate physician indicated Resident #8's primary physician was out of the country for two weeks and was not available. The alternate physician stated she was providing care to the primary physician's residents in his absence, but she was not familiar enough with the residents to answer any specific questions about their previous care and treatment. She stated she was able to briefly review the physician's notes for Resident #8, and there were no notes in the related to weight loss, but she was not comfortable saying whether the facility had or had not notified the primary physician regarding the weight loss. During an interview on 06/09/2022 at 10:58 AM, the Director of Nursing (DON) indicated weights should be measured within three days of admission, and any weight changes should be reported by a licensed nurse to the physician via phone or in person. She indicated that the expectation was that the communication be documented in the progress notes under physician notification within 24 hours. The DON stated she expected the ADON to review weights, compare the current weight to the previous weight, and for any significant weight loss, notify the DON and the physician in person or via telephone. She indicated the communication should be documented in the progress notes. The DON stated when weight loss was identified, the physician, RD, responsible party, and ADON/DON should have been notified, at a minimum. During an interview on 06/09/2022 at 12:08 PM, the Administrator indicated he expected the physician to be notified in a timely manner about changes in weight. 2. Review of an Admission Record revealed Resident #20 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 05, indicating severe cognitive impairment. The resident required supervision, encouragement, or cueing with setup help while eating, had a 10% or more weight loss in the last six months, and was not on a physician-prescribed weight loss regimen. A review of the Care Plan, dated as revised on 05/23/2022, revealed Resident #20 had a nutritional problem or potential nutritional problem related to poor teeth, high blood sugars, and a high body mass index (BMI). Interventions included: - Provide and serve snacks as ordered (revised 05/05/2021). - Dietitian to follow up related to weight loss (dated 05/23/2022). - Record/report to physician as needed (PRN) any signs or symptoms of malnutrition, such as emaciation, muscle wasting, significant weight loss of 3 pounds in one week, greater than 5% in one month, greater than 7.5% in three months, or greater than 10% in six months (revised 05/23/2022). - Offer supplements/snacks in between meals (dated 05/23/2022). A review of an Order Summary Report revealed a physician's order dated 11/30/2021 for Resident #20 to receive a low-concentrated-sweets diet with minced and moist/ground texture. There were no orders for nutritional supplements. A review of a Weight Summary in the electronic health record revealed Resident #20 had a 12.21% weight loss in a six-month period as follows: - 12/04/2021: 155.6 pounds. - 01/01/2022: 150.4 pounds. - 02/01/2022: 150.2 pounds. - 03/10/2022: 146.0 pounds. - 04/01/2022: 139.4 pounds. - 05/03/2022: 138.2 pounds. - 06/01/2022: 136.6 pounds. A review of a Nutrition Risk Assessment, completed by the Registered Dietitian (RD) and dated 02/07/2021, revealed the resident was at high risk for nutritional impairment. There were no recommendations at that time. There were no additional nutrition assessments or progress notes completed by the RD from 02/07/2021 to 06/09/2022. A review of Progress Notes, dated 03/29/2022 and created by Licensed Vocational Nurse (LVN) A, revealed that much prompting and encouragement was provided by staff to increase the resident's meal consumption, as weight loss had been reported by the restorative aide (RA). A review of Progress Notes, dated 05/11/2022 and created by the Social Worker (SW), revealed a questionnaire that indicated the resident had a poor appetite or overeating nearly every day. A review of Progress Notes, dated 05/12/2022 and created by the SW, revealed a psychosocial note which indicated the resident reported no issues when eating but had recently had a decline in appetite and that the dietitian had been informed. The note did not indicate the physician was informed. A review of an email, dated 05/12/2022 at 4:38 PM, revealed the SW sent an email to the RD, Administrator, ADON, and MDS Coordinator on that date. The email contained information that indicated the resident had a 10% weight loss within the last six months. The email did not indicate the physician was consulted regarding the weight loss. A review of a Multidisciplinary Care Conference, dated 05/26/2022, revealed the resident had an unplanned weight loss of 10% in the last six months and the dietary consult was pending. The consult was related to nutritional supplementation, as the resident had a decrease in appetite. The conference notes did not indicate the physician was consulted regarding the weight loss. A review of Progress Notes, dated 05/27/2022 and created by LVN A, revealed that staff set up the resident's food at the bedside, as the resident fed him/herself 100% only of what he/she preferred to eat. The note indicated the resident was on a weight loss alert and that much patient teaching and prompting were done by staff to modify food preferences, as the resident reportedly ate only pancakes and maple syrup every day at almost every meal. The notes did not indicate the physician was consulted regarding the nutritional issues and weight loss. A review of Progress Notes, dated 06/01/2022 and created by LVN A, revealed the resident's meals were set up at the bedside, as the resident fed him/herself. The note indicated the resident had experienced a recent weight loss, with dietary management consulted. The resident required much prompting and the note indicated patient teaching was done by staff to try other nutritious menu items. The note revealed the resident continued to eat only pancakes and maple syrup. The note did not indicate the physician was consulted regarding the resident's weight loss. As of 06/07/2022, there was no documentation in the Progress Notes to indicate the physician had been consulted regarding Resident #20's weight loss. During an interview on 06/07/2022 at 1:10 PM, LVN A indicated the resident's record had been flagged for weight loss because he/she had not maintained his/her weight. She stated that when a resident's record was flagged due to weight changes, this indicated that the RA had weighed the resident and gave the weights to the Director of Nursing (DON), who oversaw the weight system. During an interview on 06/08/2022 at 10:25 AM, the RA stated she was responsible for obtaining resident weights and did not have the resident listed as needing weekly weights. She stated the nurse notified her of who needed to be weighed each week. She stated she emailed the weights to the charge nurse and Assistant Director of Nursing (ADON), who then sent the weights to the registered dietitian (RD). She stated she notified LVN A of Resident #20's weight loss but did not tell anyone else. During an interview on 06/08/2022 at 10:45 AM, the Dining Supervisor stated that when Dining Management was consulted, the RD was also consulted. The Dining Supervisor further stated she just updated the resident's care plan with decreased meal intake and weight loss. She indicated the Food and Nutrition Services Director (FNSD) position was vacant and had been for a few months. During an interview on 06/08/2022 at 12:37 PM, LVN E stated the RA obtained the resident's weights and emailed them to the charge nurse, ADON, and DON. The physician notification of any significant weight changes should be documented, but LVN E was not sure where. LVN E stated if a resident was losing weight by choice, it should be documented, and the physician should be notified. During an interview on 06/08/2022 at 1:55 PM, the previous DON stated the RD received a list of weights on a weekly basis, via email. She stated the RD responded within 24-48 hours with any nutritional recommendations, then she, as the previous DON would send those recommendations to the physician for approval. She stated she left the DON position in April 2022 and did not remember Resident #20 having weight loss. During an interview on 06/08/2022 at 2:37 PM, the ADON stated she was not involved in the weight monitoring system other than forwarding the residents' weights to the SW. The RA included the ADON on the weekly weight email, and the ADON then forwarded it on to the SW. During an interview on 06/08/2022 at 3:10 PM, the RD stated she was in the building once a week and did nutritional assessments on new admissions and any nutrition consults received via email from the MDS Coordinator, DON, ADON, or SW. Per the RD, long-term residents did not have nutritional assessments done unless the RD received a consult. The FNSD was responsible for quarterly and annual nutrition assessments. The RD further stated she did not know how long the FNSD position had been vacant and did not know who completed the quarterly and annual nutrition assessments in the absence of an FNSD. The RD stated she was probably currently responsible for completing the assessments. When asked if there was a reason why no nutritional assessment had been done for Resident #20 since 02/07/2021, the RD stated she had no answer for that. The RD further stated she did not know why the facility did not notify her of Resident #20's significant weight loss. She stated if she had been aware, she would have implemented nutritional interventions. During an interview on 06/08/2022 at 4:04 PM, the alternate physician stated that although she was providing care to the resident in the absence of the resident's primary physician, she was not familiar with the resident and did not know if the primary physician had been notified of a significant weight change. The resident's attending physician was out of the country and unavailable for interview. During an interview on 06/09/2022 at 10:05 AM, the MDS Coordinator stated she notified the RD, via email on 05/12/2022 of Resident #20's weight loss, and the RD did not respond to the email. During an interview on 06/09/2022 at 11:00 AM, the DON stated this was her first week as the DON. She indicated the RA was to weigh the residents and she would forward them to the DON and ADON for review, who would then notify the physician of a resident's significant weight change and document the notification in the progress notes. She indicated the RD would then complete a nutritional assessment and make recommendations. She stated that it was important to implement nutritional supplements in a timely manner, because the facility wanted to prevent further weight loss and ensure a resident's nutritional needs were met. During an interview on 06/09/2022 at 12:08 PM, the Administrator stated the facility had recently some turnover in the DON position and that the FNSD position was vacant. He stated that the nursing staff were to request nutritional consults from the RD, who assessed residents and made nutritional recommendations. He indicated that he expected the RD to follow up on the recommendations and that it was important to do so in case something was missed. The Administrator further stated he expected the physician to be notified of any significant weight changes. A review of the Nutrition and Unplanned Weight Loss Clinical Protocol, dated 2001 and revised September 2017, revealed, The staff and physician will identify individuals with anorexia, weight loss or gain, and significant risk for impaired Nutrition. The staff will report to the physician significant weight gains or losses or any abrupt or persistent change from baseline appetite or food intake. Texas Administrative Code (TAC) §554.403(l)(1)(A), Tag 1130. This requirement is not met as evidenced by: For evidence of violation refer to CMS Form 2567 dated 06/09/2022, F580.

Based on record review, observation, interviews, document review, and facility policy review, it was determined the facility failed to identify and initiate appropriate nutrition interventions after identifying significant weight loss occurred to prevent further weight loss. This affected two (Resident #8 and Resident #20) out of four residents reviewed for nutritional needs and resulted in significant unfettered and unplanned weight loss. Findings included: A review of the facility's Weight Assessment and Intervention Policy, dated 2001 and revised September 2008, revealed The Dietitian will review the unit weight record by the 15th of the month to follow individual weight trends over time. Negative trends will be evaluated by the treatment team whether or not the criteria for significant weight change has been met. The threshold for significant unplanned and undesired weight loss will be based on . c. 6 months - 10% weight loss is significant, greater than 10% is severe. A review of the Nutrition and Unplanned Weight Loss Clinical Protocol, dated 2001 and revised September 2017, revealed, The staff and physician will identify individuals with anorexia, weight loss or gain, and significant risk for impaired Nutrition . The staff will report to the physician significant weight gains or losses or any abrupt or persistent change from baseline appetite or food intake. A review of the Dietitian Policy, dated 2001 and revised in October 2017, revealed, Our facility's dietitian is responsible for assessing nutritional needs of residents, developing and evaluating regular and therapeutic diets, developing and implementing person centered education programs involving food and nutrition services for all facility staff . and participating in quality assurance and improvement (QAPI) when food and nutrition services are involved. 1. A review of the Face Sheet revealed the facility admitted Resident #8 on 01/21/2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #8 was discharged to a hospital on 02/14/2022, a fixator (a device used to keep fractured bones stabilized and in alignment) was removed on 02/18/2022, the resident was admitted from the hospital on 03/03/2022, discharged to a hospital on 03/15/2022, and admitted from the hospital on 03/24/2022. A review of a significant change Minimum Data Set (MDS) dated [DATE], indicated that Resident #8 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated no cognitive impairment. Per the MDS, Resident #8 required extensive assistance with bed mobility and toileting and setup assistance for independent eating. The MDS noted transferring did not occur during the assessment period. Further review indicated the resident had lost 5% or more weight in the last month or 10% or more in the last six months. The resident was not on a physician prescribed weight loss regime and the current weight was 145 pounds (lbs). The resident was 66 inches tall. A review of a care plan, initiated on 04/08/2022, revealed the resident had an unplanned/unexpected weight loss. Per the plan, the dietitian would follow the resident as scheduled and PRN (pro re nata; as needed). Staff were to monitor and record food intake at each meal. The resident was to be weighed per facility policy and physician orders. A review of the monthly weight report from January 2022 through June 2022 revealed: - January weight 170 lbs. - February 172.6 lbs. - March 171.8 lbs. - April 146.2 lbs. - May (no recorded weights provided) - June 130.4 lbs. - This indicated a significant weight loss of 14.9% in one month and 24.1% in three months. During an interview on 06/07/2022 at 10:46 AM, the Registered Dietician (RD) revealed she had only completed three nutritional assessments for Resident #8. She noted she had not documented any progress notes in relation to the resident's nutritional status. A review of a Nutritional Assessment completed on 01/24/2022 for Resident #8 revealed a score of 24 indicating a medium nutritional risk with a recommendation for Med Pass (a dietary supplement high in calories and protein) 60 milliliters (mL) twice daily. A review of a Nutritional Assessment completed on 03/27/2022 revealed a score of 26 for Resident #8 indicating a high risk of unplanned weight loss. Further review revealed a recommendation for Med Pass 60 mL twice daily. A review of Current Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no current order for Med Pass. Further review revealed physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of nutrition Progress Notes revealed no progress notes related to nutritional needs or RD recommendations. A review of physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview on 06/08/2022 at 4:03 PM with a Physician revealed Resident #8's primary physician was out of the country for two weeks and was not available. The Physician stated she was seeing the primary physician's residents, but she was not familiar enough with them to answer any specific questions about care and treatment. However, the Physician stated she was able to briefly review the notes for Resident #8 and stated there were not any notes in the resident's chart related to weight loss anywhere. She noted she was not comfortable saying if the facility ever notified the physician of weight loss for Resident #8. An observation on 06/07/2022 at 12:34 PM of lunch tray pass revealed Resident #8 received a regular texture diet with thin liquids and NAS. An interview on 06/08/2022 at 10:25 AM with a Restorative Aide (RA) revealed she was responsible for obtaining weights for all newly-admitted residents and getting residents' weekly and monthly weights. The RA stated that nursing staff let her know which residents were new admissions, and which resident needed weekly or monthly weights that day. The RA stated the nurse told her the names of the residents and she wrote them down on a list. The RA stated that any weights that showed a 3% weekly loss, or a 5% monthly loss, automatically required a reweigh and that she emailed those weights to the charge nurse and Assistant Director of Nursing (ADON). She highlighted the weights that represented a 3% or 5% loss in weight. The RA stated the only reason a weight would be missed was if a resident refused. The RA stated weights were documented in Point Click Care (PCC) and in an email to the charge nurse. The RA stated the ADON sent all weights to the RD. She stated she had not seen the RD in the facility in a long time and could not remember the last time she saw the RD. The RA stated there was no way to run a report to check if any resident weights were missed, noting the only way she would know would be to check in each resident's electronic medical record (EMR). The RA said Resident #8 refused to allow weights to be taken in May of 2022 and she should have an email showing that she notified the nurse about the refusal and the weight decline. RA provided a copy of an email sent on 05/03/2022 at 2:41 PM that Resident #8 refused to be weighed. When asked if she attempted on another date/time to get a May 2022 weight she replied in the affirmative, but stated she did not document that anywhere. She reiterated that all refusals should be documented, and the charge nurse should also be made aware. The RA stated she did not know why there was no documentation. The RA also provided an email sent on 04/01/2022 at 2:30 PM when Resident #8 refused for a weight to be taken. When asked about the email notification for the weight that was logged on 04/05/2022 of 146.2 that represented a 14.90% decline she stated there was no documentation that she notified anyone of the weight loss but stated she would have reported it verbally to the charge nurse on duty that day, who was Licensed Vocational Nurse (LVN) E. The RA stated she did not reweigh Resident #8 after the 04/05/2022 weight or the 06/02/2022 weight that showed significant weight loss. A review of emails sent by the RA revealed Resident #8 refused to be weighed on 04/01/2022 and 05/03/2022, weighed 146.2 lbs on 04/05/2022, and weighed 130.4 lbs on 06/02/2022. An interview on 06/08/2022 at 12:37 PM with LVN E revealed she was a charge nurse. She stated that the RA got weights, but when the RA was not there and there was a new admission, then a Certified Nursing Assistant (CNA) got the weights. LVN E stated there was a notification on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN E stated the RA obtained the weights and sent an email to the charge nurse, ADON, and the Director of Nursing (DON). The email was the primary method of notification per LVN E. LVN E stated the DON would then notify the Dietary Manager, RD, and the physician to make them aware. LVN E stated the physician notification should be documented in the EMR, but she was not sure specifically where in the EMR. LVN E stated Resident #8 controlled their meals and decided what and when they ate, but she stated any weight loss should be tracked and monitored. LVN E stated when Resident #8 was first admitted to the facility in January of 2022, the resident had a lot of [CONDITION(S)] (swelling). According to LVN E, the resident had a fixator on one leg which may have accounted for additional weight, but she wasn't sure if these were considered when Resident #8 was being weighed. LVN E stated the RA did not notify her of the 14.90% weight loss on 04/05/2022 for Resident #8. She stated that, if she had been made aware, she would have notified the physician and the DON. LVN E also stated that Resident #8 did not currently have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN E stated if a resident was losing weight by choice, then that should be documented and the physician made aware. An interview on 06/08/2022 at 1:53 PM with the former DON revealed her last day with the facility was about six weeks prior. The former DON stated the RA was responsible for getting all resident weights and that the RA had a list (Excel worksheet) of daily, weekly, and monthly weights the RA logged and provided to her, which the DON entered into the system. The former DON stated QAPI members approved a process for the RA to enter weights into PCC, noting a spreadsheet was still turned into her. The former DON stated any changes in a resident's weight would require a reweigh for 2-3 days in a row to check for accuracy and, if an error occurred, the weight would be struck out and, if the weight was correct, then staff started working on care planning the resident for weight loss and alerting the RD by email. The former DON also stated the RD received all weekly weights, completed chart reviews, and made recommendations within 24-48 hours. However, if it was more urgent, the DON would call the RD to get a faster recommendation. The former DON stated the RD would also provide the DON and facility with a weekly report for residents with diet recommendations, but the report was not provided during the survey. The former DON stated the facility had a Weekly at Risk (WAR) meeting and weights were reviewed during that time. The former DON stated significant triggers for weight loss were 5% in one month, 7.5% in three months, or 10% in six months, and that she ran an exception report every week for all residents to look at trending, but these were not provided during the survey. The former DON stated all RD recommendations were provided to her, which she sent to the physical for approval, after which orders were entered into PCC. The former DON noted it was rare for a recommendation to not receive approval. The former DON stated orders came in an email on which she signed off. The former DON stated RD recommendations were reviewed during the WAR meeting, but staff didn't go into PCC to actually check if an order was in place. Per the interview, it was the DON's responsibility to make sure the order was in place. The former DON stated she remembered that Resident #8 had weight loss and refused care and food a lot. The former DON also stated Resident #8 had a fixator on one of the resident's legs that was not being subtracted from the weight since the facility didn't know what the weight of the fixator was. However, there was no weight loss until a month and a half after the removal of the fixator. The former DON confirmed Resident #8 was supposed to take Med Pass, but the order for Med Pass was never put in place. The former DON stated she thought there was an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . However, the former DON stated she would expect additional monitoring and the identification of alternatives if the resident was refusing supplements and foods. The former DON stated staff were talking to Resident #8 about food preferences, trying alternatives, and providing choices. Per the former DON, the Dietary Assistant (the position of Food and Nutrition Services Director/FNSD was vacant) spoke with Resident #8 on several occasions about food preferences. She indicated that the physician was aware, but she was not sure why there was no documentation to reflect physician notification, the resident's refusals of Med Pass, or food options offered, asserting there was ongoing monitoring of the resident. An interview on 06/08/2022 at 2:37 PM with the ADON revealed the former DON was responsible for putting weights into PCC after the RA obtained resident weights. The ADON stated after the former DON left in April of 2022, the RA emailed resident weights to the ADON and the ADON reviewed them. The ADON then forwarded the weights to the Social Worker (SW). The ADON stated the current process in place was for the RA to obtain the weights, enter them into PCC, and email them to the ADON. The ADON stated the former DON would receive RD recommendations, notify the physician, and input any associated orders into PCC. The ADON stated she was not aware of or involved with weight loss monitoring or how the RD's recommendations were followed up on. An interview on 06/08/2022 at 3:10 PM with the RD revealed she was at the facility once weekly, but she did not have a set number of hours in her contract with the facility. The RD stated her standard process was for all new admissions to have a nutritional screening completed. Any residents in the facility that had a concern were also emailed to her. The RD stated she knew about new admissions by reviewing a 24-hour report and UDA report. When asked what the UDA report was, the RD stated she was not sure, but she knew it was a list that had the residents' names. The RD stated she completed an initial nutritional assessment and only wrote a progress note if there was additional information she needed to add to the assessment, given that there was a maximum number of characters allowed in the assessment. The RD stated the former Dietary Manager completed quarterly and annual assessments thereafter. The RD stated she was not sure who was taking care of the quarterly and annual assessments currently. The RD stated she only saw residents if the facility requested a consultation. She noted she was not sure how many residents she saw on a monthly basis. The RD stated the MDS Coordinator, DON, ADON, or SW notified her if a consultation was required for a resident. The RD stated she did not receive a consultation request for Resident #8. The RD stated when she was in the facility, she observed meals to see what and how much residents were eating. The RD stated when a consultation was requested by the facility, she reviewed the associated resident's diagnoses, medications that could be contributing to weight loss, weight history, laboratory testing results, intakes (percentage of meals consumed) if the resident required staff assistance to eat, and progress notes. If consulted, she talked to the resident, when able, about weight loss and interventions. The RD stated she did not look at or monitor weights of residents without a consultation from the facility. She also noted she was not a part of the weekly weight meetings. The RD stated she relied on nursing staff to notify her of any significant weight loss and that she expected to be notified about changes in residents' weights. The RD stated she did not have a system that monitored residents who had triggered for significant weight loss but, instead, waited on staff to request for her to reevaluate a resident with weight loss. She noted she did not follow up with a resident after she had completed a consultation and she had no system to monitor a resident on her own. The RD stated the former Dietary Manager completed all the follow up. Once the RD had completed the initial assessment, she did not look at the resident again unless staff requested her to do so. The RD stated all of her recommendations were recorded on a Word document that she emailed to the ADON, DON, and Dietary Manager. The Word document in question was not provided during the survey. The RD stated if the physician did not approve a recommendation, the DON let her know, prompting her to possibly attempt another intervention. The RD stated she remembered that Resident #8 was readmitted , but was not aware whether the Med Pass was ever implemented in January or March of 2022. The RD reiterated that she did not monitor weight loss or recommendations and relied completely on staff to notify her of changes. The RD stated she did not complete a review of any resident after a significant weight loss had been identified and she expected staff to tell her about a resident's progress or decline or any other changes. An interview on 06/09/2022 at 10:05 AM with the MDS Coordinator revealed that, during morning meetings, staff discussed any changes noted on the 24-hour report. The MDS Coordinator stated she had a schedule for care planning that she created in relation to quarterly assessments or if there was a significant change assessment completed. The MDS Coordinator noted she attended the WAR meetings and weights were discussed. The MDS Coordinator stated the RA provided the DON a list of weights monthly and the DON made the MDS Coordinator aware of newly identified weight concerns. The MDS coordinator was unable to state how she received the information that Resident #8 had weight loss that was captured on the 03/29/2022 MDS due to there not being any documentation related to the weight loss. The MDS Coordinator stated the care plan change was made close to the beginning of the month and it may have been discussed during the morning meeting or WAR meeting. The MDS Coordinator stated all the department heads participated in the meetings except for the RD. The MDS Coordinator stated when a significant weight loss was identified in the meeting, she updated the care plan, but she stated she was not responsible for notifying the RD and she was not sure who was. The MDS Coordinator stated during the time when the facility had no DON or Dietary Manager, she would reach out to the RD on occasion, but she did not speak to the RD about Resident #8. The MDS Coordinator stated it would be the nursing department's responsibility to do that. The surveyor called LVN A on 06/09/2022 at 10:57 AM. A message was left asking LVN A to return the call regarding the weight report email, but there was not a return call received during the survey. An interview on 06/09/2022 at 10:58 AM with the current DON revealed she had currently been in the DON position for five days. The DON stated her expectation going forward with weight monitoring was to ensure the staff responsible for weights had received proper training. The DON further stated weights should be collected within three days of admission and any weight changes should be reported to the physician by a licensed nurse via phone or in person. She noted she expected communication to be documented in progress notes under physician notification within 24 hours. The DON stated the current process was for the RA to get all the weights. The DON stated all newly-admitted residents should be weighed upon admission and every week for the first four weeks and monthly thereafter unless one of the physicians had other weight requirements. The DON stated once weights were obtained, the ADON and DON should be made aware of any weight changes or changes in condition. The DON stated she expected the ADON to review weights and compare them to previous weights, noting the DON should be notified either telephone or in person along with the physician when there was any significant weight loss, which should be documented in progress notes. The DON stated the ADON was responsible for notifying the RD by email, phone, or in person, and, once an email was sent to the RD, she expected a response from the RD to confirm receipt. Per the DON, any recommendations from the RD should be sent back to the facility within 24 hours at the latest. The DON stated any resident identified with weight loss should be placed on weekly weights, meal intake should be monitored, referrals should be made to therapy to rule out other issues, and staff should continue to follow the resident for a minimum of 60 days to monitor and ensure orders/recommendations were in place. The DON stated it was important to monitor to ensure there was no additional weight loss, the resident received good nutrition, and there was no additional negative outcomes related to weight loss. In addition, after the RD made recommendations, she expected the ADON, along with herself, to review the resident's EMR to ensure orders were in place, a dietary communication form was competed, and the diet was amended. She noted she expected the RD to conduct assessments upon admission, assess significant changes, complete routine assessments, review weights, and provide guidance about recommendations to residents and/or their representatives. The DON also stated she expected the information from WAR meetings to be shared with the RD. For the resident's RD reviews, she expected the RD to monitor those residents weekly on her own, either in person or remotely, including meal intake, weights, and orders that may affect nutritional status. The DON also stated when weight loss was identified, the physician, RD, responsible party (RP), ADON or DON, and licensed nurse should be notified, at a minimum. An interview on 06/09/2022 at 12:08 PM with the Administrator revealed the facility should monitor resident weights and follow certain protocols for weight oversight. The Administrator stated that, over the last six months, the facility had had some issues with weight monitoring and there was a Performance Improvement Plan (PIP) in place. The PIP was requested but never provided during the survey. The Administrator noted the former DON was also placed on the PIP due to missing items and not following up on identified concerns. The Administrator stated after the PIP was put in place, the former DON put in her work notice two weeks later. The Administrator stated they had an outside company conduct an audit to help identify areas of concern. The Administrator noted the facility had tried to monitor weights weekly in WAR meetings, but due to the staff changes, they stopped the PIP related to weight monitoring, which was expected to resume once they had retained certain staff. The Administrator stated he expected the RD to follow up with consultations and to ensure RD recommendations were acted upon. The Administrator stated he also expected the physician to be notified timely about any changes in weight. A review of facility in-services and education revealed there was no training provided related to the process to identify weight loss or the process required to monitor and implement weight loss interventions. 2. A review of a Face Sheet revealed the facility admitted Resident #20 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #20's quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 5 out of 15, indicating severe cognitive impairment. Per the MDS, Resident #20 required supervision, encouragement, or cueing with setup help while eating. The MDS noted Resident #20 experienced a 10 percent or more weight loss in the last six months and was not on a physician-prescribed weight loss regimen. A review of Resident #20's care plan revealed a focus of the resident has nutritional problem or potential nutritional problem related to poor teeth, high blood sugars and high body mass index (BMI), low concentrated sweets diet, soft and bite size, prefers to drink bottled water, and unplanned weight loss, initiated on 02/02/2021 and revised on 05/23/2022. Interventions listed included for the dietitian to follow up related to weight loss and to report to the physician PRN (pro re nata; as needed) any signs or symptoms of malnutrition such as emaciation (cachexia), muscle wasting, significant weight loss of 3 pounds in one week, greater than 5% in one month, greater than 7.5% in three months, and greater than 10% in six months. A review of Resident #20's June 2022 physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no orders for a nutrition supplement. A review of Resident #20's medical record on 06/08/2022 revealed a 12.21% weight loss in six months. 12/04/2021 155.6 pounds 01/01/2022 150.4 pounds 02/01/2022 150.2 pounds 03/10/2022 146.0 pounds 04/01/2022 139.4 pounds 05/03/2022 138.2 pounds 06/01/2022 136.6 pounds A review of Resident #20's Nutrition Risk Assessment, completed by the Registered Dietitian (RD) and dated 02/07/2021, revealed Resident #20 was a high nutritional risk and there were no recommendations at that time. There were no further nutrition assessments or progress notes completed by the RD from 02/07/2021 to 06/09/2022. A review of Resident #20's progress notes, dated 06/01/2022 and created by Licensed Vocational Nurse (LVN) A, revealed, Meals set up at bedside as resident feeds self. Has recent weight loss with dietary management consulted. Much prompting and patient teaching done by staff to try other nutritious menu items. Resident continues to only eat pancakes and maple syrup. LVN A did not document they notified Resident #20's physician of the weight loss. A review of Resident #20's progress notes, dated 05/27/2022 and created by LVN A, revealed, Staff sets up food at bedside as feeds self-100% only of what they prefer to eat. Resident on weight loss alert. Much patient teaching and prompting done by staff to modify food preference as resident reported to eat only pancakes and maple syrup every day almost every meal. LVN A did not document they notified Resident #20's physician of the weight loss. A review of Resident #20's progress notes, dated 05/12/2022 and created by the Social Worker (SW), revealed a psychosocial note where Resident #20 reports no issues when eating but has recently had a decline in appetite. Dietitian has been informed. The SW did not document they notified Resident #20's physician of the decline in appetite. A review of Resident #20's progress notes, dated 05/11/2022 and created by the SW, revealed a Patient Health Questionnaire (PHQ)-9 assessment with poor appetite or overeating. Presence: yes. Frequency: 12-14 days (nearly every day). A review of Resident #20's progress notes, dated 03/29/2022 and created by LVN A, revealed, Much prompting and encouragement done by staff to increase meal consumption as weight loss reported by Restorative Aide (RA). During an interview on 06/07/2022 at 1:10 PM, LVN A stated Resident #20 was a weight alert because they were not maintaining their weight. When asked what a weight alert meant, LVN A stated that meant the RA weighed the resident weekly and gave the weights to the Director of Nursing (DON), who oversaw the weight system. LVN A further stated that when dietary management was consulted on 06/01/2022, the Dining Supervisor met with Resident #20 to go through the menu options. During an interview on 06/08/2022 at 10:25 AM, the RA stated they were responsible for getting resident weights and did not have weekly weights for Resident #20. The nurse notified the RA who needed to be weighed each week and the RA emailed the weights to the charge nurse and Assistant Director of Nursing (ADON), who then sent the weights to the RD. The RA notified LVN A of Resident #20's weight loss but did not tell anyone else. During an interview on 06/08/2022 at 10:45 AM, the Dining Supervisor stated that when dining management was consulted for a resident, that meant the RD was consulted with Resident #20. The Dining Supervisor further stated they just updated Resident #20's care plan with decreased meal intake and weight loss since their previous care plan. The Dining Supervisor then stated the Food and Nutrition Services Director (FNSD) position was vacant and had been for a few months. During an interview on 06/08/2022 at 11:08 AM, the SW stated they recently had a care plan meeting for Resident #20 with the family member and discussed Resident #20's weight loss. The SW further stated Resident #20 had a bit of a cognitive decline and had sent an email to the RD to notify them of the weight loss. The SW further stated the RD was responsible for following up on weight losses and any nutrition interventions. A review of an email, dated 05/12/2022 at 4:38 PM, revealed the SW sent an email to the RD, Administrator, ADON, and MDS Coordinator which revealed Resident #20 had a 10% weight loss within the last six months. A review of Resident #20's multidisciplinary care conference dated 05/26/2022 revealed Resident #20 had an unplanned weight loss of 10% in the last six months, pending dietary [consultation]. There was a consultation with a dietitian related to supplements. Per the care conference notes, Resident #20's appetite had decreased and the dietitian had been informed. During an interview on 06/08/2022 at 12:37 PM, LVN E stated the RA got resident weights and emailed them to the charge nurse, ADON, and DON. The DON then notified the Dining Supervisor but not the RD. The physician notification of any significant weight changes should be documented, but LVN E was not sure where. LVN E further stated they did not know the process of how an RD nutrition recommendation was communicated to staff and the physician. LVN E stated if a resident was losing weight by choice, it should be documented and the physician should be notified. During an interview on 06/08/2022 at 1:55 PM, the previous DON stated the RD received a list of weights weekly via email and emailed the RD as soon as they identified a significant weight change. The previous DON further stated the RD responded within 24-48 hours with any nutrition recommendations, then the previous DON sent those recommendations to the physician for approval. The previous DON further stated they left that position in April 2022 and did not remember Resident #20 having weight loss. The previous DON then stated they expected the RD to do quarterly assessments and to document more often if there were significant weight changes. During an interview on 06/08/2022 at 2:37 PM, the ADON stated they were not involved in the weight monitoring system. The RA included the ADON on the weekly weight email who then forwarded it on to the SW. During an interview on 06/08/2022 at 3:10 PM, the RD stated they were in the building once a week and did nutrition assessments on new admissions and any n