Every finding on record at War Memorial Hospital

Based on observation, record review and staff interview, the facility failed to ensure food was stored under sanitary conditions and in a manner that prevented foodborne illness to the resident. This failed practice had the potential to affect more than a limited number of residents. FACILITY:FACILITY. Facility Census: 14.Findings included: a) The facility's Policy and Procedure for Food Storage and refrigerator Safety stated, A.2, Dry foods should be stored in a manner that maintains the integrity of the packaging until they are ready to use. Practice B.7. stated, Label, date, and monitor refrigerated food so it is used by its use-by-date, or discarded. Practice B.9. stated, All refrigerators will be cleaned and outdated food discarded. b) On 04/07/2026 at %:45 AM, the kitchen investigation was initiated with [NAME] #15. The following items were identified: Dry Goods and Canned Storage - Harvest penne pasta - hole in bag.Light brown sugar - no use by date.Powered [NAME] Sugar - no use by date.Quaker Individual packets of Oatmeal in a plastic bin - date received 6/26, dated incorrectly and no use by date.D'Gari Gelatin - date received 6/26, dated incorrectly with no received date.Sweet Crackers Educational snacks - no received date.Red Gold Marinara Sauce - no use by date. On 04/07/2025 at 6:00 AM, the above listed items were confirmed by [NAME] #15. Refrigerator - Sliced onions - not sealed and use by date 4/6/26.[NAME] slaw - no opened date.Roseli Imported Parmesan Cheese - opened with a sticker that stated: Must be used by the end of the day 4/6/26. On 04/07/2026 at 6:15 AM, the above listed items were confirmed by [NAME] #15. Freezer - Bag of opened carrots - no open or use by date.Diced onions - not labeled, no open or use by date.Cheese pizza - individual in a plastic bag, not labeled and no open or use by date.Bagels - not labeled or dated.Chicken Breasts - opened, not labeled or dated. On 04/07/2026 at 6:15 AM, [NAME] #15 confirmed the above listed items and stated, I don't know when it was opened, referring to the chicken. Items removed from the freezer by [NAME] #15.

Based on interviews and record reviews during a recertification survey on 10/16/24, the facility did not ensure timely notification to the physician of Resident's significant weight loss. This is true for one (1) of three (3) Resident's reviewed for weight loss. Resident identifiers: Resident #2. Facility census: 15. Findings included: a) Resident #2 Resident #2 had diagnoses of Polyosteoarthritis, Heart failure, Chronic Obstructive Pulmonary Disease, Major Depressive Disorder, Type 2 diabetes, hypertension, and age-related physical debility. Record review on 10/15/24 at approximately 2:18 PM revealed the following: Resident had been weighed on 08/06/24 at 11:58 AM, and the weight recorded as 218.2 pounds. A nursing note on 08/07/24 at 10:28 PM by Licensed Practical Nurse (LPN) #21, which stated: Resident alert and oriented to person, place, time and situation. Speech clear. Resident able to make her needs known. Resident independent, set-up to supervision for ADL's, has been requiring staff assistance on occasion with ADLs depending on ability that day. Resident able to feed herself meals after tray set up. Resident wears upper and lower dentures. Resident takes care of her own dentures. Denies oral pain or discomfort at this time. No issues with chewing or swallowing noted. Resident continent of bladder and bowel but does have occasional incontinence episodes. Resident has bilateral hearing aids but usually does not wear them. Resident wears PRN oxygen at 2L via nasal cannula to maintain oxygen saturations above 92%. Resident walks with rollator walker independently in room and hallway. Has been using wheelchair for longer distances at times depending on ability that day. Resident participates with unit activities. Enjoys watching television, playing Bingo and participates with some unit activities. A nursing note on 08/08/24 at 6:50 PM by Registered Nurse (RN) #1 which stated: Resident with increased weakness and dyspnea with exertion. Resident is experiencing some confusion and states she feels shaky. Upon assessment, resident's vital signs WNL for resident. Blood glucose is 319. Resident does have tremors to hands and is having difficulty staying awake, even while conversing with staff. Lung sounds diminished to right side; fine crackles auscultated to left base. Resident required 2 staff assist to ambulate from the bathroom and reported fear of falling due to weakness. [Physician] was notified of change in condition. New orders for ER evaluation. POA, called and updated. POA and resident agreeable to transfer to ER. A note by LPN #21 on 08/08/24 at 7:00 PM which stated: Resident left floor via wheelchair with staff to ER. A follow up note on 08/08/24 at 10:26 PM by LPN #21 which stated: Spoke with ER nurse, resident admitted to (local hospital). MPOA, made aware. A note on 08/12/2024 at 10:23 AM by RN #5 which stated: Resident returned to unit via wheelchair on 2L portable oxygen from (local hospital) unit. VS were taken and are WNL for resident. Last BM reported on 8/11. Bowel sounds active in all 4 quads. Resident lung sounds are clear. Bilateral lower leg swelling +1 pitting edema noted. Resident c/o right knee pain 6/10 that is alleviated with Tylenol. Multiple bilateral arms bruising due to blood draws and IVs. Resident is currently sitting in recliner with call bell in reach. POA notified of residents return to unit. Plan of care ongoing. Resident's weight upon re-admission to the facility on [DATE] at 10:08 AM was documented as 201.4 pounds. This was a loss of 16.8 pounds in six (6) days, which correlates to a 7.7% weight change. During an interview with the Director of Nursing (DON) #34 on 10/16/24 at approximately 10:55 AM, she revealed a patient weighing policy. Review of the policy revealed that residents were to be re-weighed if resident's weight had increased or decreased by five (5) pounds, per physician's order, or at the request of the RN or Dietitian. Record review further revealed that facility staff were compliant with the policy. Resident #2 was re-weighed multiple times on 08/12/24: At 10:45 AM, her weight was again recorded as 201.4 pounds. At 11:15 AM she had been weighed once again and her weight was recorded as 201.4 pounds. On 08/13/24 at 10:31 AM resident's weight was recorded as 201.6 pounds. A progress note on 08/16/24 at 6:24 PM by DON #34 stated: [Resident] triggered for significant change in status (decline) in urinary incontinence this assessment period. On state assessment, [Resident] triggered for significant change in status (decline) in mood this assessment period. [Resident] has episodes of bladder incontinence and mood fluctuates from day to day and times throughout the day, therefore, will not complete a significant change in status this assessment period. During the seven days look back period (ARD 08/02/24), POC documents [Resident] as independent for bed mobility, transfer, toilet use, and supervision for eating. [Resident] was occasionally incontinent of bladder and always continent of bowel this assessment period. [Resident] has no behavior problems. [Resident] has no pressure injuries. Skin is intact. Current weight is 217.6 pounds (08/01/2024). [Resident] attends activities of her choosing and also participates in self-directed activities (television, music, crocheting, talking on the phone). [Resident] had no falls this assessment. [Resident's] family (son and family) live out of state and are supportive. [Resident] has no concerns for care conference and does not wish to participate in care conference. Letter regarding care conference was mailed to MPOA, with no response back. [Resident] requested a copy of her care plan be mailed to her MPOA, per pre request, a copy of care plan was mailed to [Resident's] MPOA. [Resident's] plan of care will continue. A review of Resident #2's care plan revealed the following note: NUTRITIONAL STATUS: [Resident] has the potential for nutritional problem related to Obese II BMI. Diet order Regular Consistency/Regular Diet with regular liquids. [Resident] has Type II Diabetes. Date Initiated: 03/18/19 Revision on: 08/16/24 GOALS: [Resident] will be free from any sign/symptoms of hyperglycemia through next review date. Date Initiated: 06/05/18 Revision on: 06/07/19 Target Date: 11/07/24 [Resident] will be free from any sign/symptoms of hypoglycemia through the next review date. Date Initiated: 06/05/18 Revision on: 06/07/19 Target Date: 11/07/24 [Resident] will have no complications related to Diabetes through the next review date. Date Initiated: 06/05/18 Revision on: 06/07/19 Target Date: 11/07/24 [Resident] will maintain adequate nutritional status as evidenced by maintaining weight within +/- 5%, no s/sx of malnutrition, and consuming at least 76-100% of each meal daily through the next review date. Date Initiated: 06/05/18 Revision on: 06/07/19 Target Date: 11/07/24 INTERVENTIONS: Administer medications (Lantus Insulin, 20 units SQ at bedtime x 1 week) as ordered. Monitor for adverse effects and effectiveness. Notify MD as indicated. Date Initiated: 08/13/24. Dietician offered education to resident due to excessive snacking at times, [Resident] declined education. She verbalized I know exactly what I am doing. Dietician will provide education to [Resident] as requested or indicated. Date Initiated: 03/18/19. Record review revealed a dietitian's note on 09/03/24 at 1:36 PM by Dietitian #27 which stated: Weight loss verified after re-weight. Significant weight loss noted. Current weight on 9/2/24 204.6 Lbs -5.0% change [ Comparison Weight 8/6/2024, 218.2 Lbs. -6.2%, -13.6 Lbs] Discussed POC with RN and [Resident] who are aware of weight loss. During recent acute care hospitalization , they removed fluid. Weight loss was expected. Skin intact at this time. No concerns noted during morning meal rounds. Feeds herself. Normally consumes 100 % of meals. An attempt was made to interview the Dietitian #27 on 10/16/24 at approximately 5:18 PM. The dietitian was not available for interview at that time. Further record review revealed no physician's orders, or progress notes, documenting or addressing the weight loss. An interview with RN #5 on 10/16/24 at approximately 8:55 AM revealed that she was aware of Resident #2's weight loss. During a follow-up interview with DON #34 on 10/16/24 at approximately 1:55 PM, she was asked whether she could produce any record that the facility notified the physician of the resident's 16.8-pound weight loss. DON #34 stated that she would review the facility records. At approximately 3:30 PM on 10/16/24 the DON #34 produced a handwritten physician's order dated 08/13/24 concerning Resident #2's diagnosis, and treatment, but did not refer to the resident's weight loss. She stated That's all I've got.

Based on medical record review and staff interview, the facility failed to ensure physician orders and care plans matched the resident and/or medical power of attorney's requests documented on the West Virginia Physician Orders for scope of treatment (POST) form. This is true for four (4) of four (4) residents reviewed. Resident identifiers: 3, 8, 13, 16. Facility census: 16. Findings include: a) Resident (R) #3 Review of the medical record on [DATE], revealed R #3 completed a POST form with his medical power of attorney and physician on [DATE]. The form states Do Not Attempt Resuscitation if found without a pulse and not breathing. Limited interventions include intravenous fluids (IV) for a trial period of no longer then three days and no feeding tube. The physician orders state DNR (Do not resuscitate) but lack any information related to the requested limited interventions. The care plan acknowledges his request to be a DNR but lacks information related to limited interventions of IV fluids for a trial period and no feeding tube. The Director of Nursing (DON) reviewed the medical record during an interview on [DATE] at 2:00 PM. The DON confirmed the physician's order and the care plan do not address R #3's requests listed on the POST form for limited interventions of IV fluids and no tube feedings. b) Resident (R) #8 Review of the medical record on [DATE], revealed R #8 completed a POST form with his physician on [DATE]. The form states Do Not Attempt Resuscitation if found without a pulse and not breathing. Limited interventions include IV fluids for a period of seven days and no feeding tube. The physician's order states DNR (Do not resuscitate) but is silent for the requested limited interventions of IV fluids for seven days and no feeding tube. The care plan identifies his request to be a DNR but lacks information related to limited interventions of IV fluids for a trial period and no feeding tube. The Director of Nursing (DON) reviewed the medical record during an interview on [DATE] at 2:00 PM. The DON confirmed the physician's order and the care plan do not address R #8's limited intervention requests listed on the POST form. c) Resident #13 A medical record review, completed on [DATE] at 3:00 PM, revealed the following details: -A Physician Orders for Scope of Treatment (POST) form, signed on [DATE], indicating the resident wanted to be considered a DNR, wanted to receive limited additional interventions, requested to receive IV fluids for a trial period of no longer than 10 days, and did not want to have a feeding tube. -Resident's Care Plan, dated [DATE], stated [Resident's First Name] is a DNR per MPOA and physician order. -A physician order, dated [DATE], stated, Physician Order: CODE STATUS: DNR. During an interview, on [DATE] at 3:17 PM, the DON stated the physician order and care plan only reflected the resident's desire to be considered a DNR. They did not match the resident's POST form which reflected limited additional interventions, a desire to receive IV fluids for a trial period or the desire to not have a feeding tube. d) Resident #16 A medical record review, completed on [DATE] at 3:13 PM, revealed the following details: -A Physician Order for Scope of Treatment (POST) Form, signed on [DATE], indicating resident wanted to receive CPR, wanted to receive full interventions, requested to receive IV fluids for a trial period of two (2) weeks, and did not want to have a feeding tube. -Resident's Care Plan, dated [DATE], stated, CODE STATUS: [Resident's First Name] is a Full Code per resident and physician order. -A physician order, dated [DATE], stated, Physician Order. Code Status: FULL CODE. During an interview, on [DATE] at 3:19 PM, the DON stated the physician order and care plan only reflects the resident's desire to receive CPR. They did not match the resident's POST form which reflected full interventions, a desire to receive IV fluids for a trial period or the desire to not have a feeding tube. 43340

Based on facility documentation and staff interview, the facility failed to meet at least quarterly to conduct required Quality Assurance and Performance Improvement (QAPI) activities. This practice had the potential to affect more than a limited number of residents at the facility. Facility census 16. Findings included: a) QAPI meetings Review of the facility's Quality Assurance and Performance Improvement (QAPI) plan revealed that the Medical Director, [NAME] President of Medical Affairs/designee, [NAME] President, DON, Dietician, Pharmacist, Infection Control Preventionist, Director of Activities, and the Director of Housekeeping were on the committee. A request was made for the attendance sheet from the QAPI meetings for the previous 12 months. Attendance sheets from April 2022 - November 2022 were provided. During an interview, on 11/01/22 at 2:30 PM, the Director of Nursing (DON) reported the facility did not have any QAPI meetings from October 2021 - March 2022. The DON reported she had participated in meetings on the acute care side of the hospital but failed to have meetings for the long-term care unit. The DON reported she had misinterpreted CMS guidance and had erroneously believed the QAPI meetings were waived altogether. The DON confirmed there were no meetings for the October 2021 - December 2021 quarter and the January 2022 - March 2022 quarter.

Based on record review, review of facility grievances, policy review, and staff interview, the facility failed to ensure that all allegations of neglect were reported within 24 hours to appropriate state agencies as required. This was a random opportunity for discovery. Resident identifier: #7. Facility census: 16. Findings included: a) Resident #7 On 11/02/22 at 9:04 AM, a review of the facility grievance log from May 2022 through October 2022 found the following resident complaint: -Resident #7 reported, on 10/05/22, that she had asked the Certified Nurse Aide (CNA) to hand her oxygen to her. The CNA asked if she could say, Please? Resident also reported the CNA would not assist her with washing her bottom. A subsequent medical record review revealed the following details: -The annual Minimum Data Set (MDS) for Resident #7, with an assessment reference date of 08/29/22, reflected resident was cognitively intact and had a BIMS [Brief Interview for Mental Status] score of 15. -Resident #7 had experienced a fall in her room on 09/29/22 and sustained a broken right arm. Review of the facility's Abuse Prevention and Reporting policy, dated July 2022, indicates the facility will support all residents in reporting any suspected acts of abuse, neglect, or exploitation in accordance with West Virginia State Law without the fear of reprisal or retribution. Further, the facility policy defines neglect as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. During an interview on 11/02/22 at 9:25 AM, the Director of Nursing (DON) agreed that the concerns mentioned in the resident grievance should have been considered an allegation of neglect and it should have been reported according to state guidelines. The DON also acknowledged Resident #7 may have required more help with her routine following her broken arm.

Based on medical record review and staff interview, the facility staff failed to accurately complete an annual comprehensive assessment of a resident's psychiatric/mood disorders. This is true for one of five reviewed for unnecessary medications. Resident identifiers: 7. Facility census: 16. Findings include: a) Resident #7 Review of the medical record on 11/01/22 revealed R #7 diagnoses includes anxiety. A physician order dated 03/11/22 notes Celexa (antidepressant used to treat depression and anxiety) 30 milligrams once a day for depression and anxiety. The annual Minimum Data Set (MDS) comprehensive assessment with an assessment reference date of 08/29/22 is not marked to reflect the diagnosis of anxiety under section I5700 titled Psychiatric/Mood disorder. The Director of Nursing confirmed R #7's annual MDS assessment was coded incorrectly and does not reflect her diagnosis of anxiety during an interview on 11/01/22 at 4:00 PM.

Based on record review and interview, the facility failed to report a resident's major injury to the appropriate state entities, in a timely manner. This is true for one (1) of one (1) resident reviewed for accidents. Resident identifier: #6. Facility census: 16. Findings included: a) Resident #6 On 07/17/21 at 5:10 PM, Resident #6 had an unwitnessed fall. Vital signs were obtained. The resident complained of right hip pain and was immediately sent to the Emergency Department of a local acute care hospital. The resident returned to the facility at 8:45 PM on this same date. X-rays showed no evidence of a broken bone. A Computed Tomography Scan (CT) was ordered by the physician. This scan found an Acute nondisplaced right inferior pubic ramus fracture. This is a stable pelvic fracture. This acute fracture is difficult to see on yesterday's x-ray of the pelvis. According to federal regulations serious bodily injuries should have been reported within two (2) hours of discovery. On 07/27/21 at 4:40 PM, the Director of Nursing (DON) explained she was not aware this regulation.

Based on record review and staff interview, the pharmacist failed to recommend a gradual dose reduction (GDR) for a Resident #14 related to the use of an antidepressant. This is true for one (1) of five (5) residents reviewed for unnecessary medications. Resident identifier: #14. Facility census: 16. Findings included: a) Resident #14 A medical record review for Resident #14 revealed [MEDICATION(S)] (antidepressant) with a start date of 06/07/20 received the same dose of [MEDICATION(S)] for greater than one (1) year. Continued review of the medical records found no evidence the pharmacist made a GDR for this antidepressant in the prior year, as required by federal Medicare and Medicaid regulations. On 07/28/21 at 10:00 AM, the Director of Nursing (DON) confirmed the pharmacist did not complete the GDR.

Based on observation and staff interview the facility failed to safeguard the content of Resident personal information displayed on a computer. This is a random opportunity for discovery. Resident identifier: #10. Facility census: 16. Findings included: a) Resident #10 During medication pass on 02/05/20 at 1:20 PM licensed nurse (LPN) #15 used a computer to determine medications to give to Resident #10 and then walked away from the computer to administer the medication. Licensed nurse #15 did close the screen on the computer leaving the residents' medical information available for any person passing by to observe. Interview with licensed nurse #15 on 02/05/20 at 1:30 PM agreed she forgot to clear the computer screen.

Based on observation and staff interview, the facility failed to deliver respiratory care services consistent with professional standards of practice. An oxygen humidifier bottle was not labeled with a date as to when it was last changed. This practice has the potential to affect a limited number of residents receiving respiratory care services. Resident identifiers: #15. Resident census: 16. Findings included: a) Resident #15 An observation on 02/04/20 at 08:40 AM, revealed the Resident #15 had an oxygen humidifier bottle attached to the wall oxygen flowmeter. There was no date on the oxygen humidifier bottle. An interview with Licensed Practical Nurse (LPN) #15, on 02/04/20 at 8:45 AM, revealed the oxygen humidifier bottle should be changed and dated every seven (7) days. She stated, the night shift nurse is responsible for changing and dating the humidifier bottle. LPN #15 verified the tubing was not dated and immediately changed and dated the humidifier bottle.

Based on observation, staff interview, and policy review, the facility failed to store food in accordance with professional standards of food safety. There were multiple items in the walk-in cooler which were stored beyond the use by date, not dated when opened, and/or stored beyond the manufacturer's sell by date. This had the potential to affect all of the resident's in the facility. Facility census: 16. Findings included: a) Initial Tour of the Kitchen An initial tour of the kitchen on 04/15/19 beginning at 11:00 AM and concluding at 11:31 AM with dietary employee #23, found the following concerns in the walk-in refrigerator: 1. An opened, partially used plastic bag of cubed Swiss cheese, which weighed approximately two (2) pounds, was dated as having first been opened for use on 03/31/19. Its label directed to use by 04/09/19. 2. A clear, plastic, four (4) quart bowl was filled to the two (2) quart line with kidney beans. This bowl of beans was dated 04/07/19, with directions to use by 04/13/19. 3. An opened, partially used plastic bag of shredded mozzarella cheese, which weighed approximately one (1) pound, was dated as having first been opened for use on 04/05/19. Its label directed to use by 04/12/19. 4. An opened, partially used plastic bag of cubed cheddar cheese, which weighed about half a pound, was dated as having first been opened for use on 04/04/19. Its label directed to use by 04/13/19. 5. An opened, partially used plastic bag of Romano cheese, which weighed about one (1) pound, was dated as having first been opened for use on 03/29/19. Its label directed to use by 04/07/19. 6. An opened, nearly full gallon jug of Dairy Pure 2% reduced fat milk was labeled to sell by 04/08/19. There was no date to indicate when it was first opened for use. 7. An opened, nearly empty gallon jug of whole milk was labeled to sell by 04/15/19. There was no date to indicate when it had first been opened for use. There was approximately three (3) inches of milk which remained in the bottom of the milk jug. The above listed food items were shown to dietary employee #23 on 04/15/19 at 11:31 AM. She agreed the first five (5) items named above should have been discarded by the use by dates inscribed. She agreed that the milk items listed in number six (6) and in number seven (7) should have been dated when initially opened. She immediately began to dispose of those seven (7) items. An interview was conducted with the dietary manager on 04/16/19 at 3:00 PM. She was aware that dietary employee #23 discarded those seven (7) named food items yesterday. On 04/17/19 the facility provided a copy of the Food Storage and Refrigerator Safety policy and procedure which was most recently reviewed in 02/2019. Under section A., Practices to maintain safe refrigerated storage, item number seven (7) included Labeling, dating and monitoring of refrigerated food, so it is used by the expiration date or discarded.

Based on observation, staff interview, review of manufacturer's guidelines, and review of Nursing 2019 drug handbook, the facility failed to maintain a medication administration error rate of less than five percent (5%). The error rate was 7.69% (percent). This was evident for two (2) medication errors out of twenty-six (26) opportunities. Resident identifier: #10. Facility census: 16. Findings included: a) During an observation on 04/16/19 at 7:36 AM licensed practical nurse #30 (LPN #30) handed a [MEDICATION NAME] 160/4.5 microgram inhaler to resident #10. Resident #10 immediately inhaled two (2) puffs of the medication in rapid succession, then rinsed her mouth with water. On 04/16/19 at 7:37 AM LPN #30 handed her a ProAir 90 microgram inhaler. The resident again immediately inhaled two (2) puffs of the medication in rapid succession, then rinsed her mouth with water. Review of manufacturer's instructions for [MEDICATION NAME] administration found directives to wait at least one (1) minute between successive inhalations for maximum effectiveness. Review of manufacturer's instructions for ProAir administration found directives to wait at least one (1) minute between successive inhalations for maximum effectiveness. Review of the Nursing 2019 handbook which was kept at the nurses' station for reference, found directives that if using other inhalers at the same time, wait at least two (2) minutes between the use of each medication. An interview was conducted with the director of nursing (DON) on 04/16/19 at 8:55 AM. She said this resident will not allow nurses to administer inhalers. Rather, the resident uses her inhalers in the presence of the nurses. Upon inquiry, the DON said she did not know if anyone had educated the resident on the correct spacing of the inhaled medications. She said the facility has no policy or procedure about the spacing of inhaled medications. On 04/17/19 at 12 PM the DON stated that nursing completed education with the resident today as to the correct use of inhaled medications. The DON stated that the resident told her she used the inhalers at the facility the same way she used them at home prior to coming to the facility, and did not realize there was a more effective way to use them.

Based on observation and staff interview, the facility failed to prepare and serve food in a sanitary manner. This had the potential to affect any resident who receives nourishment from the dietary kitchen. Facility census: 16. Findings included: a) Lunch tray serve line observation in the kitchen On 05/08/18 at 11:50 a.m., water was observed on the floor beside the tray serve line in the dietary kitchen. Cook Employee #10's (E#10) work station on the food serve line ensured that she stood between the tray line and the water spill on the floor. At this time of observation, E#10 was in the process of assisting to serve food to the residents and to the patients in the hospital. She wore purple-colored latex gloves during the food tray serve to ensure her bare hands did not come into direct contact with resident's or hospital patient's food or items on the tray. At 11:50 a.m. on 05/08/18, E#10 used a white-colored cleaning cloth to mop the water spill on the floor, while wearing her purple-colored latex gloves. After she wiped the spill thoroughly, E#10 carried the wet cloth into the area which housed the dishwashing machine and disposed of the now wet, dirty, cleaning cloth. E#10 immediately returned to her station on the tray line serve, to resume serving the lunch meal to residents. As she reached for a clean plate, she wore the same purple-colored latex gloves which she wore while wiping the water spill on the floor. Upon inquiry as to whether she should change gloves and wash hands now, she replied in the affirmative and thanked the questioner for the reminder. On 05/08/18 at 12:22 p.m., an interview was conducted with the dietary manager, Employee #59. She said Employee #10 should have washed hands and changed gloves after wiping up the water on the floor. E#59 said the water on the floor came from condensation from the steamer, which is located across from the tray line. She said that all dietary staff have received on-going in-service education on cleanliness and infection control, which included hand hygiene principles.

Based on personnel file review, facility policy/procedure review, review of Chapter 514.4 of the Medicaid manual and a clarification memorandum from the Bureau for Medical Services (BMS) regarding the requirements of the Affordable Care Act, and staff interview, the facility failed to ensure criminal background investigations were completed for all employees prior to hire and every 3 years there after throughout the remainder of employment to determine whether the individuals had been found guilty of abuse, neglect, or mistreatment of [REDACTED]. This was not completed for one (1) of ten (10) employees whose personnel files were reviewed. Employee identifier: #48. Facility census: 16. Findings include: a) Employee #48, Rehabilitation Physical Therapy Aide (Rehab PTA) Review of the personnel files on 03/08/16 at 3:50 p.m. with Senior Human Resources Director (SRD #159), revealed Rehab PTA #48's file lacked a criminal background check. SRD# 159 stated, I will not be here tomorrow but will research and provide the criminal background check. On 03/09/16 at 8:55 a.m., the Administrator provided copies of communication from the West Virginia State Police to Rehab PTA #48. A copy of an email sent to an employee in the Human Resources Department on 02/18/14 from WV Easypath-Morpho Trust with a letterhead from the West Virginia State Police. The FBI (Federal Bureau Investigations) has rejected the fingerprint submission and the employee must be re-fingerprinted. A review of the facility Resident Abuse/Neglect policy and procedure on 03/09/16 at 9:00 a.m. stated; .D. Miscellaneous Screening Efforts 1. as part of the pre-employment process, all applicants for employment on the long term care facility will have a criminal conviction investigation completed and a complete set of fingerprints. On 03/09/16 at 9:10 a.m. the Director of Nursing (DON) stated, We do not have anything on her (Rehab PTA #48) for any background checks. She has been working with out a background check on file since her hire date (hire date 06/26/1984). 514.4.1 Employment Restrictions Criminal Investigation Background Check (CIB) results which may place a member at risk of personal health and safety or have evidence of a history of Medicaid fraud or abuse must be considered by the nursing facility before placing an individual in a position to provide services to the member. At a minimum, a fingerprint-based State level criminal investigation background check must be conducted initially by the employer prior to hire and every three years thereafter throughout the remainder of the employment ). A policy clarification memorandum (memo) was issued to all Medicaid participating facilities on February 15, 2013. The memo included . at a minimum, a fingerprint-based state level criminal investigation background check must be conducted initially by the employer prior to hire and every 3 years thereafter throughout the remainder of the employment. This policy pertains to new hires and current employees. Due to the magnitude of current employees in nursing facilities throughout the State of West Virginia, the Bureau for Medical Services will allow the nursing facility until March 1, 2014, to have all current employees up to date with criminal investigation background checks. For any new hires in the nursing facility, the policy is effective for those individuals as of January 1, 2013

Based on observation and staff interview the facility failed to ensure food was served under sanitary conditions. An employee did not practice proper hygienic practices by not keeping their hands away from their hair and face when serving meals. This practice had the potential to affect all residents who received food from the kitchen. Facility census: 16. Findings include: a) During observation of the noon meal service, on 03/08/16 at 12:00 p.m., Activities Director (AD) #146 was observed serving lunch trays to the residents in the dining room and the residents' rooms. AD #146 pushed her long unsecured hair behind her ear each time she retrieved a lunch tray from the meal cart. In addition, her long unsecured hair touched the meal trays as she delivered each tray to the residents. At 12:02 p.m. on 03/08/16, Licensed Practical Nurse (LPN) #16 confirmed AD# 146 was touching her hair every time she retrieved a lunch tray from the meal cart. On 03/08/16 at 12:05 p.m. AD# 146 acknowledged she was pushing her hair back while pulling meal trays from the food cart. She immediately obtained a hair clip and pulled her hair back before delivering the remainder of the lunch trays. During an interview on 03/09/16 at 8:00 a.m. Infection control nurse #97 stated, Our policy is their hair is to be pulled back when serving meals.

Based on record review and staff interview, the facility failed to complete a Significant Correction to a Prior Quarterly Assessment (SCQA) after the Interdisciplinary Team (IDT) determined the resident's recent assessment contained a significant error identifying a change in her condition. Resident #19's minimum data set (MDS) assessment was incorrect related to independent functioning. Resident identifier: #19. Facility census: 16 Findings include: a) Resident #19 Review of the resident's medical record, on 02/03/15 at 2:00 p.m., found her quarterly minimum data set (MDS), with an assessment reference date (ARD) of 01/01/15, indicated her ability to function independently with bed mobility, transfers and toileting had declined since the prior assessment with an ARD of 10/02/14. The prior assessment indicated she required limited to extensive assistance to complete these functions. A progress note, dated 01/15/15, stated the Quarterly MDS with an ARD of 01/01/15 was incorrectly coded to indicate the resident needed extensive assistance with bed mobility, toileting, and dressing. The resident was re-evaluated and found to require only supervision to limited assistance with all of her activities of daily living (ADLs). The Centers for Medicare and Medicaid Services (CMS) resident assessment instrument (RAI) version 3.0 manual dated October 2014 states on page 2-32, "The Significant Correction to Prior Quarterly Assessment (SCQA) is an Omnibus Budget Reconciliation Act (OBRA) non-compliance assessment that must be completed when the IDT determines that a resident's prior assessment contains a significant error.... A significant error is an error in an assessment where: 1. The resident's overall clinical status is not accurately represented (i.e., miscoded) on the erroneous assessment; and 2. The error has not been corrected via a submission of a more recent assessment." No documentation was found indicating the facility filed a correction. Nurse aide #18, reported Resident #19 was "pretty much independent with all of her ADL care," during an interview on 02/03/15 at 2:13 p.m. In an interview with the MDS nurse, Employee #7, on 02/03/15 at 2:30 p.m., she confirmed the assessment dated [DATE] was coded incorrectly, as nursing assistant documentation showed the resident was more independent in ADLs than the MDS indicated. She acknowledged she had not submitted a correction after the therapy department reevaluated the resident and verified she did not decline in her ADL functions. .

Based on medical record review and staff interview, the facility failed to develop measurable goals for the care plan for one (1) of five (5) residents reviewed for unnecessary medications. The care plan identified Resident #2 had problematic behaviors and received antipsychotic medication daily. The care plan contained no measurable goals for which treatment and interventions were being provided related to the behaviors. Resident identifier: #2. Facility census: 15. Findings include: a) Resident #2 The medical record was reviewed for Resident #2. This resident was diagnosed with [REDACTED]. This was defined by "specific behaviors as quantitatively (number of episodes) and objectively (such as biting biting, kicking, and scratching) documented by the facility which cause the resident to actually interfere with staff's ability to provide care". This resulted in the initiation of [MEDICATION NAME] (an antipsychotic medication) 25 milligrams (mg) daily. The [MEDICATION NAME] was begun on 09/28/13. Review of the care plan revealed this resident had repetitive obsessive behaviors. Numerous behaviors and interventions to treat the behaviors were identified on the care plan. However, the care plan contained no goals related to potential outcomes as the result of using the antipsychotic medication and the non-pharmacological interventions. On 10/16/13 at 2:10 p.m., an interview was completed with a licensed nurse, Employee #16. She said this resident had been sleeping during the day, especially when up to activities. She said she had noticed an improvement in the resident's activity participation and wakefulness over the past few weeks. An interview was conducted with the consultant administrator (Employee #48) on 10/16/13 at 2:15 p.m. She said this resident had been awake a good bit during the nights while displaying repetitive, obsessive behaviors. Numerous non-pharmacological interventions were tried by staff, to no avail. As a result of these obsessive, repetitive behaviors during the nights, she would then be too tired by day to take part in activities she once enjoyed. She said since beginning the [MEDICATION NAME] a few weeks ago, this resident had been getting more rest at night. Subsequently, the resident was more wakeful, active and able to socialize more by day. Employee #48 said she believed the resident's quality of life had improved since beginning the [MEDICATION NAME]. On 10/16/13 at 4:20 p.m., an interview was completed with the Director of Nursing (DON) and Employee #48. They acknowledged there were no measurable goals on the care plan related to the obsessive behaviors. They agreed there were no non-pharmacological interventions noted on the psychoactive medication monthly flow record, as there was not a place for that information. They said non-pharmacological interventions would be documented in the nurses' progress notes. However, since beginning the [MEDICATION NAME] on 09/28/13, there was no evidence staff were consistently trying non-pharmacological methods to address the behaviors. There were nineteen (19) shifts in October on the monthly flow record with documented obsessive behaviors. Review of nurses' progress notes for those shifts found no evidence of which, if any, non-pharmacological interventions may have been tried. Employee #48 said it was such a small facility, staff would just know what worked for the resident. She said staff should have documented the interventions, to receive credit for what they did. She added this issue would be addressed. .

Based on medical record review and staff interviews, the facility failed to ensure the pharmacist identified and reported irregularities to the physician and the director of nursing for two (2) of five (5) Stage 2 sample residents reviewed for unnecessary medications. Each of these residents used antidepressant medications for an excessive period of time without an attempt at a gradual dose reduction. There was no evidence the pharmacist identified this and recommended the consideration of a gradual dose reductions. Resident identifiers: #5 and #13. Facility Census: 15. Findings Include: a) Resident #5 Review of Resident #5's medical record revealed the resident was prescribed the antidepressant Zoloft since 01/14/11. The pharmacist's monthly drug regimen reviews, from December 2012 through October 2013 revealed no indication the pharmacist had made a recommendation for a gradual dose reduction for this medication. The records did not identify a history of failed dose reductions of the Zoloft. b) Resident #13 Review of Resident #13's medication administration records revealed the resident was prescribed the antidepressant Lexapro since 07/08/11. The resident's drug regimen reviews revealed no indication the pharmacist had made any recommendations for a gradual dose reduction for this medication. The resident's records did not identify a history of any failed dose reductions of the Lexapro. c) During an interview on 10/17/13 at 9:40 a.m., the administrator, Employee #48, stated the facility had focused on anti-psychotics and did not complete gradual dose reduction reviews on anti-depressants. An interview on 10/16/13 at 4:40 p.m., with the facility pharmacist, Employee #50, revealed she had not completed gradual dose reduction recommendations on antidepressants due to being focused on antipsychotics. .

Based on medical record record review and staff interview, the facility failed to revise a care plan for one (1) of five (5) sampled residents, to include additional activities and/or services to ensure optimal quality of life. Resident identifier: #1. Facility census: 14. Findings include: a) Resident #1 Review of a social service's progress note, dated 09/14/12, revealed the Medical Power of Attorney (MPOA) had asked about hospice services. The MPOA's goals for hospice services were to ensure more people visited the resident because the MPOA was not able to visit often. A social services progress note, dated 10/12/12, revealed the MPOA had met with the facility care plan team. An agreement was reached to have increased visits from pastoral care and volunteers in lieu of Hospice, related to the MPOA only wanting Hospice for increased visits. The current care plan included interventions to increase 1:1 visits with staff and activities, as the resident enjoyed 1:1 visits and conversation. According to the current care plan, he enjoyed 1:1 "making over him", smiles, laughs and loves extra attention. The current care plan made no mention of increased visits from pastors and volunteers, as previously decided in the October 2012 care plan meeting. During an interview with the licensed social service manager, on 02/13/13 at 9:45 a.m., she said that Resident #1 receives pastoral visits from two (2) to four (4) times each month. She said that he does not have an assigned volunteer, but when volunteers visit during the week, they will visit with him 1:1. During an interview with the MDS (Minimum Data Set) coordinator/registered nurse, Employee #18, and the consultant administrator, on 02/13/13 at 4:00 p.m., they agreed there was not a care plan to have extra pastoral visits and volunteer visits. .

Based on record review, staff interview, and physician interview, the facility failed to follow physician's orders for a prescribed diet, or alternatively, to consult the physician regarding a need for a change in the resident's diet order for one (1) of five (5) sampled residents. Resident identifier: #1. Facility census: 14. Findings include: a) Resident #1 Observation of the morning meal, on 02/13/13 at 8:30 a.m., found Resident #1 being assisted with his meal which included french toast. He showed no visible signs at that time of choking, or difficulty swallowing. Observation of the noon meal, on 02/13/13 at 12:15 p.m., found a nursing assistant sitting by his side in the dining/activity room, assisting him with his meal. He was served a chicken salad sandwich that had been cut in half, as well as soup and some pureed food and Ensure. During an interview with a licensed nurse, Employee #14, on 02/13/13 at 12:30 p.m., she said Resident #1 was on a regular diet when he first arrived from an assisted living facility, but he would not eat well. He would pocket food in his cheek. He had no dentures and no natural teeth, and he could not chew all foods on a regular diet. He received a regular diet at breakfast with soft foods such as scrambled eggs and french toast or pancakes with syrup. She said he was served a soft sandwich at lunch and dinner daily. Sometimes he refused the sandwich, and at other times he ate nothing but the sandwich. He also received soft textured foods such as ice cream, pie without the hardened crust, cake, soft vegetables, soup, soft fruit such as bananas. She said the texture of the food served was in relation to his being edentulous. She said his food intake declined while on a regular diet, but increased when the texture was changed to pureed. She said he did not choke on foods to her knowledge. Review of a social service care plan note, dated 10/12/12, revealed the Medical Power of Attorney (MPOA) had concerns with pureed food, and the MPOA asked that he have a sandwich at lunch and dinner time. The registered dietitian agreed to try this, and send it along with his pureed food. The Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 12/31/12, was reviewed. It revealed his Brief Mental Assessment (BIM) score was only three (3) which signified severe cognitive loss. He was coded as having a swallowing/nutritional status problem with loss of liquids/solids from his mouth, coughing or choking. He was 74 inches tall, and weighed 119 pounds. A dietary progress note, dated 01/03/13, revealed the resident had a regular diet for breakfast and NDD1 (National Dysphagia Diet - a pureed diet) for lunch and dinner. In this note, the dietitian said the resident continued to have loss of liquid from the mouth, coughing and choking at meal times, and he was on a mechanically altered diet. Review of an Informed Refusal form, dated 01/25/13, revealed physical therapy, occupational therapy, and speech/language pathology had made a recommendation for a pureed diet for all meals. This was also recommended by the Interdisciplinary Team (IDT), but was refused by the MPOA. The purpose and benefit of those care or treatment recommendations was noted, as well as the risks of refusing them, and of possible alternatives. The current care plan was reviewed. It revealed the resident received a regular diet for breakfast and a NDD2 (National Dysphagia Diet - a mechanically altered diet) for lunch and dinner, and he coughed and choked at meals at times. Review of the current physician's orders revealed an order for [REDACTED]. During an interview with the MDS coordinator/registered nurse, Employee #18, and consultant administrator, Employee #22, on 02/13/13 at 4:00 p.m., they agreed there was not a physician's order for the sandwiches for lunch and dinner which the resident was receiving daily. During a telephone interview with the physician, on 02/13/12 at 4:30 p.m., he said he recalled the MPOA asking him if it would hurt the resident to have a sandwich once in awhile, to which he told her that it would not hurt him. He said he did not recall if nursing staff had requested sandwiches for the lunch and dinner meals, but said they probably did, and he would write an order to that effect. He said he did not recall anyone asking for regular diets for all meals. .

Based on record review and staff interview, the facility failed to provide care and services to one (1) of seven (7) sampled residents as determined necessary by his comprehensive assessment and plan of care to attain the highest practicable physical status. Resident #15 was admitted to the facility on [DATE], at which time he weighed 147 pounds (#). On 10/01/10, he weighed 141#, the physician ordered a nutritional supplement three (3) times daily for additional calories. On 11/03/10, the physician ordered changes to the consistency of his meals, serving pureed foods at lunch and dinner, and on 11/04/10, he weighed 124#. The resident continued to lose weight after 11/04/10, with no evidence of further assessments for the cause(s) of the unplanned weight loss and no further additional interventions implemented in an effort to slow or reverse the weight loss. By 01/04/11, he weighed 115#, which represented a 32# unplanned weight loss over a period of approximately three (3) months with no evidence to reflect this weight loss was clinically unavoidable. Additionally, on 10/01/10, the physician ordered restorative nursing services to improve his physical functioning. The resident refused to participate in the restorative nursing programs for two (2) months. A significant change in status assessment, with an assessment reference date of 01/04/11, revealed he had experienced a significant decline in self-performance of activities of daily living in at least five (5) areas since admission. There was no evidence of efforts by the facility's interdisciplinary team, prior to this survey event, to reassess or revise the resident's care plan to address the resident's refusal of participate in the restorative services intended to improve his physical functioning. Resident identifier: #15. Facility census: 16. Findings include: a) Resident #15 When reviewed on 01/04/11, Resident #15's medical record revealed this [AGE] year old male had been admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. 1. Record review revealed a note entered by the facility's consultant registered dietitian (RD), dated 01/04/11, stating the resident had a "33 pound weight loss since admission". Review of the resident's vital signs and weight record revealed the following weights: - 147# on 09/27/10 - 141# on 10/01/10 - 124# on 11/04/10 - 119# on 12/02/10 - 115# on 01/04/11 This represented a loss of 32# in approximately three (3) months. Further review disclosed that, on 10/11/10 (the date of the care plan review), the facility received a physician's orders [REDACTED]. Documentation on a "Resident Nutritional Assessment" revealed notations of the resident's weights and a note, dated 11/03/10, stating the resident's diet was changed from regular consistency foods at all meals to regular consistency foods for breakfast only and pureed consistency foods for lunch and dinner; the author also noted that the resident did not want nursing staff to feed him. There were no further entries in the record by dietary personnel until 01/04/11, when the RD noted the resident's weight loss, described meal intakes, medications, etc., and ended by saying "resident is currently not meeting care plan goal of consuming 70% of meals or maintaining his weight." The medical record revealed no evidence of further interventions related to this significant unplanned weight loss. - 2. A physical therapy daily note, dated 10/01/10, discontinued the resident from physical therapy to a restorative nursing program. The restorative nursing program plans stated: "Ambulate on level surface with CAN (sic) and no loss of balance x 50 feet with rolling walker. Appropriate use of rolling walker during stand, pivot, transfer (sic). Exercise to improve function." The care plan problem was noted to be: "Decreased posture, decreased balance, decreased functional mobility. Recent decreased function / cognition. Dx (diagnosis): [MEDICAL CONDITION]." Approaches included: "Ambulate with rolling walker 250 feet with supervision. Promote good seated / standing posture, transfer with supervision." Review of the restorative nursing and progress summary reports revealed that, after 11/07/10, the resident did not participate in the restorative program. As of 01/04/11, there had been no reassessment to determine why the resident was refusing to participate, nor was any revision made to the care plan in light of the resident's refusal of treatment. - 3. Review of the resident's admission assessment, with an assessment reference date (ARD) of 10/07/10, revealed in Section G the resident required supervision and set-up assistance with eating; the limited assistance of one (1) person for walking in the corridor, locomotion off the unit, and toilet use; the limited assistance of two or more persons with transfers; and the extensive physical assistance of two (2) or more persons with walking in the room. Review of a significant change in status assessment, with an ARD of 01/03/11, revealed in Section G the resident required the limited assistance of one (1) person with eating; the extensive physical assistance of two (2) or more persons for transfers and toilet use; the activity of walking in the room occurred only once or twice during the reference period and required the assistance of one (1) person; the activity of walking in the corridor did not occur at all during the reference period; the resident was totally dependent on one (1) person for locomotion off the unit. A comparison of these two (2) assessments revealed the resident had significant declines in self-performance in transfers, walking in room, walking in the corridor, locomotion off the unit; and toilet use in a three (3) month period. - 4. The director of nursing (DON - Employee #14), when interviewed on 01/04/11 at 4:14 p.m., confirmed that staff was aware of the resident's weight loss and that, other than the addition of the Mighty Shakes and a change of consistency of the resident's diet early in his stay, nothing else had been done. Employee #14 further stated the resident's medical power of attorney representative did not want aggressive treatment. This employee confirmed the resident had refused to participate in the physician-ordered restorative nursing services and that no reassessment or revision to the resident's care plan had occurred. - 5. At the time of survey team's exit from the facility at 1:15 p.m. on 01/05/11, facility staff had not provided evidence that the resident's significant unplanned weight loss had been discussed with him and/or his responsible party in an effort to assess for cause(s) of the loss and to develop and implement a plan to reverse the weight loss. .

Based on record review and staff interview, the facility failed, for one (1) of seven (7) residents reviewed who entered the facility without a pressure ulcer, to provide care and services to prevent the development of a pressure ulcer. When admitted to the facility on [DATE], Resident #15 had no pressure ulcers present and no history of having had resolved pressure sores. Facility staff failed to implement measures to assure the resident maintained good nutritional status, and the resident experienced a clinically avoidable 32 pound (#) weight loss in three (3) months at the facility. Physical therapy had developed a plan for restorative nursing care, in which the resident refused to participate for two (2) months with no re-assessment by staff. Staff interview confirmed Resident #15 had sustained a significant unplanned weight loss and that the resident's refusal to participate in restorative services could have contributed to the pressure ulcer development. The resident developed two (2) Stage II pressure ulcers with no evidence to indicate this skin breakdown was clinically unavoidable. Resident identifier: #15. Facility census: 16. Findings include: a) Resident #15 When reviewed on 01/04/11, Resident #15's medical record revealed this [AGE] year old male had been admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Documentation on the resident's comprehensive assessment, completed at the time of admission on 09/27/10 at 10:45 a.m., stated (in the area of skin assessment) the resident had a lesion on left upper eyelid, a bruise on his left forearm, a brown birthmark on his posterior right leg, and a skin tear on the anterior right lower leg. This document stated the resident, at that time, had no pressure ulcers and no history of resolved pressure ulcers. An initial care plan developed on 09/28/10 identified: "Alteration in skin integrity (sic) episodes of incontinence and Hx (history) of acne / rash (sic) Currently on neck base of hair line." The goal associated with this problem stated: "Resident will have no skin breakdown through next review." The interventions to assist the resident achieving this goal were: "1) Assess skin every shift and observe for signs of reddness (sic). Charge nurse will notify physician for treatment orders. 2) Bactrim DS i (1) PO (by mouth) everyday - MPOA (medical power of attorney representative) states resident has history of pustules on face - resolved with maintenance dose of bactrim (sic). Currently has rash on neck - hair / collar line. Will observe for signs of healing or if treatment is needed. 3) Resident's functional ability to transfer and ambulate has declined over last several wks (weeks) - assist resident, but encourage functional activity, ROM (range of motion), exercise. Therapy to evaluate for restorative nursing program." - According to the resident's comprehensive care plan dated 10/11/10, the interdisciplinary team (IDT) identified the following problem: "History of acne / rash currently on neck base of hair line. At risk for skin breakdown due to decreased mobility, medication use, disease process. Fragile skin, bruises easily, Skin (sic) tear RFA (right forearm). Pressure ulcers (sic)." (Note: According to documentation in the resident's record, the resident had no pressure ulcers at this time.) The goal related to this problem statement was: "Resident will have no skin breakdown through next review." The interventions to assist the resident in achieving this goal remained essentially the same as stated in the initial care plan, with the following additions: "Braden skin assessment quarterly. Wound / pressure ucler (sic) record if indicated. RFA skin tear treatment: [MEDICATION NAME] (sic) dressing covered with opsite (sic). Change prn (as needed) discontinue when healed. Notify physician if there are signs of infection or poor healing. When sitting up, ensure that resident is sitting on foam cushion." - Documentation recorded on forms titled "Pressure Ulcer Record" described the development of a Stage II pressure ulcer to his left heel on 11/17/10 and a Stage II pressure ulcer on his right buttock on 12/12/10. - Further record review disclosed that, on 10/11/10 (the date the resident's comprehensive care plan was established), the facility received a physician's orders [REDACTED]. On 11/03/10, the facility changed the resident's diet from regular consistency foods at all meals to pureed consistency foods for lunch and dinner and regular consistency foods at breakfast. Review of the resident's nutritional assessment disclosed that, by the time the first pressure ulcer developed on the resident's left heel, the resident had already experienced an unplanned weight loss of 13# from his admitting body weight of 147#. At that time, no new nutritional interventions were implemented to promote wound healing / skin integrity. Review of the resident's vital signs and weight record revealed the following weights: - 147# on 09/27/10 - 141# on 10/01/10 - 124# on 11/04/10 - 119# on 12/02/10 - 115# on 01/04/11 This represented a loss of 32# in approximately three (3) months. After 11/02/10, there were no further entries in the record by dietary personnel until 01/04/11, when the registered dietitian noted the resident's weight loss, described meal intakes, medications, etc., and ended by saying "resident is currently not meeting care plan goal of consuming 70% of meals or maintaining his weight." The medical record revealed no evidence of interventions (after 11/03/10) related to this significant unplanned weight loss or evidence of efforts to improve the resident's nutritional status as a means of promoting wound healing. - A physical therapy daily note, dated 10/01/10, discontinued the resident from physical therapy to a restorative nursing program. The restorative nursing program plans stated: "Ambulate on level surface with CAN (sic) and no loss of balance x 50 feet with rolling walker. Appropriate use of rolling walker during stand, pivot, transfer (sic). Exercise to improve function." The care plan problem was noted to be: "Decreased posture, decreased balance, decreased functional mobility. Recent decreased function / cognition. Dx (diagnosis): [MEDICAL CONDITION]." Approaches included: "Ambulate with rolling walker 250 feet with supervision. Promote good seated / standing posture, transfer with supervision." Review of the restorative nursing and progress summary reports revealed that, after 11/07/10, the resident did not participate in the restorative program. As of 01/04/11, there had been no reassessment to determine why the resident was refusing to participate, nor was any revision made to the care plan in light of the resident's refusal of treatment. - According to a Braden assessment of the resident's risk for developing pressure sores, completed on 10/03/10, the resident scored "17", indicating he was at "mild risk" for developing a pressure sore. According to a subsequent Braden assessment, completed on 01/03/11, the resident scored "12", indicating he was now at "high risk" for developing a pressure sore. - When interviewed on 01/04/11, the unit's director of nursing (DON - Employee #14) was not aware the resident had a pressure ulcer. Employee #14 confirmed Resident #15 had sustained a significant unplanned weight loss and that the resident's refusal to participate in restorative services could have contributed to the pressure ulcer development. .

Based on record review and staff interview, the facility failed to provide care and services, to one (1) of seven (7) sampled residents, to maintain acceptable parameters of nutritional status. Resident #15 was admitted to the facility on [DATE], at which time he weighed 147 pounds (#). On 10/01/10, he weighed 141#, and the physician ordered a nutritional supplement three (3) times daily for additional calories. On 11/03/10, the physician ordered changes to the consistency of his meals, serving pureed foods at lunch and dinner, and on 11/04/10, he weighed 124#. The resident continued to lose weight after 11/04/10, with no evidence of discussions with the resident or responsible party about the weight loss, no evidence of further assessments to identify possible reversible causes of the unplanned weight loss, and no evidence of further interventions implemented in an effort to slow or reverse the weight loss. By 01/04/11, he weighed 115#, which represented a 32# unplanned weight loss over a period of approximately three (3) months with no evidence to reflect this weight loss was clinically unavoidable. Resident identifier: #15. Facility census: 16. Findings include: a) Resident #15 When reviewed on 01/04/11, Resident #15's medical record revealed this [AGE] year old male had been admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident had a combined medical power of attorney and living will document dated 10/05/09, which identified his chosen representative and the following directives: "no tube feeding, breathing machines, [MEDICAL TREATMENT], cardiopulmonary resuscitation." Review of the resident's vital signs and weight record revealed that, on the date of admission (09/27/10), he weighed 147# with a height of 62 inches. According to his admission assessment with an assessment reference date (ARD) of 10/07/10, the assessor encoded in Section G that the resident required only supervision and set-up assistance with eating. According to the resident's initial comprehensive care plan (dated 10/11/10), the interdisciplinary team identified the following problem: "Leaves 25% of meals uneaten. Self feeding difficulty. constant (sic) drooling - loss of liquids and food during mealtime. Nutrition (sic)." At the bottom of this problem statement was: "Potential for dehydration." (This handwritten entry was not dated.) The goal related to this problem was: "Resident will consume 70% of meals and maintain current weight plus or minus 5 pounds of baseline through next review." Interventions to assist the resident in achieving this goal were: "Will provide menu for resident and friend to complete and return to dietary weekly with resident' (sic) personal food preferences. Will check labs, weights and intakes as available. Will provide nutritional supplement 3x/day (three times daily) with meals. Nursing or friend will assist with feeding as needed. Resident will be provided with opportunity to drinks fluids throughout the day. Coffee / snack cart will provide between meals coffee and snacks twice daily." As of 01/04/11, no additions or modifications had been made to this care plan since it was established on 10/11/10. - Review of the resident's record revealed a note entered by the facility's consultant registered dietitian (RD), dated 01/04/11, stating the resident had a "33 pound weight loss since admission". Review of the resident's vital signs and weight record revealed the following weights: - 147# on 09/27/10 - 141# on 10/01/10 - 124# on 11/04/10 - 119# on 12/02/10 - 115# on 01/04/11 This represented a loss of 32# in approximately three (3) months. Further review disclosed that, on 10/11/10 (the date the resident's comprehensive care plan was first established), the facility received a physician's orders [REDACTED]. Documentation on a "Resident Nutritional Assessment" revealed notation of the weights and a note, dated 11/03/10, stating the resident's diet was changed from regular consistency foods at all meals to regular consistency foods for breakfast only and pureed consistency foods for lunch and dinner; the author also noted that the resident did not want nursing staff to feed him. There were no further entries in the record by dietary personnel until 01/04/11, when the RD noted the resident's weight loss, described meal intakes, medications, etc., and ended by saying "resident is currently not meeting care plan goal of consuming 70% of meals or maintaining his weight." The medical record revealed no evidence of further interventions related to this significant unplanned weight loss. - When interviewed on 01/04/11 at 4:14 p.m., the unit's director of nursing (DON - Employee #14) confirmed that staff was aware of the weight loss; she also confirmed that, other than the interventions of the Mighty Shakes and a change in the consistency of foods served to the resident early in his stay, nothing else had been done to address the resident's weight loss. This employee further stated the resident's medical power of attorney representative did not want aggressive treatment. At the time of survey exit at 1:15 p.m. on 01/05/11, facility staff had not provided evidence that the resident's significant unplanned weight loss had been discussed with him and/or his responsible party, in an effort to identify possible reversible causes of the weight loss and/or additional interventions to retard or reverse the weight loss. .