Every finding on record at View Heights Conv Hosp

Based on interview and record review, the facility failed to ensure a resident's orthostatic blood pressures (blood pressures taken to help healthcare providers determine if the body is struggling to regulate blood pressure when moving to an upright position) were obtained for one of four sampled residents (Resident 1) according to the facility's established procedure for a resident who suffered a recent fall with injury. This failure had the potential to prevent identification of orthostatic hypotension (a drop in blood pressure when standing up) as a contributing factor to Resident 1's fall, delayed clinical interventions to reduce dizziness, and placed Resident 1 at risk for subsequent falls with injury. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE]. Resident 1's diagnoses included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior) and obesity (complex, chronic disease characterized by an excessive amount of body fat). During a review of Resident 1's Minimum Data Set ([MDS], a resident assessment tool), dated 4/20/2026, the MDS indicated Resident 1's cognitive skills (ability to think and reason) for daily decision making were moderately impaired. The MDS indicated Resident 1 was independent for activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 1's Physician Orders, dated 1/4/2024, the Physician Orders indicated to monitor and record orthostatic blood pressures (blood pressures taken to help healthcare providers determine if the body is struggling to regulate blood pressure when moving to an upright position) laying, sitting, and standing every evening shift every four weeks on Tuesdays for orthostatic hypotension (a drop in blood pressure when standing up) monitoring. During a review of Resident 1's General Acute Care Hospital (GACH) Emergency Department (ED) Note, dated 6/20/2026, the ED Note indicated, on 6/20/2026, Resident 1 presented to the ED with a closed head injury prior to arrival. The GACH ED note indicated Resident 1 suffered a slip and fall injury in the hallway at the facility. The GACH ED Note indicated Resident 1 sustained dental fractures (broken bone) and a fracture to the right-hand pinky finger. During a review of Resident 1's Morse Fall Scale (rapid, widely used clinical tool to assess a patient's risk of falling), dated 5/31/2026, the fall scale indicated Resident 1 was at moderate risk for a fall. During an interview on 6/25/2026 at 9:15 a.m. with Registered Nurse (RN) 1, RN 1 stated obtaining orthostatic blood pressures was imperative to detect orthostatic hypotension. RN 1 stated Resident 1 required diligent orthostatic blood pressure monitoring because the resident was known to be prescribed multiple psychotropic medications (mood altering medications), which increased her risk for dizziness and falls. During a concurrent interview and record review on 6/25/2026 at 3:36 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 1's Monitoring Medication Administration Record (MAR) and Medication Administration Audit Report, dated 6/2026, were reviewed. The Medication Administration Audit Report indicated Resident 1's blood pressures were obtained in the following order on 6/23/2026: sitting at 10:34 p.m., standing at 10:39 p.m., and lying at 10:59 p.m. LVN 1 stated his usual practice when obtaining orthostatic blood pressure measurements was to assess the resident in the sitting position first, followed by the standing position, and lastly in the lying position. LVN 1 confirmed he followed this same sequence when obtaining Resident 1's orthostatic blood pressure measurements on 6/23/2026. During a concurrent interview and record review on 6/25/2026 at 3:50 p.m. with LVN 1, the facility's lesson plan for orthostatic blood pressure measuring, dated 5/22/2026, was reviewed. The lesson plan indicated licensed nurses were instructed to obtain orthostatic blood pressure measurements in the lying, sitting, and standing positions. LVN 1 stated he had not obtained Resident 1's orthostatic blood pressure measurements in the correct sequence and stated the incorrect technique could result in undetected orthostatic hypotension, delayed appropriate clinical intervention, and placed Resident 1 at increased risk for falls, especially because Resident 1 was receiving psychotropic medications. During a review of the facility's Policy & Procedure (P&P) titled, Falls Management System, revised 12/2025, the P&P indicated the facility was to provide each resident with appropriate assessment and interventions to prevent falls and minimize complications if a fall occurs. During a review of the facility's P&P titled, Monitoring of Vital Signs, dated 12/2025, the P&P indicated the facility was to ensure optimum resident assessment and to ensure optimum monitoring of resident change of condition.

Based on interview and record review, the facility failed to ensure orthostatic blood pressure measurements (blood pressures taken to help healthcare providers determine if the body is struggling to regulate blood pressure when moving to an upright position) were accurately documented for one of three sampled residents (Resident 2). This failure had the potential to result in the delayed identification of orthostatic hypotension (a drop in blood pressure when standing up), delayed clinical interventions to reduce dizziness, and placed Resident 2 at risk for subsequent falls with injury.Findings: During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was initially admitted to the facility on [DATE]. Resident 2's diagnoses included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), hypoosmolality (an excess of total body water relative to electrolytes), hypertension (high blood pressure), and diabetes (poor blood sugar control). During a review of Resident 2's Minimum Data Set ([MDS], a resident assessment tool), dated 5/26/2026, the MDS indicated Resident 2's cognitive skills (ability to think and reason) for daily decision making were intact. The MDS indicated Resident 2 was entirely independent on staff for activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 2's Physician Orders, dated 8/9/2024, the Physician Orders indicated to monitor and record orthostatic blood pressures (blood pressures taken to help healthcare providers determine if the body is struggling to regulate blood pressure when moving to an upright position) laying, sitting, and standing, every evening shift every four weeks on Tuesdays, for orthostatic hypotension (a drop in blood pressure when standing up) monitoring. During a review of Resident 2's Change of Condition Note, dated 5/9/2026, the note indicated, on 5/9/2026, Resident 2 suffered a witnessed fall. During a review of Resident 2's Morse Fall Scale, dated 5/27/2026, the fall scale indicated Resident 2 was at moderate risk for falls. During a concurrent interview and record review on 6/25/2026 at 2:33 p.m. with Licensed Vocational Nurse (LVN) 2, Resident 2's Monitoring Medication Administration Record (MAR) and Medication Administration Audit Report, dated 6/2026, were reviewed. The MAR and audit report indicated Resident 2's orthostatic blood pressures in the lying, sitting, and standing positions was documented as 139/85 millimeters of mercury ([MM Hg]- unit of measurement that describes the amount of force blood uses to get through the vessels of the body [normal range of 120-129 [top number] and 80-84 [bottom number]) for all three measurements. The audit report indicated Resident 2's orthostatic vital signs (three values) were recorded at 6:47 p.m. LVN 2 stated the facility's standard practice was to document orthostatic vital signs as they were obtained. LVN 2 stated she performed Resident 2's orthostatic blood pressure assessment but inadvertently entered the same blood pressure values for all three positions without verifying the recorded measurements. LVN 2 acknowledged the documentation was inaccurate and stated orthostatic vital signs should be documented accurately to ensure the assessment reflected the resident's actual condition. LVN 2 stated inaccurate documentation of orthostatic blood pressures could result in failure to identify orthostatic hypotension, delayed clinical evaluation, or medical adjustments, and placed the resident at risk for falls. During a review of the facility's Policy & Procedure (P&P) titled, Charting and Documentation, dated 1/2025, the P&P indicated the facility was to ensure all services provided to the resident would be documented in the resident's medical record. During a review of the facility's P&P titled, Monitoring of Vital Signs, dated 12/2025, the P&P indicated the facility was to ensure optimum resident assessment and to ensure optimum monitoring of resident change of condition. During a review of the facility's Charge Nurse Job Description (undated), the job description indicated the charge nurse was to perform routine charting duties as required and in accordance with established charting documentation policies and procedures.

Based on interview and record review, the facility failed to employ a dietary supervisor (DS) that met the qualifications of having an associate's degree or higher in food service management or in hospitality, was a certified dietary manager, certified food service manager or had national certification for food service management and safety. This deficient practice had the potential to affect 145 residents residing in the facility by potentially not receiving the nutritional assistance and guidance required to attain their highest practicable well-being.Findings:During an interview on 5/4/2026 at 8:30 a.m., a kitchen staff, introduced as Dietary Supervisor (DS) 1, was unable to produce credentials which indicated she was qualified as a Certified Dietary Manager (CDM). DS 1 stated she did not possess a CDM certification. DS 1 stated she was in the process of scheduling an examination to obtain the certification in June 2026. DS 1 stated there was a second dietary supervisor (DS 2) employed part-time.During an interview on 5/5/2026 at 9:00 a.m. with DS 2, DS 2 presented a certification titled Food Protection Manager dated 8/31/2025. DS 2 stated he was aware the certification did not meet the regulatory requirements to function as a CDM or equivalent. DS 2 stated he was enrolled in coursework to become eligible to take an examination to obtain CDM certification.During a concurrent observation, interview, and record review on 5/6/2026 at 11:00 a.m., with Dietary Aide (DA 1), the Dietary Work Schedules dated 2026 was reviewed. The document indicated DS 1 was not scheduled Wednesday, Thursday, or Saturday. Observed DS 1 and DS 2 were not in the kitchen or in the facility. DA 1 stated neither DS 1 nor DS 2 reported to work that day (5/6/2026) as they were both scheduled off on Wednesdays. DA 1 stated that it was a routine occurrence to have no supervisor on duty on Wednesdays in the seven months DA 1 has been employed at the facility. DA 1 stated DS 1 and DS 2 did not appear on the schedule.During an interview with the facility Administrator (ADM) on 5/6/2026 at 12:30 p.m., the ADM stated he was not aware DS 2 credentials did not meet regulatory requirements. The ADM stated he was expecting DS 2 to report to work however did not arrive due to unknown reasons. The ADM stated that hiring a CDM was required per regulations and the presence of a CDM in the kitchen would improve supervision, handling, and the preparation of food.During a review of the facility's job description titled Dietary Supervisor dated December 2025, the job description indicated a qualified Dietary Supervisor will be chosen by the Administrator, and they must meet the Federal and State laws or have met equivalent requirement.

Based on observation, interview, and record review, the facility failed to:1. Properly wash dishware using water temperature lower than manufacturer specifications.2. Practice standard hygienic practices in the kitchen when [NAME] 1 failed to wear a beard restraint during food preparation.3. Practice standard hygienic practices when [NAME] 2 wore 11 pieces of jewelry during food preparation.These deficient practices had the potential to result in harmful bacterial growth that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or toxins) in 145 of 145 residents.Findings:1. During a concurrent observation and interview on 5/4/2026 at 9:12 a.m. with Dietary Aides (DA 2 and DA 3), DA 2 and DA 3 were observed operating the dishwashing machine for soiled plate ware from breakfast service. The sink reservoir thermometer read 96 degrees Fahrenheit ( F). The inlet pipe thermometer (meter which reads the temperature of water coming in from the water heater just before entering the dishwashing machine) read 117.6 F. DA 2 stated that the temperature of the dishwashing machine was logged using the inlet thermometer. DA 2 stated in the event temperatures were not to specifications, DA 2 would inform a supervisor.During a review of the facility document titled Dish Machine Temperature Log dated 5/2026, the document indicated Wash temperatures must be 120 F. Use manufacturer guidelines on machine for range of wash and rinse temperatures.During an observation on 5/5/2026 at 9:43 a.m., the dishwashing machine was observed operating at 105 F. The inlet thermometer read 116.4 F. During a concurrent observation and interview on 5/5/2026 at 9:48 a.m., with Dietary Supervisor (DS) 1, the dishwashing machine was observed. The temperature read 90 F. The inlet thermometer read 107.2 F. DS1 observed a verification of the temperatures using an external probe thermometer and was unable to produce any maintenance requests. DS 1 stated she was unaware of any issues. DS 1 stated that lower operating temperatures than manufacturer specifications may result in bacteria not being killed properly and was unsanitary. DS 1 stated that maintenance should be contacted to correct the issue. During a review of the manufacturer's Installation Instructions dated 5/4/2021, the instructions indicated, Failure to provide adequate water quantity, pressure and temperature to the machine will cause the machine to function improperly. and While the supply water must have a minimum of 120F degrees, 130-140F degrees is recommended for best results.During a review of the facility's document titled 2022 FDA Food Code section 4-501.110 , the document indicated The wash solution temperature in mechanical warewashing equipment is critical to proper operation. The chemicals used may not adequately perform their function if the temperature is too low. Therefore, the manufacturer's instructions must be followed and section 4-501.114 indicates The effectiveness of chemical sanitizers can be directly affected by the temperature.During a review of the facility's policy and procedure (P&P) titled Cleaning Dishes/Dish Machine dated 12/2024, the P&P indicated that dish machines will be checked prior to meals to assure proper functioning and appropriate temperatures for cleaning and sanitation, to run the machine until verification of proper temperatures and machine function is made, and that Staff should check the fish machine gauges throughout the cycle to assure proper temperatures for sanitation.2. During a concurrent observation and interview on 5/4/2026 at 9:30 a.m., with DS 1, [NAME] 1 was observed with a goatee beard approximately one inch in length. [NAME] 1 was without a beard restraint while preparing soup for lunch service. DS 1 stated [NAME] 1 should be wearing a beard net to prevent contamination of food. DS 1 stated that beard restraints were not kept at the entrance of the kitchen alongside hair nets, however, they were available in the office adjacent to the entrance of the kitchen. DS 1 then proceeded to retrieve a clear plastic bag of beard restraints from a cabinet located in DS 1's office. During an observation on 5/4/2026 at 11:00 a.m., [NAME] 1 was observed in the kitchen transferring a tray of food from the oven to the food preparation table. A beard restraint was off his beard and hung around his neck.During an observation on 5/4/2026 at 11:30 a.m., [NAME] 1 was observed standing at the serving counter placing pans of food onto the steam table. A beard restraint was off his beard and hung around his neck.During an interview with the Administrator (ADM) on 5/6/2026 at 12:30 p.m., the ADM stated that beard restraints should be treated in the same manner as hair nets for the purpose of safety and preventing potential bacterial contamination of food.During a review of the facility's P&P titled Code Dress, dated 12/2025, the P&P indicated that beards and mustaches (any facial hair) must wear beard restraint.During a review of the facility's P&P titled Food Safety and Sanitation, dated 12/2025, the P&P indicated that employees are required to wear beard nets when facial hair is visible.During a review of the facility document titled 2022 FDA Food Code section 2-402.11, the P&P indicated that food employees shall wear hair coverings, including nets or beard restraints that are designed and worn to effectively keep hair from contacting exposed food, clean equipment and utensils.3. During an observation on 5/4/2026 at 9:30 a.m., [NAME] 2 was observed preparing soup for lunch service. [NAME] 1 was wearing one necklace, five bracelets (two on the left wrist, three on the right wrist), one watch, and four earrings (two studs, two hoops). The eleven pieces of jewelry were visibly exposed throughout the duration of [NAME] 2's work shift on 5/4/2026.During an interview with the ADM on 5/6/2026 at 12:30 p.m., the ADM stated he was aware of the facility policy indicating that no excessive jewelry should be worn. The ADM stated [NAME] 2's jewelry was considered excessive.During a review of the facility's P&P titled Code Dress, dated 12/2025, the P&P indicated No excessive jewelry, just wedding rings on hand, non-dangling earrings on ears, and wristwatch. Wristwatch and wedding rings need to be covered with gloves with handling food.During a review of the facility's document titled 2022 FDA Food Code section 2-303.11, the document indicated Items of jewelry such as rings, bracelets, and watches may collect soil and the construction of the jewelry may hinder routine cleaning. As a result, the jewelry may act as a reservoir of pathogenic organisms transmissible through food.

Based on interview and record review, the facility failed to implement its policy and procedure (P&P) titled Informed Consent, dated 12/2025, for three of three sampled residents (Resident 18, Resident 97, and Resident 24) when: 1. Informed consent was not obtained when Resident 18's dose of Clozapine (an antipsychotic [work by altering brain chemistry to help reduce psychotic symptoms like hallucinations, delusions and disordered thinking] medication) was increased on [DATE].2. Resident 97's informed consents for Clozapine, Seroquel (an antipsychotic medication), Haldol (an antipsychotic medication), and lithium carbonate (a mood stabilizer and an antimanic agent) were not obtained or renewed every six (6) months.3. Resident 24's informed consent for Clozapine and lithium carbonate were not renewed every six (6) months. These deficient practices failed to honor Resident 18's, 97's, and 24's responsible parties' rights to consent to or decline new and/or continued treatment of the psychotropic medications (drugs that treat mental health disorders, affecting mood, thoughts, and behaviors). Findings: 1. During a review of Resident 18's admission Record, the admission Record indicated Resident 18 was admitted to the facility on [DATE]. Resident 18's diagnoses included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior). The admission Record indicated Resident 18 had a Public Guardian (PG, a court-appointed public official or agency responsible for managing the personal, medical, or financial affairs of individuals deemed legally incapacitated), PG 1. During a review of Resident 18's Minimum Data Set (MDS, a resident assessment tool), dated [DATE], the MDS indicated Resident 18 had severe cognitive impairment (difficulty with thinking, memory, concentration, judgment, and learning that exceeds normal aging). The MDS indicated Resident 18 was independent for all activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily) except for personal hygiene and oral hygiene. During a review of Resident 18's physician order, dated [DATE], the order indicated to administer Clozapine 200 milligrams (mg, a unit of dose measurement) in the morning, and administer 300 mg at bedtime. During an interview on [DATE] at 2:23 p.m., with the Director of Nursing (DON), the DON stated Resident 18's dose of Clozapine was increased on [DATE] and the facility did not obtain informed consent. The DON stated a new informed consent form should have been obtained to ensure PG 1, was aware of the planned change, and to ensure PG 1 was agreeable to the new treatment. The DON stated it was PG 1's right to be notified of the change and make an informed decision to consent to or refuse the new dose. The DON stated the facility did not honor that right. 2. During a review of Resident 97's admission Record, the admission Record indicated Resident 97 was admitted to the facility on [DATE]. Resident 97's diagnoses included schizoaffective disorder (a chronic mental health condition characterized by a combination of psychosis symptoms of hallucinations or delusions and mood disorder of anger or depression), insomnia (a common sleep condition characterized by persistent difficulty falling asleep, staying asleep, or waking too early, despite having adequate opportunity for sleep), and stimulant dependence. During a review of Resident 97's MDS, dated [DATE], the MDS indicated Resident 97's cognitive skills for daily decision making was intact. The MDS indicated Resident 97 was independent with ADLs. During a review of Resident 97's physician order dated [DATE], the physician order indicated to administer clozapine (an antipsychotic medication) 300 mg at bedtime for psychosis related to schizophrenia disorder. During a review of Resident 97's physician order dated [DATE], the physician order indicated to administer haloperidol (an antipsychotic medication) oral tablet 20 mg three times a day for psychosis related to schizophrenia disorder. During a review of Resident 97's physician order dated [DATE], the physician order indicated to administer clozapine oral tablet 50 mg in the morning for psychosis. During a review of Resident 97's physician order dated [DATE], the physician order indicated to administer clozapine oral tablet 50 mg, at noon for delusions and hallucinations. During a review of Resident 97's physician order dated [DATE], the physician order indicated to administer lithium carbonate (a mood stabilizer and an antimanic agent) oral capsule 900 mg in the morning for mood swings. During a review of Resident 97's physician order dated [DATE], the physician order indicated to administer Seroquel (an antipsychotic medication) oral tablet 25 mg at bedtime for lack of sleep at bedtime. During a concurrent interview and record review on [DATE] at 2:24 p.m., with the Director of Nursing (DON), Resident 97's physician orders for clozapine dated [DATE], haloperidol dated [DATE], lithium carbonate dated [DATE], and Seroquel dated [DATE] were reviewed. The physician orders did not indicate evidence of informed consent and/or evidence of renewal. The DON stated that psychotropic medications such as clozapine, haloperidol, lithium, and Seroquel required informed consent prior to initiation of treatment to ensure the resident and/or responsible party understands the risks, benefits and potential side effects. The DON stated that informed consent forms should be signed, dated, and maintained in the resident's medical record prior to the administration of the medications. The DON stated that informed consent for psychotropic medications should be renewed when there was an increase in the medication dose and upon expiration of the existing consent. The DON stated that failure to obtain or renew informed consent could place residents at risk of receiving medication without full knowledge and agreement of the treatment plan and would not follow facility policy and resident rights regulations. The DON stated it is the facility's responsibility to ensure informed consent documentation is current, accurate, and readily available in the clinical record. 3. During a review of Resident 24's admission Record, the admission Record indicated Resident 24 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 24's diagnoses included schizophrenia. During a review of Resident 24's MDS, dated [DATE], the MDS indicated Resident 24's cognitive skills for daily decision making was intact. The MDS indicated Resident 24 was independent with ADLs. The MDS indicated Resident 24 received antipsychotic medication. During a review of Resident 24's physician order, dated [DATE], the physician order indicated to administer Lithium Carbonate 150 mg by mouth two times a day for manic disorder (a serious mental state). During a review of Resident 24's physician order, dated [DATE], the physician order indicated to administer Clozapine 200 mg by mouth two times a day for psychosis (a mental health symptoms). During a concurrent interview and record review on [DATE] at 9:56 a.m., with the DON, Resident 24's informed consents for Lithium, dated [DATE], and Clozapine, dated [DATE], were reviewed. The consent forms for Lithium and Clozapine did not indicate they were renewed. The DON stated this failure did not meet facility policy or regulatory standards and should have been completed to ensure compliance and protection of resident rights. The DON stated it was the facility's responsibility to ensure that informed consent for all psychotropic medication were obtained and maintained current in the resident's medical record. The DON stated consents must be renewed at least every six months, including when medications were continued over time or when prior consents have expired. The DON stated medications such as Lithium and Clozapine required documented informed consent due to their potential risks and side effects, and that failure to maintain current consent forms may result in Resident 24 or the resident representative not being fully informed regarding continued use of psychotropic medication. During a review of the facility's policy and procedure (P&P) titled Informed Consent, dated 12/2025, the P&P indicated the use of an antipsychotic drug was not to be initiated until the facility is able to verify that the resident or their authorized representative has given informed consent. The P&P indicated the facility staff shall verify the resident or his/her surrogate has given informed consent to the proposed treatment or procedure prior to the initiation of psychotherapeutic drugs, antipsychotic drugs, physical restraints or the prolonged use of device that may lead to the inability to regain use of normal bodily function. The P&P indicated the facility must obtain written informed consent for treatment using psychotropic drugs, with renewal every six months.

Based on interview and record review, the facility failed to ensure two of two sampled resident's (Resident 89 and Resident 54) responsible parties were provided the opportunity to be involved in their care. This deficient practice resulted in Resident 89's Responsible Party (RP 1) and Resident 54's Public Guardian (PG, a court-appointed public official or agency responsible for managing the personal, medical, or financial affairs of individuals deemed legally incapacitated), PG 6, being unaware of changes in the residents' conditions and unable to provide input in the plan of care and decision-making process.Findings: During a review of Resident 89's admission Record, the admission Record indicated Resident 89 was admitted to the facility on [DATE]. The admission Record indicated Resident 89's diagnoses included paranoid schizophrenia (a mental illness that is characterized by disturbances in thought). The admission Record indicated Responsible Party (RP) 1 was identified as Resident 89's responsible party. During a review of Resident 89's Minimum Data Set (MDS, a resident assessment tool), dated 2/6/2026, the MDS indicated Resident 89 cognitive skills for daily decision making were intact (ability to think and reason). The MDS indicated Resident 89 could eat independently. During a review of Resident 89's physician order, dated 5/6/2025, the physician order indicated to provide a low-fat diet. During a review of Resident 89's physician order, dated 3/13/2026, the physician order indicated to administer Metformin Hydrochloride (a medication used to treat high blood sugar levels) twice a day for overweight. During a telephone interview on 5/6/2026 at 1:45 p.m., with RP 1, RP 1 stated the facility never discussed Resident 89's weight, nutritional status, or planned weight loss with him. RP 1 stated it was better for Resident 89 to gain weight. RP 1 stated he would not want Resident 89 to lose weight. RP 1 stated weight loss would worry him and cause him to think something was wrong with Resident 89. RP 1 stated Resident 89 never mentioned wanting to lose weight, or expressed concerns about her weight. RP 1 stated he would not be agreeable to Resident 89 being on a weight loss program. RP 1 stated he would have wanted the facility to discuss this with him before implementing medications for weight loss and a low-fat diet. During an interview on 5/7/2026 at 1:31 p.m., with the Registered Dietician (RD), the RD stated that when she adjusted Resident 89's care plan, including the implementation of a low-fat diet and encouragement of weight loss, she did not notify RP 1. The RD stated the decision was based on her judgment and what she felt was best for Resident 89. The RD stated it was not her routine practice to consult with the RPs of the facility's residents when altering the plan of care. During an interview on 5/7/2026 at 3:39 p.m., with the Director of Nursing (DON), the DON stated the RD was expected to notify the residents' RPs when there were plans to change a resident's diet. The DON stated the RD would need to notify RP 1 of any planned changes to allow him the opportunity to accept or decline the change. The DON stated it was RP 1's right to be involved in the care planning process, and to accept or decline changes to the care plan. The DON stated the RD's role was to educate, but the RP was to make their own decision. The DON stated the RD was not to make decisions on behalf of the residents or their RPs. 2. During a review of Resident 54's admission Record, the admission Record indicated Resident 54 was admitted to the facility on [DATE]. Resident 54's diagnoses included schizophrenia and obesity. The admission Record indicated Public Guardian (PG) 6 was Resident 54's public guardian. During a review of Resident 54's MDS, dated [DATE], the MDS indicated Resident 54 did not have cognitive impairment. The MDS indicated Resident 54 was independent with all activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily) except for personal and oral hygiene. During a review of Resident 54's record titled Initial Interdisciplinary (IDT, group of different disciplines working together towards a common goal of a resident) Case Conference/Patient Care Plan Review, undated, the record indicated a case conference meeting was conducted on 7/7/2025. The record did not indicate PG 6 was notified. The record did not indicate PG 6 attended the case conference meeting. The record did not indicate a reason for PG 6's absence. During a review of Resident 54's laboratory results, dated 12/22/2025, the results indicated Resident 54 had abnormal triglyceride levels (amount of fat in your blood). During a review of Resident 54's physician order, dated 2/5/2026, the order indicated Resident 54 was placed on a low-fat diet. During a review of Resident 54's record titled Interdisciplinary Quarterly Case Conference/Patient Care Plan Review, undated, the record indicated a case conference meeting was conducted on 3/2/2026. The record indicated Resident 54's PG, PG 6, was notified via email of the case conference meeting, and indicated PG 6 was not in attendance. The record indicated did not indicate PG 6's reason for the absence. During a telephone interview, on 5/6/2026 at 2:26 p.m., with PG 6, PG 6 stated she did not recall receiving any notification about care conference meetings to discuss Resident 54's plan of care. PG 6 stated she had not participated in any care planning meetings since Resident 54's admission to the facility. PG 6 stated she was responsible for Resident 54's overall care and well-being and stated she was unaware that Resident 54's diet had been changed or that she had abnormal laboratory results on 12/22/2025. PG 6 stated she wanted to be notified of abnormal labs to be aware and ensure that she followed up with the facility on repeat laboratory testing. PG 6 stated involvement in the care conference meetings would be helpful for her to adequately support Resident 54 and be aware of the care she was receiving. During an interview on 5/7/2026 at 3:11 p.m., with the DON, the DON stated Resident 54's PG was to be notified of all case conference meetings because they were actively providing input in care decisions. The DON stated it was the PG's right to be involved in and aware of these meetings. During an interview on 5/7/2026 at 4:04 p.m., with Registered Nurse (RN) 3, RN 3 stated she assisted in coordinating case conference meetings within the facility. RN 3 stated the facility was unable to locate records indicating PG 6 was notified of the case conference meetings conducted on 7/7/2025 and 3/2/2026. During a review of the facility's policy and procedure (P&P) titled Care Planning, dated 12/2025, the P&P indicated an interdisciplinary treatment team, in coordination with private or public guardians, were to develop and maintain a comprehensive Care Plan for each resident.

Based on interview and record review, the facility failed to ensure two of two sampled residents (Resident 54 and Resident 89) were permitted to make choices about their diets and snack preferences. This deficient practice resulted in Resident 89 and Resident 54 reporting they did not receive enough food to feel full after meals, reported experiencing unaddressed hunger, and denial of additional food when requested.Findings: During a review of Resident 89's admission Record, the admission Record indicated Resident 89 was admitted to the facility on [DATE]. The admission Record indicated Resident 89's diagnoses included paranoid schizophrenia (a mental illness that is characterized by disturbances in thought). The admission Record indicated Resident 89 was not self-responsible and had a responsible party, RP 1. During a review of Resident 89's admission Minimum Data Set (MDS, a resident assessment tool), dated 5/6/2025 indicated Resident 89's cognitive skills for daily decision making was intact (ability to think and reason). The MDS indicated Resident 89 reported it was very important for her to have snacks between meals. The MDS indicated Resident 89 was able to eat independently. The MDS indicated Resident 89 had not experienced any significant or severe weight loss or gain. During a review of Resident 89's quarterly MDS, dated [DATE], the MDS indicated Resident 89's cognitive skills for daily decision making were intact. The MDS indicated Resident 89 could eat independently. The MDS indicated Resident 89 had not experienced significant or severe weight loss or gain. During a review of Resident 89's physician order, dated 5/6/2025, the physician order indicated low-fat diet. The physician order did not indicate orders for snacks. During a review of Resident 89's record titled Nutritional Assessment, dated 8/1/2025, by the Registered Dietician (RD), the assessment indicated Resident 89 was on a low-fat diet, receiving regular-sized meal portions. The assessment indicated Resident 89 declined to change to small portions to promote [weight] loss. The assessment indicated the goals of care included Resident 89 having gradual weight loss. The assessment indicated the RD recommended Resident 89 to participate in the [physical activity] program two to three times per week for [weight] loss. During a review of Resident 89's record titled Nutritional Assessment, dated 11/4/2025, by the Registered Dietician (RD), the assessment indicated Resident 89 remained on a low-fat diet. The assessment indicated the RD asked Resident 89 to consider small portions to help promote lower caloric intake and to help with [weight] loss. The assessment indicated Resident 89 refused this intervention. The assessment indicated the RD encouraged Resident 89 to be more physically active to promote [weight] loss. The assessment indicated the goals of care remained gradual [weight] loss. During a review of Resident 89's record titled Nutritional Assessment, dated 1/30/2026, by the Registered Dietician (RD), the assessment indicated Resident 89 remained on a low-fat diet, and was not agreeable to small portions to help with weight loss. During an interview on 5/4/2026 at 1:33 p.m., with Resident 89, Resident 89 stated she would like extra snacks, such as a baloney sandwich or banana, between meals. Resident 89 stated she talked with the RD twice in the last year and the RD told her she was obese (excess in body weight). Resident 89 stated she was comfortable with her weight and did not want to lose weight. Resident 89 stated she still felt hungry after lunch and would like an extra snack when the bedtime (8:00 p.m.) snacks were distributed. During an interview on 5/4/2026 at 1:42 p.m., in the hallway, with Resident 89, Resident 89 approached the surveyor and said, I'm hungry. When asked if she had requested a snack, Resident 89 appeared fearful and replied, Can you ask?. When the surveyor approached the Northside Nurse's Station, Resident 89 appeared nervous and in a hushed voice stated, Never mind, it's ok. During an interview on 5/6/2026 at 1:28 p.m., with Resident 89, Resident 89 stated she received a snack at 2:00 p.m. after lunch, and 8:00 p.m. after dinner. Resident 89 stated she never received snacks at 10:00 a.m. but knew that other residents did. Resident 89 stated she was limited to one snack item at 8:00 p.m. but would like extra. When asked what extra meant to her, Resident 89 stated staff provided sandwiches as a snack, but it didn't feel fair because only half of the sandwich was provided instead of a whole sandwich. Resident 89 stated she had asked for another half in the past, but staff always denied the request. Resident 89 stated staff tell her she had to to talk to the RD. Resident 89 stated when she spoke to the RD, the RD told her she was obese. Resident 89 stated she asked for extra food because she was still hungry. During a telephone interview on 5/6/2026 at 1:45 p.m., with RP 1, RP 1 stated the facility never discussed Resident 89's weight, nutritional status, or a plan for planned weight loss with him. RP 1 stated it was better for Resident 89 to gain weight. RP 1 stated he would not want Resident 89 to lose weight. RP 1 stated weight loss would worry him and cause him to think something was wrong with Resident 89. RP 1 stated Resident 89 never mentioned wanting to lose weight, or expressed concerns about her weight. RP 1 stated he would not be agreeable to Resident 89 being on a weight loss program. RP 1 stated he would have wanted the facility to discuss this with him before implementing medications for weight loss and a low-fat diet. During an interview on 5/7/2026 at 1:31 p.m., with the RD, the RD stated that when she adjusted Resident 89's care plan, including the implementation of a low-fat diet and encouragement of weight loss, she did not notify RP 1. The RD stated the decision was based on her judgment and what she felt was best for Resident 89. The RD stated it was not her routine practice to consult with the RPs of the facility's residents when altering the plan of care. During an interview on 5/7/2026 at 3:39 p.m., with the Director of Nursing (DON), the DON stated the RD was expected to notify the residents' RPs when there were plans to change a resident's diet. The DON stated the RD would need to notify RP 1 of any planned changes to allow him the opportunity to accept or decline the change. The DON stated it was RP 1's right to be involved in the care planning process, and to accept or decline changes to the care plan. The DON stated the RD's role was to educate, but the RP was to make their own decision. The DON stated the RD was not to make decisions on behalf of the residents or their RPs. 2. During a review of Resident 54's admission Record, the admission Record indicated Resident 54 was admitted to the facility on [DATE]. Resident 54's diagnoses included schizophrenia and obesity. The admission Record indicated Resident 54 had a PG, PG 6. During a review of Resident 54's MDS, dated [DATE], the MDS indicated Resident 54's cognitive skills for daily decision making were intact. The MDS indicated Resident 54 was independent with all activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily) except for personal and oral hygiene. During a review of Resident 54's record titled Initial Interdisciplinary (IDT, group of different disciplines working together towards a common goal of a resident) Case Conference/Patient Care Plan Review, undated, the record indicated a case conference meeting was conducted on 7/7/2025. The record did not indicate PG 6 was notified. The record did not indicate PG 6 attended the case conference meeting. The record did not indicate a reason for PG 6's absence. During a review of Resident 54's laboratory results, dated 12/22/2025, the results indicated Resident 54 had abnormal triglyceride levels (amount of fat in your blood). During a review of Resident 54's physician order, dated 2/5/2026, the order indicated Resident 54 was placed on a low-fat diet. During a review of Resident 54's record titled Interdisciplinary Quarterly Case Conference/Patient Care Plan Review, undated, the record indicated a case conference meeting was conducted on 3/2/2026. The record indicated PG 6 was notified via email of the case conference meeting but was not in attendance. The record did not indicate PG 6's reason for the absence. During a telephone interview, on 5/6/2026 at 2:26 p.m., with PG 6, PG 6 stated she did not recall receiving any notification of care conference meetings to discuss Resident 54's plan of care. PG 6 stated she had not participated in any care planning meetings since Resident 54's admission to the facility. PG 6 stated she was responsible for Resident 54's overall care and well-being. PG 6 stated she was unaware that Resident 54's diet was changed or that she had abnormal laboratory results on 12/22/2025. PG 6 stated she wanted to be notified of abnormal labs to be aware and ensure that she followed up with the facility on repeat laboratory testing. PG 6 stated involvement in the care conference meetings would be helpful for her to adequately support Resident 54 and be aware of the care she was receiving. During an interview on 5/7/2026 at 3:11 p.m., with the DON, the DON stated PG 6 was to be notified of all case conference meetings because PG 6 was actively providing input in care decisions. The DON stated it was PG 6's right to be involved in and aware of these meetings. During an interview on 5/7/2026 at 4:04 p.m., with Registered Nurse (RN) 3, RN 3 stated she assisted in coordinating case conference meetings within the facility. RN 3 stated the facility was unable to locate records to indicate PG 6 was notified of the case conference meetings conducted on 7/7/2025 and 3/2/2026. During a review of the facility's policy and procedure (P&P) titled Weight Assessment and Intervention, dated 12/2025, the P&P indicated interventions for undesired weight gain were to consider the resident's preferences and rights. The P&P indicated that a weight loss regimen was not to be initiated for a cognitively capable resident without his/her approval and involvement. During a review of the facility's P&P titled Care Planning, dated 12/2025, the P&P indicated an interdisciplinary treatment team, in coordination with private or public guardians, were to develop and maintain a comprehensive Care Plan for each resident.

Based on interview and record review, the facility failed to notify the physician of abnormal laboratory results for two of two sampled residents (Resident 89 and Resident 57) when:1. Resident 89 had:a. An abnormal valproic acid level (the level of valproic acid [an anticonvulsant medication] in the bloodstream) on 8/6/2025.b. An abnormal triglyceride level (amount of fat in the blood) and valproic acid level on 10/23/2025.c. An abnormal valproic acid level on 1/23/2026.d. Abnormal blood urea nitrogen (BUN, a waste product that forms as your body breaks down proteins) and creatinine (a measure of how well the kidneys are doing their job of filtering waste from the blood) levels on 4/23/2026.2. Resident 57 had abnormal valproic acid levels on 5/8/2025, 9/2/2025, and 10/24/2025. This deficient practice placed Residents 89 and 57 at risk of not receiving timely interventions to address the abnormal laboratory values, including monitoring and/or adjustments to medications and treatments.Findings: During a review of Resident 89's admission Record, the admission Record indicated Resident 89 was admitted to the facility on [DATE]. The admission Record indicated Resident 89's diagnoses included paranoid schizophrenia (a mental illness that is characterized by disturbances in thought), hypokalemia (low potassium levels in the blood), hypo-osmolality (a low concentration of electrolytes, proteins, and/or nutrients) in the blood plasma), hyponatremia (low sodium levels in the blood), and anemia (a condition where the body does not have enough healthy red blood cells). During a review of Resident 89's admission Minimum Data Set (MDS, a resident assessment tool), dated 2/6/2026 indicated Resident 89 cognitive skills for daily decision making was intact (ability to think and reason). The MDS indicated Resident 89 was independent for all activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily) except for personal and oral hygiene. During a review of Resident 89's laboratory results, dated 8/6/2025, the results indicated Resident 89's valproic acid level was 44.0 micrograms (mcg) per milliliter (mL) (mcg/mL, a unit of measurement [normal reference range, NRR, 50 to 100 mcg/mL]). During a review of Resident 89's laboratory results, dated 10/23/2025, the results indicated Resident 89's valproic acid level was 45.0 mcg/mL. Resident 89's triglyceride level was 185 milligrams (mg) per mL (mg/mL, a unit of measurement [NRR and normal triglyceride levels were indicated as 35 to 160 mg/mL. During a review of Resident 89's laboratory results, dated 1/23/2026, the results indicated Resident 89's valproic acid level was 39.8 mcg/mL. During a review of Resident 89's laboratory results, dated 4/23/2026, the results indicated Resident 89's BUN was six (6) mg per deciliter (dL) (mg/dL, a unit of measurement [NRR seven (7) to 23 mg/dL]). The laboratory results indicated Resident 89's creatinine was 0.5 mg/dL (NRR 0.6 mg/dL to 1.4 mg/dL). During an interview on 5/7/2026 at 3:44 p.m., with the Director of Nursing (DON), the DON stated there was no documentation in Resident 89's medical record to indicate the abnormal lab values on 8/6/2025, 10/23/2025, 1/23/2026, and 4/23/2026 were reported to Resident 89's physician. Resident 89 stated the abnormal laboratory results should have been reported to ensure the physician was aware in case interventions or changes to the resident's care might be needed. The DON stated that it was best practice to notify the doctor of all abnormal laboratory results. 2. During a review of Resident 57's admission Record, the admission Record indicated Resident 57 was admitted to the facility on [DATE]. Resident 57's diagnoses included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior). During a review of Resident 57's MDS, dated [DATE], the MDS indicated Resident 57 had moderate cognitive impairment. The MDS indicated Resident 57 was independent for all ADLs, except personal and oral hygiene. During a review of Resident 57's care plan titled Anti-convulsant medication Depakote (valproic acid) related to behavior management, dated 3/19/2025, the care plan indicated staff were to monitor labs as ordered by the physician. During a review of Resident 57's laboratory results, dated 5/8/2025, the results indicated Resident 57's valproic acid level was 35.7 mcg/mL. During a review of Resident 57's laboratory results, dated 9/2/2025, the results indicated Resident 57's valproic acid level was 107.1 mcg/mL. During a review of Resident 57's laboratory results, dated 10/24/2025, the results indicated Resident 57's valproic acid level was 100.5 mcg/mL. During an interview on 5/7/2026 at 2:46 p.m., with the DON, the DON stated there was no documentation in Resident 89's medical record to indicate her physician was notified of the abnormal valproic acid levels on 5/8/2025, 9/2/2025, and 10/24/2025. The DON stated the licensed nurse was expected to notify the physician as soon as the results were reviewed, or at least within 24 hours. During a review of the facility's policy and procedure (P&P) titled Laboratory, Radiological, and Diagnostic Results, dated 12/2025, the P&P indicated the resident's attending physician was to be notified of the results of diagnostic tests.

Based on observation, interview, and record review, the facility failed to ensure adequate monitoring of psychotropic medications (any drug that changes brain function resulting in alteration to mood, thoughts, feelings or behavior) for four of seven sampled residents (Resident 5, Resident 18, Resident 57 and Resident 109) when the facility failed to: 1. Monitor Resident 5's behaviors of manic speech (speaking urgently and rapidly often jumping between unrelated topics) and rapid thought process. 2. Ensure adequate behavior monitoring for Resident 18's use of ativan (a medication that works to slow down the nervous system and create a calming effect), lithium carbonate (used as a mood stabilizer to treat and prevent manic and depressive episodes in bipolar disorder), and clozapine (a medication used to treat mental health conditions).3. Ensure a behavior manifestation was indicated and monitored for Resident 57's use of ativan.4. Reassess Resident 109's continued need for remeron (Mirtazapine, a medication used to treat major depressive disorder and increase appetite).These deficient practices had the potential to place Residents 5, 18, 57, and 109 at risk for unnecessary psychotropic medication use and unidentified and unaddressed changes in behavior.Findings: 1. During a review of Resident 5's admission Record, the admission Record indicated Resident 5 was admitted to the facility on [DATE]. Resident 5's diagnoses included schizophrenia (a mental illness that is characterized by disturbances in thought) and insomnia (persistent difficulty falling or staying asleep). During a review of Resident 5's History and Physical (H&P) dated 6/5/2025, the H&P indicated Resident 5 was alert and oriented with intact cognitive (ability to think and understand) function. During a review of Resident 5's Minimum Data Set (MDS- a resident assessment tool) dated 4/10/2026, the MDS indicated Resident 5 had moderate cognitive impairment. The MDS indicated Resident 5 was independent with eating, toileting and bathing. During a review of Resident 5's care plan titled, Uses Antipsychotic medication Lithium related to schizoaffective disorder (a mental illness that can affect thoughts, mood and behavior) and manic speech rapid thought process dated 1/9/2026, the care plan indicated to administer psychotropic medications as ordered by physician, and monitor for side effects and effectiveness Q (every) shift. During a concurrent interview and record review on 5/5/2026 at 11:22 a.m. with Licensed Vocational Nurse (LVN) 3, Resident 5's medical record and physician order's dated 1/8/2026 were reviewed. The physician orders indicated, Lithium Carbonate oral capsule 150 milligrams (mg- a metric unit of measurement, used for medication dosage and/or amount) Give one capsule by mouth in the morning for manic speech, rapid thought process. The medical records did not indicate there was a physician order for the behavior monitoring of Resident 5's manic speech or rapid thought process. LVN 3 stated there should always be orders to monitor for the indicated behavior of psychotropic medications. LVN 3 stated there should have been an order to monitor Resident 5's manic speech and rapid thought process to ensure effectiveness of medication regimen and to determine the need of physician reassessment. LVN 3 stated not monitoring Resident 5's manic speech or rapid thought process placed the resident at risk of unidentified and unaddressed changes in behavior. During an interview on 5/7/2026 at 9:42 a.m. with the Director of Nursing (DON), the DON stated monitoring indicated behaviors for psychotropic medications was important to ensure any significant trends or changes in behavior were identified and communicated to the physician. The DON stated adequate monitoring of behavior ensured appropriate physician reassessment or medication adjustment. 2. During a review of Resident 18's admission Record, the admission Record indicated Resident 18 was admitted to the facility on [DATE]. Resident 18's diagnoses included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior). During a review of Resident 18's MDS dated [DATE], the MDS indicated Resident 18 had severe cognitive impairment. The MDS indicated Resident 18 was independent for all activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily) except for personal hygiene and oral hygiene. During a review of Resident 18's physician order, dated 2/17/2023, the order indicated to administer Ativan 0.5 mg twice a day for anxiety manifested by tearful and irritable behavior. During a review of Resident 18's physician order, dated 5/23/2024, the order indicated to administer lithium carbonate 300 mg twice a day for manic symptoms. The order did not indicate what Resident 18's specific manic symptoms were. During a review of Resident 18's physician order, dated 2/6/2026, the order to administer clozapine 200 mg in the morning, and 300 mg at bedtime, for psychosis. The order did not indicate what Resident 18's specific psychosis behaviors were. During an interview on 5/7/2026 at 2:31 p.m., with the DON, the DON stated the behavioral indications for Resident 18's Ativan, lithium carbonate, and clozapine were different. The DON stated all three medications would require behavior monitoring for their specific behavioral indications. The DON stated manic symptoms was not a specific behavior that staff could quantify. The DON stated Resident 18's order for lithium carbonate needed to be more specific. The DON stated psychosis was also not specific enough for staff to monitor the effectiveness of Resident 18's clozapine. During a concurrent interview and record review on 5/7/2026 at 2:37 p.m., with the DON, Resident 18's records titled Monitoring, dated from 1/2026 to 5/2026 were reviewed. The DON stated the records indicated staff were not documenting the frequency of Resident 18's tearful and irritable behavior related to his Ativan use. The DON stated staff were also unable to monitor the effectiveness of Resident 18's lithium carbonate and clozapine due to the lack of specific indicated behavior. The DON stated accurate record of behavior frequency affected the plan of care, including attempts for gradual dose reduction (GDR, stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued). 3. During a review of Resident 57's admission Record, the admission Record indicated Resident 57 was admitted to the facility on [DATE]. Resident 57's diagnoses included schizoaffective disorder. During a review of Resident 57's MDS, dated [DATE], the MDS indicated Resident 57 had moderate cognitive impairment. The MDS indicated Resident 57 was independent for all ADLs except personal and oral hygiene. During a review of Resident 57's care plan titled Uses anti-anxiety medications., dated 2/12/2025, the care plan indicated staff were to assess degree and manifestations of anxiety and mental status prior to and periodically during therapy. During a review of Resident 57's discontinued physician order, dated 7/5/2025, the order indicated staff were to administer Ativan 1 mg in the morning for anxiety for 14 days. The order did not indicate the specific anxious behavior. During a review of Resident 57's Electronic Medication Administration Record (EMAR), dated 7/1/2025 to 7/31/2025, the EMAR indicated Resident 57 was administered Ativan every day, from 7/5/2025 to 7/18/2025. During a review of Resident 57's record titled Monitoring, dated 7/1/2025 to 7/31/2025, the record did not indicate behavior monitoring was conducted for anxiety, a specific anxious behavior, or Resident 57's use of Ativan. During a review of Resident 57's active physician order, dated 8/16/2025, the order indicated to administer Ativan 1 mg in the morning for anxiety. The order did not indicate the specific anxious behavior. During a review of Resident 57's records titled Monitoring, dated from 1/2026 to 5/2026, the records did not indicate behavior monitoring was conducted for anxiety, a specific anxious behavior, or Resident 57's use of Ativan. During an interview on 5/7/2026 at 2:55 p.m., with the DON, the DON stated Resident 57's active Ativan order, dated 8/16/2025, indicated it was for anxiety. The DON stated that the order, as currently written, was not specific enough for staff to adequately monitor effectiveness of the medication. The DON stated the order should be more specific and include the manifesting anxious behavior. The DON stated there was also no documentation that staff were monitoring the effectiveness of Resident 57's current Ativan orders. During an interview on 5/7/2026 at 3:00 p.m., with the DON, the DON stated there was no documentation in Resident 57's medical record indicating why Ativan was started on 8/16/2025. The DON stated there should be a clearly documented indication to justify the continued use of Ativan following completion of her previous Ativan order on 7/19/2025. The DON stated Ativan was a psychotropic medication, and stated staff should attempt non-pharmacological interventions prior to initiation psychotropic medication. The DON stated non-pharmacological interventions assisted in avoiding potential adverse effects associated with Ativan, such as drowsiness, dizziness, nausea, confusion, and risk for falls. The DON stated there was no documentation to indicate Resident 57's Ativan was a necessary medication. 4. During a review of Resident 109's admission Record, the admission Record indicated Resident 109 was admitted to the facility on [DATE]. Resident 109's diagnoses included schizophrenia. During a review of Resident 109's MDS, dated [DATE], the MDS indicated Resident 109's cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 109 was independent for ADLs. During a review of Resident 109's care plan titled Mirtazapine, dated 12/4/2025, the care plan indicated staff would monitor for fatigue, weakness, and decreased appetite. The care plan interventions indicated the facility would discuss with Resident 109's physician and conservator (public guardian [PG]- a court-appointed public official or agency responsible for managing the personal, medical, or financial affairs of individuals deemed legally incapacitated) regarding ongoing need for the use of the medication. During a review of Resident 109's physician order, dated 12/10/2025, the physician order indicated to administer Remeron (Mirtazapine) 15 mg by mouth at bedtime for appetite. During an observation on 5/4/2026 at 8:40 a.m., 11:35 a.m., and 2:20 p.m., at Resident 109's bedside, Resident 109 was observed lying in bed with eyes closed, unarousable. Resident 109 did not respond to verbal prompts or attempts to engage the resident during the observation. During an observation on 5/5/2026 at 10:10 a.m., 12:10 p.m., and 3:20 p.m., at Resident 109's bedside, Resident 109 was observed lying in bed with eyes closed, unarousable. During a concurrent observation and interview on 5/6/2026 at 8:55 a.m., at Resident 109's bedside, with Certified Nursing Assistant (CNA) 2, Resident 109 was observed lying in bed with eyes closed, unarousable. CNA 2 attempted to verbally prompt Resident 109, however, Resident 109 did not respond. CNA 2 stated Resident 109 was usually sleepy and difficult to wake up especially in the morning. CNA 2 stated Resident 109 did not eat breakfast often but had a good appetite for lunch and dinner. During an interview on 5/6/2026 at 11:35 a.m., with LVN 4, LVN 4 stated Resident 109 received Mirtazapine 15 mg at bedtime for appetite stimulation. LVN 4 stated Mirtazapine may cause sleepiness or sedation. LVN 4 stated there was no documented assessment indication for Resident 109's continued need for Mirtazapine or whether the medication remained effective for appetite stimulation. LVN 4 stated he was not aware that Resident 109 had a poor appetite. LVN 4 stated Resident 109 often skipped breakfast because he was sleepy but had a good appetite for lunch and dinner. LVN 4 stated Resident 109's increased sleepiness and inability to be aroused were not evaluated as possible adverse effects of Mirtazapine. During an interview on 5/7/2026 at 9:30 a.m., with the DON, the DON stated residents receiving psychotropic medications should be monitored for continued clinical need, effectiveness, and possible side effects. The DON stated Mirtazapine may cause sleepiness and sedation. The DON stated if Resident 109 was repeatedly difficult to arouse, the licensed nurse should have assessed the resident, notified the physician, and documented the resident's condition and any follow-up actions taken. The DON stated there was no documented evidence that the facility assessed the continued need for Mirtazapine, evaluated the medication's effectiveness for appetite stimulation, monitored for adverse effects, or notified the physician regarding Resident 109's repeated sleepiness and inability to be aroused. The DON stated this placed Resident 109 at risk for unnecessary psychotropic medication use, chemical restraint, over-sedation, decline in condition, and adverse medication effects. During a review of the facility's P&P titled Psychotropic Medication Use and Monitoring, dated 12/2025, the P&P indicated psychotropic medications were to be used to address behaviors only if non-drug approaches and interventions were attempted prior to their use. The P&P indicated all medications used to treat behaviors must have clinical indication and be used in the lowest possible doses to achieve the desired therapeutic effect. The P&P indicated the prescriber will not use psychotropic medications to address behaviors without first determining if a medical, physical, functional, psychological, social or environmental cause of the resident's behaviors. The P&P indicated all residents receiving medications used to treat behaviors should be monitored for efficacy, risks, benefits, harm or adverse consequences. The P&P indicated facility staff will monitor the resident for side effects for residents receiving psychotropic medications.

Based on interview and record review, the facility failed to ensure a Minimum Data Set ([MDS]- a resident assessment tool) for a significant change was completed within fourteen (14) days for one of two sampled residents (Resident 30) after the resident experienced significant weight loss.This deficient practice resulted in delayed assessment and transmitting Resident 30's significant change in condition to the Centers for Medicare and Medicaid Services (CMS) and had the potential to negatively affect the resident's care planning, and delivery of necessary care and services to address significant weight loss.Cross Reference F657 and F692Findings: During a review of Resident 30's admission Record, the admission Record indicated Resident 30 was admitted to the facility on [DATE]. Resident 30's diagnoses included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior) and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). During a review of Resident 30's Minimum Data Set ([MDS]- a resident assessment tool), dated 2/8/2026, the MDS indicated Resident 30's cognition (the ability to think and process information) was severely impaired. The MDS indicated Resident 30 was independent (resident completes the activities by himself) with activities of daily living ([ADLs]- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a concurrent interview and record review on 5/7/2026 at 11:10 a.m., with Registered Nurse (RN) 3, Resident 30's records, including weight and vitals summary, dated 1/27/2026 through 2/23/2026, were reviewed. The weight and vitals summary indicated Resident 30's weighed 225.6 pounds (lbs.) on 1/27/2026 and 206 lbs. on 2/23/2026. Resident 30 experienced a total weight loss of 19.6 lbs. and 8.8 percentage [%] of body weight, in approximately one month. RN 3 stated she was responsible for completing the MDS assessments for the facility. RN 3 stated Resident 30's weight loss was significant and should have triggered further assessment to determine the cause of the weight loss and whether current nutritional interventions were effective. RN 3 stated the facility should have evaluated Resident 30's weight loss, nutritional status, intake, and need for updated care and services. RN 3 stated the facility should have completed a MDS for significant change after the weight loss was identified. RN 3 stated there was no documented evidence that a significant change MDS assessment was completed within 14 days after Resident 30's significant weight loss was identified on 2/23/2026. During an interview on 5/7/2026 at 9:45 a.m., with the Director of Nursing (DON), the DON stated residents with significant weight loss should be assessed to determine whether the resident had a significant change in condition. The DON stated a MDS for significant change should be completed within 14 days when the resident's condition declined, and the change required review and revision of the resident's care and services. The DON stated the interdisciplinary team (a coordinated group of healthcare professionals who collaborate and evaluate comprehensive care for a resident) should have evaluated the resident's intake, weight trends, food preferences, and need for additional nutritional approaches. The DON stated failure to complete a significant change MDS assessment may delay identification of the resident's current needs, negatively affect care planning and delivery of necessary care and services. The DON stated this placed Resident 30 at risk for continued weight loss, inadequate nutritional intake, weakness, decline in ADLs, and further decline in overall condition. During a review of the facility's policy and procedure (P&P) titled Frequency of Conducting Resident Assessments, dated 12/2025, the P&P indicated the assessment coordinator must ensure the interdisciplinary team conducts and reviews resident assessments within 14 days of a significant change in condition.

Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS, a resident assessment tool) was accurately coded following a fall for one of one sampled resident (Resident 57). This deficient practice created the potential for Resident 57 to not receive the necessary care and interventions to prevent further falls and possible injuries.Findings: During a review of Resident 57's admission Record, the admission Record indicated Resident 57 was admitted to the facility on [DATE]. Resident 57's diagnoses included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior). During a review of Resident 57's Minimum Data Set (MDS, a resident assessment tool), dated 2/25/2026, the MDS indicated Resident 57 had moderate cognitive impairment (a significant decline in memory, language, or reasoning that interferes with daily life, such as managing finances or complex tasks). The MDS indicated Resident 57 was independent for all activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily) except personal and oral hygiene. During a review of Resident 57's Change of Condition (COC) assessment, dated 8/29/2025, the assessment indicated Resident 57 slipped and fell to the floor while in the shower. The COC assessment indicated Resident 57's fall was unwitnessed. During a review of Resident 57's Quarterly MDS, dated [DATE], the MDS indicated Resident 57 had no falls since admission. During an interview on 5/7/2026 at 11:26 a.m., with Registered Nurse (RN) 3, RN 3 stated she conducted the MDS assessments. RN 3 stated she completed Resident 57's MDS assessment dated [DATE]. RN 3 stated Resident 57 had an unwitnessed fall on 8/29/2025. RN 3 stated the fall should have been coded in her MDS assessment dated [DATE], but it was not. RN 3 stated that accurately indicating Resident 57's fall would have prompted staff to develop a care plan to monitor fall complications, identify the cause of the fall, and try to prevent additional falls. During a review of the facility's policy and procedure (P&P) titled Falls Management System, dated 12/2025, the P&P indicated it was the policy of the facility to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs. During a review of the facility's P&P titled Resident Assessment Instrument (MDS 3.0), dated 12/2025, indicated the purpose of the MDS assessment was to describe the resident's capability to perform daily life functions and to identify significant impairments in functional capacity. The P&P indicated that information derived from the comprehensive assessment enabled the staff to plan care that allows the resident to reach his/her highest practicable level of functioning.

Based on interview and record review, the facility failed to develop a care plan for psychotropic medications (medications that affect the mind, emotions, and behavior) for one of five residents sampled for unnecessary medication review (Resident 18). This deficient practice had the potential to result in Resident 18 not receiving non-pharmacological (non-medicinal) interventions to address his lack of sleep, for which staff were administering Trazodone (a prescription medication, with sedative properties, typically used to treat major depressive disorder [a serious, common mood disorder characterized by at least two weeks of persistent, severe low mood, sadness, or loss of interest in activities]).Findings: During a review of Resident 18's admission Record, the admission Record indicated Resident 18 was admitted to the facility on [DATE]. Resident 18's diagnoses included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior). During a review of Resident 18's Minimum Data Set (MDS, a resident assessment tool), dated 2/16/2026, the MDS indicated Resident 18 had severe cognitive impairment (difficulty with thinking, memory, concentration, judgment, and learning that exceeds normal aging). The MDS indicated Resident 18 was independent for all activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily) except for personal hygiene and oral hygiene. During a review of Resident 18's physician order, dated 2/29/2024, the order indicated to administer Trazodone 50 milligrams (mg, a unit of dose measurement) at bedtime for lack of sleep. During an interview on 5/7/2026 at 2:41 p.m., with the Director of Nursing (DON), the DON stated Resident 18 received Trazodone at bedtime for lack of sleep. The DON stated there should be a care plan to monitor for side effects. The DON stated Trazodone should also have a care plan to include non-pharmacological interventions to reduce or discontinue the use of Trazodone. The DON stated the least restrictive measures should always be attempted, if possible, to address a behavior prior to the use of psychotropic medications like Trazodone. During a review of the facility's policy and procedure (P&P) titled Care Planning, dated 12/2025, the P&P indicated the purpose of a care plan was to identify the resident's needs and develop a comprehensive, standardized plan of care for each resident to meet the resident's psychiatric, psychosocial, and medical needs. During a review of the facility's P&P titled Psychotropic Medication Use and Monitoring, dated 12/2025, the P&P indicated the resident or the resident's representative should be involved in the discussion of potential non-drug and medication interventions to address the management of behaviors. The P&P indicated this involvement should be documented in the resident's medical record.

Based on interview and record review, the facility failed to revise the comprehensive care plan and interventions for one of two sampled residents (Resident 30) after the resident experienced a significant weight loss. This deficient practice had the potential to result in Resident 30 not receiving individualized and updated nutritional interventions to address significant weight loss, placing the resident at risk for continued weight loss, nutritional decline, and further decline in health status.Cross Reference F637 and F692Findings: During a review of Resident 30's admission Record, the admission Record indicated Resident 30 was admitted to the facility on [DATE]. Resident 30's diagnoses included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior) and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). During a review of Resident 30's Minimum Data Set ([MDS]- a resident assessment tool), dated 2/8/2026, the MDS indicated Resident 30's cognitive skills for daily decision making (the ability to think and process information) was severely impaired. The MDS indicated Resident 30 was independent with activities of daily living ([ADLs]- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a concurrent interview and record review on 5/6/2026 at 11:30 a.m., with the Registered Dietitian (RD), Resident 30's weight and vitals summary, dated 1/27/2026 through 5/2/2026, was reviewed. The weight and vitals summary indicated Resident 30's weight was 225.6 pounds ([lbs.]- a unit of weight) on 1/27/2026 and 189.2 lbs. on 5/2/2026, a total weight loss of 36.6 lbs. in approximately three months. The RD stated Resident 30's weight loss was significant. The RD stated Resident 30's care plan should have been revised with updated and individualized nutritional interventions to address the significant weight loss. The RD stated new updated interventions were necessary to help prevent continued weight loss and nutritional decline. During a concurrent interview and record review on 5/7/2026 at 11:10 a.m., with Registered Nurse (RN) 3, Resident 30's care plan titled Weight, dated 1/26/2026, was reviewed. The care plan did not indicate additional interventions after Resident 30's significant weight loss was identified. RN 3 stated Resident 30 had a care plan that addressed the resident's risk for weight loss; however, the care plan was not revised with additional interventions after Resident 30's significant weight loss was identified. During an interview on 5/7/2026 at 9:45 a.m., with the Director of Nursing (DON), the DON stated residents with significant weight loss should have their comprehensive care plans reviewed and revised to include updated interventions based on the resident's current condition and needs. The DON stated licensed staff should have evaluated Resident 30's weight loss and updated the care plan with resident centered interventions to address the risk for continued weight loss. The DON stated these new interventions would guide staff in providing consistent care for Resident 30 and help ensure staff were aware of the resident's current nutritional risks and needs. The DON stated failure to revise the care plan after significant weight loss placed Resident 30 at risk for continued weight loss, inadequate nutritional intake, weakness, and decline in ADLs. During a review of the facility's policy and procedure (P&P) titled Care Plans- Comprehensive, dated 12/2025, the P&P indicated residents' care plans were reviewed and revised whenever a resident's condition changes.

Based on observation, interview, and record review, the facility failed to follow physician orders for orthostatic (measures changes in blood pressure and heart rate when moving from lying down to standing up) blood pressure monitoring and recording by failing to accurately obtain, document, and evaluate orthostatic blood pressure readings for three of three sample residents (Resident 57, Resident 124, and Resident 2).This deficient practice had the potential to place Residents 57, 124, and 2 at risk for undetected orthostatic hypotension, dizziness, syncope (fainting), falls, injury, delayed medical intervention, and adverse cardiovascular complications related to changes in blood pressure upon position changes.Findings: 1. During a review of Resident 57's admission Record, the admission Record indicated Resident 57 was admitted to the facility on [DATE]. Resident 57's diagnoses included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior). During a review of Resident 57's Minimum Data Set (MDS, a resident assessment tool), dated 2/25/2026, the MDS indicated Resident 57 had moderate cognitive impairment (a significant decline in memory, language, or reasoning that interferes with daily life, such as managing finances or complex tasks). The MDS indicated Resident 57 was independent for all activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily) except personal and oral hygiene. During a review of Resident 57's Change of Condition (COC) assessment, dated 8/29/2025, the assessment indicated on 8/29/2026, Resident 57 slipped and fell to the floor while in the shower. The assessment indicated Resident 57's fall was unwitnessed. During a review of Resident 57's care plan titled Remains at risk for fall and injuries related to combine usage of different class of psychoactive drugs ., dated 2/11/2025 and revised 9/1/2025, the care plan indicated staff were to remind and explain risks and benefits of safety measures to Resident 57. During an interview on 5/6/2026 at 10:34 a.m., with Resident 57, Resident 57 stated she fell a few weeks ago at her bedside. Resident 57 stated she was getting up to use the bathroom and felt dizzy when she stood up. Resident 57 stated that after the fall she had pain in her back that lasted a few days. During a review of Resident 57's physician order, dated 1/11/2026, the order indicated staff were to administer Norvasc (a medication to treat high blood pressure) 5 milligrams (mg, a unit of dose measurement) at bedtime. During a review of Resident 57's physician orders, dated 2/18/2025, the orders indicated staff were to monitor and record Resident 57's orthostatic blood pressure (the measurement of blood pressure while sitting or lying down compared to standing up) while standing, lying, and sitting. The orders indicated these measurements were to be taken every four weeks, on Tuesday evening. During a review of Resident 57's record titled Monitoring, dated 1/1/2026 to 1/31/2026, the record indicated on 1/20/2026, Registered Nurse (RN) 2 documented three orthostatic blood pressure readings for Resident 57. The record indicated the lying, sitting, and standing blood pressure readings were 113/81 millimeters of mercury (mmHg, a unit for measuring blood pressure). During a review of Resident 57's record titled Monitoring, dated 2/1/2026 to 2/28/2026, the record indicated on 2/17/2026, RN 2 documented three orthostatic blood pressure readings for Resident 57. The record indicated the lying, sitting, and standing blood pressure readings were 118/75 mmHg. During a review of Resident 57's record titled Monitoring, dated 3/1/2026 to 3/31/2026, the record indicated on 3/17/2026, Licensed Vocational Nurse (LVN) 1 documented three orthostatic blood pressure readings for Resident 57. The record indicated the lying, sitting, and standing blood pressure readings were 118/83 mmHg. During a review of Resident 57's record titled Monitoring, dated 4/1/2026 to 4/30/2026, the record indicated on 4/14/2026, RN 2 documented three orthostatic blood pressure readings for Resident 57. The record indicated the lying, sitting, and standing blood pressure readings were 132/70 mmHg. During an interview on 5/6/2026 at 3:55 p.m., with RN 2, RN 2 stated the certified nursing assistants (CNAs) obtained the residents' blood pressure readings. RN 2 stated she only checked blood pressures in emergencies. RN 2 stated all blood pressures were taken in the Utility Room, or in the hallway immediately outside of the Utility Room. During a concurrent observation and interview on 5/6/2026 at 3:59 p.m., with RN 2, in the Utility Room, a folding chair was observed. RN 2 stated blood pressures were taken while the resident was seated in the folding chair. RN 2 stated the folding chair could be moved into the hallway if needed. RN 2 stated that to her knowledge, there were no blood pressures taken in a lying or standing position and stated there was no surface in the utility room for residents to lay on. RN 2 stated the CNAs took Resident 57's blood pressure while sitting and she used that blood pressure measurement when documenting the lying and standing blood pressure readings. RN 2 stated the purpose of monitoring orthostatic blood pressures was to identify low blood pressure. RN 2 stated that low blood pressure could cause dizziness, lethargy, and create a fall risk. During an interview, on 5/7/2026 at 2:12 p.m., with the Director of Nursing (DON), the DON stated that when checking orthostatic blood pressures, staff were to obtain three different readings, each with the resident in a different position. The DON stated the significance of taking orthostatic blood pressure readings was to identify if there were changes in the resident's blood pressure when the resident changed positions because changes increased the risk for falls. The DON stated low orthostatic blood pressure was a side effect of psychotropic medications (that affect the central nervous system, altering an individual's mental state, mood, emotions, and behavior). The DON stated Resident 57 was receiving multiple psychotropic medications. The DON stated it was not correct for staff to document a seated blood pressure reading for all three orthostatic readings because the order required an orthostatic blood pressure to be taken in three different positions. The DON stated that using the same readings for all three positions was not appropriate and could negatively impact care. During an interview, on 5/6/2026 at 10:45 a.m., with CNA 1, CNA 1 stated stated she did not know if Resident 57 had a history of falls or if she was a fall risk. During an interview 5/6/2026 at 11:03 a.m., with LVN 2, LVN 2 stated she was not aware of any residents in the Northside Unit (unit where Resident 57 resided) that were currently at risk for falls. LVN 2 stated she was not aware Resident 57 had a history of falls and stated she did not know Resident 57 was at risk for falls. During an interview, on 5/7/2026 at 2:17 p.m., with the DON, the DON stated that if a resident had a history of falls, they were at increased risk for repeat falls. The DON stated that the use of psychotropic medications and blood pressure medications also increased the resident's risk for falls. The DON stated all the facility's residents were at risk of falls and stated it was expected that staff knew this. The DON stated it was important for staff to know this to ensure resident safety and stated it was not appropriate for a CNA or LVN to say that they were not sure if a resident was a fall risk. 2. During a review of Resident 124's admission Record, the admission Record indicated Resident 124 was admitted to the facility on [DATE]. Resident 124's diagnoses included schizoaffective disorder (a mental illness that can affect thoughts, mood and behavior), insomnia (persistent difficulty falling or staying asleep) and suicidal ideations (contemplation of self-harm or ending one's life). During a review of Resident 124's MDS dated [DATE], the MDS indicated Resident 124 had no cognitive impairment. The MDS indicated Resident 124 was independent with eating, toileting, dressing and bathing. During a review of Resident 124's physician order dated 11/5/2025, the physician order indicated staff were to monitor and record Resident 124's orthostatic blood pressure while lying, sitting and standing. The physician order indicated the orthostatic blood pressure was to be taken every four weeks, on Tuesday evening. During a review of Resident 124's record titled Monitoring dated 3/1/2026 to 3/31/2026, the record indicated on 3/3/2026, LVN 6 documented Resident 124's orthostatic blood pressure readings. Resident 124's lying, sitting, and standing blood pressure readings were 127/89 mmHg. During a review of Resident 124's record titled Monitoring dated 3/1/2026 to 3/31/2026, the record indicated on 3/31/2026, LVN 6 documented Resident 124's orthostatic blood pressure readings. The record indicated Resident 124's lying, sitting, and standing blood pressure readings were 133/88 mmHg. During a review of Resident 124's record titled Monitoring dated 4/1/2026 to 4/30/2026, the record indicated on 4/28/2026, LVN 6 documented Resident 124's orthostatic blood pressure readings. Resident 124's lying, sitting, and standing blood pressure readings were 108/83 mmHg. During a concurrent interview and record review on 5/6/2026 at 2:50 p.m. with LVN 2, Resident 124's Monitoring record dated 3/1/2026 – 3/31/2026 was reviewed. The record indicated on 3/3/2026, Resident 124's lying, sitting, and standing blood pressure readings were 133/88 mmHg. LVN 2 stated both the CNAs or LVN's took the residents orthostatic blood pressure. LVN 2 stated she had never taken an orthostatic blood pressure that resulted with the same value for lying, sitting, and standing. LVN 2 stated it appeared as if Resident 124's orthostatic blood pressure was not actually taken and only one blood pressure value was used and documented for all three values (lying, sitting, and standing). LVN 2 stated it was important to check the residents orthostatic blood pressure to ensure staff were monitoring for orthostatic hypotension (a sudden drop in blood pressure that occurs when standing up from a sitting or lying position) a common side effect of psychotropic medications. LVN 2 stated not checking the orthostatic blood pressure placed residents at risk of unidentified and unaddressed orthostatic hypotension, accidents, and falls. During an interview on 5/7/2026 at 12:03 p.m. with the Director of Staff Development (DSD), the DSD stated orthostatic blood pressure taking was not a skill LVN's or CNA's were taught or evaluated on upon hire to the facility. The DSD stated the facility had not conducted any in-services regarding orthostatic blood pressure taking but should have because staff should be competent in the skills they were expected to perform. During an interview with the DON on 5/7/2026 at 9:42 a.m., the DON stated orthostatic blood pressures should be accurately taken and documented. The DON stated checking orthostatic blood pressures were important for ensuring appropriate psychotropic side effect monitoring was performed, such as orthostatic hypotension. 3. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE]. Resident 2's diagnoses included schizoaffective disorder and major depressive disorder (a serious mood disorder characterized by a persistent low mood, loss of interest and low energy, lasting at least two weeks). During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's cognitive skills for daily decision making was intact. The MDS indicated Resident 2 was independent with ADLs. During a review of Resident 2's physician order dated 7/2/2025, the physician order indicated to monitor and record Resident 2's orthostatic blood pressure while standing, lying, and sitting. The orders indicated these measurements were to be taken every four weeks, on Tuesday evening. During a review of Resident 2's record titled Monitoring, dated 3/1/2026 to 3/31/2026, the record indicated on 3/17/2026, Resident 2's lying, sitting, and standing blood pressure readings were 116/77 mmHg. During a concurrent interview and record review on 5/6/2026 at 3:13 p.m., with the DON, Resident 2's physician order dated 7/2/2025 and the clinical record titled Monitoring dated 3/1/2026 through 3/31/2026 were reviewed. The record indicated on 3/17/2026, Resident 2's blood pressure readings were 116/77 mmHg in all three positions. The DON stated the blood pressure readings would typically vary between positions due to positional changes affecting blood pressure and pulse. The DON stated that identical readings for lying, sitting, and standing positions were not an appropriate or expected orthostatic blood pressure result. The DON stated that the documentation suggested staff likely obtained only one blood pressure reading and recorded the same result for all three positions instead of performing the ordered orthostatic assessment correctly. The DON stated that inaccurate orthostatic blood pressure monitoring could prevent the physician from identifying significant positional blood pressure changes, including hypotension, dizziness, or increased fall risk. The DON stated that nursing staff were expected to follow physician orders, accurately obtain orthostatic blood pressures in all required positions, and ensure documentation reflected the actual readings obtained for each position. During a review of the facility's policy and procedure (P&P) titled Falls Management System, dated 12/2025, the P&P indicated it was the policy of the facility to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs. During a review of the facility's document titled, Charge Nurse Job Description the document indicated, Nursing Care Functions: Take and record blood pressures.

Based on interview and record review, the facility failed to ensure appropriate nutritional interventions were implemented and evaluated for one of two sampled residents (Resident 30) after the resident experienced significant weight loss. This deficient practice had the potential to place Resident 30 as risk for further weight loss and could lead to harm. Cross Reference F637 and F657 Findings: During a review of Resident 30's admission Record, the admission Record indicated Resident 30 was admitted to the facility on [DATE]. Resident 30's diagnoses included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior) and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). During a review of Resident 30's Minimum Data Set ([MDS]- a resident assessment tool), dated 2/8/2026, the MDS indicated Resident 30's cognitive skills for daily decision making (the ability to think and process information) was severely impaired. The MDS indicated Resident 30 was independent (resident completes the activities by himself) for activities of daily living ([ADLs]- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a concurrent interview and record review on 5/6/2026 at 11:30 a.m., with the Registered Dietitian (RD), Resident 30's Weight and Vitals Summary, dated 1/27/2026 through 2/23/2026, was reviewed. The weight and vitals summary indicated on 1/27/2026, Resident 30 weighed 225.6 pounds (lbs.). The weight and vitals summary indicated on 2/23/2026, Resident 30 weighed 206 lbs. Resident 30 had a total weight loss of 19.8 lbs. or 8.8 percentage [%] of body weight in approximately one month. The RD stated Resident 30's weight loss was significant. The RD stated Resident 30 should have been assessed to determine the cause of the weight loss and whether current nutritional interventions were effective. The RD stated that updated nutritional interventions were necessary to help prevent continued weight loss and nutritional status. The RD stated additional interventions may have included increased monitoring of meal intake, calorie counts, high calorie snacks, increased supplemental review, and additional dietitian follow-up. During a concurrent interview and record review on 5/7/2026 at 11:10 a.m., with Registered Nurse (RN) 3, Resident 30's care plan titled Weight, dated 1/26/2026 was reviewed. The care plan did not indicate additional nutritional interventions after Resident 30's significant weight loss was identified. RN 3 stated Resident 30 had a care plan that addressed the resident's risk for weight loss; however, the care plan was not revised with additional nutritional interventions after Resident 30's significant weight loss was identified. RN 3 stated the facility should have evaluated whether the exsisting interventions were effective and implemented additional nutritional interventions to address Resident 30's continued weight loss. During an interview on 5/7/2026 at 9:45 a.m., with the Director of Nursing (DON), the DON stated residents with significant weight loss should be assessed and monitored to ensure they receive appropriate nutrition based on current condition. The DON stated significant weight loss may indicate that the current interventions were not effective and that the interdisciplinary team (a coordinated group of healthcare professionals who collaborate and evaluate comprehensive care for a resident) should have evaluated the resident's intake, weight trends, food preferences, and need for additional nutritional approaches. The DON stated failure to implement and evaluate appropriate nutritional interventions placed Resident 30 at risk for continued weight loss, inadequate nutritional intake, weakness, decline in ADLs, and further decline in overall condition. During a review of the facility's policy and procedure (P&P) titled Weight Assessment and Intervention, dated 12/2025, the P&P indicated: Any weight changes of 5% or more since the last weight assessment is retaken the next day for confirmation.If the weight was verified, nursing will immediately notify the dietitian in writing. Undesirable weight changes was elevated by the treatment team. The physician and multidisciplinary team identify conditions and medications that may cause weight loss or increase risk of weight loss.

Based on interview, observation, and record review, the facility failed to ensure the physician orders for metoprolol tartrate ([treats increased heart rate] medication administered for tachycardia [abnormally high resting heart rate]) included heart rate parameters (specific, clinical rules (like dose ranges, lab results, or symptom thresholds) that dictate how, when, or if a drug should be safely) prior to administration for one of one sampled resident (Resident 121).This deficient practice placed Resident 121 at risk for adverse cardiovascular complications, including bradycardia (slow heart rate), hypotension (low blood pressure), dizziness, syncope (faintness), and potential decline in condition related to the unsafe administration of Metoprolol without clear physician guidance.Findings:During a review of Resident 121's admission Record, the admission Record indicated Resident 121 was admitted to the facility on [DATE]. Resident 121's diagnoses included schizoaffective disorder (a chronic mental health condition characterized by a combination of psychosis symptoms of hallucinations or delusions and mood disorder of anger or depression), alcohol dependent, opioid dependent, anemia (a condition where the blood lacks enough healthy red blood cells reducing oxygen flow to organs), and thrombocytopenia (a condition characterized by an abnormally low blood clotting factors increasing the risks of bleeding).During a review of Resident 121's Minimum Data Set (MDS - a resident assessment tool), dated 3/27/2026, the MDS indicated Resident 121's cognitive skills for daily decision making was intact. The MDS indicated that Resident 121 was independent (resident completes the activities by themselves with no assistance from helper) with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).During a concurrent interview and record review on 5/6/2026 at 3:09 p.m., with the Director of Nursing (DON), Resident 121's physician order for metoprolol dated 1/27/2026 was reviewed. The physician order indicated to administer metoprolol oral tablet 25 milligrams (mg, unit metric of measurement) twice daily for tachycardia. The DON stated that Metoprolol had been ordered and administered to Resident 121 for tachycardia management. The DON stated that the physician order failed to include specific parameters and clinical instructions regarding when the medication should be administered or held depending on the resident's acceptable heart rate ranges. The DON stated that medications such as Metoprolol require clear and complete parameters to ensure safe administration and appropriate monitoring of the resident's cardiovascular status. The DON stated that the incomplete order should have been clarified with the physician prior to administration of the medication to Resident 121. The DON stated that nursing staff were responsible for reviewing the physician orders for completeness, accuracy, and safety before carrying out the order. The DON stated that administering Metoprolol without defined parameters placed the resident at risk for adverse outcomes, including bradycardia (slow heart rate), hypotension (low blood pressure), dizziness, syncope (faintness), and potential cardiac complications. The DON stated that the facility failed to ensure the physician order contained adequate instructions for the safe administration and monitoring of Metoprolol for Resident 121.During a review of the facility's document titled, Charge Nurse Job Description the document indicated, Report all discrepancies noted concerning physician orders to the nurse supervisor.

Based on interview and record review, the facility failed to ensure Lisinopril (a medication used to treat hypertension ([HTN- high blood pressure) was administered within the ordered parameters (specific, measurable, and objective clinical criteria set by a healthcare provider that dictate when a medication should be given, withheld, or adjusted) for one of one sampled residents (Resident 60). This deficient practice increased Resident 60's risk of hypotension (low blood pressure) and bradycardia (slower heart rate) that could cause dizziness, fainting, weakness, or sudden cardiac arrest (when the heart suddenly and unexpectedly stops pumping).Findings: During a review of Resident 60's admission Record, the admission Record indicated Resident 60 was admitted to the facility on [DATE] with diagnoses including hypertension (low blood pressure). During a review of Resident 60's Minimum Data Set ([MDS] - a resident assessment tool), dated 3/23/2026, the MDS indicated Resident 60's cognition (the ability to think and process information) was severely impaired. The MDS indicated Resident 60 was independent (resident completes the activities by himself) with activities of daily living ([ADLs]- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).During a review of Resident 60's care plan titled Hypertension, dated 3/16/2026, the care plan indicated to administer Lisinopril as ordered by the physician. During a review of Resident 60's physician order, dated 3/20/2026, the order indicated to administer Lisinopril 20 milligrams ([mg]- metric unit of measurement, used for medication dosage and/or amount), one tablet by mouth at bedtime for hypertension. The order indicated to hold (not give) if systolic blood pressure ([SBP]-the top number in a blood pressure reading, representing the pressure in the arteries when the heart beats and pumps blood out) was less than 110 millimeters of mercury (mm Hg, unit of pressure measurement).During an interview on 5/7/2026 at 11:05 a.m., with Registered Nurse (RN) 1, RN 1 stated prior to administering Lisinopril, the licensed nurse was responsible for checking Resident 60's blood pressure and checking the orders for hold parameters (specific instructions that dictate whether the medication is safe to administer). RN 1 stated if Resident 60's blood pressure was within the parameters, the licensed nurse would administer Lisinopril, however, if Resident 60's blood pressure was less than 110 mm Hg, the nurse would hold the Lisinopril. RN 1 stated whether Lisinopril was administered or held, the licensed nurse was responsible for documenting accurately on the Medication Administration Record (MAR- a daily documentation record used by a licensed nurse to document medications and treatments given to a resident).During a concurrent interview and record review on 5/7/2026 at 1:34 p.m., with the Director of Nursing (DON), Resident 60's MAR, dated 3/21/2026 through 4/30/2026, was reviewed. The MAR indicated Resident 60 was administered Lisinopril 20 mg for the following SBP readings:3/21/2026- SBP of 108 mm Hg.3/22/2206- SBP of 108 mm Hg.3/23/2206- SBP of 108 mm Hg.4/3/2026- SBP of 106 mm Hg.4/4/2026- SBP of 106 mm Hg.The DON stated Lisinopril should not have been administered when Resident 60's SBP was below 110 mm Hg. The DON stated Lisinopril was a medication used to help decrease blood pressure. The DON stated the licensed nurses were responsible for checking the resident's blood pressure before administering and holding Lisinopril when the SBP was below the ordered parameters. The DON stated Lisinopril was not administered in accordance with the physician's ordered parameters. The DON stated administering Lisinopril when Resident 60's SBP was below 110 mm Hg placed the resident at risk for hypotension, dizziness, weakness, falls, and other adverse effects related to low blood pressure. The DON stated this resulted in Resident 60 receiving medication outside the ordered parameters. During a review of the facility's policy and procedure (P&P) titled Physician's/Psychiatrist (Prescriber's) Orders', dated 12/2025, the P&P indicated the licensed nurse was to administer medications and hold parameters when necessary. During a review of the facility's P&P titled RN Supervisor- Job Description, undated, the P&P indicated the RN Supervisor was responsible for monitoring medication passes to ensure that medications were being administered as ordered.

Based on observation, interview, and record review, the facility failed to:1. Ensure Resident 89's discontinued trazadone hydrochloride (HCl) (drug used to treat depression and anxiety disorders) was removed from one of three inspected medication carts (North Station Medication Cart 2) and properly disposed.2. Ensure an expired bottle of Rybelsius (drug used to help lower blood sugar and slow digestion) was removed from one of three inspected medication carts (North Station Medication Cart 2) and labeled with the resident's name.3. Ensure three different medications were not transferred into another container found in one of three inspected medication carts (North Station Medication Cart 2).4. Ensure Resident 121's Ozempic [(generic name - semaglutide) injectable medication used to treat diabetes and chronic weight management by reducing appetite and increasing feelings of fullness] prefilled pen was stored in accordance with manufacturer's specifications and per facility policy.These deficient practices had the potential to compromise medication effectiveness placing 144 residents at risk of uncontrolled blood sugar levels, uncontrolled appetite, ingestion of unidentified medications and medication errors. Findings:1. During a review of Resident 89's admission Record, the admission Record indicated Resident 89 was admitted to the facility on [DATE]. Resident 89's diagnoses included schizophrenia (a mental illness that is characterized by disturbances in thought), anemia (a condition where the body does not have enough healthy red blood cells) and alcohol abuse (pattern of drinking that results in harm to one's health).During a review of Resident 89's History and Physical (H&P) dated 4/2/2026, the H&P indicated Resident 89 was alert and oriented with intact cognitive (ability to think and understand) functioning.During a review of Resident 89's Minimum Data Set (MDS- a resident assessment tool) dated 2/26/2026, the MDS indicated Resident 89 was cognitively intact. The MDS indicated Resident 89 was independent for eating, toileting and bathing.During a concurrent observation and interview on 5/5/2026 at 1:15 p.m. with Licensed Vocational Nurse (LVN) 2 of North Station Medication Cart 2, a bubble pack (pharmacy prepared secure packaging system that organizes pills into individual, clear plastic sealed compartments labeled by date and time of day) of Trazadone HCl 100 milligram (mg, metric unit of measurement used for medication dosage and/or amount) for Resident 89 was observed in the bottom drawer. LVN 2 stated she usually did not work with North Station Medication Cart 2 and was not sure why the Trazadone HCl bubble pack was found in the bottom drawer, where the blood pressure cuff and vital sign equipment was usually stored.During a concurrent interview and record review on 5/5/2026 at 1:15 p.m. with LVN 2, Resident 89's physician orders dated 4/13/2026 were reviewed. The physician orders indicated, Trazadone HCl oral tablet give 100 mg by mouth at bedtime for insomnia (trouble falling asleep or staying asleep) was discontinued. LVN 2 stated the Trazadone HCl bubble pack should have been removed from the medication cart and disposed of in the destruction bin located in the locked medication storage room in the north station. LVN 2 stated failure to remove discontinued medication from the medication cart placed residents at risk of medication errors.During an interview on 5/7/2026 at 9:42 a.m. with the Director of Nursing (DON), the DON stated it was important to ensure discontinued medications were removed from medication carts and properly disposed. The DON stated failure to ensure proper disposal of discontinued medications placed residents at risk of administration of discontinued medications and medication errors.During a review of the facility's Policy and Procedure (P&P), titled, Disposition of Drugs revised 10/2019, the P&P indicated, Medications must be removed for destruction if: the physician issues an order to discontinue the medication.2. During a concurrent observation and interview on 5/5/2026 at 1:15 p.m. with LVN 2 of North Station Medication Cart 2, a bottle of Rybelsius was observed without a resident label and an expiration date of 7/31/2025. LVN 2 stated she did not know which resident the bottle of Rybelsius was ordered for. LVN 2 stated the bottle of Rybelsius should have been labeled with a resident name and removed from the medication cart when it expired. LVN 2 stated removal of expired medications from medication cart was important because medications may no longer be effective after the expiration date. LVN 2 stated failure to ensure medication was labeled with resident's name placed residents at risk of medication errors.During an interview on 5/7/2026 at 9:42 a.m. with the DON, the DON stated not removing expired medications from the medication cart placed residents at risk of administration of medications with reduced efficacy. The DON stated medications should be labeled with residents names to ensure they were administered to the correct resident.During a review of the facility's P&P titled, Disposition of Drugs revised October 2019, indicated, Medications must be removed for destruction if: .the expiration date on the label has been reached.During a review of the facility's P&P titled, Medication Labeling revised October 2019, indicated, The required elements of a prescription label will include: Resident's name.3. During a concurrent observation and interview on 5/5/2026 at 1:15 p.m. with LVN 2 of North Station Medication Cart 2, a container of three different medications with a handwritten label of Hydroxyzine 50 mg was observed. LVN 2 stated the three medications observed were transferred from their original bottle and placed into a urine specimen cup (medical-grade plastic container used to collect and transport urine samples). LVN 2 stated she did not know which medications were in the urine specimen cup, which residents they were ordered for, or their expiration dates. LVN 2 stated only pharmacists were able to place medications into a container. LVN 2 stated once medications were removed from their original bottle, nursing staff must either administer to a resident or waste the medication. LVN 2 stated the storage of a urine specimen cup with three unidentified medications placed residents at risk of being administered unidentified medications and medication errors.During an interview on 5/7/2026 at 9:42 a.m. with the DON, the DON stated nursing staff should never transfer medications from their original packaging. The DON stated storage of unidentified medications in medication carts placed residents at risk of being administered the wrong medication.During a review of the facility's P&P titled, Administration of Medications - Medication Pass dated 12/2025, the P&P indicated, Only a pharmacist may place medications into a container. A nurse may not transfer medications from one bottle to another or return medications to a container after they have been poured. If not administered, the medications must be wasted (destroyed).4. During a review of Resident 121's admission Record, the admission Record indicated Resident 121 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 121's diagnoses included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), anemia (a condition where the body does not have enough healthy red blood cells), and insomnia (trouble fallingDuring a review of Resident 121's Minimum Data Set (MDS- a resident assessment tool) dated 3/27/2026, the MDS indicated Resident 121 was cognitively (ability to think and understand) intact. The MDS indicated Resident 121 was independent for toileting, eating and bathing.During a concurrent observation and interview on 5/6/2026 at 9:53 a.m. with LVN 5 of south station front medication cart, observed a single, unopened Ozempic prefilled pen, labeled for Resident 121. LVN 5 stated the medication had not been opened or used. LVN 5 stated the Ozempic prefilled pen should have been stored in the refrigerator until first use. LVN 5 stated lack of refrigeration had the potential to compromise the medication effectiveness for Resident 121.During a record review of the manufacturer guidelines for Ozempic (semaglutide) (undated), the guidelines indicated unopened insulin must be stored under refrigeration until first use.During a review of the facility's Policy and Procedure (P&P) titled, Storage of Medications revised October 2019, indicated the facility would ensure medications were stored in an environment that maintained the integrity of the product.During an interview on 5/7/2026 at 9:42 a.m. with the DON, the DON stated not removing expired medications from the medication cart placed residents at risk of administration of medications with reduced efficacy. The DON stated medications should be labeled with residents names to ensure they were administered to the correct resident.During a review of the facility's P&P titled, Disposition of Drugs revised October 2019, indicated, Medications must be removed for destruction if: .the expiration date on the label has been reached.During a review of the facility's P&P titled, Medication Labeling revised October 2019, indicated, The required elements of a prescription label will include: Resident's name.

Based on observation, interview, and record review, the facility failed to ensure one of nine sampled residents observed during dining observations (Resident 105) received meals in accordance with their preferences when: 1. Resident 105's diet order was not updated following the Registered Dietician's (RD) recommendations for double portions of protein on 4/7/2026. 2. Resident 105 was provided with milk and fish for lunch on 5/5/2026, which were documented as food items he disliked. 3. Staff did not follow Resident 105's diet order for double portions of protein during lunch on 5/6/2026. These deficient practices had the potential to negatively impact Resident 105's meal intake and placed him at risk of not receiving the nutrients and calories needed to maintain a stable body weight. These deficient practices also negatively impacted Resident 105's overall satisfaction during meals.Findings:a. During a review of Resident 105's admission Record, the admission Record indicated Resident 105 was admitted to the facility on [DATE] and was recently re-admitted on [DATE]. Resident 105's diagnoses included hypocalcemia (low calcium levels in the blood) and idiopathic hypoparathyroidism (an endocrine disorder that causes hypocalcemia and elevated levels of phosphorus in the blood).During a review of Resident 105's Minimum Data Set (MDS, a resident assessment tool), dated 4/8/2026, the MDS indicated Resident 105 had disorganized thinking. The MDS indicated Resident 105 was independent for all activities of daily living (ADLs, routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).During a review of Resident 105's Nutritional Assessment, dated 4/7/2026, the assessment indicated that in the last 30 days, Resident 105 sustained a gradual weight loss of 0.6 percent (%). The assessment indicated Resident 105's caloric needs might not be met and that he might benefit from more calories to promote weight stability. The assessment indicated the Registered Dietician's (RD) recommendation was to remove large portions at all meals and update the diet order to include double portions of protein at all meals. The assessment indicated Resident 105 also requested double portions of protein.During a review of Resident 105's physician order, dated 5/4/2026, the order indicated that on 5/4/2026, Resident 105's diet order was updated to double portions of protein at all meals as recommended in his Nutritional assessment dated [DATE]. During an interview on 5/7/2026 at 12:24 p.m., with the RD, the RD stated that while completing Resident 105's Nutritional Assessment on 4/7/2026, she indicated a goal for Resident 105 to maintain a stable weight. The RD stated her recommendation was to add double portions of protein to all meals. The RD stated double portions of protein would increase his calorie intake and stated this diet update should have been completed within 24 to 48 hours. The RD stated timely update of Resident 105's diet order was important to ensure Resident 105's preference for double portions of protein was honored, and to ensure he was receiving the additional calories.During a concurrent interview and record review, on 5/7/2026 at 12:42 p.m., with the RD, Resident 105's diet order was reviewed. The RD stated on 4/7/2026, she made a recommendation for double portions of protein, but the order was not updated until 5/4/2026. b. During an observation on 5/5/2026 at 12:11 p.m., in the dining room, observed Resident 105's tray tag (a plastic card that indicates the resident's diet order, preferences, and allergies) and lunch tray. Resident 105's tray tag indicated he disliked milk and fish. Resident 105's lunch tray had a filet of fried fish and two cartons of milk. During an interview on 5/7/2026 at 12:42 p.m., with the RD, the RD stated Resident 105 should not have received fish or milk on his lunch tray. The RD stated the licensed nurse who checked the meal trays before serving should have informed the kitchen to remove the milk and provide a substitution instead. The RD stated staff could offer juice instead of milk. The RD stated that for the main entree, Resident 105 should have been provided with a sandwich with double portions of deli meat. The RD stated this was a missed opportunity to offer Resident 105 with an alternative meal option.During a review of the facility document titled Spring Cycle Menus, dated 5/6/2026, the document indicated that lunch on Wednesday, 5/6/2026, consisted of a main dish of green chili cheese squares. The document indicated that a single portion included one (1) 3-inch by 2.5-inch green chili cheese square. The document indicated that a large portion included one 3-inch by 2.5-inch square, and another half-sized square.c. During an observation on 5/6/2026 at 12:26 p.m., in the dining room, Resident 105's lunch tray was observed. Resident 105's tray tag indicated Resident 105 was to receive large portions. The tray tag did not reflect Resident 105's current order for double portions of protein. Resident 105's plate had one whole green chili cheese square, and a half-sized square.During an interview on 5/7/2026 at 12:42 p.m., with the RD, the RD stated the kitchen staff referenced Resident 105's tray tag when plating his tray.During an interview on 5/7/2026 at 1:02 p.m., with the RD, the RD stated it was important for the tray tag to be up to date and aligned with the resident's current diet order to prevent malnutrition, weight loss, and to honor the resident's preferences.During a review of the facility's policy and procedure (P&P) titled Weight Assessment and Intervention, dated 12/2025, the P&P indicated interventions for undesirable weight loss were to be based on careful consideration of the Resident's choices and preferences, and the nutrition and hydration needs of the resident. During a review of the facility's P&P titled Food Preferences Policy, dated 12/2025, the P&P indicated a resident's food preferences were to be adhered to within reason, and substitutes for all foods disliked were to be given from the appropriate food group.During a review of the facility's P&P titled Nutritional Screening/Assessments/Resident Care Planning, dated 12/2025, the P&P indicated the resident's nutritional status and nutritional needs were to be assessed, and a nutritional program specific to the resident's needs was to be planned and implemented. The P&P indicated the facility's RD should complete and/or review the Nutritional Assessment and dietary recommendations were to be completed within three days.

Based on interview and record review, the facility failed to ensure the residents' Public Guardian ([PG]- a court-appointed public official responsible for managing a person's financial assets and making medical decisions) information was reviewed and updated in the medical record for two of two sampled residents (Resident 109 and Resident 105).This deficient practice had the potential to result in delayed communication with Resident 109 and 105's PG and may affect timely notification, consent, and involvement in Residents 109 and 105's care planning and treatment decisions.Findings: 1. During a review of Resident 109's admission Record, the admission Record indicated Resident 109 was admitted to the facility on [DATE]. Resident 109's diagnoses included schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 109's Minimum Data Set ([MDS]- a resident assessment tool), dated 3/18/2026, the MDS indicated Resident 109's cognitive skills for daily decision making (the ability to think and process information) was severely impaired. The MDS indicated Resident 109 was independent with activities of daily living ([ADLs]- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a telephone interview on 5/5/2026 at 9:26 a.m., with Resident 109's Public Guardian (PG 3), PG 3 stated as of 1/2026, she was no longer Resident 109s' PG. PG 3 stated she was no longer responsible for making decisions or receiving notification regarding Resident 109's care. During a concurrent interview and record review on 5/6/2026 at 9:45 a.m., with Social Services (SS) 2, Resident 109's PG information was reviewed. The record indicated Resident 109's PG information was not current and continued to list PG 3's information who was no longer the resident's representative. SS 2 stated the facility was responsible for ensuring the resident records were complete, accurate, and current. SS 2 stated Resident 109's PG information should be updated in the resident's medical record to ensure when changes occur the appropriate person could be contacted regarding the resident's care, treatment decisions, changes in condition, and other important matters. During an interview on 5/7/2026 at 9:10 a.m., with the Director of Nursing (DON), the DON stated residents' responsible party and/or legal representative information should be reviewed and updated when the facility becomes aware of a change, including when a listed representative, such as PG 3, was no longer responsible for the resident. The DON stated Resident 109's record should not have continued to list PG 3 as the resident's representative after PG 3 was no longer serving in that role as of 1/2026. The DON stated the facility failed to update Resident 109's PG information in the medical record. The DON stated this failure did not meet the facility's expectation for maintaining accurate and current resident records and had the potential to delay communication with the appropriate representative regarding Resident 109's care and treatment decisions. 2. During a review of Resident 105's admission Record, the admission Record indicated Resident 105 was admitted to the facility on [DATE] and was recently re-admitted on [DATE]. Resident 105's diagnoses included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior). PG 2 was indicated as Resident 105's public guardian. During a review of Resident 105's MDS, dated [DATE], the MDS indicated Resident 105 had disorganized thinking. The MDS indicated Resident 105 was independent for all ADLs. During an interview on 5/4/2026 at 9:29 a.m., with Resident 105, Resident 105 stated he did not make medical decisions for himself. During a telephone interview, on 5/6/2026 at 9:26 a.m., a telephone call was placed to the telephone number indicated for PG 2 on Resident 105's admission Record. An unidentified individual stated the number contacted was for the Public Guardian's office and stated there was no one by the name of PG 2. During a review of Resident 105's progress note, dated 3/19/2026, by Social Services Designee (SSD) 1, the progress note indicated SSD 1 was informed that Resident 105's PG was now PG 5. The progress note did not indicate contact information for PG 5, including an email address or telephone number. During an interview on 5/7/2026 at 10:34 a.m., with Social Worker (SW) 1, SW 1 stated Resident 105's PG's contact information was located on the resident's admission Record. SW 1 stated Resident 105's current public guardian was indicated as PG 2. During an interview on 5/7/2026 at 10:43 a.m., with SW 1, SW 1 stated there was no documentation in Resident 105's medical record to indicate how to contact PG 5. SW 1 stated Resident 105's medical record should have been updated. SW 1 stated it was important to have PG 5's contact information because it was important for PG 5 to be involved in the care planning process to ensure Resident 105 received the best care, and to ensure Resident 105 was making progress to eventually downgrade to a lower level of care (a care environment where a resident functions more independently). SW 1 stated the public guardian also had the final say in care planning decisions and served as an advocate for the resident. During a review of the facility's policy and procedure (P&P) tiled Charting and Documentation, dated 12/2025, the P&P indicated the resident's medical record will be complete and accurate.

Based on interview and record review, the facility failed to develop and implement a comprehensive care plan addressing eating behaviors for one of one sampled resident (Resident 1). On [DATE], the Registered Dietician (RD) observed Resident 1 eating too quickly and not chewing food items thoroughly. The RD recommended to encourage slower eating, chew foods thoroughly and swallow. On [DATE], the RD observed the resident eating quickly and not clearing her mouth between bites. The RD recommended Resident 1 be placed on mechanically soft finely chopped texture diet and 1:1 supervision during meals. There was no care plan developed for staff to implement the interventions of the RD. As a result of this deficient practice, on [DATE] at approximately 12:15 p.m., LVN 1 found Resident 1 slumped over to her right side, in the dining room, unresponsive with food particles in her mouth. Resident 1 choked, cardiopulmonary resuscitation ([CPR] an emergency procedure to restart a person's heart and breathing after one or both suddenly stop) was performed, and Resident 1 was pronounced dead on [DATE] at approximately 1:02 p.m. On [DATE] at 11:33 a.m., the Administrator (Admin), Director of Nursing (DON), program manager (PM), Infection Preventionist (IP), and Director of Staff Development (DSD) were notified of an Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident) was called for the facility's failure to develop and implement a comprehensive care plan addressing eating behaviors for Resident 1 after the RD identified concerns. The RD recommended to encourage slower eating, chew foods thoroughly and swallow, mechanically soft finely chopped texture diet and 1:1 supervision during meals. The interventions were not care planned and carried out. The facility's Admin, DON, PM, IP, and DSD were notified of the seriousness of all residents' health and safety being threatened by the licensed nurses not developing a care plan for staff to implementing for Resident 1's eating behaviors. An IJ removal plan (an intervention to immediately correct the deficient practices) was requested. On [DATE] at 8:20 a.m., the facility submitted an acceptable IJ Removal Plan. After onsite verification that the IJ Removal Plan was implemented through observations, interviews, and record reviews, the IJ was removed on [DATE] at 1:34 p.m., in the presence of the ADM and the DON. The IJ Removal Plan included the following: a. The DON and RD conducted a review and audit of 155 residents' medical records with emphasis on appropriateness of Nutritional Care Plan. No similar deficient practice identified. The occurrence was isolated and not found to be widespread. b. The DON and RD conducted a review and audit of 22 residents on special diet with emphasis on appropriateness of Nutritional Care Plan. No similar deficient practice identified. The occurrence was isolated and not found to be widespread. c. The DON and DSD initiated in-service and training to nursing staff on [DATE] and completed 75% of training on ,d+[DATE]//2023 regarding the following: Development and Implementation of comprehensive care plan to address behaviors per RD recommendation such as residents at risk for choking with meals. Following resident's Nutritional Care Plan including level of supervision, provision of adequate supervision, etc. Providing supervision as ordered by MD to residents with impulsive behavior of eating food too quickly. d. The DON and DSD will provide ongoing in-services and training to nursing staff every week for a month, then every quarter for one year. Nursing staff who are on leave of absence or vacation will be provided with in-service and training upon return to work before start of shift. e. The DON and DSD initiated in-service and training to interdisciplinary team ([IDT] team members from different disciplines working together towards a common goal) regarding the facility's Care Plan Goals and Objectives Policy with emphasis on comprehensive resident-centered care planning. f. A list of high-risk residents, such as those with impulsive behavior of eating food too quickly, will be communicated during safety huddle by Licensed Nurse every shift to ensure that care plan has been developed and implemented. g. IDT will conduct residents care plan review quarterly and as needed to ensure that care plan has been developed and implemented accordingly. Any deficient practice will be corrected as identified and will be reported to the DON. h. MRD (Medical Records Department) will conduct residents' care plan audit five times a week. Any deficient findings will be corrected as identified and will be reported to the DON. i. The DON and/or designee will monitor facility compliance, report findings, and provide a summary trend analysis to Quality Assurance and Performance Improvement (QAPI) committee quarterly for further evaluation and/or recommendation for six months. Findings: During a review of Resident 1's face sheet (admission record), dated [DATE], the face sheet indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), type 2 diabetes (abnormal blood sugar), and hypertension (high blood pressure). The face sheet indicated Resident 1 expired on [DATE]. During a review of Resident 1's Minimum Data Set ([MDS], a standardized assessment and care planning tool), dated [DATE], the MDS indicated Resident 1 usually understood and was usually able to be understood by others. The MDS indicated Resident 1 was independent with eating, locomotion (moving from one location to another), dressing and toileting. During a review of Resident 1's Registered Dietitian's (RD) note dated [DATE], indicated Resident 1 was observed eating too quickly and not chewing meals thoroughly. The RD's note indicated to provide close monitoring at all mealtimes to encourage Resident 1 to chew foods thoroughly before swallowing and provide meals portions in a few small containers to encourage slower eating. During a review of Resident 1's RD's Follow-Up Note dated [DATE], the RD note indicated on [DATE], the RD observed Resident 1 had risky eating behaviors. The resident was observed eating quickly, not clearing mouth between bites, and eating chicken without pulling the meat away from the bones then spitting out the bones. The RD recommendations included 1:1 supervision during meals and a diet order change, small portions with all meals, mechanical soft and finely chopped diet. During a review of Resident 1's medication review report (MD orders), dated [DATE], the MD orders indicated mechanical soft finely chopped textured diet and 1:1 supervision during meals. During a review of Resident 1's change in condition (COC) report, dated [DATE], the COC indicated on [DATE], at approximately 12:15 p.m., Resident 1 was observed unresponsive sitting in a chair in the dining room, leaning to her right side, with no palpable pulse and no breath sounds. The report indicated cardiopulmonary resuscitation ([CPR] an emergency procedure to restart a person's heart and breathing after one or both suddenly stop) was initiated and 911 (an emergency alert system) was called. The report indicated Resident 1 was pronounced dead on [DATE], at 1:02 p.m. During a concurrent interview and record review with Licensed Vocational Nurse (LVN 2) on [DATE] at 2:15 p.m., Resident 1's dietary care plan titled Resident has altered nutritional status related to history of skipping meals, obesity (excess body fat), diabetes, and hypertension, dated [DATE] was reviewed. LVN 2 stated the care plan did not include the RD's recommendations for Resident 1 to be on 1:1 supervision during meals. LVN 2 stated when a resident's diet was changed, licensed nurses were supposed to develop a new care plan based on the current diet order and the RD's recommendations. LVN 2 stated Resident 1 did not have a care plan to address the RD's recommendations dated [DATE], for Resident 1 to be supervised with meals. During a concurrent interview and record review with the DON on [DATE] at 4:19 p.m. of Resident 1's dietary care plan, titled Resident has altered nutritional status related to history of skipping meals, obesity, diabetes, and hypertension, dated [DATE] was reviewed. The DON stated the care plan was too general and it should have indicated 1:1 supervision during mealtimes. The DON stated no care plan was developed to address the RD's recommendations on [DATE], and [DATE]. During a review of the facility's policy and procedure (P&P) titled, Care Plans-Comprehensive, dated 2020, the P&P indicated an individualized comprehensive care plan that included measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs was developed for each resident. The P&P indicated each resident's care plan had been designed to incorporate risk factors associated with identified problems and aided in preventing or reducing declines in the resident's functional status and or functional levels. During a review of the facility's P&P titled, Care Plan Goals and Objectives, dated 2020, the P&P indicated goals and objectives were reviewed and or revised when there had been a significant change in the resident's condition.

Based on observation, interview, and record review, the facility failed to supervise one of one sampled resident (Resident 1) during meals by failing to: 1. Followthe facility ' s policy and procedure (P&P), titled High Risk Safety Monitoring, which indicated assigned staff for residents on 1:1 monitoring, will be within two feet ([ft] unit of measurement) from the resident. 2. Follow the Registered Dietitian (RD) recommendation, dated [DATE], to provide Resident 1 with 1:1 supervision (one staff supervising one resident only) during dining. 3. Follow the Physician ' s Order dated [DATE], to provide 1:1 supervision during mealtimes. These deficient practices caused Resident 1 to choke on food, while eating in the dining room without 1:1 supervision, the resident became unresponsive, cardiopulmonary resuscitation ([CPR] an emergency procedure to restart a person ' s heart and breathing after one or both suddenly stop) CPR was initiated, and the resident was pronounced dead on [DATE] at 1:02 p.m. On [DATE] at 11:33 a.m., the Administrator (Admin), Director of Nursing (DON), program manager (PM), Infection Preventionist (IP), and Director of Staff Development (DSD) were notified of an Immediate Jeopardy ([IJ] a situation in which the facility ' s noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident) was called for the facility ' s failure to supervise Resident 1 during mealtime. There was no 1:1 supervision provided to Resident 1as ordered by the physician and RD recommendation. The facility ' s Admin, DON, PM, IP, and DSD were notified of the seriousness of all residents ' health and safety were at risk due to staff ' s failure to supervise Resident 1 during mealtime. An IJ removal plan (an intervention to immediately correct the deficient practices) was requested. On [DATE] at 8:20 a.m., the facility submitted an acceptable IJ Removal Plan and was informed the plan was approved. After onsite verification if the IJ Removal plan was implemented through observations, interviews, and record reviews, the IJ was removed on [DATE] at 1:34 p.m., in the presence of the ADM and the DON. The Removal Plan included the following: a. All residents have the potential to be affected. The DON (Director of Nursing) and PD (Program Director) conducted a review and audit of 155 residents ' medical records with emphasis on safety monitoring as ordered by MD to ensure the safety and well-being of residents who are at risk for unsafe behavior, no similar deficient practice identified. This occurrence was isolated and not found to be widespread. b. The DON and DSD (Director of Staff Development) initiated in-service and training to nursing staff on [DATE] and completed 75% of training on ,d+[DATE]//2023 regarding the following: Facility's policy and procedure titled, Resident Safety Monitoring with emphasis on assuring the safety and well-being of residents who are at risk for unsafe behavior. Providing supervision as ordered by MD to residents with impulsive behavior of eating food too quickly. c. The DON and DSD will provide ongoing in-services and skills competency training with return demonstration to nursing staff every week for a month, then every quarter for one year. Any identified issues will be corrected immediately and reported to the DON. Nursing staff who are on leave of absence or vacation will be provided with in-service and training upon return to work before start of shift. d. A list of high-risk residents, such as those with impulsive behavior of eating food too quickly, will be communicated during safety huddle by Licensed Nurse every shift to ensure supervision is provided as ordered by MD. e. The Licensed Nurse will assign staff to provide supervision to resident/s as ordered by MD. f. The RN Supervisor on duty will conduct random checks to ensure appropriate supervision is provided as ordered by MD. Any deficient practice will be corrected as identified and will be reported to the DON. g. The DON and/or designee will monitor facility compliance, report findings, and provide a summary trend analysis to Quality Assurance & Performance Improvement ([QAPI] a proactive approach to quality improvement) committee quarterly for further evaluation and/or recommendation for six months. Findings: During a review of Resident 1 ' s face sheet (admission record), dated [DATE], the face sheet indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including schizophrenia (a disorder that affects a person ' s ability to think, feel, and behave clearly), type 2 diabetes (abnormal blood sugar), and hypertension (high blood pressure). The face sheet indicated Resident 1 expired on [DATE]. During a review of Resident 1 ' s Minimum Data Set ([MDS], a standardized assessment and care planning tool), dated [DATE], the MDS indicated Resident 1 usually understood and was usually able to be understood by others. The MDS indicated Resident 1 was independent with eating, locomotion (moving from one location to another), dressing and toileting. During a review of Resident 1 ' s Medication Review Report (MD orders), dated [DATE], the MD orders indicated mechanical soft finely chopped textured diet and 1:1 supervision during meals. During a review of Resident 1 ' s Registered Dietitian ' s (RD) note dated [DATE], indicated Resident 1 was observed eating too quickly and not chewing meals thoroughly. The RD note indicated to provide close monitoring at all mealtimes to encourage Resident 1 to chew foods thoroughly before swallowing and provide meal portions in a few small containers to encourage slower eating. During a review of Resident 1 ' s RD ' s Follow-Up Note dated [DATE], the RD note indicated on [DATE], the RD observed Resident 1 had risky eating behaviors. The resident was observed eating quickly, not clearing mouth between bites, and eating chicken without pulling the meat away from the bones then spitting out the bones. The RD recommendations included 1:1 supervision during meals and a diet order change to small portions with all meals, mechanical soft and finely chopped diet. During a review of Resident 1 ' s change in condition (COC) report, dated [DATE], the COC indicated on [DATE], at approximately 12:15 p.m., Resident 1 was observed unresponsive sitting in a chair in the dining room, leaning to her right side, with no palpable pulse and no breath sounds. The report indicated CPR was initiated and 911 (an emergency alert system) was called. The report indicated Resident 1 was pronounced dead on [DATE], at 1:02 p.m. During a concurrent interview and record review with the DON on [DATE] at 4:19 p.m., Resident 1 ' s MD orders were reviewed. The DON stated Resident 1 ' s MD orders indicated mechanical soft finely chopped textured diet and 1:1 supervision during meals for safety. The DON stated Resident 1 did not have an assigned staff member for 1:1 supervision when she choked on [DATE]. During a phone interview on [DATE] at 11:26 a.m. with Licensed Vocational Nurse (LVN 1), LVN 1 stated on [DATE], at approximately 12:15 p.m., she (LVN 1) was busy assisting other residents and not within two feet of Resident 1, when she observed Resident 1 slumped over. LVN 1 stated she did not see a staff member sitting next to Resident 1. LVN 1 stated Resident 1 did not have an order for 1:1 supervision with meals. LVN 1 stated she did not see Resident 1 ' s MD orders dated [DATE] which indicated Resident 1 should be supervised during meals. LVN 1 stated it was her responsibility to verify and carryout all MD orders. LVN 1 stated, she assumed Resident 1 did not require 1:1 supervision and was not supervised during meals when she choked and died . During a concurrent interview and video footage review on [DATE] at 2:27 p.m., with the DON and Admin, the facility ' s video surveillance of the north dining area dated [DATE], was reviewed. The ADM stated, on [DATE] at 12:17:54 p.m., LVN 1 served Resident 1 a lunch tray., and walked away to serve other residents. LVN 1 was observed walking out of the room. The ADM stated 12:24 p.m., while Resident 1 was eating, staff continued to pass meal trays to other residents and Resident 1 was not supervised (1:1). The ADM stated at 12:26 p.m., LVN 1 noticed Resident 1 slumped over and rushed to Resident 1 ' s side. The ADM stated at 12:27 p.m., LVN 1 started the Heimlich maneuver (a method for forcing an object out the airway of a choking person) on Resident 1. During a review of the facility ' s policy and procedure (P&P), titled High Risk Safety Monitoring, dated 2020, the P&P indicated the facility closely monitored the status of residents at risk for unsafe behavior, to observe for a significant change in their behavior or physical or mental condition. The P&P indicated its purpose was to ensure the safety and wellbeing of residents at risk for unsafe behaviors were monitored appropriately. The P&P indicated assigned staff for residents on 1:1 monitoring, will be within two feet from the resident. During a review of the facility ' s P&P titled Mealtime Supervision, dated 2022, the P&P indicated all residents will be observed during mealtime to monitor meal acceptance and safety of the residents. The P&P indicated observations will be noted and referrals made as needed to the appropriate staff, for residents with difficulty chewing, swallowing, using utensils and self-feeding. During a review of the facility ' s P&P titled Physician Orders, dated 2020, the P&P indicated Physician orders must be given and managed in accordance with applicable laws and regulations.

Based on observation, interview, and record review, the facility failed to supervise and observed a resident while eating and implement a resident's care plan to observed for pocketing (keeping some food in the cheeks or back of the mouth rather than swallowing fully) of food in cheeks for one of three sampled residents (Resident 1). Resident 1, who had history of pocketing food in her cheeks, was not observed during her dinner meal on [DATE] and encourage to take small bites and swallow as indicated on the Speech Therapist ((ST) specialist trained to help people with speech and language problems to speak more clearly) recommendations. These deficient practices resulted in Resident 1 experiencing a choking (severe difficulty in breathing because of a lodge object or food obstructing the throat blocking airflow) episode and going into [MEDICAL CONDITION] (sudden, unexpected loss of heart function, breathing, and consciousness) and subsequently being transferred to a general acute care hospital (GACH) in [MEDICAL CONDITION] on [DATE]. Resident 1 was admitted to the general acute care hospital (GACH) Emergency Department (ED) on [DATE] at 5:26 p.m. and pronounced deceased at 5:56 p.m. (30 minutes after ED arrival). On [DATE] at 4:54 p.m., the Administrator (ADM) and the Director of Nursing (DON), were notified an Immediate Jeopardy ((IJ), a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was called for the facility's staff failure to supervise and follow ST orders for Resident 1. Resident 1 had orders for finely chopped diet and was recommended to be monitor during meals that lead to Resident 1 choking. The facility's ADM and DON were notified of the immediacy and seriousness of all residents' health and safety being threatened by staff not monitoring residents during meals. On [DATE] at 4:39 p.m., the ADM and DON were notified the Plan of Action (POA) was approved and at 5:20 p.m., the ADM, DON, Director of Staff Development (DSD), and Program Director (PD) were notified the IJ was lifted after review and on-site validation of the POA via observations, interviews and record review of the following: 1) The DON and DSD initiated in-service and training to nursing staff on [DATE] and completed 75 percent (%) of training on [DATE] regarding: a) Following resident's Nutritional Care Plan including types of diets, textures, frequency of mouth checks, level of supervision, provision of adequate supervision etc. b) Identification and reporting of Resident's Change of Condition with emphasis in pocketing of food. c) Emergency response with emphasis on how to handle a choking victim and how to perform abdominal thrusts/[MEDICATION NAME] maneuver. d) Resident Nutritional care plans of residents who were identified on mechanical soft diet were reviewed and updated on [DATE] based on Registered Dietitians (RD), Speech Therapist (ST) and physician orders. e) The DON and DSD will provide ongoing in-services and skills competency training with return demonstration to nursing staff every week for a month, then every quarter for one year, then annually. f) Nursing staff who are on leave of absence will be provided with in-service and training upon return to work and before the start of their shift. Findings: A review of Resident 1's autopsy report, dated [DATE] and timed at 4 p.m., indicated there was a free piece of partially chewed food (skeletal muscle of animal origin) lodged (firmly fixed or embedded in a particular place) tightly over the orifice of the larynx (organ in the top of the neck involved in breathing, producing sound and protecting the trachea against food) measuring 4.5 centimeters ((cm) units of measurement) by (x) 3.8 cm x 3.8 cm completely occluding the airway. The autopsy report indicated Resident 1 died from asphyxia (deprivation of oxygen to the body, causing unconsciousness or death; suffocation) due to a large piece of meat lodge in her throat. The autopsy indicated Resident 1 had many teeth absent and other loose. A review of Resident 1's Admission Face Sheet indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE]. A review of Resident 1's admission History and Physical (H & P), dated [DATE] indicated Resident 1 did not have the capacity to understand and make decisions. The H/P indicated Resident 1 had [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), a resident assessment and care screening tool, dated [DATE] indicated Resident 1 had severe memory problems, impaired decision-making, but was able to usually understand and sometimes understood others. The MDS indicated Resident 1's [DIAGNOSES REDACTED]. of direction). The MDS indicated Resident 1 required a one-person physical set-up of tray and did not have natural teeth and was edentulous (lacking teeth). A review of Resident 1's care plan titled, Pocketing food in Cheeks, dated [DATE] indicated the goal was for Resident 1 to chew and swallow food with no difficulty for the next 90 days. The staffs' intervention included to encourage small, frequent feedings and rest in between periods, provide diet as ordered, observe for pain when swallowing, and observe Resident 1 during mealtimes. A review of Resident 1's Progress Notes, dated [DATE] and timed at 11:37 p.m., indicated an order was received from the Medical Director (MD) to change Resident 1's diet to pureed (cooked food, usually vegetables, fruits or legumes, that has been ground, pressed, blended or sieved to the consistency of a creamy paste or liquid), Nectar Thickened (easily pourable and comparable to apricot nectar or thicker cream soups) liquids, and to provide supervision during meals. A review of the Interdisciplinary Team ((IDT) group of health care professionals with various areas of expertise working together toward the goals of their residents) conference note dated [DATE] indicated Resident 1 was noted pocketing food in her left side jaw when staff was feeding and requiring heavy prompting during meals to chew and swallow food. The IDT recommendations were to refer Resident 1 to a speech therapist for evaluation ability to swallow and for staff to aid during meals. A review of Resident 1's Speech and Language Evaluation, dated [DATE] indicated Resident 1 was referred for a swallowing evaluation due to increased pocketing of food. The evaluation indicated Resident 1 was downgraded to a regular finely chopped diet with nectar thick (easily pourable and comparable to apricot nectar or thicker cream soups) liquids and required some assistance with feeding. The evaluation indicated during the assessment Resident 1 was missing upper right and lower left molars (tooth with a rounded or flattened surface adapted for grinding specifically) which impacted her ability to effectively masticate food. The evaluation indicated Resident 1 had mild to moderate oral phase dysphagia (problems with using the mouth, lips and tongue to control food or liquid), reduced oral strength, coordination, sensation and mastication inefficiency. The Speech Therapist ((ST) specialist trained to help people with speech and language problems to speak more clearly) recommended for mechanical soft food with finely chopped meats, extra gravy, thin liquids, no corn, salad, or raw vegetables, upper partial dentures to be on prior to meals, verbal cues to take single bites, swallow all the food in Resident 1's mouth and then proceed to take the next bite, take sips of liquid between bites, and ensure mouth is clear of food after meal. A review of Resident 1's physician order [REDACTED]. On [DATE] at 1:33 p.m., during an observation of the facility's video surveillance of the south dining area, dated [DATE] and timed at 4:50 p.m. in the presence of the DON and the ADM the following events were observed as followed: At 4:52 p.m. Certified Nurse Assistant 1 (CNA 1) provided Resident 1 with a dinner tray. At 4:54 p.m. CNA 1 was observed picking a dark color object with a fork and giving it to Resident 1 to eat and then walking away to continue passing food trays. Resident 1 was observed putting the object in her mouth and a few seconds later, Resident 1 was observed covering her mouth with a napkin and then placing it on the tray. At 4:56 p.m. Resident 1 walks to the other room in south side dining room, faces CNA 1 for a few seconds and CNA 1 is observed putting her hand on Resident 1's shoulder and taking her back to her table. CNA 1 was observed rubbing and tapping Resident 1's back and Resident 1 leaning forward. At 4:58 p.m. Resident 1 was observed leaning forward towards the table and CNA 1 was observed grabbing Resident 1 by the neck and pressing on resident's neck while a staff member was punching Resident 1 on the breast area. At 4:59 p.m. Registered Nurse 1 (RN 1) was observed performing three episodes of [MEDICATION NAME] maneuver and stopping to hit Resident 1 multiple times in the back and CNA 1 once more was observed grabbing Resident 1 by the neck and pressing against it with her right arm. At 5:01 p.m. Licensed Vocational Nurse 1 (LVN 1) attempts [MEDICATION NAME] on Resident 1 and then places her on the floor to initiate CPR. At 5:10 p.m., paramedics are observed entering the facility's dining area and continue with CPR. At 5:31 p.m., Resident 1 was observed placed in a gurney and removed from the dining area by the paramedics. On [DATE] at 2:39 p.m., during an interview, DSD stated licensed nurses and CNA's were in-serviced at the beginning of the year on how to perform the [MEDICATION NAME] maneuver when a resident is seeing choking. The DSD stated the staff is to do three checks to ensure the correct diet was given and to monitor the residents during meals. On [DATE] at 4:07 p.m., during an interview, CNA 1 stated on [DATE] during diner time she placed a food tray on Resident 1's table and then left to get juice for the resident. CNA 1 stated Resident 1 got up from her chair and showed her food she had in her mouth, she then noticed Resident 1 leaning forward like if she was tired and then falling forward towards the table unconscious and unable to wake up. CNA 1 stated Resident 1 was on Choked, food. CNA 1 stated she did not checked Resident 1's food card to ensure Resident 1 received the correct diet as ordered by the ST. On [DATE] at 4:44 p.m., during an interview, CNA 2 stated Resident 1 was in a chopped diet and required assistance when eating and constant reminder to chew and swallow her food. CNA 2 stated CNA 1 provided the dinner tray to Resident 1 on [DATE] and was supposed to supervise Resident 1 during dinner. On [DATE] at 5:23 p.m., during an observation of the video surveillance from [DATE] and timed at 4:54 p.m., in the presence of ADM and DON and review of Resident 1's care plan and ST recommendations, the DON stated per the video Resident 1 was not being supervised by the staff during feeding. The DON stated recommendations of the ST were not followed to remind Resident 1 to chew and swallow her food after each bite. The DON stated Resident 1 required a one to one supervision during feeding due to behavior of pocketing food. On [DATE] at 5:59 p.m., during an interview, Resident 2 stated on the day Resident 1 choked they were served big pieces of dry meat that had no flavor, carrots, mash potatoes and cake. Resident 2 stated seeing staff giving the meat to Resident 1 that caused her to choke and then walking away. A review of Resident 1's GACH's ED report, dated [DATE] indicated Resident 1 was admitted to the ED on [DATE] at 5:29 p.m. in active [MEDICAL CONDITION] with active CPR after experiencing a choking episode while eating and then going into [MEDICAL CONDITION]. The ED note indicated the paramedics administered three (3) rounds of [MEDICATION NAME] (medication that constricts the blood vessels to increase blood pressure, heart rate and cardiac output) with no regain pulse and no active cardiac activity. The ED report indicated Resident 1 was immediately intubated (placing a tube through the resident's throat to help move air in and out of the lungs), given three (3) rounds of [MEDICATION NAME] and aggressive Advanced Cardiac Life Support ((ACLS) set of clinical process for the urgent treatment of [REDACTED]. Resident 1 was pronounced dead on [DATE] at 5:56 p.m. A review of the facility's policy and procedures (P/P) titled, Mealtime Supervision, dated ,[DATE] indicated all residents would be observed during mealtime to monitor safety. The P/P indicated food services manager or designee would do meal rounds in the dining rooms and staff would ensure residents received the appropriate meal and services.

Based on observation, interview, and record review, the facility failed to ensure Certified Nurse Assistant 1 (CNA 1) followed its policy and procedure for Choking-Obstructive Airway Clearance, to ensure one of three sampled residents (Resident 1) was immediately provided with the [MEDICATION NAME] (emergency rescue procedure for application to someone choking on a foreign object, in which the rescuer places a fist between the victim's lower ribs or upper abdomen from behind and exerts sudden pressure in the form of thrusts of sufficient force to help eject the object from the windpipe) maneuver during aspiration (condition in which food, liquids, saliva, or vomit is breathed into the airways) on a foreign object (food debris) during dinner. This deficient practice resulted in Resident 1 suffocating (process of dying from being deprived of air or unable to breathe) and subsequently being transferred to a general acute care hospital (GACH) in [MEDICAL CONDITION] (sudden, unexpected loss of heart function, breathing, and consciousness) on [DATE]. Resident 1 was admitted to the general acute care hospital (GACH) Emergency Department (ED) on [DATE] at 5:26 p.m. and pronounced deceased at 5:56 p.m. (30 minutes after ED arrival). On [DATE] at 4:54 p.m., the Administrator (ADM) and the Director of Nursing (DON), were notified an Immediate Jeopardy ((IJ), a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was called for the facility's staff inability to perform the [MEDICATION NAME] maneuver on Resident 1 when observed choking. The facility's ADM and DON were notified of the immediacy and seriousness of other residents' health and safety being threatened by staff not knowing how to perform the [MEDICATION NAME] maneuver. On [DATE] at 4:39 p.m., the ADM and DON were notified the Plan of Action (POA) was approved and at 5:20 p.m., the ADM, DON, Director of Staff Development (DSD), and Program Director (PD) were notified the IJ was lifted after review and on-site validation of the POA via observations, interviews and record review of the following: 1) The DON and DSD initiated in-service and training to nursing staff on [DATE] and completed 75 percent (%) of training on [DATE] regarding: a) Following resident's Nutritional Care Plan including types of diets, textures, frequency of mouth checks, level of supervision, provision of adequate supervision etc. b) Nursing standards of practice with emphasis on how to handle a choking victim and how to perform abdominal thrusts/[MEDICATION NAME] maneuver. c) Emergency response with emphasis on how to handle a choking victim and how to perform abdominal thrusts/[MEDICATION NAME] maneuver. d) Resident Nutritional care plans of residents who were identified on mechanical soft diet were reviewed and updated on [DATE] based on Registered Dietitians (RD), Speech Therapist (ST) and physician orders. e) The DON and DSD will provide ongoing in-services and skills competency training with return demonstration to nursing staff every week for a month, then every quarter for one year, then annually. f) Nursing staff who are on leave of absence will be provided with in-service and training upon return to work and before the start of their shift. 2) Certified Cardiopulmonary Resuscitation ((CPR) emergency procedure that combines chest compressions often with artificial ventilation to manually preserve intact brain function until further measures are taken to restore spontaneous blood circulation and breathing in a person who is in [MEDICAL CONDITION]) trainer conducted Emergency Response training with emphasis on how to handle a choking victim and how to perform abdominal thrusts/[MEDICATION NAME] maneuver with return demonstration to nursing staff on [DATE]. 3) DON, DSD, and/or designee will provide ongoing in-service and training on emergency response to nursing staff with return demonstration every week for one month, then every quarter for one year, then annually. 4) Nursing staff who are on leave of absence will be provided with in-service and training upon return to work before start of shift. Findings: A review of Resident 1's Admission Face Sheet indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE]. A review of Resident 1's admission History and Physical (H & P), dated [DATE] indicated Resident 1 did not have the capacity to understand and make decisions. The H/P indicated Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), a resident assessment and care screening tool, dated [DATE] indicated Resident 1 had severe memory problems, impaired decision-making, but was able to usually understand and sometimes understood others. The MDS indicated Resident 1's [DIAGNOSES REDACTED]. of direction). The MDS indicated Resident 1 did not have natural teeth and was edentulous (lacking teeth). A review of Resident 1's physician order [REDACTED]. A review of Resident 1's Speech and Language Evaluation, dated [DATE] indicated Resident 1 was referred for a swallowing evaluation due to increased pocketing of food (keeping some food in the cheeks or back of the mouth rather than swallowing full). The evaluation indicated during the assessment Resident 1 was missing upper right and lower left molars (tooth with a rounded or flattened surface adapted for grinding specifically) which impacted her ability to effectively masticate (chew) food. The evaluation indicated Resident 1 had mild to moderate oral phase dysphagia (problems with using the mouth, lips and tongue to control food or liquid), reduced oral strength, coordination, sensation and mastication inefficiency. The Speech Therapist ((ST) specialist trained to help people with speech and language problems to speak more clearly) recommended for mechanical soft food with finely chopped meats, extra gravy, thin liquids, no corn, salad, or raw vegetables, upper partial dentures to be on prior to meals, verbal cues to take single bites, swallow all the food in Resident 1's mouth and then proceed to take the next bite, take sips of liquid between bites, and ensure mouth is clear of food after meal. On [DATE] at 1:33 p.m., during an observation of the facility's video surveillance of the south dining area events, dated [DATE] and timed at 4:50 p.m. in the presence of the DON and the ADM the following events were observed and verified by the DON and ADM as followed: At 4:52 p.m. CNA 1 provided Resident 1 with a dinner tray. At 4:54 p.m. CNA 1 was observed picking a dark color object with a fork and giving it to Resident 1 to eat and then walking away to continue passing food trays. Resident 1 was observed putting the object in her mouth and a few seconds later, Resident 1 was observed covering her mouth with a napkin and then placing it on the tray. At 4:56 p.m. Resident 1 walks to the other room in the South side dining room to get CNA 1's attention and CNA 1 then brought Resident 1 back to her chair. CNA 1 was observed rubbing and tapping Resident 1's back while Resident 1 was leaning forward. At 4:58 p.m. Resident 1 was observed leaning forward towards the table and CNA 1 was observed grabbing Resident 1 by the neck and pressing on Resident 1's neck while a staff member was punching Resident 1 on the breast area. At 4:59 p.m. Registered Nurse 1 (RN 1) was observed performing three episodes of [MEDICATION NAME] maneuver and stopping to hit Resident 1 multiple times in the back and CNA 1 once more was observed grabbing Resident 1 by the neck and pressing against it with her right arm. At 5:01 p.m. Licensed Vocational Nurse 1 (LVN 1) attempts [MEDICATION NAME] on Resident 1 and then places her on the floor to initiate CPR. At 5:10 p.m., paramedics are observed arriving at the facility and continue with CPR. At 5:31 p.m., Resident 1 was transferred to the GACH. On [DATE] at 2:39 p.m., during an interview, DSD stated licensed nurses and CNA's were in-serviced at the beginning of the year (2020) on how to perform the [MEDICATION NAME] maneuver when a resident is observed to be choking. On [DATE] at 3:40 p.m., during an interview, Registered Nurse 1 (RN 1) stated on [DATE] during dinner time, she heard a page for CODE BLUE (medical emergency such as cardiac or respiratory arrest) to the south dining area. RN 1 stated CNA 1 told her Resident 1 was choking and noticed there were food particles coming from Resident 1's mouth. RN 1 stated she was not able to perform the [MEDICATION NAME] maneuver because Resident 1 was sitting down. RN 1 stated the only time she was in-serviced on the [MEDICATION NAME] maneuver by the facility was after ,[DATE]. On [DATE] at 4:07 p.m., during an interview, CNA 1 stated on [DATE] during the dinner time she placed a food tray on Resident 1's table and then left to get juice for the resident. CNA 1 stated Resident 1 got up from her chair and showed her the food she had in her mouth, she then noticed Resident 1 leaning forward like if she was tired and then falling towards the table unconscious and unable to wake her up. CNA 1 stated Resident 1 was on Choked, food. CNA 1 stated she did not check Resident 1's food card to ensure the resident received the correct diet as ordered. CNA 1 stated finely chopped meat cannot be pinched by the fork because its small and it can only be scooped from the plate. CNA 1 stated she did not perform the [MEDICATION NAME] maneuver because she was unaware on how to do it. On [DATE] at 4:33 p.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated on [DATE] responding to a Code Blue over page to the south dining room. LVN 1 stated being notified by a staff member (did not remember who) of Resident 1 having food in her mouth. LVN 1 stated he unsuccessfully performed the [MEDICATION NAME] maneuver because Resident 1 was following down, and he proceeded to perform CPR because Resident 1 had no pulse. On [DATE] at 4:44 p.m., during an interview, CNA 2 stated Resident 1 was on a chopped diet and required assistance when eating and constant reminder to chew and swallow her food. CNA 2 stated CNA 1 provided the dinner tray to Resident 1 on [DATE] and was supposed to supervise Resident 1 during her dinner. On [DATE] at 5:23 p.m., during an observation of the video surveillance from [DATE] and timed at 4:54 p.m., in the presence of ADM and DON and review of Resident 1's care plan and ST recommendations, the DON stated per the video Resident 1's tray was not checked by the staff and supervised during feeding and did not perform the [MEDICATION NAME] immediately. The Don stated recommendations of the ST were not followed to remind Resident 1 to chew and swallow on her food after each bite. The DON stated Resident 1 required a 1:1 supervision during feeding. On [DATE] at 5:59 p.m., during an interview, Resident 2 stated on the day Resident 1 choked they were served big pieces of dry meat that had no flavor, carrots, mash potatoes and cake. Resident 2 stated seeing staff giving the meat to Resident 1 that caused her to choke. On [DATE] at 3:42 p.m., during an interview, Housekeeping (HK) stated on [DATE] he was called to the south dining room to clean the floor and saw Resident 1 hunched over the table and staff members patting her on the back. HK stated telling the staff to perform the [MEDICATION NAME] maneuver, but they told him to clean the floor instead. HK stated he was sweeping large pieces of meat intact and carrots from the floor. On [DATE] at 3:22 p.m., during a telephone interview, the Medical Director (MD) stated the staff should have initiated the [MEDICATION NAME] maneuver immediately after identifying the resident was choking and not wait ,[DATE] minutes. The MD stated Resident 1 could have suffered brain damage for being deprived of oxygen for more than ,[DATE] minutes depending on her diagnosis. The MD stated reviewing the surveillance video after of Resident 1's choking incident and noted staff padding the resident on her back, which was not appropriate for an adult. The MD stated Resident 1 clearly died from a [MEDICAL CONDITION] that was possibly caused by asphyxia (deprivation of oxygen to the body, causing unconsciousness or death; suffocation). A review of Resident 1's GACH's ED report, dated [DATE] indicated Resident 1 was admitted to the ED on [DATE] at 5:29 p.m. with no active cardiac activity. The ED report indicated Resident 1 was immediately intubated (placing a tube through the resident's throat to help move air in and out of the lungs), given three (3) rounds of [MEDICATION NAME] (medication that constricts the blood vessels to increase blood pressure, heart rate and cardiac output), and aggressive Advanced Cardiac Life Support ((ACLS) set of clinical process for the urgent treatment of [REDACTED]. Resident 1 was pronounced diseased on [DATE] at 5:56 p.m. A review of the facility's policy and procedures (P/P) titled, Choking-Obstructed Airway Clearance, revised ,[DATE] indicated to look for signs and symptoms of distress such as unable to speak. The P/P indicated to not slap the resident's back during choking because it can make it worse. The P/P indicated for the staff to stand behind the resident with arms around his/her waist, tilt forward, make a fist and place the thumb side of the fist against the resident's abdomen slightly above the naval and below the ribcage (do not put hands on the resident's breastbone or rib cage). A review of the undated American Heart Association (AHA) document provided by the facility and titled, Adult Choking, indicated to ask the resident if he/she is choking, give thrust slightly above the belly button until the object is forced out, the resident can breathe or becomes unresponsive. The AHA indicated to perform CPR if the resident became unresponsive.

Based on observation, interview and record review, the facility failed to follow the menu as written for residents on a finely chopped (ingredients cut into very small pieces (food specially meat) roughly the size of kernel of corn) diets for one of 12 sampled residents (Resident 1). Food Service Staff (FSS) staff failed to follow Resident 1's diet orders for finely chopped diet with nectar thickened liquid (easily pourable and comparable to apricot nectar or thicker cream soups). Resident 1, who had history of pocketing food (keeping some food in the cheeks or back of the mouth rather than swallowing fully) and difficulty chewing, was provided with a finely chopped diet. This deficient practice resulted in Resident 1 receiving a regular diet of roast beef causing her to experience a choking (severe difficulty in breathing because of a lodge object or food obstructing the throat blocking airflow) episode, going into [MEDICAL CONDITION] (sudden, unexpected loss of heart function, breathing, and consciousness) and subsequently being transferred to a general acute care hospital (GACH) in [MEDICAL CONDITION] on [DATE]. Resident 1 was admitted to the GACH's Emergency Department (ED) on [DATE] at 5:26 p.m. and pronounced deceased at 5:56 p.m. (30 minutes after ED arrival) On [DATE] at 4:54 p.m., the Administrator (ADM) and the Director of Nursing (DON), were notified an Immediate Jeopardy ((IJ), a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was called for the facility's staff inability to supervise Resident 1 during meals and follow Speech Therapist ((ST) specialist trained to help people with speech and language problems to speak more clearly) orders for Resident 1 to have finely chopped diet and recommendations for Resident 1 to be monitor during meals. The facility's ADM and DON were notified of the immediacy and seriousness of other residents' health and safety being threatened by staff not following diet orders and monitoring residents during meals. On [DATE] at 4:39 p.m., the ADM and DON were notified the Plan of Action (POA) was approved and at 5:20 p.m., the ADM, DON, Director of Staff Development (DSD), and Program Director (PD) were notified the IJ was lifted after review and on-site verification and confirmation of the POA implementation via observations, interviews and record review of the following: 1. The facility conducted a review of the resident's diets and identified 16 residents on mechanical soft diet and reviewed the nutritional care plan for appropriateness. 2. The Registered Dietitian (RD) and Dietary Supervisor (DS) provided in-service and training to dietary staff on [DATE] regarding following resident's nutritional care plan including types of diets and textures as ordered by the physician, portion sizes, measuring different textures such as mechanical soft. 3. RD and DS will conduct random checks of meal tray line preparation five (5) times a week for one month and will conduct ongoing skills competency checks every week for one month, then every quarter for one year, then annually. 4. The DON and DSD initiated an in-service and training to nursing staff on [DATE] and completed 75 percent (%) of training on [DATE] regarding: a) Following resident's Nutritional Care Plan including types of diets, textures, frequency of mouth checks, level of supervision, provision of adequate supervision etc. b) Identification and reporting of Resident's Change of Condition with emphasis in pocketing of food. c) Emergency response with emphasis on how to handle a choking victim and how to perform abdominal thrusts/[MEDICATION NAME] maneuver (a first-aid procedure for dislodging an obstruction from a person's windpipe in which a sudden strong pressure is applied on the abdomen, between the navel and the rib cage). d) Resident Nutritional care plans of residents who were identified on mechanical soft diet were reviewed and updated on [DATE] based on Registered Dietitians (RD), Speech Therapist (ST) and physician orders. e) The DON and DSD will provide ongoing in-services and skills competency training with return demonstration to nursing staff every week for a month, then every quarter for one year, then annually. f) Nursing staff who are on leave of absence will be provided with in-service and training upon return to work and before the start of their shift. Findings: A review of Resident 1's Admission Face Sheet indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE]. A review of Resident 1's admission History and Physical (H&P), dated [DATE] indicated Resident 1 did not have the capacity to understand and make decisions. The H&P indicated the resident had [MEDICAL CONDITION] disorder (mental disorder in which people interpret reality abnormally such hallucinations, delusions, and extremely disordered thinking and behavior that impairs daily functioning) and hypertension (high blood pressure). A review of Resident 1's Minimum Data Set (MDS), a resident assessment and care screening tool, dated [DATE], indicated Resident 1 had severe memory problems, impaired decision-making, but was able to usually understand and sometimes understood others. The MDS indicated Resident 1's [DIAGNOSES REDACTED]. of direction). The MDS indicated Resident 1 did not have natural teeth and was edentulous (lacking teeth). A review of Resident 1's care plan titled, Pocketing food in Cheeks, dated [DATE] indicated the goal was for Resident 1 to chew and swallow food with no difficulty for the next 90 days. The staffs' intervention included to encourage small, frequent feedings and rest in between periods, provide diet as ordered, observe for pain when swallowing, and observe Resident 1 during mealtimes. A review of Resident 1's Progress Notes, dated [DATE] and timed at 11:37 p.m., indicated an order was received from the Medical Director (MD) to change Resident 1's diet to pureed (cooked food, usually vegetables, fruits or legumes, that has been ground, pressed, blended or sieved to the consistency of a creamy paste or liquid), nectar thickened (easily pourable and comparable to apricot nectar or thicker cream soups) liquids, and to provide supervision during meals. A review of the Interdisciplinary Team ((IDT) group of health care professionals with various areas of expertise working together toward the goals of their residents) conference note dated [DATE] indicated Resident 1 was noted pocketing food in her left side jaw when staff was feeding and requiring heavy prompting during meals to chew and swallow food. The IDT recommendations were to refer Resident 1 to a speech therapist for evaluation for ability to swallow, and for staff to aid during meals. A review of Resident 1's Speech and Language Evaluation, dated [DATE] indicated Resident 1 was referred for a swallowing evaluation due to increased pocketing of food. The evaluation indicated during the assessment, Resident 1 was missing upper right and lower left molars (tooth with a rounded or flattened surface adapted for grinding specifically) which impacted her ability to effectively masticate (chew) food. The evaluation indicated Resident 1 had mild to moderate oral phase dysphagia (problems with using the mouth, lips and tongue to control food or liquid); reduced oral strength; and coordination, sensation and mastication inefficiency. The ST recommended for mechanical soft food with finely chopped meats, extra gravy, thin liquids, no corn, salad, or raw vegetables, upper partial dentures to be on prior to meals, verbal cues to take single bites, swallow all the food in Resident 1's mouth and then proceed to take the next bite, take sips of liquid between bites, and ensure mouth is clear of food after meal. A review of Resident 1's physician order [REDACTED]. A review of the facility's document titled, Mechanical Soft Diets and Mechanical Soft Finely Chopped Diet, revised ,[DATE] indicated mechanical soft diets and soft finely chopped diets were designed for residents with chewing or swallowing limitations. The document indicated all mechanical soft finely chopped diet were soft and cut into ¼ inch pieces. On [DATE] at 11:20 a.m., during a concurrent interview and record review of Resident 1's Change of Condition (COC) and care plans, the DON stated on [DATE] Resident 1 was observed unable to chew her food and on [DATE], her diet was changed to puree texture by the RD. The DON stated on [DATE], Resident 1 had a follow-up COC indicating Resident 1 required help with feeding and redirection to chew and swallow food. The DON stated finely chopped food was best described as small cuts of food. The DON stated the care plan for nutrition was updated and the interventions included for staff to encourage Resident 1 to slowly swallow her food and avoid pocketing. The DON stated staff was responsible to supervise residents during dining. On [DATE] at 12:20 p.m., during a dining observation of the north dining room, no staff members were observed supervising the residents having lunch. Four (4) staff members were observed at the tray carts standing waiting for residents to bring their empty trays. On [DATE] at 1:33 p.m., during a viewing of the facility's recorded video surveillance of the south dining area, dated [DATE] and timed at 4:50 p.m. in the presence of the DON and the ADM, the following events were observed as followed: At 4:52 p.m. Certified Nursing Assistant 1 (CNA 1) provided Resident 1 with a dinner tray. At 4:54 p.m. CNA 1 was observed picking a dark color object with a fork and giving it to Resident 1 to eat and then walking away to continue passing food trays. Resident 1 was observed putting the object in her mouth and a few seconds later, Resident 1 was observed covering her mouth with a napkin and then placing it on the tray. At 4:56 p.m. Resident 1 walks to the other room in south side dining room to get CNA 1's attention by tapping her on the shoulder and then the resident was brought back to her chair. CNA 1 was observed rubbing and tapping Resident 1's back and Resident 1 leaning forward. At 4:58 p.m. Resident 1 was observed leaning forward towards the table and CNA 1 was observed grabbing Resident 1 by the neck and pressing on resident's neck while a staff member was punching Resident 1 on the breast area. At 4:59 p.m. Registered Nurse 1 (RN 1) was observed performing three episodes of [MEDICATION NAME] maneuver and stopping to hit Resident 1 multiple times in the back and CNA 1 once more was observed grabbing Resident 1 by the neck and pressing against it with her right arm. At 5:01 p.m. Licensed Vocational Nurse 1 (LVN 1) attempts [MEDICATION NAME] on Resident 1 and then places her on the floor to initiate Cardiopulmonary Resuscitation ((CPR) an emergency lifesaving procedure performed when the heart stops beating). At 5:10 p.m., paramedics arrived at the facility's dining room and continued with CPR. At 5:31 p.m., Resident 1 was transferred to the GACH. On [DATE] at 2:39 p.m., during an interview, the DSD stated the staff was to do three checks to ensure the correct diets were being provided to the residents. The DSD stated the first check is done by the FSS, the second check by the licensed nurse and the final check by the CNAs prior to the food tray given to the residents. The DSD stated the staff was responsible to check food trays, passing trays, assisting residents requiring assistance to eat, monitor the residents and document meal percentage. On [DATE] at 2:48 p.m., during an interview, the DS stated the charge nurses were in charge of checking the food trays and compare them with the resident's orders to ensure the correct diet is provided to the residents. On [DATE] at 3:40 p.m., during an interview, Registered Nurse 1 (RN 1) stated on [DATE] during dinner time, she heard a page for CODE BLUE (a medical emergency code for cardiac or respiratory arrest) to the south dining area. RN 1 stated CNA 1 told her Resident 1 was choking and noticed there were food particles coming from Resident 1's mouth. On [DATE] at 5:40 p.m., during a telephone interview, FSS 1 stated not remembering the last time she received an in-service regarding food textures. FSS 1 stated FSS 2 was terminated from the facility for not following the resident's diet orders and ensuring the resident's received the appropriate diet orders. On [DATE] at 4:07 p.m., during an interview, CNA 1 stated on [DATE] during dinner time, she placed a food tray on Resident 1's table and then left to get juice for the resident. CNA 1 stated Resident 1 got up from her chair and showed her the food she had in her mouth, she then noticed Resident 1 leaning forward like if she was tired and then falling forward towards the table unconscious and unable to wake up. CNA 1 stated Resident 1 was on a choked diet order. CNA 1 stated she did not check Resident 1's food tray to ensure Resident 1 received the correct diet as ordered as recommended by the ST. CNA 1 stated finely chopped diet could not be pinched with the fork, instead it had to be scooped because the pieces were small. On [DATE] at 4:44 p.m., during an interview, CNA 2 stated Resident 1 received a chopped diet and the resident required assistance when eating and a constant reminder to chew and swallow her food. CNA 2 stated CNA 1 provided the dinner tray to Resident 1 on [DATE]. On [DATE] at 4:58 p.m., during an interview, LVN 3 stated all staff were aware Resident 1 required supervision during meals and a constant reminder to chew and swallow her food because she had the behavior of pocketing food in her cheeks. On [DATE] at 5:23 p.m., during the viewing of the recorded video surveillance from [DATE] and timed at 4:54 p.m., in the presence of ADM and DON and review of Resident 1's care plan and ST recommendations, the DON stated per the video, Resident 1's tray was not checked by the staff. The DON stated the recommendations of the ST were not followed to remind Resident 1 to chew and swallow her food after each bite. On [DATE] at 12:51 p.m., during an observation and interview, LVN 2 was observed distributing lunch trays without checking if the residents received their appropriate diet order. LVN 2 stated not having a printout of the resident's diet orders to ensure the residents received their appropriate order prior to distributing the trays to the residents. On [DATE] at 3:33 p.m., during an interview, RN 2 stated a daily diet report is printed and given to the charge nurses and CNA's to check diet orders are prepared per physician's orders [REDACTED]. On [DATE] at 3:42 p.m., during an interview, Housekeeping (HK) stated on [DATE], he was called to the south dining room to clean the floor and saw Resident 1 hunched over the table and staff members patting her on the back. On [DATE] at 3:22 p.m., during a telephone interview, the MD stated the staff should have initiated the [MEDICATION NAME] maneuver immediately after identifying the resident was choking and not wait ,[DATE] minutes. The MD stated Resident 1 could have suffered brain damage for being deprived of oxygen for more than ,[DATE] minutes depending on her diagnosis. The MD stated he reviewed the surveillance video of Resident 1's choking incident (on [DATE]) and noted staff patting the resident on her back, which was not appropriate for an adult. The MD stated Resident 1 clearly died from a [MEDICAL CONDITION] that was possibly caused by asphyxia. On [DATE] at 4:31 p.m., during an interview, FSS 2 stated on [DATE] dinner trays included beef that was of poor quality and hard. The FSS 2 stated large portion sizes were served to all residents. The FSS 2 stated not being aware who served Resident 1 with a regular diet. The FSS 2 stated he serves meal plates according to the portion size and texture instead of the name of the residents and diet orders. A review of Resident 1's GACH's ED report, dated [DATE] indicated Resident 1 was admitted to the ED on [DATE] at 5:29 p.m. in active [MEDICAL CONDITION] with active CPR after experiencing a choking episode while eating and then going into [MEDICAL CONDITION]. The ED note indicated the paramedics administered three (3) rounds of [MEDICATION NAME] (a medication that constricts the blood vessels to increase blood pressure, heart rate and cardiac output) with no regained pulse and with no active cardiac activity. The ED report indicated Resident 1 was immediately intubated (placing a tube through the resident's throat to help move air in and out of the lungs), given three (3) rounds of [MEDICATION NAME] and aggressive Advanced Cardiac Life Support ((ACLS) set of clinical process for the urgent treatment of [REDACTED]. Resident 1 was pronounced deceased on [DATE] at 5:56 p.m. A review of Resident 1's autopsy report, dated [DATE] and timed at 4 p.m., indicated there was a free piece of partially chewed food (skeletal muscle of animal origin) lodged (firmly fixed or embedded in a particular place) tightly over the orifice of the larynx (organ in the top of the neck involved in breathing, producing sound and protecting the trachea against food) measuring 4.5 centimeters ((cm) units of measurement) by (x) 3.8 cm x 3.8 cm completely occluding the airway. The autopsy report indicated Resident 1 died (on [DATE]) from asphyxia (deprivation of oxygen to the body, causing unconsciousness or death; suffocation) due to a large piece of meat lodge in her throat. The autopsy indicated Resident 1 had many teeth absent and others loose. A review of the facility's policy and procedures (P/P) titled, Resident Nutrition Services, revised ,[DATE] indicated nursing personnel would ensure residents were served the correct food tray. The P/P indicated prior to serving the nurse aide/feeding assistant would check the tray card to ensure the correct food tray was being served to the resident.

Based on observation, interview, and record review, the facility failed to provide the necessary care and services for one of three sampled residents (Resident 1). Resident 1, who had a history of [REDACTED]. The paramedics were not called until 16 minutes after Resident 1 complained of chest pain. This deficient practice resulted in a delay in diagnosis, care and treatment due to Resident 1 not receiving a timely assessment care and services, which resulted in Resident 1 having a [MEDICAL CONDITION] and resident being pronounced deceased by the paramedics nine hours after the resident complained of heartburn. Findings: A review of Resident 1's Admission Face Sheet indicated the resident was admitted to the facility on [DATE] with the following diagnoses, [MEDICAL CONDITION] disorder (a chronic mental health condition) and [MEDICAL CONDITION](rapid heart rate). A review of Resident 1's quarterly Minimum Data Set (MDS), an assessment and care screening tool, dated [DATE], indicated the resident was moderately impaired in cognition (ability to reason and think). The MDS indicated Resident 1 was independent with activities of daily living ((ADLs), routine everyday activities) such as eating, bathing, dressing, toileting, and walking. A review of Resident 1's Nurse's Notes, dated [DATE] and timed at 8:44 a.m., and on [DATE] and timed at 5:35 a.m., indicated the resident was complaining of chest pain. The physician was called and notified and ordered [MEDICATION NAME] (a medication used to relieve heartburn, acid indigestion or gas discomfort) 30 milliliters and to reassess the resident in 30 minutes. On [DATE] at 1:26 p.m., during an interview and a review of a declaration ( a formal written statement), Certified Nurse Assistant 1 (CNA 1) stated on [DATE] after lunch, at approximately 12:15 p.m., the resident complained to her of having heartburn and stated she was going to lie down in bed. CNA 1 stated she went on her lunch break and did not report Resident 1's complaint of heartburn pain to a charge nurse and she was not aware if the charge nurse was informed. CNA 1 stated she should have notified and reported to the charge nurse of Resident 1's complaint of heartburn so the resident could receive medications. On [DATE] at 12:30 p.m., during observation of the facility's video footage dated [DATE], the day of the incident, with the Administrator. The following was observed and verified by the Administrator as the events that occurred with Resident 1: a. At 8:56 p.m., Resident 1 came out of her room and approached the nurse's station looking into the nurse's station. The Administrator stated Resident 1 collapsed to the floor and CNA 4 approached the resident. b. At 8:57 p.m., Resident 1 was observed with her hands over her chest and Licensed Vocational Nurse (LVN 1) came out of the nurse's station to see the resident. c. At 8:57.51 p.m., LVN 1 and CNA 4 assisted Resident 1 up from the floor and back to the room. d. At 8:58.11 p.m., CNA 4 left Resident 1's room and walked down the hallway. e. At 8:58.22 p.m., LVN 1 came out of Resident 1's room and went to the nurse's station. The Administrator verified at this time it appears that Resident 1 was in the room unattended. f. At 8:58.44 p.m., LVN 1 reentered Resident 1's room. g. At 8:58.47 p.m., Registered Nurse (RN 1) and CNA 4 entered Resident 1's room. h. From 8:59 p.m. to 9:11 p.m., the staff was observed going in and out of Resident 1's room. i. At 9:12 p.m., staff was seen bringing in an oxygen tank into Resident 1's room (16 minutes after the resident had fallen complaining of chest pain). j. At 9:20 p.m., the paramedics were seen outside of Resident 1's room in the hallway of the facility. On [DATE] at 5:20 p.m., during an interview, the Assistant Director of Nursing (ADON) stated when a resident complained of heartburn, it was considered a change in condition and it should have been reported to the charge nurse immediately, so that the charge nurse could assess the resident. The ADON stated the charge nurse would assess the location of discomfort, onset, and the quality of discomfort. The ADON stated based on the findings of the assessment, then the charge nurse could offer medications as needed (PRN medications). The ADON stated after the administration of PRN medications then the charge nurse should assess the resident for the effectiveness of the PRN medication and notify physician if not effective. The ADON stated heartburn could be mistaken for chest pain and each individual could experience chest pain differently. On [DATE] at 4:22 p.m., during an interview, CNA 4 stated on [DATE] at approximately 8:50 p.m., she and Licensed Vocational Nurse 1 (LVN 1) were at the nurse's station. CNA 4 stated Resident 1 came to the nursing station requesting [MEDICATION NAME] for heartburn and resident fell to the floor. CNA 4 stated Resident 1 had her hands over her chest and stated that she did not feel good and her chest hurt. CNA 4 stated she and LVN 1 were assisting Resident 1 back to her room and the resident lost her balance and was assisted to the floor next to her bed. CNA 4 stated she went to get the supervisor, Registered Nurse 1 (RN 1). CNA 4 stated when RN 1 arrived to see Resident 1, the resident was not verbally responsive and could only make sounds like huh . huh. CNA 4 stated when Resident 1 stopped making sounds and became unresponsive, RN 1 initiated chest compression (a lifesaving technique to restore blood circulation to the brain and other organs). CNA 4 stated LVN 1 called 911 for emergency help and once the paramedics arrived they provided cardiopulmonary resuscitation ((CPR) lifesaving procedure to restore blood circulation and provide rescue breathing) to Resident 1, but the resident was declared deceased by the paramedics. On [DATE] at 4:43 p.m., during an interview, LVN 1 stated on [DATE] at 8:50 p.m., after the resident fell complaining of chest pain with labored breathing she was taken to her room. LVN 1 stated 911 was not called until Resident 1 became unresponsive and stopped breathing. On [DATE] at 6:57 a.m., during an interview, RN 1 stated when she arrived in Resident 1's room on [DATE] she saw the resident on the floor. RN 1 stated there was no oxygen being delivered to the resident and no vital signs had been assessed for the resident at that time. RN 1 stated Resident 1 was not able to produce words. RN 1 stated vital signs were taken: blood pressure ,[DATE] (normal reference range (NRR) ,[DATE]), heart rate 82 (NRR ,[DATE]), and fluctuating oxygen saturation between 80 to 90% (NRR ,[DATE]%). RN 1 stated Resident 1 was placed on her side because the resident had a tendency to drool. RN 1 stated when she checked Resident 1's carotid pulse (carotid pulse located on either side of the front of the neck just below the angle of the jaw and was used to determine the heart rate (pulse)), the pulse was thready (weak and difficult to feel). Resident 1 became unresponsive and RN 1 initiated chest compression on Resident 1, who was on the floor next to her bed. RN 1 stated at 9:12 p.m. (same day) (16 minutes after the resident complained of chest pain and had falling to the floor twice) the physician and an emergency call was made to 911. RN 1 stated she requested for an oxygen tank and Ambu bag (resuscitator bag used to assist with emergency breathing) from the staff. RN 1 stated once the paramedics arrived, they took over, but Resident 1 was pronounced deceased at 9:39 p.m., on [DATE] at the facility. RN 1 stated the staff had only informed her that Resident 1 had requested [MEDICATION NAME] for heartburn, but no other information was provided to her regarding the resident's change of condition. On [DATE] at 5:20 p.m., during an interview, the ADON stated when a resident complained of chest pain, the staff should assess the quality and location of pain and it was a medical emergency and 911 should be called as soon as possible. The ADON stated the facility did not have a specific policy and procedure on chest pain and emergency care. A review of CNA 1's witness statement indicated on [DATE] at 9:10 p.m., Resident 1 was lying on her side and staff was assessing the resident's vital signs. The witness statement indicated Resident 1 was initially breathing shallow and then stopped breathing and moving. The witness statement indicated the staff was told to get an oxygen tank, but no one knew how to work it. A review of RN 1's written declaration, dated [DATE], indicated that CNA 4 came to her and stated, I don't know what is going on with the resident (Resident 1), but the charge nurse told me to call you. The declaration indicated upon assessment of Resident 1, the resident's pulse was difficult to be felt and had minimal response with fluctuating oxygen saturation of 80 to 85%. The declaration indicated when Resident 1 became unresponsive, she (RN1) asked the charge nurse to call the physician and 911, because the resident's condition was deteriorating very fast. A review of LVN 1's written declaration, dated [DATE], indicated when Resident 1 was on the floor in her room, LVN 1 turned the resident on her left side because the resident appeared uncomfortable. The declaration indicated when RN 1 came in, she asked LVN 1 to take Resident 1's vital signs. The declaration indicated LVN1 went to the nurse's station to call the physician and left a message for the physician and then RN1 instructed her to call 911. A review of the facility's incident note, dated [DATE], indicated at 8:50 p.m., Resident 1 walked to the nurse's station and stated she had heartburn and requested [MEDICATION NAME], while the resident was touching her stomach area. The incident note indicated when Licensed Vocational Nurse 1 (LVN 1) turned to prepare the [MEDICATION NAME] she heard another nurse ask the resident what was wrong? After seeing Resident 1 fall to the floor. LVN 1 asked Resident 1 if she was okay and the resident replied, Yes. The incident note indicated the staff assisted Resident 1 to her feet and escorted her to her room, but the resident had lost her balance again, while in the room, near the bed, and the staff had to assist her to the floor. According to the incident note, Registered Nurse 1 (RN 1) supervisor was notified and immediately came to see Resident 1. The incident note indicated Resident 1's vital signs ((VS), measurements of the body's most basic functions and include temperature, heart rate, respiratory rate, and blood pressure) were: blood pressure ,[DATE], heart rate 82, and oxygen saturation was 89%. The incident note indicated at 9:14 p.m., on the same day, emergency 911 was called and arrived at 9:18 p.m. The incident note indicated at 9:39 p.m. on [DATE], Resident 1 was declared deceased . A review of the Fire Department's Prehospital Care Report Summary, dated [DATE], indicated a call was received at 9:12 p.m. (which was approximately 15 minutes after Resident 1 complained of chest pain). The paramedics arrived and made contact with Resident 1 at 9:19 p.m. The report indicated the chief complaint and the provider impression was [MEDICAL CONDITION] (heart stop beating). The report indicated at 9:20 p.m., Resident 1 was assessed as unresponsive and unconscious (not alert and awake) lying supine (lying face upward) on the floor pulseless (no pulse) and apneic (breathless or respiratory arrest) with no trauma. The report indicated Resident 1 was in ventricular fibrillation (a serious heart rhythm, in which the heart quivers (tremble/shakes) and the heart cannot pump any blood causing [MEDICAL CONDITION]) and CPR was attempted but was unsuccessful. Resident 1's Glasgow Coma Score was 3 (a scoring system used to describe the level of consciousness with a score between 3 and 15; 3 being the worst and 15 being the best). The report indicated the facility's staff stated Resident 1 was unresponsive for 10 minutes before calling the Fire Department and total time w/o CPR before EMS arrival. The report indicated Resident 1 was pronounced dead at 9:39 p.m. On [DATE] at 5:20 p.m., during review of Resident 1's health record and concurrent interview, the Assistant Director of Nursing (ADON) stated Resident 1 had a [DIAGNOSES REDACTED]. There were no care plans in the resident's clinical record to address the resident's [DIAGNOSES REDACTED]. The ADON stated after reviewing the record that there were no care plans to address Resident 1's [MEDICAL CONDITION] complaints of chest pain and should have been. The ADON stated a care plan should include interventions for the resident to meet the resident's goals. A review of the facility's policy and procedure titled, Change in a Resident's Condition, dated 2015, indicated the nurse supervisor/ charge nurse will notify the resident's attending physician or on-call physician when there has been: a significant change in the resident; a need to alter the resident's medical treatment and or medications; a need to transfer the resident to a hospital/treatment center; and instructions to notify the physician of changes in the resident's condition. A review of Resident 1's Certificate of Death, dated [DATE], indicated the Resident 1 expired on [DATE] at 9:39 p.m. with the immediate cause of death being [MEDICAL CONDITION] (the heart and lungs failure).

Based on observation, interview, and record review, the facility failed to ensure a resident, who was assessed at risk for weight loss, was reevaluated and had individualized interventions developed to address unintended changes in weight for one of 24 sampled residents (Resident 11). For Resident 11, the facility failed to: 1. Have an interdisciplinary care team (a group of healthcare professionals from diverse fields who work in a coordinated fashion toward a common goal for the resident) to evaluate and address insidious (slow, progressive) and significant weight losses according to the facility policy and procedure. Resident 11 lost the following weights: a. 8 pounds (lbs.) from 3/2015 to 4/2015 (30 days) b. 17 pounds from 6/2015 to 7/2015 (30 days) c. 7 from 7/2015 to 8/2015 (30 days) d. 6 pounds from 9/2015 to 10/2015 (30 days) and another e. 1 pound from 10/2015 to 11/2015 (30 days) For a total of 39 pounds of unplanned weight loss in 7 months. 2. Ensure the registered dietitian conducted a nutritional reassessment of Resident 11's nutritional status. 3. Provide the dietary supplements needed as ordered by the physician to have a sandwich three times a day in between meals from 8/9/15 to 10/18/15 for two months. 4. Update the nutritional care plan of Resident 11's actual weight losses, identify other factors contributing to Resident 11's weight losses, implement appropriate and individualized interventions to address actual weight losses from 3/2015 to 11/2015 and to re-evaluate effectiveness of interventions. 5. Weigh the resident four times per month as ordered on [DATE]. These deficient practices resulted in Resident 11 having an unplanned severe weight loss of the following: i. 24 pounds in three months, a12.24 percent weight loss from 6/2015 to 8/2015. ii. 28 pounds in six months, a 14% from 3/2015 to 8/2015, and iii. 39 lbs. or 19% of his body weight in 7 months from 3/2015 to 11/2015. The State Operations Manual indicated: Significant weight loss: One month = 5% Three months = 7.5% Six months =10% Severe weight loss: One month = greater than 5% Three months = greater than 7.5% Six months = greater than 10% Findings: A review of Resident 11's Admission Record indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 11 was 71 inches and weighed 200 lbs. at the time of admission. A review of Resident 11's Minimum Data Set (MDS), a resident assessment and care screening tool, dated 4/08/15, indicated the resident was cognitively (mentally) intact. The MDS indicated that nutritional status was triggered in the Care Area Assessment summary (CAA, a care area triggered in the MDS for care planning decision). A review of the facility document, Significant Loss/Gain Log for Resident 11, dated 2015, indicated the following: March -200 pounds April- 192 pounds May- 192 pounds June- 196 pounds July- 179 pounds August- 172 pounds September- 177 pounds October- 171 pounds November- 170 pounds December- Resident 11 refused to be weighed A review of Resident 11's meal intake record titled, CNA Daily Care Flow Sheet, indicated the following: In June, the resident consumed 90-100% of meals but refused meals 12 times. In July, the resident consumed 50-100% of meals but refused meals 2 times. In August, the resident consumed 50-100% of meals but refused meals 6 times. In September, the resident consumed 60-100% of meals but refused meals 10 times. In October, the resident consumed 60-80% of meals but refused meals 3 times. In November, the resident consumed 50-100% of meals but refused meals 11 times. A review of the dietary supervisor's (DS) progress notes, dated 6/22/15, incorrectly indicated that Resident 11 has no significant changes, is within ideal body weight (IBW) range, has no new diet order at this time, no food complaint at this time, oral intake is 100 percent, continue to monitor for 3 months. Another review of the dietary supervisor's progress notes dated 9/22/15, indicated that Resident 11 gained 5 pounds, is within IBW range, has no new diet order at this time, has no food complaints, oral intake is 100 percent, continue to monitor for 3 months. There was no documentation that the DS addressed Resident 11's refusal of meals and referred concern to the registered dietitian (RD). On 12/7/15, at 12:35 p.m., a concurrent interview and record review of Resident 11's initial nutritional care plan with the MDS coordinator (MDS1) indicated that a care plan was developed on 3/27/15 titled, Risk for Weight Loss related to schizo-affective disorder. The approach plans (interventions) included monitoring the resident's weight every month and to report significant weight loss to the physician, monitor diet compliance, and ensure that the resident was maintained at the line of sight for nourishment and meal consumption if indicated for close monitoring. The approach plan was updated on 8/9/15 that indicated May have sandwich for snack at hour of sleep. The initial care plan was not updated to indicate Resident 11's progressive weight loss from March 2015 (significant weight losses), and did not indicate identification of other factors contributing to the weight loss or, implement appropriate individualized interventions to prevent further weight loss, and re-evaluation of the interventions. On 12/7/15 at 12:35 p.m., during a concurrent interview and record review, the MDS coordinator (MDS 1) stated the facility did not have an interdisciplinary team or a weight variance committee that addressed issues for residents with weight loss. There was no documented evidence that an alternate meal or snack was offered to Resident 11 each time the resident refused a meal. A review of the registered dietitian (RD) Nutritional Assessment, dated 7/10/15, indicated Resident 11 had a 9% weight loss in 30 days. The RD recommended Resident 11 to be given 4 ounces (oz.) of health shake (a nutritional drink) three times a day between meals and weekly weights for 4 weeks. A review of Resident 11's Physician Order, dated 7/12/15, indicated to provide 4 oz. of health shake three times a day in between meals and conduct weekly weights for 4 weeks due to weight loss. A review of the RD's Nutritional Progress Notes, dated 8/6/15, indicated Resident 11 had a 14% weight loss since admission in 3/2015 (5 months). The RD recommended for Resident 11 be provided with a sandwich three times a day and a sandwich at bedtime. A review of Resident 11's physician's orders [REDACTED]. A review of Resident 11's Medication Administration Record [REDACTED]. There was no documented evidence that a facility staff attempted to clarify with the physician regarding the recommendations of the RD to provide Resident 11 with a sandwich at bedtime from 8/9/15 to 10/18/15. A review of the RD's Nutritional Progress Notes, dated 10/16/15, indicated Resident 11 had a 14.5% weight loss in 180 days (6 months). The RD repeated the recommendation for Resident 11 to be provided with 4 oz. of health shake and a sandwich three times a day between meals and to conduct weekly weights for 4 weeks. A review of Physician Orders, dated 10/18/15, indicated that Resident 11 be provided with 4 oz. of health shake and a sandwich three times a day between meals and weekly weights for 4 weeks. However, a concurrent review of the Diet Type Reports with the DS, dated 11/25/15 and 12/7/15, did not indicate that Resident 11's physician's orders [REDACTED]. A review of the Diet Type Report for 11/25/15 and 12/7/15 (only available copies given to survey team) did not indicate that any nourishment was provided to Resident 11. A review of the Vital Signs and Weight Record indicated there was no documented evidence that Resident 11 was weighed weekly for 4 weeks for the months of October/November 2015 as ordered by the physician on 10/18/15. On 12/7/15 at 12:35 p.m., during a concurrent interview and record review, MDS 1 acknowledged that Resident 11's physician's orders [REDACTED]. A review of the Nourishment Delivered to Nursing Stations from Dietary, dated 12/7/15, indicated the Nursing Station, the type of nourishment and quantity of nourishment allocated /allotted for each Nursing Station. The form did not identify the residents receiving the nourishments. Resident 11 was located in South Back and the form did not indicate a supply of sandwich for any resident in South Back. On 12/7/15 at 1:45 p.m., during an interview, Resident 1 was asked if he was receiving health shake and a sandwich between meals, he stated that he only received health shake for the first week, few months back (Resident 11 could not recall the month). Resident 11 stated, I did not get any shake or sandwich after that. On 12/7/15 at 2:15 p.m., during an observation, Resident 11 was asleep in bed. The licensed vocational nurse (LVN 2) was asked if Resident 11 received the nourishments (health shake and a sandwich) as scheduled at 2 p.m. LVN 2 was unsure and stated she only signed for the nourishment delivery from dietary staff but did not know which residents the nourishments belonged to. On 12/7/15 at 2:30 p.m., during an interview, the dietary supervisor (DS) stated that the Diet Type Report was a document that contained the diet list of all residents in the facility including snacks and nourishments ordered by the physician. The DS stated Resident 11 needed to be included in the Diet Type Report in order to receive nourishments (the health shake and sandwich three times a day) because that was the list that guided the dietary staff in providing the residents' meals and nourishments. During a concurrent review of the Diet Type Reports with the DS on 11/25/15 and 12/7/15, the DS acknowledged that she was aware of Resident 11's orders but did not know why the orders for health shake and sandwich did not generate into the Diet Type Report. A review of the RD's Nutritional Progress Notes from 8/6/15 to 10/16/15 indicated, there was no documented evidence that the RD calculated the nutritive value (calorie and protein contents) of the nourishments recommended, re-evaluated the previous interventions ordered, and reassessed resident's nutritional status each month Resident 11 had an unplanned weight loss. There was no documented evidence in the RD's Nutritional Progress Notes that addressed Resident 11's percentage of meal intake and refusals. Attempts were made to interview the RD, however she was not available. A review of the facility's 2013 policy and procedure titled, Immediate Temporary Interventions for Unplanned Significant Weight Loss, indicated the RD or designee will document the specific interventions used or recommended for residents including its nutritive value (portion, number of times per day provided, calories and protein). The policy indicated the RD or designee will assess the nutrition status and intervention may be changed as needed based on the reassessment process. The facility's policy titled, Medical Nutrition Therapy Assessment: Components of a Comprehensive Assessment, dated 2013, indicated the following: .The interdisciplinary team develops an individualized care plan with input from the resident/patient and/or representative .the care plan reflects the individual's goals and choices, and identifies individual-specific interventions. It includes a time frame in which goals are achieved, and parameters for monitoring progress.

Based on observation, interview, and record review, the facility failed to provide the necessary care and services in accordance with the plan of care and the physician's orders [REDACTED]. Resident 12, who was assessed at risk for skin alteration related to [DIAGNOSES REDACTED]. On 2/2/12, Resident 12's right great toe was red, swollen, had purulent (discharge of yellow-white fluid - pus) drainage and the resident complained the toe was severely painful. The resident was not receiving treatment to the affected toe, the pain was not managed and the podiatrist had not evaluated the resident for over three months. The resident was diagnosed with [REDACTED]. Resident 1, who had pain on the right heel, a heel cushion was not provided as ordered and the heel pain was not monitored and the resident had difficulty and pain when walking. Findings: 1. On 2/2/12, at 6 p.m., during the initial tour of the facility, in the presence of Registered Nurse 1 (RN 1), Resident 12 was observed in his room complaining of pain to his right foot. The resident was wearing closed shoes and socks. Upon interview, the resident stated he has had pain to the right great toe for approximately two months and had requested from the nurses to be seen by the podiatrist but nothing was done. The resident stated he did not know if the problem was an ingrown nail but he needed to be examined by a podiatrist. The resident removed his right shoe and sock exposing his right great toe (first toe) which was observed swollen, red in color, with yellow thick (pus) drainage. The resident stated the severity of the pain was 9 out of 10 (9/10 - pain scale range from zero to 10, where zero represents no pain and 10 is the worst pain possible). On 2/2/12, at the end of the tour, a review of the clinical record revealed Resident 12 was admitted to the facility on [DATE], and re-admitted on [DATE], with [DIAGNOSES REDACTED]. The body does not produce enough insulin or the cells ignore the insulin. Insulin is necessary for the body to be able to use glucose for energy.), [MEDICAL CONDITION] disorder (a condition in which a person experiences a combination of [MEDICAL CONDITION] symptoms - such as hallucinations or [MEDICAL CONDITION] - and of mood disorder symptoms, such [MEDICAL CONDITION] depression) and obesity. The quarterly Minimum Data Set (MDS - standardized assessment and care planning tool) dated 1/20/12, indicated the resident was alert and oriented, had no memory problems, had clear speech, was able to communicate his needs and required supervision in eating, dressing, personal hygiene and walking. The resident medication regimen included three daily oral anti-diabetics (to lower blood sugar), subcutaneous insulin per sliding scale four times a day, seven [MEDICAL CONDITION] (mind altering) medications for behavior control and one anti-[MEDICAL CONDITION] medication ([MEDICATION NAME]) twice daily for arthritis. A physician's orders [REDACTED]. Another physician's orders [REDACTED]. A plan of care dated 10/13/11, developed for the resident's problem of having a [DIAGNOSES REDACTED]. The interventions included protecting the extremities from pressure or injury, check feet and toes every shower day, provide podiatry care as ordered, prevent injury to feet and ankles and monitor for signs and symptoms of infections. The clinical record lacked documentation of a monthly podiatry service for diabetic foot care. The last podiatry evaluation was dated 10/27/11. Further record review revealed no documented evidence the nursing staff had addressed the resident's right great toe condition. There was no evidence the attending physician and the podiatrist had been made aware of the right great toe condition. The licensed nursing notes, the weekly summary notes which included an assessment of the resident's skin condition and toenails, and the nursing assistant's Daily Body Check Report form, did not document the status of the resident's right great toe. A review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. According to the nursing note dated 2/2/12, timed at 7:20 p.m., the resident was offered Tylenol for pain (rated 5/10) which the resident refused. At 7:35 p.m., the physician was notified and ordered the resident to be transferred to an acute hospital emergency room for evaluation of the right great toe. On 2/2/12, at 8:15 p.m., the resident was transferred via ambulance and on 2/3/12, at 1:10 a.m., the resident returned to the facility. The resident was diagnosed with [REDACTED]. On 2/2/12, at 7:40 p.m., an interview was conducted with Licensed Vocational Nurse 1 (LVN 1), who documented the resident refused the Tylenol for pain. LVN 1 stated the resident stated the Tylenol did not help with the pain but did not attempt to obtain an order for [REDACTED]. On 2/3/12, at 3 p.m., during an interview, Certified Nursing Assistant 1 (CNA 1), stated that approximately two weeks ago (could not remember the date) she reported to RN 2 that the resident's right great toe was red. CNA 1 stated she did not document the redness but she had reported it to the supervisor. On 2/3/12, at 3:15 p.m., during an interview, RN 2 stated she did not remember if CNA 1 had reported to her the resident's redness on the toe. On 2/4/12, at 10:53 p.m., during an interview, CNA 2 stated she noticed on Sunday (1/29/12) the resident was limping when coming out from church service and complained his toe was hurting. CNA 2 stated the resident asked one of the staff member (could not recall who) to put him in the list for the podiatrist. 2. On 2/4/12, at 12:30 p.m., Resident 1 was observed walking in the hallway with some difficulty. Upon interview, the resident explained she had a bone spur (a projection of bone from a body structure) on her right heel that was aggravated by walking. The resident stated it was very painful to walk and she needed a cushion on the heel to reduce the pain, however, even though the physician had ordered a heel support, she was not provided with one. The resident was noted without a right heel support. A review of the clinical record revealed the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS assessment dated [DATE], indicated the resident had no memory problems, and needed supervision from staff for her activities of daily living (ADLs). A physician's orders [REDACTED]. Another order indicated [MEDICATION NAME] 800 milligrams (mg) one tablet twice a day as needed for pain. There was no documented addressing the resident's right heel pain. There was no plan of care developed for the resident's concern/problem of pain on the right heel. According to the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The physician's progress notes dated 6/15/11, 7/27/11 and 8/14/11, documented the resident complained of pain on the right heel and the plan was providing the resident a heel support. On 2/4/12, at 3 p.m., the director of nursing stated the resident must have a heel support as ordered by the physician.