Every finding on record at Tuttle Care Center

Based on observation, record review, and interview, the facility failed to: a. disinfect a glucometer after each use for 2 (#20 and #37) of 2 sampled residents reviewed for glucose monitoring;b. perform hand hygiene between performing FSBS for 2 (#20 and #37) of 2 sampled residents reviewed for glucose monitoring;c. sanitize a blood pressure cuff used between residents for 1 (#12) of 1 sampled resident who received blood pressure monitoring; andd. ensure a barrier was placed on a wired linen cart to prevent cross contamination during linen transport. The administrator identified 42 residents resided in the facility. Findings: 1. On 07/22/26 at 3:54 p.m., LPN #2 was observed to don a pair of gloves to perform a FSBS with a single use lancet on Resident #37. After performing the FSBS, LPN #2 was observed to doff their gloves with no hand hygiene. LPN #2 was observed to place the glucometer back in the drawer of the medication cart in a plastic container without cleaning or sanitizing. The glucometer was not placed on a barrier inside the room of the resident or on the treatment cart. The top of the treatment cart was not observed to be sanitized. On 07/22/26 at 3:58 p.m., LPN #2 was observed to don a pair of gloves and utilize a single use lancet for a FSBS on Resident #20. The strip did not work, and LPN #2 dropped the lancet in the trash can. LPN #2 returned to the cart in the hall and was observed to don a new pair of gloves. LPN #2 was observed to wipe the finger of Resident #20 with an alcohol pad, push up their glasses, take their glasses off and placed them on the resident's bed, touched their face, and then perform the FSBS. LPN #2 was observed to doff their gloves and place the glucometer back in the top treatment cart drawer without sanitizing. LPN #2 was not observed to wash or sanitize their hands in between residents. The top of the treatment cart was not observed to be sanitized. A policy titled Blood Glucose Monitoring, revised 12/04/24, read in part, the nurse will abide by the infection control practices of cleaning and disinfection of the glucometer as per the manufacturer's instructions and in accordance with the facility policy.Procedure; perform hand, hygiene and don gloves. Remove and discard gloves and perform hand hygiene.clean and disinfect the glucometer as per manufacturer's instructions.Perform hand hygiene. On 07/22/26 at 4:15 p.m., LPN #2 stated they typically did not wipe down the glucometer until all the residents' FSBS were done because each resident had their own glucometer. LPN #2 showed the orange top sanitizing wipes with a wet time of four minutes for proper sanitization. LPN #2 stated they honestly did not know how long to let them stay wet. On 07/24/24 at 11:52 p.m., the IP stated the basket in the treatment cart for glucometers had not been cleaned. The IP stated the LPN should have washed their hands in between tasks. The IP stated they would do some education with the staff and glucometers needed to be sanitized between residents. 2. On 07/22/26 at 10:13 a.m., CMA #2 was observed to remove a reusable blood pressure cuff from the medication cart to assist CMA #3 with the medication pass. CNA #2 returned the blood pressure cuff to the top of the medication cart without sanitization. On 07/22/26 at 10:43 a.m., CMA #3 was observed to remove the reusable blood pressure cuff from the cart to take Resident #12's blood pressure. After obtaining the blood pressure, the cuff was placed back on the top of the medication cart without sanitization. On 07/24/26 at 3:54 p.m., CMA #2 was observed to remove the reusable blood pressure cuff from the medication cart to take Resident #12's blood pressure. After obtaining the blood pressure, the cuff was placed back on the top of the medication cart without sanitization. A policy titled Infection Prevention, and Control Program, revised 02/05/25, read in part, hand, hygiene shall be performed in accordance with our facilities, established and hygiene procedures.licensed staff shall adhere to safe injection and medication administration practices, as described in relevant facility policies.Environmental cleaning, and disinfection shall be performed according to facility policy. 3. On 07/20/26 at 2:35 p.m., a linen cart was observed to be pushed down the South hall with clean clothes. There was no barrier observed under the clean linens to prevent cross contamination. On 07/23/26 at 3:40 p.m., a tour of the laundry facility showed a wired rolling rack was used to transport linens to residents' rooms. The wired rolling rack was not observed to have a barrier on the bottom of the rack to prevent cross contamination. A policy titled Infection Prevention and Control Program, dated 02/05/25, read in part, 11. Linens: c. Clean linen shall be delivered to resident care units on covered linen carts with covers down. On 07/23/26 at 3:44 p.m., Laundry Staff #1 stated there should be a bottom cover on the rolling rack to prevent debris and contamination from direct contact with clean linen.

Based on observation and interview, the facility failed to ensure: a. the shower room on the South hall was maintained clean and in good repair, and shower curtains were free from debris and an unknown black substance for 1 (South hall) of 2 shower rooms observed,b. the exhaust fan was free from lint/debris in 1 (South hall) of 2 shower rooms observed, c. shower wall tiles were not missing with exposed sheetrock for 1 (South hall) of 2 shower rooms observed, andd. a mechanical lift was free from dirt and debris for 1 of 2 lifts observed on the South hall. The administrator identified 21 residents resided on the South hall. Findings: On 07/20/26 at 1:55 p.m., a mechanical lift on the South hall was observed to have a buildup of dirt and debris. On 07/20/26 at 6:30 p.m., the shower room on the South hall was observed. The curtain, walls, and floor were observed to have a black unknown black substance on them. The South wall was observed to have a missing tile and the sheetrock was exposed. On 07/23/26 at 6:34 p.m., the shower room on the South hall was observed to have dirt and debris on the exhaust fan. On 07/24/26 at 4:30 p.m., the IP was shown the areas of concern in the South shower room. The IP stated the black substance looked like it could be mold, but without testing, could not be sure. The IP stated they would notify maintenance and housekeeping to repair the tile and clean the exhaust fan. The IP stated they did not know if there was routine cleaning on the shower curtain. The IP stated they would put the lifts on a routine cleaning schedule.

Based on record review and interview, the facility failed to ensure a physician's response to a gradual dose reduction was implemented for 1 (#18) of 5 sampled residents reviewed for unnecessary medication. The administrator identified 44 residents resided in the facility. Findings: A physician's order, dated 01/20/23, showed sertraline hydrochloric acid (Zoloft) (an antidepressant) 100 mg, give one tablet by mouth one time a day for depression. A Consultant Pharmacist/Physician Communication form, dated 08/26/24, showed a pharmacist gradual dose reduction recommendation for sertraline (Zoloft) 100 mg daily. The communication form showed a physician's response dated 09/09/24, to reduce Zoloft to 75 mg by mouth daily. There was no documentation Zoloft was reduced to 75 mg daily. On 05/30/25 at 11:45 a.m., the DON stated if a physician decreased a medication dose on a gradual dose reduction recommendation, they would write the order and scan to the resident's chart. On 05/30/25 at 11:46 a.m., the DON stated they would implement the changes the same day or the next day. On 05/30/25 at 11:48 a.m., the DON stated the physician's response to decrease the Zoloft on 09/09/24 was not implemented. They stated Resident #18 continued to receive Zoloft 100 mg daily.

Based on record review and interview, the facility failed to ensure a care plan was developed to address anxiety and post traumatic stress disorder for 1 (#44) of 1 sampled resident's care plan reviewed for serious mental health diagnosis. The administrator identified 44 residents resided in the facility. Findings: Resident #44's admission MDS assessment, with an ARD of 03/19/25, showed they had psychatric disorders of anxiety and post traumatic stress disorder. Resident #44's care plan, initiated on 03/27/25, did not address the diagnoses of anxiety and post traumatic stress disorder. Resident #44's admission Record, dated 04/29/25, showed they were admitted on [DATE] with diagnoses of anxiety and post traumatic stress disorder. On 05/29/25 at 10:20 a.m., MDS coordinator #1 stated the care plan addressed depression, but did not address anxiety and post traumatic stress disorder. MDS Coordinator #1 stated the care plan should be developed to address the diagnosis so staff were aware of their current condition.

Based on record review and interview, the facility failed to ensure a resident's discharge assessment was encoded and transmitted for 1 (#11) of 12 sampled residents whose assessments were reviewed. The administrator identified 44 residents resided in the facility. Findings: A Physician Discharge Summary, dated 12/30/24, showed Resident #11 had diagnoses which included dementia and bipolar disorder. A nursing note, dated 12/30/24 at 11:49 a.m., read in part, resident out of facility at 11:30 via stretcher, discharge paperwork given to transport and poa [power of attorney]. A Physician Discharge Summary, dated 12/30/24 at 1:43 p.m., showed the resident was discharged on 12/30/24 to another facility. There was no documentation a discharge resident assessment was completed. On 05/28/25 at 11:13 a.m., MDS coordinator #1 stated they did their discharge assessments on the day the resident discharged . On 05/28/25 at 11:15 a.m., MDS coordinator #1 stated Resident #11 discharged to another facility on 12/30/24. On 05/28/25 at 11:17 a.m., MDS coordinator #1 stated they did not complete a discharge resident assessment. They stated it should have been completed.

Based on record review and interview, the facility failed to administer a pneumococcal vaccine as ordered for 1 (#43) of 5 sampled residents reviewed for immunizations. The administrator identified 44 residents resided in the facility. Findings: An undated facility policy titled Pneumococcal Vaccine, read in part, All residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. An admission record, with an initial admit date of 01/10/25, showed Resident #43 had diagnoses which included asthma and protein calorie malnutrition. A Pneumococcal Vaccine Consent Form, dated 02/18/25, showed the resident's representative gave consent for the pneumococcal vaccine. Resident #43's quarterly resident assessment, dated 04/17/25, showed the resident had severe cognitive impairment with a brief interview for mental status score of 5. A physician's order, dated 04/24/25, showed pneumovax 23 (pneumococcal vaccine) injectable 25 microgram/0.5 ml, inject 0.5 ml intramuscularly one time only for prevention for one day. An order administration note, dated 04/24/25 at 9:59 p.m., showed awaiting medication. A nursing medication administration record, dated 04/24/25 at 9:59 p.m., showed HD for the pneumovax 23 vaccine. There was no documentation the vaccine was administered. On 05/29/25 at 1:45 p.m., LPN #1 stated if a treatment was not available in the facility, they would put it on hold, notify the provider, call the pharmacy and document in the notes. On 05/29/25 at 1:51 p.m., LPN #1 stated the HD on the administration record probably meant hold. They stated the vaccine was not administered. On 05/30/25 at 9:14 a.m., the DON stated the resident had not received a pneumococcal vaccine.

Based on observation, record review, and interview, the facility failed to ensure residents were allowed to exercise their right to smoke regardless of diagnoses for two (#1 and #2) of three sampled residents reviewed for resident rights. The DON identified 43 residents resided in the facility. Eight residents smoked. Findings: A facility COVID-19 policy, revised 05/01/24, did not document residents with COVID-19 would be prohibited from smoking. Alternative means to ensure residents with COVID-19 were allowed to smoke were not addressed in the policy. A facility training report, dated 09/23/24, documented a subject of COVID SMOKING. 1. Res #1 had diagnoses which included COPD. A Smoking Policy - Residents, dated 06/07/24, signed by Res #1, did not document residents with COVID-19 were prohibited from smoking. A progress note, dated 09/26/24 at 5:08 a.m., documented Res #1 had tested positive for COVID-19. A progress note, dated 09/27/24 at 10:20 a.m., documented Res #1 was upset because they were not allowed to go outside to smoke. A progress note, dated 10/01/24 at 6:10 p.m., documented Res #1 was upset and had behaviors related to smoking restrictions placed on them due to being diagnosed as COVID-19 positive. On 10/17/24 at 11:05 a.m., LPN #1 stated the staff did not let the COVID-19 positive residents smoke. On 10/17/24 at 12:28 p.m., the administrator stated Res #1 was refusing to abide by masking regulations within the facility which was why their smoking privileges were revoked. On 10/17/24 at 1:24 p.m., LPN #2 stated residents diagnosed with COVID-19 were not allowed to go outside and smoke and were instead offered a nicotine patch. On 10/17/24 at 1:30 p.m., the administrator stated the COVID-19 positive residents were not allowed to go outside to smoke. They stated there was an inservice on the new policy and they would provide the documentation of when that went into effect. On 10/17/24 at 2:24 p.m., the administrator stated they were unable to locate the policy with the changes regarding smoking restrictions for COVID-19 positive residents, but the training report was provided was regarding the change. 2. Res #2 had diagnoses which included COPD. A Smoking Policy - Residents, dated 06/07/24, signed by Res #2, did not document residents with COVID-19 were prohibited from smoking. A progress note, dated 09/30/24 at 10:39 a.m., documented Res #2 had tested positive for COVID-19. On 10/17/24 at 1:39 p.m., Res #2 was observed reading in their bed in their room. They stated the facility did not allow them to smoke when they were COVID-19 positive. They stated the reason was not explained to them and it didn't make sense to them at the time. They stated they dealt with it during that time and were allowed to smoke once off of quarantine.

Based on record review and interview, the facility failed to complete discharge summaries for two (#1 and #4) of two sampled residents reviewed for discharge. The DON identified three residents discharged from the facility within the last 30 days. Findings: 1. Res #1 discharged from the facility on 10/02/24. A record review documented no discharge summary had been completed. 2. Res #4 discharged from the facility on 09/05/24. A record review documented no discharge summary had been completed. On 10/17/24 at 1:11 p.m., the MDS coordinator stated the nurses on the floor at the time of discharge complete the discharge summaries. On 10/17/24 at 1:24 p.m., LPN #2 stated discharge summaries were documented under the forms tab of the EHR. They reviewed the charts for Res #1 and Res #4 and stated they had not been completed.

Based on observation, record review, and interview, the facility failed to prevent physical abuse for one (#1) of six sampled residents reviewed for abuse allegations. The administrator identified 45 residents resided in the facility. Findings: A quarterly MDS, dated [DATE], documented Res #1 was cognitively intact, and was dependent on staff for most ADLs. An undated witness statement, documented CMA #1 had noticed a bruise on Resident #1's right hand and wrist. Resident #1 reported that CNA #1 pushed all their weight on their hand that was holding the bed rail, thereby smashing Resident #1's hand between the wall and handrail. CMA #1 heard Resident #1 tell CNA #1 they wanted someone else to feed them. CMA #1 stated when they went back to Resident #1's room approximately 15 minutes later, CNA #1 was still feeding Resident #1 even though they were saying please stop feeding me, I don't want anymore. CMA #1 reported they left the room. A witness statement, dated 07/11/24, documented that Resident #1 reported to CNA #4 that CNA #1 told them they would kill them. On 07/23/24 at 12:33 p.m., Resident #1 was observed in their bed. They were very hard to understand and mumbled quietly. When Resident #1 was asked about their hand, they put it up in the air and moved in back and forth to look at it but did not respond. On 07/23/24 at 1:44 p.m., the Administrator reported that CNA #1 was agency and the incident was reported to the agency, OSDH, and the police department. CNA #1 was put on the Do Not Return list. On 07/23/24 at 2:00 p.m., the Administrator reported that CNA #1 was not removed from the building during the shift because they were not notified of the incident until the next morning.

Based on record review and interview, the facility failed to ensure an allegation of abuse was reported within 2 hours to OSDH for one (#1) of six sampled residents reviewed for allegations of abuse. The administrator identified 45 residents resided in the facility. Findings: A witness statement, dated 07/11/24, documented that Resident #1 reported to CNA #4 that CNA #1 told them they would kill them. An incident report was filed with OSDH on 07/12/24 at 3:10 p.m., the incident date was documented as 07/10/24. On 07/23/24 at 2:00 p.m., the Administrator reported they were not notified of the incident until the next morning. The staff completed Abuse training in June. Abuse training was provided again on July 12th in response to this incident.

Based on record review and interview, the facility failed to provide the ABN form to residents who received skilled services and afterwards stayed in the facility for three (#3, 31, and #32) of three residents sampled for beneficiary protection notification review. The MDS coordinator identified 22 residents who had been discharged from skilled services in the last six months. Findings: According to Res #3's medical record, Res #3 started skilled services on 11/01/22 and was discharged on [DATE]. The ABN form was not provided. According to Res #31's medical record, Res #31 started skilled services on 02/02/23 and was discharged on [DATE]. The ABN form was not provided. According to Res #32's medical record, Res #32 started skilled services on 10/28/22 and was discharged on [DATE]. The ABN form was not provided. On 02/15/23 at 10:38 a.m., the MDS coordinator was asked if residents/residents beneficiary was provided the SN ABN CMS-10055 form. She reported she was unaware that they needed to sign it also.

Based on record review and interview, the facility failed to offer the choice to formulate an advance directive for one (#40) of 14 sampled residents reviewed for advanced directives. The Residents Census and Conditions of Residents reports documented 39 residents resided in the facility and 14 residents had advanced directives. Findings: Res #40 was admitted to the facility on [DATE]. There was no documentation the resident was offered the choice to formulate an advanced directive. On 02/15/23 at 3:11 p.m., the DON reported the resident's parents were her power of attorney and they had not returned the paperwork. On 02/15/23 at 3:15 p.m., the administrator reported since they had not received power of attorney paperwork they had the resident sign her admission paperwork including the advanced directive acknowledgement. The administrator provided the resident's admission packet. On 02/15/23 at 3:40 p.m., the resident's admission packet was reviewed, the resident's advanced directive acknowledgement was not signed.

Based on record review, observation, and interview, it was determined the facility failed to provide baths/showers as scheduled for one (#17) of two sampled residents. The Resident Census and Conditions of Residents form documented 39 residents resided in the facility. Findings: Res #17 was admitted on [DATE] with diagnoses of hypertension, diabetes mellitus, hallucinations, and cellulitis. A care plan, dated 01/27/23, documented the resident required limited assistance of one staff with showering at least two times weekly and as necessary. A bath/shower log documented the resident had received two showers, 02/01/23 and 02/10/23, since admission. On 02/15/23 at 1:00 p.m., the DON was asked if the resident's showers were charted on the bath/shower log. The DON reported showers and refusals are supposed to be charted on the log. The DON reported if the resident refused, the CNAs turn in paper shower forms. There were no shower forms provided.

Based on record review, observation, and interview, it was determined the facility failed to ensure oxygen was administered only when ordered by a physician for one (#40) of one sampled resident reviewed for respiratory services. The Resident Census and Conditions of Residents form documented 10 residents received respiratory treatment. Findings: Res #40 had diagnoses which included heart failure, anemia, schizophrenia, and hypertension. On 02/15/23 at 8:43 a.m., the resident was observed sitting up on the side of the bed with oxygen on via nasal cannula. The oxygen concentrator was set at 3.5 l/m. There was no documentation the resident had a physician's order to receive oxygen. On 02/15/23 at 2:45 p.m., the DON was asked if the resident had an order for oxygen. The DON replied she would have to check. On 02/15/23 at 3:13 p.m., the DON reported the resident had oxygen at home. The DON reported the resident was placed on oxygen and the doctor should be in the facility today and decide if the resident needed it for medical reason or comfort reasons.

Based on record review, observation, and interview, the facility failed to administer medications as ordered for one (#7) of five residents sampled for medication administration. The Resident Census and Conditions of Resident report documented 39 residents resided in the facility. Findings: An Administering Medications policy, revised December 2012, documented medications must be administered within one hour of their prescribed time. Res #7 had diagnoses which included chronic atrial fibrillation, heart failure, hypertension, and acute pulmonary edema. A physician order, dated 10/06/20, documented to administer furosemide (diuretic medication) 40 mg daily for heart failure. A care plan, dated 12/01/20, documented to administer the anticoagulant as ordered by the physician at the same time daily. The care plan documented to administer diuretic medications as ordered by physician. A physician order, dated 02/25/21, documented to administer apixaban (anticoagulant medication) 2.5 mg twice daily for clot prevention. A Medication Administration Audit Report, dated 02/01/22-02/28/22, documented furosemide was administered past the one hour scheduled time frame for 10 administrations. Apixaban was administered past the one hour scheduled time frame for 16 administrations. A Medication Administration Audit Report, dated 04/01/22-04/30/22, documented furosemide was administered past the one hour scheduled time frame for 17 administrations. Apixaban was administered past the one hour scheduled time frame for 20 administrations. An annual assessment, dated 05/13/22, documented the resident was cognitively intact, required supervision with most ADLs, and received anticoagulants and diuretics. On 02/14/23 at 1:43 p.m., Res #7 was observed sitting in a wheelchair in the commons area. Res #7 stated she was very sick back in February 2022 through April 2022. The resident stated during this time, the facility would administer the apixaban at the wrong time of day and this concerned her because her doctor had stated it should be given exactly twelve hours apart. Res #7 stated she was concerned that the facility was not giving her the diuretic at the scheduled ordered times during this time frame. On 02/15/23 at 3:00 p.m., the DON stated the medication administration time policy is one hour before or after the scheduled time. She stated a medication given outside of these parameters was considered not on time. On 02/15/23 at 4:30 p.m., the corporate RN stated the facility medication policy documented medications are to be given within a 60-minute time frame of the ordered time. She stated the apixaban and furosemide were given late but should not have been per policy.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents were free from the use of unnecessary [CONDITION(S)] medications for two (#6 and #15) of five residents reviewed for unnecessary medications. The facility failed to: a) ensure resident #6 did not receive an as-needed (PRN) [CONDITION(S)] drug and failed to evaluate the resident for use of the medication beyond 14 days; and b) ensure resident #15 had an appropriate diagnosis for the use of a [CONDITION(S)] medication. Findings: 1. Resident #6 was admitted to the facility on [DATE] and had diagnoses which included Alzheimer's disease, [CONDITION(S)] disease, diabetes, depression, and [CONDITION(S)]. A monthly pharmacy consult, dated 12/12/20, recommended a gradual dose reduction of [MEDICATION(S)] from 200 milligrams (mg) to 150 mg at bedtime. The physician's response documented no change due to the COVID situation. An annual assessment, dated 03/21/21, documented the resident was moderately impaired with cognition. The assessment documented the resident received antipsychotic and antidepressant medication seven of seven days previous. An order summary report, with a documented admission and start date of 05/24/21, documented [MEDICATION(S)] 200 mg, one tablet by mouth PRN agitation, nightly as needed. A physician order list, dated June 2021, documented the resident was prescribed [MEDICATION(S)] for catatonic [CONDITION(S)], [MEDICATION(S)] for depression, [MEDICATION(S)] for Alzheimer's disease, and [MEDICATION(S)] PRN for agitation. A care plan, dated 06/05/21, documented the resident required extensive assistance with most activities of daily living. The care plan documented the resident was resistive to care at times and had the potential to be physically aggressive. On 06/22/21 at 2:00 p.m., the resident was observed to participate in the resident group meeting. The resident was observed to be neat, clean and well-groomed. On 06/23/21 at 2:29 p.m., the administrator in training (ADM) reported the facility had a mock survey in June and identified an issue with gradual dose reductions (GDRs) related to unnecessary medications. The ADM reported the pharmacist visited the facility monthly to review medications. On 06/23/21 at 3:30 p.m., the ADM was asked for documentation for the initial start date of [MEDICATION(S)]. The ADM reported the resident had been out of the facility so medications were re-started upon return in May and that's the start date the facility used. The ADM then did an order search and provided documentation showing the resident was prescribed [MEDICATION(S)] on 10/07/20 and previously discontinued on 02/01/21 before being restarted in May. On 06/24/21 at 9:42 a.m., the ADM was asked if the physician knew it was required for the resident to be evaluated every two weeks and assessed for continuation of a PRN [CONDITION(S)] medication. The ADM stated she wasn't sure but would check. On 06/24/21 at 10:54 a.m., the ADM reported the medication was re-ordered when the resident returned from a hospital stay. The ADM reported [MEDICATION(S)] was discontinued the previous day on 06/23/21 as an unnecessary medication. 2. Resident #15 was admitted to the facility on [DATE] with diagnoses which included diabetes, chronic obstructive pulmonary disease, depression, anxiety, and Alzheimer's disease. An admission assessment, dated 05/14/21, documented the resident was moderately impaired with cognition. The assessment documented the resident received antidepressant medication six of seven days previous. A care plan, dated 05/28/21, documented the resident required extensive assistance with most activities of daily living. A physician order, dated 06/14/21, documented the resident was prescribed [MEDICATION(S)] 5 mg, one by mouth every 12 hours, PRN agitation related to Alzheimer's disease. A physician order list documented the resident also received [MEDICATION(S)] for depression, [MEDICATION(S)] XR for Alzheimer's disease, and [MEDICATION(S)] Hcl for Alzheimer's disease. A nurse note, dated 06/15/21 at 1:08 p.m., documented PRN [MEDICATION(S)] had been administered that morning by the medication aide and noted to be effective. The note documented the resident had been confused, asking, where am I. On 06/22/21 at 1:40 p.m., the resident was observed sitting up in bed finishing lunch. A staff member was observed sitting at the side of the bed assisting and encouraging the resident. A physician order, dated 06/23/21, documented to discontinue [MEDICATION(S)], due to non-use. On 06/24/21 at 11:39 a.m., the progress note for 06/15/21 was reviewed with the DON. The note documented the resident was given [MEDICATION(S)] but the medication administration record (MAR) did not document the dose given. The DON stated she didn't know why the MAR did not note the dose given. The DON and ADM was asked why the medication had been discontinued the previous day. The ADM stated they were reviewing medications and realized this medication did not have an appropriate diagnosis for use with this resident and was considered an unnecessary medication.

Based on record review and resident and staff interviews, it was determined the facility failed to ensure: ~ a resident did not have a severe, unplanned, weight loss for one (#2) of five sampled residents reviewed for nutrition and ~ a resident received physician ordered supplements for one (#7) of five sampled residents reviewed for nutrition. This resulted in resident #2 having an 8.76 percent severe weight loss in three months and a 13.77 percent severe weight loss in six months. The facility identified 37 residents resided in the facility. Findings: A facility weight assessment and intervention policy, revised September 2008, documented, .The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents .The threshold for significant unplanned and undesired weight loss will be based on the following criteria .3 months - 7.5 [percent] weight loss is significant; greater than 7.5 [percent] is severe .6 months - 10 [percent] weight loss is significant; greater than 10 [percent] is severe .The Physician and multidisciplinary team will identify conditions and medications that may be causing anorexia, weight loss .Individualized care plans shall address .The identified causes of weight loss .Goals and benchmarks for improvement .Time frames and parameters for monitoring and reassessment .Interventions for undesirable weight loss shall be based on careful consideration . 1. Resident #2 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .low concentrated sweets / ccho [consistent carbohydrate diet] low concentrated carbohydrate purred [sic] with nectar thick liquids . The resident's weight on 07/17/19 was 175 pounds (lbs). A facility weight sheet documented the resident weighed 179.3 lbs on 08/05/19. A comprehensive resident assessment, dated 08/31/19, documented the resident's cognition was moderately impaired and he required supervision and set-up help only for eating. A facility weight sheet documented the resident weighed 171.2 lbs on 09/02/19, 165.4 lbs on 10/02/19 and 157.8 lbs on 11/04/19. A care plan, revised 11/10/19, documented, .Problem/Need .[Resident] has a potential for nutritional/hydration defict [sic] r/t [related to] puree/nectar diet and dx [diagnoses] of DM, impaired cognition and mobility .Approaches .dietary eval [evaluation] as needed .weights as ordered .monitor and record meal, offer supplement if consumes less than 50 [percent] of meal .or offer replacement meal first . A quarterly resident assessment, dated 11/30/19, documented the resident's cognition was moderately impaired and he required supervision and set-up help only for eating. A facility weight sheet documented the resident weighed 156.6 lbs on 12/04/19. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Regular/PUREED/Nectar Thick Liquids . A facility weight sheet documented the resident weighed 154.6 lbs on 01/01/20. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Regular/PUREED/Nectar Thick Liquids . On 01/16/20 at 7:25 a.m., the resident was asked if he had experienced a significant weight loss. He stated, Yes, about 20 pounds. On 01/21/20 the resident weighed 150.9 lbs. The resident experienced a severe weight loss of 8.76 percent in three months from October 2019 to January 2020 and a 13.77 percent weight loss in six months from July 2019 to January 2020. There was no documentation the resident's physician had been notified of the weight loss or interventions had been implemented. On 01/21/20 at 8:05 a.m., the minimum data set (MDS) nurse was asked what the policy was for monitoring residents' weights. She stated staff weighed the residents monthly unless they noticed a weight loss. She stated the dietitian would make recommendations for weekly weights times four weeks or daily weights and then re-assess. She was asked when the physician should be notified of weight loss. She stated the physician would be made aware during his weekly rounds. The MDS nurse was asked what the policy was for documenting physician notification of weight loss. She stated it should have been documented as soon as it had been discovered. She stated it would be documented in the nurses' notes. She was shown the resident's weights from July 2019 to current and asked if she could explain the weight loss. She stated he has had a steady loss over time. She stated he had a lot of diet changes from pureed to mechanical soft and back to pureed. She stated he was very active. The MDS nurse was asked if the physician had been notified of the resident's weight loss. She stated if they identified a five percent weight loss, they would have notified the physician. She stated she didn't see any charting that documented the physician had been notified. She was asked if the physician should have been notified of the weight loss. She stated, Yes. She stated it looked like he started losing weight in September. The MDS nurse was asked if any interventions had been implemented for the weight loss. She stated he was on a regular pureed diet. She stated she believed the weight loss was due to him being so active. She was asked if there was documentation of the weight loss being related to his activity level. She stated she didn't see any charting anywhere about the weight loss. The MDS nurse was asked if there was a certain amount of weight loss the physician should be notified of. She stated, Five percent in one month and 10 percent in six months. She was made aware the resident had experienced a severe weight loss in three months and six months. She acknowledged the findings. 2. Resident #7 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .SUGAR-FREE SUPPLEMENT WITH MEALS . The December 2019 meal intake sheet documented the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The January 2020 meal intake sheet did not document the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] On 01/21/20 at 7:51 a.m., the resident was observed to have received his breakfast meal in his room. He did not receive the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] At 11:03 a.m. licensed practical nurse #3 was asked where staff were instructed to document routine supplements. She stated on the treatment administration record (TAR). There was no documentation of the ordered supplements on the TARs.

Based on record review and staff interviews, it was determined the facility failed to ensure the physician was notified of a severe, unplanned, weight loss for one (#2) of five sampled residents reviewed for nutrition. The facility identified 37 residents resided in the facility. Findings: Resident #2 had [DIAGNOSES REDACTED]. The resident's weight on 07/17/19 was 175 pounds (lbs) and 179.3 lbs on 08/05/19. A comprehensive resident assessment, dated 08/31/19, documented the resident's cognition was moderately impaired and he required supervision and set-up help only for eating. A facility weight sheet documented the resident weighed 171.2 lbs on 09/02/19, 165.4 lbs on 10/02/19 and 157.8 lbs on 11/04/19. A quarterly resident assessment, dated 11/30/19, documented the resident's cognition was moderately impaired and he required supervision and set-up help only for eating. A facility weight sheet documented the resident weighed 156.6 lbs on 12/04/19, 154.6 lbs on 01/01/20 and 150.9 lbs on 01/21/20. The resident experienced a severe weight loss of 8.54 percent in three months from October 2019 to January 2020 and a 13.77 percent in six months from July 2019 to January 2020. There was no documentation the resident's physician had been notified of the weight loss. On 01/21/20 at 8:05 a.m., the minimum data set (MDS) nurse was asked what the policy was for monitoring residents' weights. She stated staff weighed the residents monthly unless they noticed a weight loss. She was asked what the policy was for documenting the physician had been notified of the weight loss. She stated it should be documented as soon as it had been discovered. She stated it would be documented in the nurses' notes. The MDS nurse was shown the resident's weights from July 2019 to current and asked if the physician had been notified. She stated if staff had identified a five percent weight loss, they would have notified the physician. She stated she didn't see any charting that documented the physician had been notified. She was asked if the physician should have been notified of the weight loss. She stated, Yes.

Based on record review and staff interviews, it was determined the facility failed to implement their abuse policy for two (#3 and #9) of four sampled residents reviewed for abuse. The facility identified 37 residents resided in the facility. Findings: An abuse prevention policy, revised December 2007, documented, .Resident-to-Resident Altercations .All altercations, including those that represent resident-to-resident abuse, shall be investigated .If two residents are involved in an altercation, staff will .Notify each resident's representative .and Attending Physician of the incident .Document in the resident's clinical record all interventions and their effectiveness .Complete an (sic) Report of Incident/Accident form and document the incident, findings, and any corrective measures taken in the resident's medical/clinical record .Report incidents, findings, and corrective measures to appropriate agencies as outlined in our facility's abuse reporting policy . 1. Resident #3 had [DIAGNOSES REDACTED]. A nurse's note, dated 10/22/19, documented, .ate (sic) entry .pt (patient) up in lobby arguing with another resident and was grabbed (initials deleted) by the sleeve of her sweater staff intervined (sic) .resident reported other resident grabbed her by the sleeve . A nurse's note, dated 12/11/19, documented, .Resident threating (sic) and swinging her hands at a resident yelling at him. Aides separated them and she continued to verbally abuse him. This nurse had her come eat her breakfast at a bedside table near me and explained she could not threaten. She responded yes I can and I will hit him, my daddy owns this place and I can do what I want. After she ate, she watched TV (television) in lobby . On 01/21/20 at 6:48 a.m., the DON (director of nursing) was asked what the policy was for a resident-to-resident altercation. She stated they would separate them, complete an incident report, notify their family and physician, look to see when the resident had last been evaluated by an behavioral health agency, have them seen by the behavioral health agency and adjust their medications. The DON was asked what intervention had been implemented after the incident on 10/22/19. She stated they separated the residents. She was asked if a State required incident report had been completed. She reviewed the State incident report book and no response was provided. At 7:17 a.m., the DON and administrator (ADM) were asked to review the nurse's note on 12/11/19 and were asked if the physician or the family had been notified of the incident. The ADM stated she would have to check chart. The DON was asked if a State required incident report had been completed for the incident. She stated, No. At 7:45 a.m., the ADM stated she was looking for State required incident reports for both incidents. There was no further documentation provided at the end of survey. 2. Resident #9 had [DIAGNOSES REDACTED]. A nurse's note, dated 09/03/19 at 11:01 p.m., documented, .another resident entered (Resident) room (at) 1945 (7:45 p.m.) and attempted to turn out his call light other resident yelled (at) (Resident) and cursed (at) him called him names family notified of incident assured (Resident) issue had been addressed with (doctor), DON, and other resident and POA (power of attorney) (Resident's) . There was no documentation the altercation had been investigated. On 01/21/20 at 9:03 a.m., the DON was asked to locate documentation an incident report or State required incident report had been completed for the above incident. At 10:35 a.m., the ADM stated they didn't consider it an incident for an incident report or State required incident report to be completed. She was made aware the incident involved a resident-to-resident altercation. She acknowledged the findings.

Based on record review and staff interviews, it was determined the facility failed to ensure registered nurse (RN) coverage was provided eight hours a day, seven days per week for 10 of 30 days reviewed for RN coverage. The Resident Census and Conditions of Residents report, dated 02/19/19, documented 38 residents resided in the facility. Findings: The facility's nursing schedule and posted staffing was reviewed from 01/19/19 through 02/19/19. There was no documentation of RN coverage on the following dates: ~ Saturday, (MONTH) 19th, ~ Sunday, (MONTH) 20th, ~ Saturday, (MONTH) 25th, ~ Sunday, (MONTH) 26th, ~ Saturday, (MONTH) 2nd, ~ Sunday, (MONTH) 3rd, ~ Saturday, (MONTH) 9th, ~ Sunday, (MONTH) 10th, ~ Saturday, (MONTH) 16th and ~ Sunday, (MONTH) 17th, 2019. On 02/21/19 at 1:05 p.m., the director of nursing (DON) was asked what schedule she worked. She stated she worked eight to five and sometimes provided weekend coverage. She was asked if her weekend coverage would be reflected on the facility schedule. She stated not necessarily. The DON was asked to provide documentation of weekend coverage for the above dates. She stated she would have to ask the business office manager (BOM) for that information. At 1:15 p.m., the BOM stated she was going to ask the administrator (ADM) about the weekend coverage because the DON did not clock in and out. At 1:30 p.m., the BOM provided copies of daily assignment sheets for the above dates. The sheets did not document time worked. At 1:35 p.m., the ADM was shown the (MONTH) and (MONTH) 2019 schedules and the posted staffing sheets which documented there was no RN coverage for the above weekends. She stated the DON had worked those weekends. She was asked if the posted staffing was accurate if there was no documentation of the RN coverage. She stated the receptionist was responsible for documenting that information. At 1:40 p.m., the receptionist was asked how she received nursing hours worked to put on the posted staffing sheets. She stated she got the hours from the time sheets provided from the business office manager. She was asked how documented time worked if staff did not clock in and out. She stated the DON was the only staff who did not clock in and out. She stated if she knew the DON had been at work, she would put her on the staffing sheets. She was asked if the posted staffing sheets were blank for RN coverage, did that indicate there was no RN coverage. She stated, Right, that's on the weekends.