Every finding on record at Waterview Pointe Nursing & Rehabilitation

Based on closed record review, staff interview, family interview, provider interview, and policy review, the facility failed to ensure a resident was provided with accurate information regarding home care access for a discharge. This affected one resident (Resident # 84) of four residents reviewed for discharge. The facility census was 73. Findings include: Review of the closed medical record for Resident #84 revealed an admission date of 05/06/26 and a discharge date of 06/20/26 with diagnoses including encounter for other orthopedic aftercare, muscle weakness, difficulty in walking, retention of urine, fracture of right femur, and fracture of base of skull.Review of Resident #84's care plan dated 05/13/26 revealed the resident was planning on discharging from facility. Interventions included the resident will receive information regarding community resources available and have support needed in place for discharge.Review of the discharge plan of care and recapitulation dated 06/20/26 revealed a referral to Home Health Agency #200. This was authored by Social Services #300. Interview on 07/16/26 at 10:27 A.M. with Social Services #300 revealed the family requested Home Health Agency #100 and she verified she told the family they do not accept Humana as a payor source (the resident's payor source) and set up Home Health Agency #200 and the family was agreeable.Interview on 07/16/26 at 1:10 P.M. with Resident #84's daughter #504 revealed the family requested Home Health Agency #100 and were told by Social Services #300 that they do not accept his insurance payor, although she called home health agency #100 and verified they did. The facility did suggest an alternate home health provider, but they did not provide accurate information upon discharge and the home health therapy was booked out for one month.Interview on 07/16/26 at 1:57 P.M. with Home Health Agency #100's Director #503, verified they do accept Humana as a payor source for home health services.Review of facility policy titled Discharge Planning, dated 11/22/16 revealed when a resident's discharge is anticipated, the facility will develop and implement a discharge plan that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care. The facility will document that a resident has been asked about their interest in receiving information regarding returning to the community. If the resident indicates an interest in returning to the community, the facility will document any referral to local contact agencies or other appropriate entities made for this purpose. This deficiency represents non-compliance investigated under Complaint Number 3069489.

Based on record review, interviews, and review of facility policy, the facility failed to ensure the physician was notified of medications not being administered as ordered. This affected one (Resident #21) of nine residents reviewed. The facility census was 73.Findings Include: Review of the medical record for Resident #21 was admitted on [DATE] with diagnoses including dementia, restlessness and agitation, depression, anxiety disorder and neurocognitive disorder.Review of the most recent quarterly Minimum Data Set (MDS) 3.0 assessment revealed the resident had severely impaired cognition. The MDS assessment revealed Resident #21 was short tempered and easily annoyed with behaviors occurring daily.Review of Resident #21's plan of care dated 07/14/26 revealed the resident experienced alteration in mood and/or behavior with targeted behaviors that include but not limited to pushing, attempts to hit, kicking/hitting, attempting to bite, yelling/screaming and destructive behavior. Further review of the care plan revealed she had a diagnosis of depression and anxiety dated 07/23/25. Interventions included medications as ordered by physician.Review of the physician orders dated 07/01/26, revealed an order for Ativan (a medication that calms the central nervous system to treat anxiety disorders and insomnia) 1 milligram (mg), give one tablet by mouth every four hours for anxiety/agitation.Review of the medication administration record (MAR) for July 2026 revealed the prescribed medication was not administered 21 times due to Resident #21 sleeping on 07/02/26, 07/03/26, 07/04/26, 07/05/26, 07/06/26, 07/09/26, 07/10/26, 07/12/26, 07/13/26, 07/14/26 and 07/15/26.Interview on 07/15/26 at 10:53 A.M. with Hospice Clinical Manager #501 revealed they were not aware of Resident #21 having her medications held. Their expectations would be to administer the prescribed medication.Interview on 07/16/26 at 10:58 A.M. with Physician Assistant #500 revealed she was not aware of Resident #21's scheduled Ativan being held and the expectation would be to administer the prescribed medication as directed and notify the practitioner to make changes if needed.Review of the facility policy titled Medication Administration dated 06/21/17, revealed medications will be administered by legally authorized and trained persons in accordance to applicable state, local and federal laws and consistent with accepted standards of practice.Review of the facility policy titled Change of Condition dated April 2013, revealed the unit supervisor or charge nurse will notify the resident, physician and guardian/interested family member of all changes as stated above and of any other situations requiring notification.This deficiency is an incidental finding discovered during the complaint investigation.

Based on record review, interview, and policy review the facility failed to follow physician ordered parameters for medication administration. This affected two residents (#3, #5) of five residents reviewed for medication regimens.Findings Include:1. Review of Resident #3's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included Parkinson's disease, adult onset diabetes mellitus, malignant neoplasm of the colon, schizo-affective disorder of the bipolar type, and mild intellectual disabilities. Review of Resident #3's physician's orders revealed the resident had an order to receive Hydrocodone- Acetaminophen (Norco) 5-325 milligrams (mg) by mouth (po) every six hours prn for pain rating 5-10. That order originated on 07/18/25. He also had an order to receive Tylenol Extra Strength 500 mg tablets with directions to give two tablets every six hours prn for a pain rating of 1-5. Review of Resident #3's electronic medication administration record (eMAR) for June 2025 revealed the resident had an order to receive Norco 5-325 mg one tablet every four hours prn for pain levels between 5-7 and two tablets po every four hours prn for pain levels of 8-10. That order originated on 06/05/25. The resident was given two of the prn Norco 5-325 mg tablets four separate times when his pain level did not fall between the ordered parameters for administration of two tablets between a pain level of 8-10. He received those four doses of two Norco 5-325 mg tablets by mouth on 06/08/25 at 7:40 P.M., 06/09/25 at 8:54 A.M., 06/10/25 at 6:20 A.M., and 06/14/25 at 9:03 A.M. for pain levels of a 7 on 1-10 scale. He was not given just one tablet of the Norco 5-325 mg tablets for a pain level of 7 as ordered by the physician. Review of Resident #3's eMAR for July 2025 revealed the resident had orders in place to receive Norco 5-325 mg one tab po every six hours prn for a pain level between 5-10. He also had an order to receive Tylenol Extra Strength 500 mg tablets with directions to give two tablets po every six hours prn for pain levels between 1-5 on a 1-10 scale. The orders for both the Tylenol Extra Strength and the Norco originated on 07/18/25. The resident was given the Norco for pain levels outside the parameters ordered for administration by the physician. He received Norco 5-325 mg one tablet on 07/26/25 at 8:03 P.M. for a pain level of 2 and again on 07/28/25 at 12:07 P.M. for a pain level of 4 on a 1-10 scale. He was not given the Tylenol Extra Strength 500 mg tablets (two tablets= 1,000 mg) on a prn basis when his pain levels were only between 1-5 as ordered by the physician. On 07/29/25 at 2:05 P.M., an interview with the facility's Director of Nursing (DON) confirmed Resident #3 did not receive his prn pain medication in accordance with the parameters set by the physician in the orders given for Norco and Tylenol Extra Strength. She acknowledged the resident received Norco multiple times for pain levels less than what was specified by the physician for administration. She further confirmed the nurses should be following the parameters given by the physician on when to administer the Tylenol Extra Strength or when to give the resident the narcotic pain medication (Norco) for more severe pain. Review of the facility's policy on Pain Assessment and Management dated 03/31/16 revealed the facility was to provide pharmacological interventions in accordance with physician's orders. 2. Medical record review revealed Resident #5 was admitted on [DATE] with diagnoses including Parkinson's disease with dyskinesia, end stage renal disease, hypertension, diabetes mellitus with diabetic peripheral angiopathy without gangrene, dependence on renal dialysis, unspecified dementia, polyneuropathy, and anxiety disorder. a. Review of the electronic Physician Orders revealed Resident #5 was ordered to receive metoprolol succinate extended release (hypertension) 25 milligrams (mg) every Tuesday, Wednesday, Thursday, Saturday and Sunday. The medication included physician parameters including to hold the medication if the resident's diastolic blood pressure (DBP) was less than 60 mmHg. Review of the electronic Medication Administration Record (eMAR) dated October 2024 revealed metoprolol succinate XR 25 (mg) was administered on 10/31/24 with a DBP of 116/45. Review of the eMAR dated November 2024 revealed metoprolol succinate XR was administered on 11/14/24 with a BP of 146/56. Review of the eMAR dated December 2024 revealed metoprolol succinate XR was administered on 12/15/24 with a BP of 128/54. Review of the eMAR dated January 2025 revealed metoprolol succinate XR was administered on 01/12/25 with a BP of 140/58, on 01/14/25 with a BP of 123/58 and on 01/28/25 with a BP of 121/56. b. Review of the electronic Physician Orders dated June 2025 and July 2025 revealed to administer Hydrocodone-Acetaminophen (opioid) 7.5-325 (mg) one tablet by mouth every six hours as needed for a pain rating of six to 10. Review of the eMAR dated June 2025 revealed Resident #5 was administered Hydrocodone-Acetaminophen on 06/03/25 for complaints of pain rated a four out of 10. Review of the eMAR dated July 2025 revealed Resident #5 was administered Hydrocodone-Acetaminophen on 07/01/25 for complaints of pain rated a four out of 10. On 07/31/25 at 10:08 A.M., interview with the Director of Nursing (DON) verified the above physician order parameters for metoprolol succinate and Hydrcodone-Acetaminophen were not followed for Resident #5 as ordered. c. Review of the Infection Report Form dated 06/28/25 revealed Resident #5 had green-brown eye discharge from the right eye. Criteria was met for a nosocomial eye infection, the resident was diagnosed with blepharitis and ordered antibiotics. Review of the electronic Physician Orders and the eMAR dated June 2025 and July 2025 revealed Ciprofloxacin 0.3% (antibiotic) was ordered to administer two drops to the right eye while awake due to blepharitis. The order was entered into the system to start administration on 06/29/25; however, the order was discontinued on 06/28/25 at 5:31 P.M The Ciprofloxacin was not re-ordered until 06/29/25 at 8:00 A.M. and then was discontinued at 1:15 P.M. on 06/29/25. There was no evidence the Ciprofloxacin 0.3% order was entered back into the electronic ordering system until 07/01/25 at 12:00 A.M The first dose of Ciprofloxacin eye drops being administered to Resident #5 was on 07/02/25 at 4:00 A.M Review of the pharmacy DeliveryTrack Manifest dated 07/02/25 revealed Resident #5's Ciprofloxacin ophthalmic solution 0.3% was delivered to the facility on [DATE] at 3:07 A.M On 07/29/25 at 5:00 P.M., interview with the DON verified Resident #5 did not receive the above antibiotic timely stating it was due to the pharmacy did not have it available to send to the facility. On 07/30/25 at 8:27 A.M., phone interview with certified pharmacy technician (CPT) #205 stated the pharmacy received orders directly from the facility electronic documentation system. CPT #205 stated Resident #5's ciprofloxacin 0.3% eye drops were not entered into the electronic ordering system until 06/29/25 after regular hours; therefore, the pharmacy did not receive the order until 06/30/25, the ciprofloxacin order was filled on 07/01/25 and delivered to the facility on [DATE] at 3:07 A.M. CPT #205 stated the facility has an option to have the pharmacy drop ship or STAT deliver medications if needed sooner but this was not requested. CPT #205 stated the medication was available for delivery and this did not impact this ordered medication. On 07/30/25 at 3:35 P.M., interview with Licensed Practical Nurse (LPN) #118 stated the cut off time to have medications delivered in the next tote was 6:00 P.M LPN #118 stated any orders entered after 6:00 P.M. would not be delivered until the next daily tote delivery which arrives at approximately 3:00 A.M. daily to the facility. Any medications including antibiotics that were needed sooner would need to be called for a STAT order. Review of the policy: 3.4.2. Delivery and Receipt of Non-Cycle Fill Paxit Medication (dated 06/21/17) revealed the purpose was to establish the proper procedure for the receipt of Non-Cycle Fill 24 hour unit dose Paxit medications from the pharmacy by authorized facility staff. Nursing staff at the facility were responsible for verifying the accuracy of the delivery and notifying the pharmacy of any discrepancies within four hours of delivery. Procedure included: The pharmacy delivers the Non-Cycle Fill medications to the facility with each delivery, according to a facility specific predetermined schedule. Orders received before the designated cut-off time will be sent with the Facility's regular scheduled delivery. STAT delivery may be requested in between scheduled deliveries for urgent medication needs not available in the On-Site stores provided by the pharmacy after fax cut-off times for scheduled deliveries. The pharmacist will determine if the medication will be dispensed from Remedi or whether it will be dispensed from a local, back-up pharmacy. Review of the policy: Medication Administration (dated 06/21/17) revealed medications were to be administered by legally authorized and trained persons in accordance to applicable state, local and federal laws and consistent with accepted standards of practice.

Based on record review, policy review, and staff interview, the facility failed to ensure the physician addressed all the recommendations made by the facility's consulting pharmacist for irregularities that were identified during their monthly medication regimen review. This affected two residents (#3 and #8) of five residents reviewed for unnecessary medications. Findings include: 1. Review of Resident #3's medical record revealed the resident was admitted to the facility on [DATE]. His diagnoses included schizo-affective disorder, generalized anxiety disorder, and major depressive disorder. Review of a pharmacy recommendation following a monthly medication regimen review of Resident #3's medications on 03/19/25 revealed the facility's consulting pharmacist recommended the physician consider a gradual dosage reduction (GDR) attempt regarding the resident's use of Zyprexa 10 milligrams (mg) daily, Remeron 15 mg at bedtime, Buspar 10 mg daily, and Paxil 20 mg daily. The physician agreed with the recommendation for a GDR pertaining to the use of Zyprexa 10 mg daily decreasing the dose from 10 mg to 5 mg every day. He did not address the pharmacist's recommendations pertaining to the other three medications (Remeron, Buspar, or Paxil) and did not provide any resident specific rationale as to why a GDR attempt for those medications were contraindicated at that time. Review of a physician note for Resident #3 dated 03/21/25 revealed the resident was seen by his physician on that date and his Zyprexa was reduced. The physician's note did not address why a GDR for Remeron, Buspar, and Paxil were not appropriate for the resident at that time. On 07/29/25 at 2:05 P.M., an interview with the facility's Director of Nursing (DON) confirmed Resident #3's physician did not fully address the pharmacist's recommendations on 03/19/25 pertaining to GDR's for all the resident's psychotropic medications. There was no documentation from the physician that addressed the recommendation for a GDR pertaining to the resident's Remeron, Buspar, and Paxil. The DON further confirmed there was no resident- specific rationale provided to support why a GDR for those other three psychotropic medications were contraindicated for the resident at that time. She stated the physician just addressed what he wanted to even though those recommendation grouped together the recommendations for other medications. She acknowledged all of the pharmacist's recommendations should be addressed for irregularities identified on the pharmacy recommendation forms. She stated the pharmacist had since started communicating the recommendations for each medication separately and was not grouping them all together on the same pharmacy recommendation sheet as was done on 03/19/25. 2.Record review revealed Resident #8 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, major depression, anxiety disorder, bipolar disorder, hallucinations, and unspecified psychosis. Review of a care plan dated 03/16/23 revealed Resident #8 was at risk for side effects from psychotropic medications, antipsychotics due to diagnosis of dementia. The goal was for resident to have no drug related side effects and interventions included, but were not limited to, administer medications as ordered, complete abnormal involuntary movement assessment and report changes to physician, monitor for complications such as delirium and tardive dyskinesia, review medications for possible dose reduction, and taper medications as ordered. Review of physician orders revealed Resident #8 had an order in place for Seroquel (antipsychotic) 12.6 milligrams by mouth once daily related to psychosis and bipolar disorder (04/16/24), Seroquel 50 milligrams at bedtime for psychosis and bipolar disorder (04/16/24), and duloxetine (antidepressant) capsule delayed release particles 60 milligrams give one capsule by mouth daily (06/21/25). Review of a pharmacy recommendation dated 06/19/25 revealed a recommendation for gradual dose reduction for duloxetine 90 milligrams and Seroquel 12.5 milligrams in the morning and 50 milligrams at bedtime. Physician #400 agreed to reduce duloxetine to 60 milligrams daily but did not address the recommendation for Seroquel. Interview on 07/29/25 at 2:53 P.M. with the Director of Nursing (DON) confirmed multiple medications were listed for dose reduction on the pharmacy recommendation but the physician failed to address recommendation for all medications. Review of a policy titled Medication Monitoring dated 10/01/18 revealed a written report of all irregularities and recommendations resulting from the medication regimen review are provided to a facility designee for the attending physician, DON and Medical Director. The facility and attending physician must address the recommendations in a timely manner that meets the needs of the resident and should document what irregularity has been reviewed, what action has been taken to address the issues, and a rationale for accepting/declining the recommendation.

Based on observation, medical record review, policy review and interview, the facility failed to maintain adequate infection control practices during the administration of medications. This affected two residents (#35 and #51) of three residents observed for medication administration. Findings include: Medical record review revealed Resident #35 was admitted on [DATE] and Resident #51 was admitted on [DATE].On 07/29/25 between 8:48 A.M. and 9:15 A.M., observation of both Resident #35 and #51's morning medication administrations revealed Registered Nurse (RN) #200 would apply gloves, open the medication cart, removed the pharmacy package and over-the-counter bottles of the ordered medications from multiple drawers on the medication cart and then dispense the medications into his gloved hand. The medications would then be placed into the medication cup. Twice during the observations, RN #200 was observed opening the lid to the trash can to dispose of a wasted medication and throw away trash. The electronic keyboard was used to document the medication, the cart was locked and RN #200 entered the resident room wearing the same gloved hands. The medications were administered to the residents. RN #200 would then remove his gloves, throw them in the trash in the residents room and used hand sanitizer. On 07/29/25 at 4:59 P.M., interview with RN #200 verified the above. Review of the policy: Glove Technique - Clean (revised April 2002) revealed don clean gloves whenever you may come in contact with blood, urine or feces. Wash hands each time gloves are removed. Review of the policy: Hand Hygiene (revised 11/28/17) revealed staff should perform hand hygiene even if gloves were used before and after contact with the resident, after contact with blood, body fluids or visibly contaminated surfaces or other objects and surfaces in the resident's environment.

Based on observation, interview, and record review the facility failed to provide a safe environment for a resident left unattended with medications. This affected one resident (#28) of 69 residents residing in the facility. The facility census was 69. Findings Include: Medical record review revealed Resident #28 was admitted on [DATE] with diagnoses including rheumatoid arthritis, anxiety disorder, chronic pain and cerebral infarction without residual deficits. Review of the electronic Order Summary Report dated 07/31/25 revealed no evidence the resident was capable to self-administer medications. There was also no physician order for Resident #28's medications could be left at bedside unsupervised by the nurse. On 07/31/25 at 7:45 A.M., the surveyor observed Licensed Practical Nurse (LPN) #130 at the medication cart in the 400 hallway preparing medications. Resident #28's door was closed and permission to enter the room was obtained after knocking on the door twice. As the surveyor entered the resident's room the resident was observed sitting in a wheelchair in front of her overbed table. A medication cup was observed on the resident's overbed table containing twelve (12) medications. A clear, plastic water cup containing a plastic spoon and a thick white, liquid medication was also observed sitting on the overbed table. The resident stated LPN #130 brought her morning medications and she was waiting for her breakfast to take them. Resident #28 verified the nurse left the medications for her to take later and he was not in her room. At 7:47 A.M., the surveyor opened the door and looked down the hallway. LPN #130 was not observed on the 400 hall. At 7:49 A.M., Resident #28's door opened and LPN #130 entered the room. The surveyor asked him about the pill and liquid medications left unsupervised on the resident's overbed table. LPN #130 verified he left the resident and her medications unsupervised but 'was coming back'.Review of the policy: Medication Administration (dated 06/21/17) revealed medications were to be administered by legally authorized and trained persons in accordance to applicable state, local and federal laws and consistent with accepted standards of practice. Medications were to be administered and staff was to remain with the resident while medication was swallowed. Medication was never to be left in a residents room without an order to do so.

Based on record review, observations, and interviews, the facility failed to attempt new interventions for skin conditions (non-pressure related) and behaviors for Resident #42. This affected one resident (#42) of two residents reviewed for skin conditions. Additionally, the facility failed to ensure residents were positioned appropriately in their wheelchair. This affected one resident (#45) of one resident reviewed for positioning. The facility census was 69. Findings include:1.Record review revealed Resident #42 was admitted to the facility on [DATE] with diagnoses including neurocognitive disorder with Lewy bodies, seborrheic dermatitis, and psoriasis. Review of a care plan dated 06/27/22 revealed Resident #42 was at risk for alteration in skin integrity related to Lewy body dementia, pain, recent hip replacement, psoriasis- areas come and go (mainly on face)- picks at skin on face, and seborrheic dermatitis which comes and goes. Interventions included but were not limited to complete skin assessments per facility policy, notify the physician of changes as needed, provide skin care as needed, treatment per order, and provide resident/family with education on skin integrity maintenance and potential complications as needed. Review of a care plan dated 06/21/24 revealed Resident #42 had alteration in skin integrity as evidenced by rash present on her face, seborrheic dermatitis, and comes and goes. Interventions included but were not limited to body check weekly and as needed, notify physician and family of changes as needed, treatment per orders, and provide resident/family with education on skin impairment and potential complications as needed. Review of a note from Physician Assistant (PA) #313 dated 07/18/24 revealed Resident #42's seborrheic keratosis had improved with Ketoconazole. Review of a note from PA #313 dated 11/21/24 revealed Resident #42's face had improved related to seborrheic keratosis and to continue Econazole to face. Review of a psychiatric note dated 04/17/25 revealed Resident #42 had a medical history of psoriasis. The note did not address Resident #42's behavior of picking at her skin. Review of a psychiatric note dated 05/15/25 revealed Resident #42 had a medical history of psoriasis. The note did not address Resident #42's behavior of picking at her skin. Review of a note from Physician #325 dated 05/23/25 revealed Resident #42's diagnoses included psoriasis, however the skin portion of the documentation was left blank. Review of a minimum data set (MDS) completed on 06/30/25 revealed Resident #42 had mildly impaired cognition, no behaviors, and no skin issues. Review of a psychiatric note dated 07/17/25 revealed Resident #42 had a medical history of psoriasis. The note did not address Resident #42's behavior of picking at her skin. Review of a note from Physician #325 dated 07/21/25 revealed Resident #42's diagnoses including psoriasis, however the skin portion of the documentation was left blank. Observation on 07/28/25 at 3:07 P.M. revealed Resident #42 was resting in her bed with a quarter-size area on her forehead which appeared red and flaky and she was picking at her skin. Observation on 07/29/25 at 10:19 A.M. revealed Resident #42 was ambulating in her room with a front-wheeled walker. Resident #42 stated she was doing well. She did have patchy, dry skin on her forehead and the bridge of her nose was bright red. Interview on 07/29/25 at 1:22 P.M. with Certified Nursing Assistant (CNA) #192 revealed Resident #42 picks at her skin and has for as long as they've known each other. CNA #192 stated Resident #42 has a cream she receives daily or that she asks for daily. Interview on 07/29/25 at 1:37 P.M. with CNA #166 revealed Resident #42 digs at her skin even when she receives her skin cream. CNA #166 stated Resident #42 has dug at her skin for a long time, she will let it heal, then digs again and it usually happens on her face. Interview on 07/30/25 at 8:15 A.M. with the Director of Nursing (DON) confirmed psychiatric notes did not address the behaviors of Resident #42 picking at her skin, Physician #325's notes did not always have a complete assessment including skin but it could be because Resident #42's rashes fluctuate, and PA #313's notes since 11/2024 have not addressed new skin outbreaks or new interventions. The DON also confirmed there were no current notes indicating Resident #42 had areas of her skin on her face open. Interview on 07/30/25 at 8:19 A.M. with Resident #42 revealed having rashes on her skin is normal for her. During the interview, Resident #42 had a breakout across her forehead, a bright red area to the bridge of her nose, and a new, small area the size of a dime to her chin. Resident #42 requested cream for her skin at this time. Interview on 07/30/25 at 8:20 A.M. with Licensed Practical Nurse (LPN) #137 revealed Resident #42 had a cream for her face which she received with her medications and the cream was used daily. LPN #137 retrieved the cream from the treatment cart and it was econazole nitrate and ordered for Mondays and Fridays. 2.Record review revealed Resident #45 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, restlessness and agitation, and history of falling. Review of an MDS dated [DATE] revealed Resident #45 had severely impaired cognition, physical behaviors one to three days, and behaviors were worsening, and the resident was dependent on staff for activities of daily living. Review of a care plan dated 07/30/21 revealed Resident #45 was at risk for falls and has fall history, uses psychotropic medications, has impaired mobility, is incontinent, and has impaired cognition and communication. Interventions included but were not limited to not using footrests when in recliner. Observation on 07/28/25 at 9:34 A.M. revealed Resident #45 was in a reclining wheelchair in the dining room. She was noted to be fidgeting, and her feet were dangling due to no footrests in place. Interview on 07/29/25 at 1:37 P.M. with CNA #166 revealed Resident #45 stays in an upright position in her wheelchair when she's awake, but when she goes to sleep, they tilt the chair back. Resident #45 does not use the footrests because she will hit the back of her legs off the pegs. Interview on 07/30/25 at 8:15 A.M. with Certified Occupational Therapy Assistant (COTA) #222 revealed she was unable to recall information regarding Resident #45's chair or type of footrests used. Interview on 07/30/25 at 8:22 A.M. with CNA #166 revealed she was unable to locate Resident #45's footrests. Interview on 07/30/25 at 8:26 A.M. with CNA #166 revealed she retrieved COTA #222 to assist with footrests. COTA #222 brought a pair of standard footrests to try with Resident #45's wheelchair; they did not fit. COTA #222 went to search the common area for footrests and found them in the dining room. Footrest had peddles for feet and a pad to support the calves. There was no cushioning to prevent injuries if resident was restless. COTA #222 stated they had not tried a padded box footrest and they could try them instead of leaving Resident #45's feet dangling but they could not strap her in and if she wanted to slide down and get of the chair she could. CNA #166 stated she did not know where the footrests were because they hadn't been used in so long. Interview on 07/30/25 at 8:40 A.M. with CNA #166 revealed she found a cushioned box footrest and thought it would work well for Resident #45 so her feet aren't dangling and when she becomes restless, the padding will protect her legs.

Based on record review, review of email correspondence to the local Ombudsman, and staff interview, the facility failed to ensure the State Ombudsman was notified of a resident's discharge from the facility. This affected one resident (#81) of three residents reviewed for discharge. Findings include: Review of Resident #81's closed medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease, delusional disorder, anxiety disorder, and tremors. She had a discharge date to home on [DATE]. Review of Resident #81's Discharge Plan of Care and Recapitulation dated 06/13/25 revealed the resident was there for a respite stay. Review of an email correspondence from the facility's social worker (Social Service Designee #202) to the State Ombudsman's email address dated 07/07/25 at 4:04 P.M. revealed Social Service Designee (SSD) #202 sent an email notifying the local State Ombudsman of discharges that had occurred for the prior month (June 2025). There were 13 residents on that list but it did not include Resident #81, who had been discharged on 06/13/25. On 07/31/25 at 9:00 A.M., an interview with SSD #202 confirmed the email she sent to the State Ombudsman on 07/07/25 to notify them of the facility's discharges that occurred in June 2025 did not include the name of Resident #81. She further confirmed Resident #81 was discharged on 06/13/25 following her five day respite stay and should have been on that list. She reported she pulled up a report of all discharges for the previous month and used that report to add the names of the residents who had been discharged to an email she sent to the State Ombudsman to notify them of the facility's prior month's discharges. She stated all discharges including respite stays would be included on that list.

Based on medical record review, beneficiary notice review, policy review and interview, the facility failed to ensure residents were informed of what type of skilled services were being terminated. This affected three residents (#2, #20 and #83) of three residents reviewed for beneficiary notifications.Findings include:Findings Include: 1. Medical record review revealed Resident #83 was admitted on [DATE] and discharged [DATE]. Review of the Notice of Medicare Non-Coverage dated 04/28/25 for Resident #83 revealed her skilled services were ending on 04/30/25. The facility failed to document what skilled services were ending on 04/30/25. 2. Medical record review revealed Resident #20 was admitted on [DATE]. Review of the Notice of Medicare Non-Coverage dated 04/08/25 for Resident #20 revealed current services was ending on 04/10/25. The facility failed to document what skilled services were ending on 04/10/25 for Resident #20. 3. Medical record review revealed Resident #2 was admitted on [DATE].Review of the Notice of Medicare Non-Coverage dated 04/04/25 for Resident #2 revealed current therapy services was ending on 04/07/25. The facility failed to document what therapy services were ending on 04/07/25 for Resident #2. On 07/29/25 at 3:15 P.M., interview with the Director of Nursing stated the facility does not have a policy regarding beneficiary notifications and the facility was to follow federal guidelines. On 07/30/25 at 12:48 P.M., interview with Administrator verified the beneficiary notices did not indicate what skilled services were being terminated.

Based on observation, interview, record review, and facility policy review, the facility failed to evaluate and treat a resident's skin condition. This affected one of one resident (#31) reviewed for non pressure skin impairment. The facility census was 71. Findings include: Review of the medical record for Resident #31 revealed an admitted [DATE] with diagnoses including psoriasis. Review of the quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #31 required partial to moderate assistance with showers and or bathing and supervision with personal hygiene. The assessment indicated Resident #31 had no skin impairments however received application of ointment/medication to site other than his feet. Review of the physician orders dated May 2024 revealed Resident #31 had an order for Ketoconazole external shampoo 2 percent to apply to scalp topically every day shift on Monday and Thursday for Seborrhea. Review of the Medication Administration Record for May 2024 revealed Resident #31 received the shampoo as ordered. There was not a physician's order to address Resident #31 psoriasis or redness noted to chin. Review of nursing progress notes revealed on 05/07/24 at 12:02 P.M. Registered Nurse (RN) #116 documented Resident #31 reported itching and dry areas of skin to his neck and face. Resident #31 stated he had put medicated cream on the areas before and had relief of symptoms. Physician Assistant (PA) was in the facility to see Resident #31 and wrote an order for hydrocortisone one percent, topically to rash on the right neck and face two times daily for 10 days. The nursing progress notes were silent on red, blotchy area to Resident #31 chin. Review of the plan of care dated 08/10/23 revealed Resident #31 had alteration in skin integrity as evidenced by a rash related to psoriasis present on bilateral buttocks. On 08/08/23 Resident #31 may keep medication at bedside for self administration. The goal was Resident #31 would be free from signs and symptoms of infection, and have no increased pain related to skin impairment by the target date (no date). The interventions included to assess area for size, color and drainage as needed, assess for pain and provide treatment per the physician orders, body check weekly and as needed, notify the physician and family of changes as needed and the staff to provide skin care as needed. Review of the last non pressure weekly skin assessment dated [DATE] revealed no areas of concern. The medical record did not include evidence Resident #31 was seen by dermatology. The medical record did not include a self medication assessment for Resident #31. Observations of Resident #31 on 05/20/24 at 10:20 A.M., 05/22/24 at 2:43 P.M. and on 05/23/24 at 12:30 P.M. revealed Resident #31 had a bright red, blotchy area to his chin. Interview on 05/23/24 at 12:30 P.M. with Resident #31 confirmed he had a bright red blotchy area to his chin. Resident #31 stated it was itchy and was not sure if the nurse had put anything on it or notified the physician. Interview on 05/22/24 at 9:40 A.M. with the Director of Nursing (DON) confirmed there were not any residents in the facility that self administered medications. An observation on 05/22/24 at 2:10 P.M. of Resident #31 room with RN #125 confirmed in the top drawer of Resident #31 bedside table was a tube of Desonide lotion 0.05%, apply topically two times daily to skin redness, itching or discomfort related to atopic dermatitis. The cream was filled by the pharmacy on 04/12/21 and stated to discard by 04/12/22. RN #125 stated it was unknown if Resident #31 used the medication. RN #125 confirmed there was not an order for Resident #31 to have the medication or an order to keep at bedside for self administration. An interview on 05/22/24 at 2:30 P.M. with the MDS nurse #187 confirmed the plan of care indicated Resident #31 may keep medicated cream at bedside for self administration. MDS nurse #187 also confirmed there was not a current treatment order for residents skin, and Resident #31 did not have a self medication assessment. An interview on 05/23/24 at 12:34 P.M. with RN #182 confirmed Resident #31 continued to have a bright red blotchy area to his chin. RN #182 stated she would notify the physician. RN #182 stated skin assessments were completed two times weekly and with care. The State tested Nursing Assistants (STNA) were good about reporting skin issues, however, no one had reported it to her. Review of the facility policy titled Medication Storage/Bedside Storage of Medications dated 06/21/17 revealed resident who were able to self administer medications may be allowed to store at bedside. The procedure included a written physician order, stored in a locked area, and periodically reassess the ability of the resident to continue self administering medications. The facility did not provide a policy for non pressure related skin impairment.

Based on observations, staff interview, resident interview, and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents. This affected one of one residents reviewed for falls (#12). The facility census was 71. Findings include: Review of the medical record for Resident #12 revealed an admitted [DATE] and diagnoses including morbid obesity, chronic obstructive pulmonary disease, and chronic respiratory failure. Review of a fall risk assessment 02/29/24 revealed the resident was at risk for falls and had a history of a fall in the last 30 days. It indicated the resident's balance was not steady moving from a seated to standing position or with walking. Review of an incident report revealed on 03/04/24 at 4:30 P.M. Resident #12 was noted on the floor in her bathroom. The resident was sitting on her buttocks facing the grab bar with her legs straight out in front of her. The resident stated that staff assisted her to the bathroom and gave her the call light. However, she stated she let go of the call light cord and thought she could transfer herself back to her recliner. She stated her pants leg got under her socks and her foot slipped. She then fell on to her buttocks. There was no injury noted. The resident's son was notified and was to bring in shorter pants. Physician's orders were obtained on 03/04/24 for a low bed and pants to be ankle length or shorter for fall prevention. A fall risk assessment 03/04/24 continued to indicate the resident was at risk for falls due to a history of falls and unsteady balance. It indicated the resident was only able to stabilize with staff assistance. Review of a Minimum Data Set assessment completed 03/07/24 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. It indicated the resident required substantial/maximal assistance from staff with sit to stand, chair/bed transfer, toilet transfer, and walking 10 feet. Review of an incident report dated 03/12/24 at 8:30 P.M. revealed Resident #12 had fallen in the bathroom. Nursing assistant stated she assisted resident to bathroom and placed call light cord in resident's hand before leaving. Nursing assistant came back to check on resident and observed resident on floor. The resident was sitting up on buttocks with legs straight out in front of resident. Resident leaning up on side of toilet. The resident stated she got off the toilet, became dizzy, fell , and hit her head off the rim of the toilet. The resident was noted to have a 1.2 by 1.2 by 0.1 centimeter open area to the back of her head which was actively bleeding. The resident was transferred to the emergency room for evaluation. Review of nurses notes revealed on 03/13/24 at 12:10 A.M. the hospital emergency room called and stated the resident received two staples to the open area on back of scalp. The resident returned to the facility on [DATE] at 3:26 A.M. A fall risk assessment dated [DATE] stated the resident had a history of falls in the past 30 and 90 days. It stated the resident had unsteady balance and was only able to stabilize with staff assistance. Review of the plan of care revealed on 03/01/24 and revised 03/13/24 the resident was noted to be at risk for falls due to debilitation, weakness, impaired vision, history of falls, syncope, psychotropic medication use, and poor safety awareness. On 03/12/24 interventions were added for staff to offer to toilet every two hours and not leave resident unattended while toileting. Interview with Resident #12 on 05/20/24 at 2:43 P.M. revealed she had fallen twice at the facility. She stated she got hurt when she fell in the bathroom and hit her head and had to get stitches. Observations on 05/21/24 at 3:06 P.M. revealed Resident #12 to be in the bathroom of her room. Nursing assistant #137 was observed leaving the room. Resident #12 was alone in her bathroom in her room. Observations on 05/21/24 at 3:12 P.M. revealed the call light to be on in Resident #12's room. Nursing assistant #137 went to the room and assisted Resident #12 from the bathroom to her chair with the use of a walker. Interview with Licensed Practical Nurse #103 on 05/23/24 at 9:35 A.M. revealed staff are to stay with Resident #12 when she is in the bathroom. She stated staff are not to leave the room. She confirmed Resident #12 had experienced two falls in the bathroom. Interview with the Director of Nursing on 05/23/24 at 9:43 A.M. revealed staff are to stay close by, either in bathroom or in the resident's room, when she is in the bathroom.

Based on interviews and record review, the facility failed to monitor a dialysis site per the resident centered care plan. This affected one resident (#26) of one resident reviewed who was receiving dialysis. The facility census was 71. Findings include: Review of the medical record for Resident #26, revealed an admitted [DATE]. Diagnoses included: type 2 diabetes mellitus with diabetic neuropathy, heart failure, chronic kidney disease, stage 4 (severe) and dysphagia, oral phase. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15. The resident was assessed to require independent with bed mobility and transfers from bed and chairs, with supervision or touching assistance with tub/shower transfers and partial moderate assistance with shower/bathe self. Review of the progress note dated 04/10/24 for Resident #26 revealed the placement of a central venous line (CVL) for dialysis with no documentation on the location and the site had a dry bandage to it. Review of the active care plan for Resident #26 revealed to monitor permacath every shift for bleeding. Further record review for this resident revealed no monitoring of the permacath every shift and no documentation of the location of the site by the facility. Interview on 05/22/24 at 1:54 P.M. with Resident #26 revealed she lets the facility know if there is an issue with her permacath and stated They do not come in here at night to check my bandage, but I let them know if there is an issue. Observation on 05/22/24 at 1:59 P.M. of Resident #26 revealed a site to the left upper chest, dressing was clean and dry. Interview on 05/22/24 at 2:14 P.M. with the Director of Nursing (DON) verified Resident #26's active care plan stated to monitor permacath for bleeding every shift with no monitoring documentation and no site location ever being noted throughout the resident's record.

Based on interview and record review, the facility failed to ensure residents with Post Traumatic Stress Disorder (PTSD) were appropriately evaluated to identify the cause of the resident's PTSD and minimize triggers and/or re-traumatization. This affected two residents (#23 and #24) of two residents identified by the facility as having PTSD/trauma. The facility census was 71. Findings include: 1. Review of the medical record for Resident #24 revealed an admitted [DATE] with diagnoses including major depressive disorder, anxiety disorder, bipolar disorder and dated 03/23/23 PTSD. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #24 was cognitively intact with a Brief Interview of Mental Status (BIMS) of 15 with no behaviors however, did self isolate at times. Resident #24 required staff assistance to complete activities of daily living. The assessment identified Resident #24 had diagnoses of anxiety, depression, bipolar disorder, and PTSD. Review of the Brief Trauma Questionnaire dated 04/03/23 revealed Resident #24 had no traumatic events or triggers. Further record review for this resident revealed no assessment had been completed to identify the cause of PTSD for Resident #24 and to identify potential triggers which may cause re-traumatization. Review of the updated plan of care dated 03/24/24 for Resident #24 revealed no plan of care was in place addressing the cause of the PTSD, the triggers which may cause re-traumatization or interventions to reduce the risk of re-traumatization and provide care for PTSD. An observation and interview with Resident #24 on 05/20/24 at 1:45 P.M. revealed Resident #24 appeared sad, and withdrawn. Resident #24 stated she was depressed and sad but she had to work through it. An interview on 05/23/24 at 12:20 P.M. with State tested Nursing Assistant (STNA) #129 stated she was not sure which residents on her hall had PTSD. STNA #129 also stated she was not aware Resident #24 had PTSD, did not know what the triggers were or how to react to the triggers. STNA #129 stated she had not received education on PTSD or trauma informed care. An interview 05/23/24 at 12:24 P.M. with STNA #153 stated she was aware that Resident #24 had PTSD possibly related to a boating accident. However, STNA #153 did not know what Resident #24 triggers were or what to do if resident exhibited symptoms. STNA #153 stated she had not received education on PTSD or trauma informed care. An interview on 05/23/24 at 1:29 P.M. with the Director of Nursing (DON) revealed the facility did not have a policy on PTSD or trauma informed care. The DON stated the facility completed a brief trauma informed care assessment on admission along with a plan of care. The DON verified the assessment did not identify the cause of the PTSD and possible triggers. Also verified the plan of care for Resident #24 did not include triggers or interventions to prevent or minimize the risk of re-traumatization. 47987 2. Review of the medical record for Resident #23, revealed an admitted [DATE]. Diagnoses included, but were not limited to: generalized anxiety disorder, polyneuropathy, and paraplegia. Post traumatic Stress Disorder (PTSD) and hallucinations were added to the list of diagnoses as of 03/08/24. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 14. The resident was assessed to have an active diagnosis of PTSD. Review of the active care plans for Resident #23 revealed no plan of care was in place until 05/23/24 addressing the cause of PTSD, triggers which may cause re-traumatization, or interventions to reduce the risk of re-traumatization and provide care for PTSD. Further record review for this resident revealed no assessment had been completed to identify the cause of PTSD for Resident #23 and to identify potential triggers which may cause re-traumatization. Interview with the Regional Nurse on 05/28/24 at 2:22 P.M. verified an assessment of the cause of PTSD and possible triggers for Resident #23 had not been completed and additionally verified there had not been a plan of care implemented for Resident #23 to minimize the risk of re-traumatization until 05/23/24 with verbal confirmation of the triggers without an actual assessment.

Based on interview and record review, the facility failed to administer medication as ordered for Resident #26 after dialysis treatments. This affected one resident (#26) of one resident reviewed for dialysis. The facility census was 71. Findings include: Review of the medical record for Resident #26, revealed an admitted [DATE]. Diagnoses included: type 2 diabetes mellitus with diabetic neuropathy, heart failure, chronic kidney disease, stage 4 (severe), anxiety, depression, parkinson's disease, and dysphasia, oral phase. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15. The resident was assessed to require independent with bed mobility and transfers from bed and chairs, with supervision or touching assistance with tub/shower transfers and partial moderate assistance with shower/bathe self. Review of active physician orders for Resident #26 revealed the following medications were to be given upon rise at 7:00 A.M.: 1. calcitrol oral capsule 0.25 micrograms (MCG) one capsule by mouth every Monday, Wednesday and Friday. 2. Duloxetine Hydrochloride (HCL) oral capsule delayed release particles give 90 milligrams (mg) by mouth one time a day for depression/anxiety. 3. Carbidopa-Levodopa oral tablet 25-100 MG give one tablet by mouth two times a day for parkinson's. 4. Ferrous Sulfate oral tablet 325 MG give one tablet by mouth one time a day for anemia. 5. Fexofenadine HCL oral tablet 180 MG give one tablet by mouth daily. 6. Flonase Allergy Relief Nasal Suspension 50 MCG/ACT two sprays alternating nostrils one time a day for allergies. 7. Gabapentin oral tablet 600 MG give one tablet by mouth two times a day for pain. 8. Lokelma (Sodium Zirconium Cyclosilicate) oral packet 10 grams (GM) give one packet by mouth one time a day for hyperkalemia. 9. Magnesium oral tablet 500 MG give one tablet by mouth two times a day for supplement. 10. Multivitamin oral tablet give one tablet one times a day for supplement. 11. Omeprazole oral capsule delayed release 40 MG give one capsule by mouth one time a day for Gastroesophageal Reflux Disease (GERD). 12. Saccharomyces boulardii capsule give one capsule by mouth two times a day for probiotic. 13. Sodium Bicarbonate oral tablet 650 MG give by mouth three times a day for GERD. 14. Tums (Calcium Carbonate) oral tablet chewable give one tablet by mouth four times a day for GERD. 15. Vitamin D 3 oral tablet 125 MCG (5000 units) give one capsule by mouth one times a day for supplemental health. Review of May 2024 Medication Administration Record (MAR) for Resident #26 revealed for the dates of 05/06/24, 05/08/24, 05/10/24, 05/13/24, 05/15/24, 05/17/24, 05/20/24 and 05/22/24 the 15 medications ordered for upon rise at 7:00 A.M. were not administered. Interview on 05/22/24 at 1:56 P.M. with Resident #26 revealed she has not been receiving her morning medications on the days she goes out for dialysis, even when she returns. Interview on 05/22/24 at 2:14 P.M. with the Director of Nursing (DON) verified Resident #26 did not receive her 15 morning medications as ordered on her dialysis days dated 05/06/24, 05/08/24, 05/10/24, 05/13/24, 05/15/24, 05/17/24, 05/20/24 and 05/22/24. She stated I will get this fixed right now with the House Doctor so she can get them after as it does her no good before and that is why the nurses are not giving them.

Based on observation, record review, review of medical nutrition therapy best practice guidance and interview, the facility failed to develop and implement comprehensive, individualized and adequate nutritional interventions and complete accurate weight monitoring to meet the nutritional needs and prevent weight loss for all residents. Actual Harm occurred on 04/24/23, when the facility failed to implement comprehensive and individualized nutritional interventions, failed to ensure discharge orders regarding resident fluid intake were properly addressed, failed to timely implement dietician recommendations for nutritional support/supplements, failed to provide the resident with the correct diet, failed to timely address the resident's reports of mouth pain/thrush and failed to notify the resident's physician of condition changes related to lethargy and decreased meal intakes. On 05/14/23 Resident #67 was transferred to the hospital, admitted and diagnosed with toxic metabolic encephalopathy (a condition of acute global cerebral dysfunction manifested by altered consciousness, behavior changes, and/or seizures in the absence of primary structural brain disease or direct central nervous system infection with causes including infections, dehydration and malnutrition) related to acute kidney injury, sepsis, urinary tract infections likely due to poor oral intakes and severe protein calorie malnutrition with temporal wasting (loss of temporalis muscle mass commonly seen in cases of catabolism (destructive metabolism) and/or generalized nutritional deficiency), rib exposure with a body mass index less than 19. This affected three residents (#4, #18 and #67) of four residents reviewed for nutrition. The facility identified four residents (#4, #18, #34, and #43) with significant, unplanned weight loss. The facility census was 66. Findings include: 1. Review of Resident #67's hospital records (prior to facility admission) dated 04/19/23 to 04/24/23 revealed the resident had a history of severe protein calorie malnutrition and had acute on chronic renal failure related to poor intake. Review of the hospital discharge summary plan dated, 04/24/23 revealed the resident had an echocardiogram (a scan used to look at the heart and near-by blood vessels) during her hospitalization that showed a grade one diastolic dysfunction (heart cannot fully fill during the diastolic part of the heartbeat). The resident's discharge orders revealed the resident required a cardiac 1500 milliliter (ml) fluid restriction daily (used to avoid overloading your heart if you have heart failure as more fluid in your bloodstream makes it harder for your heart to pump) and a minced moisture texture diet. Hospital discharge documentation noted the resident's stay was expected to be less 30-days at the skilled nursing facility. The resident's discharge instructions included a recommendation if you were told you had heart failure weigh yourself daily at the same time each day. Call your doctor and report right away if you gain more than three (3) pounds or more in one day or if you gain five (5) pounds or more in one week or if you have any heart failure symptoms. Closed record review revealed Resident #67 was admitted to the facility on [DATE] and discharged to the hospital on 05/14/23. The resident's diagnoses included orthopedic aftercare due to a displaced intertrochanter fracture of the left femur, type two diabetes, muscle weakness, dysphagia (difficulty swallowing), heart disease, stage three chronic kidney disease, hypertension, falls and ectopic kidney (a kidney located below, above or on the opposite side of the kidney's normal position in the urinary tract). Review of Resident #67 electronic medical record (EMR) revealed a documented weight on 04/24/23 of 113.0 pounds. Review of the resident's physician's orders (from 04/2023 through 05/14/23) revealed no physician's order for any type of weight monitoring. Record review revealed an admission order, dated 04/24/23 for a no added salt (NAS) mechanical soft diet. On 04/25/23 the resident's diet was upgraded to a regular texture diet; however this was not communicated to the dietary department. Review of Resident #67's fluid restriction worksheet and physician's orders, dated 04/25/23 revealed the resident was not to exceed a total daily fluid intake of 1500 milliliters (ml); 720 ml dietary and 780 ml nursing. The worksheet noted one cup of 240 ml of fluids on each meal tray. Review of Resident #67's oral assessment dated [DATE] and authored by the Director of Nursing (DON) revealed the resident had one to three decayed or broken teeth and no dentures. Record review revealed a plan of care, dated 04/26/23 related to altered health maintenance due to progress physical and mental status. Interventions included to monitor for signs and symptoms of cardiac distress and report to the cardiac and vascular doctor if any weight gain/loss, edema, fatigue, chest pain, confusion, nausea, decreased urinary output, or increased laboratory testing (BUN/Creatine). Interventions also included to provide diet ordered; if less than 50% consumed offer supplements as ordered (the resident had no orders for nutritional supplements at this time). Stress the importance of good nutrition and how it promotes healing and increases resistance. Review of Resident #67's speech notes authored by Speech and Language Pathologist (SLP) #201 dated 04/26/23 revealed the resident ate slightly better after speech sat and ate their own individual items while the resident ate. The resident reported the food was bland, Mrs. Dash was used and the resident reported the food was better. Review of Resident #67's nutrition risk tool, dated 04/27/23 and authored by Registered Dietician (RD) #198 revealed the resident was at moderate risk for nutritional decline due to having a moderate decrease in food intake, no weight loss in three months, able to get out of bed/chair but does not go out, BMI 21 to less than 23, had suffered psychological stress or acute disease in the past three months, and no psychological problems. There were no guidelines to direct staff on how to proceed with a resident assessed with nutritional risks. Review of Resident #67's dietary assessment, dated 04/27/23 and authored by RD #198 revealed the resident was hospitalized for an intertrochanter fracture and had undergone surgery (gamma nailing) on 04/20/23 (during the resident's hospitalization ). The resident lived at home (prior to the hospitalization ), and family had provided her with breakfast and dinner. The resident reported she would often forget to eat lunch due to being home alone. The resident reported she had recently started drinking Boost (a nutritional supplement) once daily due to weight loss and lack of intake. The assessment noted, a no added salt (NAS) with thin liquids and regular textured solids diet. The current diet provided 2454 calories and 92 grams of protein. The resident reported her appetite was fair and slowly improving. The resident fed herself with no noted chewing or swallowing problems. Documentation indicated the resident was consuming 25-50% of meal trays. The dietary note indicated the RD would order a house supplement, 120 milliliters (ml) twice daily to provide an additional 240 calories and 20 grams of protein. The resident's weight was noted to be 113 pounds with a BMI of 21.3. The resident's usual body weight (UBW) was 130 pounds and last weight in 09/2022 showed a weight loss of 17 pounds in seven months which was significant. The resident had no edema noted. The dietary assessment also reflected the resident had a deep tissue injury (pressure ulcer) to the coccyx per a skin grid assessment completed on 04/25/23. Resident #67 was noted to be at risk for decline in nutritional status per the Nutrition Risk Tool with a score of 9 (moderate risk for nutritional decline). The resident had nutritional diagnoses including malnutrition, chronic illness, severe muscle/fat loss, weight loss, and suboptimal intakes. Nutritional interventions included to discuss the importance of adequate nutrition to help aid in wound healing, encourage adequate calories, protein, nutrition supplements, and micronutrients to help in wound healing, encourage oral intake with at least 50% consumption at mealtimes, encourage snacking frequently between meals, and encourage compliance with fluid restrictions. Nutrition monitoring and evaluation included monitoring weights via weight report (paper weight book), monitor intakes, and skin integrity. The nutrition goals included the resident would consume at least 50% of meals, snack once daily, and consume Prostat (supplement) 30 ml daily with 100% consumption and house supplement 120 ml twice daily with 100% consumption. Review of Resident #67's paper medical record and electronic medical record (EMR) revealed no evidence a house supplement was ordered or administered to Resident #67 during the residents stay. Review of Resident #67's admission Minimum Data Set (MDS) 3.0 assessment, dated 05/01/23 revealed the resident had severe cognitive impairment with a Brief Interview for Mental Status of three out of 15. The assessment revealed the resident required extensive assistance from two staff for bed mobility, transfers and toilet use, extensive assistance from one staff for dressing, supervision from staff for eating, and limited assistance from one staff for personal hygiene. The resident had no impairment to the upper or lower body and used a walker. The MDS assessment revealed Resident #67 was 61 inches in height and weighed 113 pounds; had no swallowing issues, weight loss, or dental problems. The resident was at risk for pressure ulcer development and had one unstageable deep tissue injury on admission located on the coccyx. On 05/02/23 Licensed Practical Nurse (LPN) #192 documented in the electronic medical record the resident weighed 113.2 pounds. On 05/10/23 RD #198 entered a weight of 112.5 pounds for the resident in the electronic medical record. On 05/11/23 Registered Nurse (RN) #136 documented the resident weighed 113.2 pounds in the electronic medical record. The resident was discharged to the hospital on 05/14/23. Review of the facility paper weight book revealed the week of 05/10/23 there were no documented weights for Resident #67 or for residents on the 200, 300, 400, or 500 halls. Resident #67's name was highlighted yellow. There was a handwritten note by an unidentified author that indicated weights need to be completed by 05/16/23, however floors 200, 300, 400, and 500 were not completed by 05/16/23 and the Director of Nursing (DON) was notified by an unidentified staff member. On 05/04/23 a speech note authored by Speech Therapist (SLP) #201 indicated the resident remarked that it hurt to eat. Speech therapy noted something that appeared ulcer-like and hurt whenever even light pressure was applied (to the resident's mouth). The note indicated the nurse was made aware and was going to have the physician look at it first before making a referral to the dentist. The nurse who was notified was not identified in the SLP documentation. On 05/05/23 a speech note authored by SLP #201 indicated the resident was still complaining of her mouth hurting when eating. The note indicated nursing was aware and would have the physician look at it when he comes in. Review of Resident #67's therapy note dated 05/08/23 and authored by SLP #201, revealed ST #201 called Resident #67's family (Family Member #199) regarding the resident's diet order. Resident #67's diet was a regular diet, however the diet slip on the meal tray had not been updated. The diet slip was now updated, and the family was notified the resident would receive the correct diet. On 05/09/23 a speech note authored by SLP #201 indicated the resident had complaints of mouth pain when eating. Nursing and physician aware. The note did not indicate which nurse was aware or who made the physician aware. Review of Resident #67's (nursing) progress notes dated 04/25/23 to 05/09/23 revealed no documented assessment or evidence of the resident's reported complaints of mouth pain. Although the resident's dietary assessment, completed on 04/27/23 reflected frequent snacking between meals, review of snack intakes, dated 05/08/23 to 05/14/23 revealed the resident was provided a snack on 05/10/23, 05/12/13, and 05/13/23. She refused a snack on 05/08/23 and there was no documentation of snacks on 05/09/23 or 05/11/23. Review of Resident #67's paper record and EMR revealed no evidence the physician was notified of Resident #67's complaints of pain that were reported to therapy by the resident. Review of a progress note dated 05/10/23 at 11:10 P.M. and authored by ADON #120 revealed the Resident #67 was complaining of sores in (her) mouth and mouth pain. The resident was noted to have inflamed gums and few white patches/sores noted. The physician was notified and ordered Clotrimazole (antifungal) lozenges for 14 days due to thrush (yeast infection in the mouth). Review of Resident #67's physician progress notes revealed no evidence the resident was assessed/seen by a physician and/or other designated healthcare provider on behalf of the physician during the resident's stay, with the exception of 04/25/23 when a history and physical was completed. Review of Resident #67's meal intake records, documented by STNA staff assigned to provide care to the resident reflected the resident had decreased intake during her stay. On 04/25/23 breakfast and lunch intakes were 1-25% and dinner 50%. On 04/26/23 breakfast and dinner intakes were 75% and lunch was 25%. On 04/27/23 breakfast intake was 75% and lunch and dinner intakes were 50%. On 04/28/23 breakfast intake was 75%, lunch 100%, and dinner was 50%. On 04/29/23 and 04/30/23 all three meals the resident had 75% intake. On 05/01/23 the resident refused breakfast, lunch intake was 25% and dinner intake was 50%. On 05/02/23 breakfast and lunch intakes were 50% and dinner was 75%. On 05/03/23 breakfast intake was 1-25%, lunch intake was 50%, and dinner intake was 25%. On 05/04/23 breakfast and dinner intakes were 50% and lunch was 25%. On 05/05/23 breakfast and dinner intakes were 25% and lunch was 75%. On 05/06/23 breakfast intake was 25% and lunch and dinner intakes were 50%. On 05/07/23 breakfast intake was 75%, lunch was 1-25%, and dinner was 25%. On 05/08/23 breakfast and dinner intakes were 25% and lunch was 50%. On 05/09/23 only two meal intakes were recorded. The breakfast meal intake was 25%, lunch was 50%, and there was no documented intake for dinner. On 05/10/23 breakfast and dinner intakes were 1-25% and lunch was 75%. On 05/11/23 breakfast intake was 75% and lunch and dinner were refused. There were no meal intakes recorded for 05/12/23. On 05/13/23 breakfast was 1-25% and lunch and dinner were 25%. On 05/14/23 the resident did not have any breakfast. Review of Resident #67's paper and EMR revealed no evidence the resident received an alternative when consuming less than 50% of her meals. Review of Resident #67's treatment administration records dated 05/01/23 to 05/13/23 revealed the resident's 24-hour fluid intakes were documented to range from 360 ml to 600 ml during this time period. Review of Resident #67's occupational therapy note dated 05/12/23 at 1:44 P.M. revealed Certified Occupational Therapy Assistant (COTA) #203 was not able to keep the resident's attention to task due to the resident falling asleep and confusion. COTA #203 took the resident to nurse's station completing communication with nursing pertaining to resident status. The resident was not unable to participate in therapy session this date secondary to mental status and lethargy. The note indicated nursing was looking into a possible urinary tract infection (UTI). Review of Resident #67's nursing progress notes, dated 05/12/23 through 05/13/23 revealed no evidence the physician was notified of the resident's change in condition reported by COTA #203. Review of Resident #67's health status progress note, dated 05/14/23 at 11:58 A.M. and authored by LPN #151 revealed the resident was in the dining room with family for lunch and not acting like herself. She had increased confusion, lethargy, and low blood pressure (91/64). The family requested the resident to be sent to the ER for evaluation where she was admitted . Review of the fire department patient care record form for Resident #67, dated 05/14/23 revealed the fire department arrived (on 05/14/23) to the facility at 12:02 P.M., arrived at the resident's bedside at 12:03 P.M., departed the facility at 12:16 P.M., arrived at the (hospital) destination at 12:22 P.M., and transferred the resident at 12:25 P.M. The call from the facility was for an [AGE] year-old requiring transport to hospital. Upon arrival, fire department staff found a patient sitting in a chair with her family. The family stated she was not acting like herself. The patient did answer several of the questions asked of her but not all. The patient was complaining about her (bake?) being sore. Checked vitals while sitting and family stated the last time the resident was known to be feeling well was last Friday. The resident's vital signs were obtained which showed a blood pressure of 84/56 (hypotensive), pulse 90 (tachycardic) per minute, respirations 16 per minute, and pulse ox (oxygen saturation) of 96%. Review of Resident #67's hospital emergency room documentation dated 05/14/23 from 1:35 P.M. to 2:52 P.M. revealed the resident presented to the emergency room with complaints of altered mental status. The patient was sent from nursing home for lethargy. The resident's daughter was at bedside to assist with the history as patient did not answer questions. Family stated the patient was normally verbal and could walk; however noticed today she was just lying in bed and staring up. Patient would occasionally complain of having left hip pain. History was limited secondary to patient not answering questions. The resident's general appearance was chronically ill appearing, cachectic (a general state of ill health involving marked weight loss and muscle tone) and appeared very dehydrated on exam. The patient's mucus membranes were dry. The resident had a Grade 2 pressure ulcer over the sacrum; her skin was warm and dry with poor skin turgor. The patient would respond to painful stimuli but not verbal stimuli, would move all four extremities if agitated. The resident's blood pressure initially was hypotensive with a pressure of 70/30 (normal 120/80). The ER gave patient a fluid bolus to determine if her (blood) pressure was responsive. The patient does have a history of congestive heart failure, but it was felt the patient needed the intravenous fluids to tolerate the prescribed intravenous fluid orders. The patient was very thin and required the physician's vigilant attention to prevent deterioration (sepsis, hypotension). Review of the hospital admission notes, dated 05/14/23 revealed the resident was admitted to the hospital with diagnoses including toxic metabolic encephalopathy related to acute kidney injury, sepsis, urinary tract infection likely due to poor oral intakes and severe protein calorie malnutrition with temporal wasting, rib exposure with a body mass index under 19, and a Stage II pressure ulcer to the left buttocks. Review of Resident #67's hospital dietary notes, dated 05/15/23 revealed the resident was at high nutritional risk as evidence supported by diagnosis of severe malnutrition based on weight decrease. The resident's estimated energy needs were not being met due to poor oral intake. The note indicated to recommend Ensure high protein supplement three times a day and obtain updated weight. The resident had intravenous fluids running at 75 ml hour at the time of visit and refused to consume ordered supplements due to lethargy. The resident was only consuming 10% of Ensure due to spilling most of it. The note indicated the resident would be tried with a magic cup to see if it improved intakes. The physical findings revealed the patient had severe muscle and fat depletion per ASPEN malnutrition guidelines; her orbital region had a hollow look, depressions, dark circles and loose skin; the temple region had significant hollowing and depression; the shoulder region had a prominent protruding (the bony process on the shoulder blade); prominent protruding clavicle bone; very little thickness of tricep skin fold; in her scapular region she had very visible bones with depressions between ribs/scapula (shoulder blade) and shoulder/spine; severe depression of the inner thigh muscles; bones prominent with little muscle present around the knee; little to no muscle definition in the posterior calf region. On 05/23/23 at 1:47 P.M. and a follow-up interview at 3:05 P.M. with Registered Dietician (RD) #198 revealed resident weights were usually obtained on Tuesday and discussed on Wednesday during the facility's risk meetings. First the RD reported she was not responsible for notifying the physician or families of weight changes. The RD reported she would email the MDS nurse and DON of any significant weight changes. During the second interview at 3:05 P.M., the RD reported she was responsible for notifying the physician of weight loss and she had just forgotten she was responsible as she had previously stated she was not the responsible person for reporting weight loss to the physician. She stated she would only report to the physician if there was a 5% weight loss in one month or 10% weight loss in six months, but not sooner. The RD revealed she was not familiar with the federal regulations for nursing homes as she was just hired last month and had no prior nursing home experience. The RD #198 reported she did not have facility policies and procedures to reference, and stated she would follow the medical nutrition therapy best practices for high risk areas. On 05/24/23 at 10:32 A.M. interview with Regional Registered Dietitian (RRD) #197 verified Resident #67's diet was upgraded on 04/25/23 to a regular texture diet from a mechanical soft diet, however the dietary department never received the order or communication form. The only order/communication form the dietary department had received was the admission order for the mechanical soft textured diet. On 05/24/23 at 11:30 A.M. interview with ADON #120 revealed there was no documentation assessing the resident on 05/12/23 or 05/13/23. The ADON revealed the resident was skilled and should have had documentation completed at least once a day. ADON #120 revealed the resident was ordered a COVID test, laboratory testing including a Complete Blood Count (CBC) and Basic Metabolic Profile (BMP) on 05/11/23 without any indication or documentation why it was ordered. The resident was also ordered a chest x-ray on 05/11/23 that indicated possible fluid overload, however there was no documentation to support the order or assessment of the resident after receiving the x-ray results. ADON #120 revealed she did not believe Resident #67 had a change of condition on 05/12/23 or 05/13/23; however there was no documented evidence to support the resident's condition except a phone interview that was completed on 05/24/23 with LPN #151 and after the above concerns that had been identified by the State survey agency. On 05/24/23 at 12:33 P.M. interview with Resident #67's family, Family Member #199 revealed she rode in the squad on 05/14/23 to the emergency room (ER) with Resident #67. The family member stated when the squad transferred Resident #67 to the bed in the emergency room the emergency room (ER) nurse looked at Resident #67's skin and reported the resident had a bad pressure ulcer on her buttocks. During this interview and a subsequent interview on 05/31/23 at 2:19 P.M. Family Member #199 reported she had visited the resident in the facility on 05/12/23. On 05/14/23 when visiting, the family member felt the resident was confused and lethargic and asked the nurse to assess the resident. The resident's blood pressure was low, and she had asked the nurse to transfer the resident to the emergency room . The facility nurse reported to her (Family Member #199) and the ambulance driver Resident 67's had been like this for three days and had not eaten or consumed fluids. Family Member #199 revealed the facility had reported to them the resident's weight was 113 pounds but in the emergency room , the family was told the resident weighed 85 pounds. The family member denied the resident or herself reporting the resident weighed 85 pounds to hospital staff. Family Member #199 reported the family didn't understand why the resident was on fluid restriction because she had not been on a fluid restriction or special diet when she was in the hospital (prior to the nursing home admission). The family member also indicated the resident would not eat the mechanically altered diet provided by the facility. After being treated in the hospital, the resident was discharged to a different skilled nursing facility in the area and had done a complete 180 degree turn around (improvement). Family Member #199 revealed she had shown co-workers pictures of the resident while she was at the facility compared to the current skilled nursing facility and they couldn't believe the improvement. The resident had gained weight and was able to use Facetime and communicate with family. The resident reported to family that facility staff never checked on her, which she felt was accurate as when family visited no staff ever came in to check on the resident. On 05/24/23 at 1:16 P.M. interview with STNA #124, STNA #188, and LPN #153 with RRD #197 revealed the STNA staff reported they did not include fluids as part of their meal intake documentation. The LPN reported she only documented on the treatment administration record (TAR) the fluids nursing staff administered. The STNA and LPN confirmed they do not calculate or document the fluids dietary provided. RRD #197 reported she was not aware staff were not monitoring or documenting the fluids dietary was providing on the meal trays. She thought 25% of the meal intakes staff were recording under the task tab in the EMR include fluids provided at mealtime. The RRD reported all residents, no matter the diagnosis, should have fluid monitoring. Nutritional intakes were more important than solid intakes. During the interview, RRD #197 verified Resident #67 was not receiving adequate fluids while in the facility especially given the admitting diagnosis to the hospital on 05/14/23. On 05/24/23 at 3:30 P.M. interview with the Administrator confirmed the RD had ordered a house supplement, 120 ml twice daily on 04/27/23, however the order was never implemented, and the resident did not receive the supplement. On 05/25/23 at 11:36 A.M. interview with COTA #203 revealed Resident #67 was more confused and lethargic (on 05/12/23) so she took the resident back to the nurse's station to report the change of condition to the nurse. COTA #203 stated the nurse thought the resident had a urinary tract infection (UTI). On 05/25/23 at 12:30 P.M. interview with Physical Therapist (PT) #204 revealed the resident was a skinny little thing. PT #204 revealed the resident spent most of her time in bed. On 05/25/23 at 12:45 P.M. interview with STNA #114 revealed she provided care to Resident #67 during the resident's stay. STNA #114 revealed the resident was confused but could let you know her needs. The resident would ask for fluids; however, since she was on a fluid restriction the nurses would have to provide fluids to the resident. STNA #114 revealed STNA staff did not monitor or document resident fluids intakes. The STNA indicated the resident was a tiny bony lady and required encouragement to eat, drink, and even to get out of bed. During the resident's stay, the resident had dried skin on the top of her buttocks and complained it was sore. On 05/25/23 at 1:36 P.M. interview with Resident #67's primary care physician, who was also the facility medical director, Medical Director #196 revealed he was not aware of the nutritional concerns with Resident #67 including the failure to provide nutritional supplements, the lack of nutritional support with the resident being admitted to the facility with a pressure ulcer as well as developing a pressure ulcer during her stay, the resident's decreased meal intakes and fluid intakes, the facility not providing the resident the correct diet, the presence of thrush for several days before it was reported or the resident's condition change over the last few days of her stay until the time of this interview. The MD reported he was the only provider for the facility and staff should notify him immediately with weight changes if they were significant or not and even if they occur sooner than one month or six months as indicated by the dietician. Weight loss needed to be addressed sooner than when the loss became significant. The MD reported he could not change the concerns identified for Resident #67 but stated he would make arrangements to meet with the dietitian to discuss the concerns and begin a corrective action plan. The physician was unaware the facility did not have policies and procedures in place related to weights, weight loss and fluid intakes. On 05/25/23 at 3:28 P.M. interview with ADON #120 revealed in the facility paper weight book, if a resident's name was highlighted yellow that indicated the resident required weekly weights. The ADON revealed STNA staff were responsible to obtain the weights, however the STNA staff did not have access to record the weights in the electronic medical record (EMR) and would either document the weight on sticky note, scrap piece of paper, or a report sheet and then give it to the nurse working to chart the weight in the EMR. The papers (used by the STNAs to document the resident weights) were then shredded. On 05/25/23 at 3:09 P.M. interview with RN #136 revealed she could not remember what Resident #67's weights were as the STNA staff obtained the weights; however, she thought the resident's weights varied. The RN also noted STNA staff did not have access to the EMR to record the weights and the STNAs would give her weights usually documented on a sticky note and then she would document the weight in the EMR for the STNA. The RN confirmed she had documented Resident #67's weight on 05/11/23, however could not recall where she got the resident's weight to record in the EMR. On 05/25/23 at 3:12 P.M. interview with RD #198 confirmed the paper weight book did not have any documented weights for any residents residing on the 200, 300, 400 or 500 halls including Resident #67 for the week of 05/10/23. The RD confirmed she had documented in the EMR on 05/10/23 the resident weighed 112.5 pounds, however she was unable to recall where she got that weight from. RD #198 confirmed Resident #67 weights that were documented in the EMR on 05/10/23 and 05/11/23 were not documented in the paper weight book. The RD stated the paper weight book was for the RD to reference and the licensed nurse would document the weight in the paper weight book after notification was received from the STNA of the resident's weight. On 05/25/23 at 3:16 P.M. interview with STNA #161 revealed she did not recall what Resident #67's weights were, however she did recall weighing the resident using a weight chair and stated she believed the resident was a weekly weight. The STNA confirmed she didn't have access to enter weights in the EMR and stated she usually documented the weights on a shift report sheet and gave the weights to the nurses to be documented in the EMR. During the interview STNA #161 revealed Resident #67 was on a mechanical soft diet and would try to feed herself. STNA #161 recalled the family wanted the resident's diet upgraded to a regular diet due to the resident's poor intake. The STNA stated the resident's family would bring drinks and food in for Resident #67 even though she was on a fluid restriction and a mechanical soft diet. On 05/30/23 at 12:37 P.M. and 1:24 P.M. interview with Hospital Coordinator [TRUNCATED]

Based on record review, hospital record review, interview and policy review the facility failed to ensure timely physician notification related to mouth pain/thrush, lethargy and decreased meal and fluid intakes. This affected one resident (Resident #67) of three resident reviewed for change in condition. The census was 66. Findings include: Review of Resident #67's hospital records (prior to facility admission) dated 04/19/23 to 04/24/23 revealed the resident had a history of severe protein calorie malnutrition and had acute on chronic renal failure related to poor intake. Review of the hospital discharge summary plan dated, 04/24/23 revealed the resident had an echocardiogram (a scan used to look at the heart and near-by blood vessels) during her hospitalization that showed a grade one diastolic dysfunction (heart cannot fully fill during the diastolic part of the heartbeat). The resident's discharge orders revealed the resident required a cardiac 1500 milliliter (ml) fluid restriction daily (used to avoid overloading your heart if you have heart failure as more fluid in your bloodstream makes it harder for your heart to pump) and a minced moisture texture diet. Hospital discharge documentation noted the resident's stay was expected to be less 30-days at the skilled nursing facility. Closed record review revealed Resident #67 was admitted to the facility on [DATE] and discharged to the hospital on 05/14/23. The resident's diagnoses included orthopedic aftercare due to a displaced intertrochanter fracture of the left femur, type two diabetes, muscle weakness, dysphagia (difficulty swallowing), heart disease, stage three chronic kidney disease, hypertension, falls and ectopic kidney (a kidney located below, above or on the opposite side of the kidney's normal position in the urinary tract). Record review revealed an admission order, dated 04/24/23 for a no added salt (NAS) mechanical soft diet. On 04/25/23 the resident's diet was upgraded to a regular texture diet; however this was not communicated to the dietary department and the resident never received the upgraded diet while in the facility. Review of Resident #67's fluid restriction worksheet and physician's orders, dated 04/25/23 revealed the resident was not to exceed a total daily fluid intake of 1500 milliliters (ml); 720 ml dietary and 780 ml nursing. The worksheet noted one cup of 240 ml of fluids on each meal tray. Record review revealed a plan of care, dated 04/26/23 related to altered health maintenance due to progress physical and mental status. Interventions included to monitor for signs and symptoms of cardiac distress and report to the cardiac and vascular doctor if any weight gain/loss, edema, fatigue, chest pain, confusion, nausea, decreased urinary output, or increased laboratory testing (BUN/Creatine). Interventions also included to provide diet ordered; if less than 50% consumed offer supplements as ordered (the resident had no orders for nutritional supplements at this time). Stress the importance of good nutrition and how it promotes healing and increases resistance. Review of Resident #67's speech notes authored by Speech and Language Pathologist (SLP) #201 dated 04/26/23 revealed the resident ate slightly better after speech sat and ate their own individual items while the resident ate. The resident reported the food was bland, Mrs. Dash was used and the resident reported the food was better. Review of Resident #67's nutrition risk tool, dated 04/27/23 and authored by Registered Dietician (RD) #198 revealed the resident was at moderate risk for nutritional decline due to having a moderate decrease in food intake, no weight loss in three months, able to get out of bed/chair but does not go out, BMI 21 to less than 23, had suffered psychological stress or acute disease in the past three months, and no psychological problems. There were no guidelines to direct staff on how to proceed with a resident assessed with nutritional risks. Review of Resident #67's dietary assessment, dated 04/27/23 and authored by RD #198 revealed the resident was hospitalized for an intertrochanter fracture and had undergone surgery (gamma nailing) on 04/20/23 (during the resident's hospitalization ). The resident lived at home (prior to the hospitalization ), and family had provided her with breakfast and dinner. The resident reported she would often forget to eat lunch due to being home alone. The resident reported she had recently started drinking Boost (a nutritional supplement) once daily due to weight loss and lack of intake. The assessment noted, a no added salt (NAS) with thin liquids and regular textured solids diet. Documentation indicated the resident was consuming 25-50% of meal trays. The dietary note indicated the RD would order a house supplement, 120 milliliters (ml) twice daily to provide an additional 240 calories and 20 grams of protein. The dietary assessment also reflected the resident had a deep tissue injury (pressure ulcer) to the coccyx per a skin grid assessment completed on 04/25/23. Resident #67 was noted to be at risk for decline in nutritional status per the Nutrition Risk Tool with a score of 9 (moderate risk for nutritional decline). The resident had nutritional diagnoses including malnutrition, chronic illness, severe muscle/fat loss, weight loss, and suboptimal intakes. Nutritional interventions included to discuss the importance of adequate nutrition to help aid in wound healing, encourage adequate calories, protein, nutrition supplements, and micronutrients to help in wound healing, encourage oral intake with at least 50% consumption at mealtimes, encourage snacking frequently between meals, and encourage compliance with fluid restrictions. Nutrition monitoring and evaluation included monitoring weights via weight report (paper weight book), monitor intakes, and skin integrity. The nutrition goals included the resident would consume at least 50% of meals, snack once daily, and consume Prostat (supplement) 30 ml daily with 100% consumption and house supplement 120 ml twice daily with 100% consumption. Review of Resident #67's paper medical record and electronic medical record (EMR) revealed no evidence a house supplement was ordered or administered to Resident #67 during the residents stay. Review of Resident #67's admission Minimum Data Set (MDS) 3.0 assessment, dated 05/01/23 revealed the resident had severe cognitive impairment with a Brief Interview for Mental Status of three out of 15. The assessment revealed the resident required extensive assistance from two staff for bed mobility, transfers and toilet use, extensive assistance from one staff for dressing, supervision from staff for eating, and limited assistance from one staff for personal hygiene. The resident had no impairment to the upper or lower body and used a walker. The MDS assessment revealed the resident was at risk for pressure ulcer development and had one unstageable deep tissue injury on admission located on the coccyx. On 05/04/23 a speech note authored by Speech Therapist (SLP) #201 indicated the resident remarked that it hurt to eat. Speech therapy noted something that appeared ulcer-like and hurt whenever even light pressure was applied (to the resident's mouth). The note indicated the nurse was made aware and was going to have the physician look at it first before making a referral to the dentist. On 05/05/23 a speech note authored by SLP #201 indicated the resident was still complaining of her mouth hurting when eating. The note indicated nursing was aware and would have the physician look at it when he comes in. Review of Resident #67's therapy note dated 05/08/23 and authored by SLP #201, revealed ST #201 called Resident #67's family (Family Member #199) regarding the resident's diet order. Resident #67's diet was a regular diet, however the diet slip on the meal tray had not been updated. The diet slip was now updated, and the family was notified the resident would receive the correct diet. On 05/09/23 a speech note authored by SLP #201 indicated the resident had complaints of mouth pain when eating. Nursing and physician aware. The speech note did not indicate who notified the physician. Review of Resident #67's (nursing) progress notes dated 04/25/23 to 05/09/23 revealed no documented assessment or evidence of the resident's reported complaints of mouth pain. Review of a progress note dated 05/10/23 at 11:10 P.M. and authored by ADON #120 revealed the Resident #67 was complaining of sores in (her) mouth and mouth pain. The resident was noted to have inflamed gums and few white patches/sores noted. The physician was notified and ordered Clotrimazole (antifungal) lozenges for 14 days due to thrush (yeast infection in the mouth). Review of Resident #67's physician progress notes revealed no evidence the resident was assessed/seen by a physician and/or other designated healthcare provider on behalf of the physician during the resident's stay, with the exception of 04/25/23 when a history and physical was completed. Review of Resident #67's meal intake records, documented by STNA staff assigned to provide care to the resident reflected the resident had decreased intake during her stay. On 04/25/23 breakfast and lunch intakes were 1-25% and dinner 50%. On 04/26/23 breakfast and dinner intakes were 75% and lunch was 25%. On 04/27/23 breakfast intake was 75% and lunch and dinner intakes were 50%. On 04/28/23 breakfast intake was 75%, lunch 100%, and dinner was 50%. On 04/29/23 and 04/30/23 all three meals the resident had 75% intake. On 05/01/23 the resident refused breakfast, lunch intake was 25% and dinner intake was 50%. On 05/02/23 breakfast and lunch intakes were 50% and dinner was 75%. On 05/03/23 breakfast intake was 1-25%, lunch intake was 50%, and dinner intake was 25%. On 05/04/23 breakfast and dinner intakes were 50% and lunch was 25%. On 05/05/23 breakfast and dinner intakes were 25% and lunch was 75%. On 05/06/23 breakfast intake was 25% and lunch and dinner intakes were 50%. On 05/07/23 breakfast intake was 75%, lunch was 1-25%, and dinner was 25%. On 05/08/23 breakfast and dinner intakes were 25% and lunch was 50%. On 05/09/23 only two meal intakes were recorded. The breakfast meal intake was 25%, lunch was 50%, and there was no documented intake for dinner. On 05/10/23 breakfast and dinner intakes were 1-25% and lunch was 75%. On 05/11/23 breakfast intake was 75% and lunch and dinner were refused. There were no meal intakes recorded for 05/12/23. On 05/13/23 breakfast was 1-25% and lunch and dinner were 25%. On 05/14/23 the resident did not have any breakfast. Review of Resident #67's paper and EMR revealed no evidence the resident received an alternative when consuming less than 50% of her meals. Review of Resident #67's treatment administration records dated 05/01/23 to 05/13/23 revealed the resident's 24-hour fluid intakes were documented to range from 360 ml to 600 ml during this time period. Review of Resident #67's occupational therapy note dated 05/12/23 at 1:44 P.M. revealed Certified Occupational Therapy Assistant (COTA) #203 was not able to keep the resident's attention to task due to the resident falling asleep and confusion. COTA #203 took the resident to nurse's station completing communication with nursing pertaining to resident status. The resident was not unable to participate in therapy session this date secondary to mental status and lethargy. The note indicated nursing was looking into a possible urinary tract infection (UTI). Review of Resident #67's nursing progress notes, dated 05/12/23 through 05/13/23 revealed no evidence the physician was notified of the resident's change in condition reported by COTA #203. Review of Resident #67's health status progress note, dated 05/14/23 at 11:58 A.M. and authored by LPN #174 revealed the resident was in the dining room with family for lunch and not acting like herself. She had increased confusion, lethargy, and low blood pressure (91/64). The family requested the resident to be sent to the ER for evaluation where she was admitted . Review of the fire department patient care record form for Resident #67, dated 05/14/23 revealed the fire department arrived (on 05/14/23) to the facility at 12:02 P.M., arrived at the resident's bedside at 12:03 P.M., departed the facility at 12:16 P.M., arrived at the (hospital) destination at 12:22 P.M., and transferred the resident at 12:25 P.M. The call from the facility was for an [AGE] year-old requiring transport to hospital. Upon arrival, fire department staff found a patient sitting in a chair with her family. The family stated she was not acting like herself. The patient did answer several of the questions asked of her but not all. The patient was complaining about her (bake?) being sore. Checked vitals while sitting and family stated the last time the resident was known to be feeling well was last Friday. The resident's vital signs were obtained which showed a blood pressure of 84/56 (hypotensive), pulse 90 (tachycardic) per minute, respirations 16 per minute, and pulse ox (oxygen saturation) of 96%. Review of Resident #67's hospital emergency room documentation dated 05/14/23 from 1:35 P.M. to 2:52 P.M. revealed the resident presented to the emergency room with complaints of altered mental status. The patient was sent from nursing home for lethargy. The resident's daughter was at bedside to assist with the history as patient did not answer questions. Family stated the patient was normally verbal and could walk; however noticed today she was just lying in bed and staring up. Patient would occasionally complain of having left hip pain. History was limited secondary to patient not answering questions. The resident's general appearance was chronically ill appearing, cachectic (a general state of ill health involving marked weight loss and muscle tone) and appeared very dehydrated on exam. The patient's mucus membranes were dry. The resident had a Grade 2 pressure ulcer over the sacrum; her skin was warm and dry with poor skin turgor. The patient would respond to painful stimuli but not verbal stimuli, would move all four extremities if agitated. The resident's blood pressure initially was hypotensive with a pressure of 70/30 (normal 120/80). The ER gave patient a fluid bolus to determine if her (blood) pressure was responsive. The patient does have a history of congestive heart failure, but it was felt the patient needed the intravenous fluids to tolerate the prescribed intravenous fluid orders. The patient was very thin and required the physician's vigilant attention to prevent deterioration (sepsis, hypotension). Review of the hospital admission notes, dated 05/14/23 revealed the resident was admitted to the hospital with diagnoses including toxic metabolic encephalopathy related to acute kidney injury, sepsis, urinary tract infection likely due to poor oral intakes and severe protein calorie malnutrition with temporal wasting, rib exposure with a body mass index under 19, and a Stage II pressure ulcer to the left buttocks. On 05/24/23 at 10:32 A.M. interview with Regional Registered Dietitian (RRD) #197 verified Resident #67's diet was upgraded on 04/25/23 to a regular texture diet from a mechanical soft diet, however the dietary department never received the order or communication form. The only order/communication form the dietary department had received was the admission order for the mechanical soft textured diet. On 05/24/23 at 11:30 A.M. interview with ADON #120 revealed there was no documentation assessing the resident on 05/12/23 or 05/13/23. The ADON revealed the resident was skilled and should have had documentation completed at least once a day. ADON #120 revealed the resident was ordered a COVID test, laboratory testing including a Complete Blood Count (CBC) and Basic Metabolic Profile (BMP) on 05/11/23 without any indication or documentation why it was ordered. The resident was also ordered a chest x-ray on 05/11/23 that indicated possible fluid overload, however there was no documentation to support the order or assessment of the resident after receiving the x-ray results. ADON #120 revealed she did not believe Resident #67 had a change of condition on 05/12/23 or 05/13/23; however there was no documented evidence to support the resident's condition except a phone interview that was completed on 05/24/23 by ADON #120, with LPN #174 and after the above concerns that had been identified by the State survey agency. On 05/24/23 at 12:33 P.M. interview with Resident #67's family, Family Member #199 revealed she rode in the squad on 05/14/23 to the emergency room (ER) with Resident #67. The family member stated when the squad transferred Resident #67 to the bed in the emergency room the emergency room (ER) nurse looked at Resident #67's skin and reported the resident had a bad pressure ulcer on her buttocks. During this interview and a subsequent interview on 05/31/23 at 2:19 P.M. Family Member #199 reported she had visited the resident in the facility on 05/12/23. On 05/14/23 when visiting, the family member felt the resident was confused and lethargic and asked the nurse to assess the resident. The resident's blood pressure was low, and she had asked the nurse to transfer the resident to the emergency room . The facility nurse reported to her (Family Member #199) and the ambulance driver Resident 67's had been like this for three days and had not eaten or consumed fluids. Family Member #199 revealed the facility had reported to them the resident's weight was 113 pounds but in the emergency room , the family was told the resident weighed 85 pounds. The family member denied the resident or herself reporting the resident weighed 85 pounds to hospital staff. Family Member #199 reported the family didn't understand why the resident was on fluid restriction because she had not been on a fluid restriction or special diet when she was in the hospital (prior to the nursing home admission). The family member also indicated the resident would not eat the mechanically altered diet provided by the facility. After being treated in the hospital, the resident was discharged to a different skilled nursing facility in the area and had done a complete 180 degree turn around (improvement). Family Member #199 revealed she had shown co-workers pictures of the resident while she was at the facility compared to the current skilled nursing facility and they couldn't believe the improvement. The resident had gained weight and was able to use Facetime and communicate with family. The resident reported to family that facility staff never checked on her, which she felt was accurate as when family visited no staff ever came in to check on the resident. On 05/24/23 at 1:16 P.M. interview with STNA #124, STNA #188, and LPN #153 with RRD #197 revealed the STNA staff reported they did not include fluids as part of their meal intake documentation. The LPN reported she only documented on the treatment administration record (TAR) the fluids nursing staff administered. The STNA and LPN confirmed they do not calculate or document the fluids dietary provided. RRD #197 reported she was not aware staff were not monitoring or documenting the fluids dietary was providing on the meal trays. She thought 25% of the meal intakes staff were recording under the task tab in the EMR include fluids provided at mealtime. The RRD reported all residents, no matter the diagnosis, should have fluid monitoring. Nutritional intakes were more important than solid intakes. During the interview, RRD #197 verified Resident #67 was not receiving adequate fluids while in the facility especially given the admitting diagnosis to the hospital on 05/14/23. On 05/24/23 at 3:30 P.M. interview with the Administrator confirmed the RD had ordered a house supplement, 120 ml twice daily on 04/27/23, however the order was never implemented, and the resident did not receive the supplement. On 05/25/23 at 11:36 A.M. interview with COTA #203 revealed Resident #67 was more confused and lethargic (on 05/12/23) so she took the resident back to the nurse's station to report the change of condition to the nurse. COTA #203 stated the nurse thought the resident had a urinary tract infection (UTI). On 05/25/23 at 12:45 P.M. interview with STNA #114 revealed she provided care to Resident #67 during the resident's stay. STNA #114 revealed the resident was confused but could let you know her needs. The resident would ask for fluids; however, since she was on a fluid restriction the nurses would have to provide fluids to the resident. STNA #114 revealed STNA staff did not monitor or document resident fluids intakes. The STNA indicated the resident was a tiny bony lady and required encouragement to eat, drink, and even to get out of bed. On 05/25/23 at 1:36 P.M. interview with Resident #67's primary care physician, who was also the facility medical director, Medical Director #196 revealed he was not aware of the nutritional concerns with Resident #67 including the failure to provide nutritional supplements, the lack of nutritional support with the resident being admitted to the facility with a pressure ulcer as well as developing a pressure ulcer during her stay, the resident's decreased meal intakes and fluid intakes, the facility not providing the resident the correct diet, the presence of thrush for several days before it was reported or the resident's condition change over the last few days of her stay until the time of this interview. The MD reported he was the only provider for the facility and he should be notified with changes in the resident's condition. On 05/25/23 at 3:16 P.M. interview with STNA #161 revealed Resident #67 was on a mechanical soft diet and would try to feed herself. STNA #161 recalled the family wanted the resident's diet upgraded to a regular diet due to the resident's poor intake. The STNA stated the resident's family would bring drinks and food in for Resident #67 even though she was on a fluid restriction and a mechanical soft diet. On 05/31/23 at 9:30 A.M. interview with Dietary Manger (DM) #104 confirmed Resident #67 never received the ordered upgrade to a regular diet because the order and/or communication form (used to notify dietary of orders or changes) was never sent to the dietary department. DM #104 verified the only written communication received about Resident #67's diet orders was on admission that indicated the resident required a mechanical soft diet. On 05/31/23 at 10:09 A.M. interview with Manger of Clinical Service #195 confirmed the physician had only seen Resident #67 once during her stay at the facility and that was on 04/25/23 when he performed the resident's history of physical. This deficiency represents non-compliance investigated under Complaint Number OH00142901.

Based on closed record review, review of hospital records, review of therapy notes, review of staff telephone statements, and interviews the facility failed to ensure pressure ulcers were timely identified. This affected one resident (Resident #67) of three residents reviewed for pressure ulcers. The census was 66. Findings included: Closed record review revealed Resident #67 was admitted to the facility on [DATE] and discharged to the hospital on 05/14/23. The resident's diagnoses included orthopedic aftercare due to a displaced intertrochanter fracture of the left femur, type two diabetes, muscle weakness, dysphagia (difficulty swallowing), heart disease, stage three chronic kidney disease, hypertension, falls and ectopic kidney (a kidney located below, above or on the opposite side of the kidney's normal position in the urinary tract). Review of Resident #67's admission assessment dated [DATE] revealed the resident had several surgical wounds, abrasion to left inner thigh, moisture associated skin damage to the buttocks, and a deep tissue pressure injury (DTPI) area (intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister) to the coccyx measuring 4.9 centimeter (cm) by 6.4 cm by unable to determine (UTD). The DTPI area to the coccyx was red to purple non-blanching area with peeling tissue, no drainage, peri wound appears normal and a skin tear to left elbow. Review of Resident #67 pressure ulcer assessment completed on 04/24/23 revealed the resident was at risk for pressure ulcer development. Review of Resident #67's alteration of skin integrity plan of care dated 04/26/23 revealed check body weekly and to notify physician and family of changes as needed. Review of Resident #67's coccyx pressure ulcer assessment completed on 05/02/23 indicated the resident had a DTPI to the coccyx had resolved. Review of Resident #67's paper record and EMR revealed no evidence of skin alteration to buttocks/coccyx or treatment to buttocks/coccyx from 05/02/23 through 05/14/23. Review of Resident #67's medication and treatment records dated 05/08/23 revealed a weekly skin assessment was completed, however there was no indication of the findings of the skin assessment. Review of Resident #67's physical therapy notes authored by Physical Therapist (PT) #204 and Physical Therapy Assistant (PTA) #205 dated 05/09/23, 05/10/23, 05/11/23, and 05/12/23 revealed the resident had reported pain and a sore on buttocks. Review of Resident #67's paper record and EMR revealed no evidence Resident #67's complaints of pain and sore buttocks that were reported to therapy 05/09/23, 05/10/23, 05/11/23, and 05/12/23 , by Resident #67, had been assessed by nursing. Review of Resident #67's shower sheet dated 05/13/23 revealed the resident had no areas and the skin was intact, however review of Resident #67's skin assessment completed on 05/10/23 indicated there was skin tear to the right elbow and surgical incision to the left lateral thigh. There was no evidence that the right elbow or left lateral thigh skin alterations had resolved. Review of the fire department patient care record form for Resident #67 dated 05/14/23 revealed the fire department arrived at the facility at 12:02 P.M., arrived to the resident at 12:03 P.M., departed the facility at 12:16 P.M., arrived at destination at 12:22 P.M., and transferred resident at 12:25 P.M. (to the ER bed). Time elapsed from pick up to transfer to ER care was 23 minutes. Review of Resident hospital notes dated 05/14/23 revealed the resident had a Stage II pressure ulcer on the buttocks upon arrival to the emergency room . Review of two handwritten unsigned statements dated 05/24/23 revealed STNA #174 was interviewed via phone on 05/24/23 by ADON #191 and reported the resident had no open areas on her body on Sunday 05/14/23. The second statement was LPN #151 revealed the resident had no pressure areas to coccyx on 05/14/23 and a patch was used for comfort. The statements were not part of the resident's medical record and none of the documentation in the medical record supported the use of a patch for comfort or the area had been observed/assessed by the nurse. Interview on 05/24/23 at 12:33 P.M., with Resident #67's family member #199 revealed she rode in the squad on 05/14/23 to the emergency room (ER) with Resident #67. When the squad transferred Resident #67 to the bed in the emergency room the ER nurse looked at Resident #67's skin and reported she had a bad pressure ulcer on her buttocks. The family member denied the resident waiting to be assessed/treated once she arrived in the emergency room and was assisted from the transport cot to the ER bed upon the resident's arrival to the ER. The nurse assisted with moving the resident from the transport cot to the ER bed and identified the resident's pressure ulcer at that time. Interview on 05/24/23 at 12:36 P.M with the ADON #120 and ADON #191 confirmed the resident had two documented skin (right elbow and left lateral thigh) alterations on 05/13/23 confirming the shower sheet dated 05/13/23 was inaccurate as skin alterations present had not been identified on the document. Interview on 05/25/23 at 12:30 P.M., with Physical Therapist (PT) #204 revealed the resident was a skinny little thing. He did not visualize Resident #67's buttocks, but the resident had reported it was sore. The resident spent most of her time in bed. Interview on 05/25/23 at 12:51 P.M., with Physical Therapy Assistant (PTA) #205 revealed she had never visualized Resident #67's buttocks, however the resident reported she had a bedsore and complained of pain and this information was reported to the nursing staff as well as documented in the therapy notes. Attempts to reach LPN #174 and STNA #151 were unsuccessful. Messages were left for the staff to return the call however, no return call was provided. This deficiency represent non-compliance investigated under Complaint Number OH00142901.

Based on record review and interview the facility failed to timely identify and treat a urinary tract infection for Resident #67. This affected one resident (#67) of four sampled residents. Findings include: Closed record review revealed Resident #67 was admitted to the facility on [DATE] and discharged to the hospital on 05/14/23. The resident's diagnoses included orthopedic aftercare due to a displaced intertrochanter fracture of the left femur, type two diabetes, muscle weakness, dysphagia (difficulty swallowing), heart disease, stage three chronic kidney disease, hypertension, falls and ectopic kidney (a kidney located below, above or on the opposite side of the kidney's normal position in the urinary tract). Review of the resident's hospital records (prior to facility admission) dated 04/19/23 to 04/24/23 revealed the resident had a history of severe protein calorie malnutrition and had acute on chronic renal failure related to poor intake. Review of Resident #67's fluid restriction worksheet and physician's orders, dated 04/25/23 revealed the resident was not to exceed a total daily fluid intake of 1500 milliliters (ml); 720 ml dietary and 780 ml nursing. The worksheet noted one cup of 240 ml of fluids on each meal tray. Record review revealed a plan of care, dated 04/26/23 related to altered health maintenance due to progress physical and mental status. Interventions included to monitor for signs and symptoms of cardiac distress and report to the cardiac and vascular doctor if any weight gain/loss, edema, fatigue, chest pain, confusion, nausea, decreased urinary output, or increased laboratory testing (BUN/Creatine). Review of Resident #67's admission Minimum Data Set (MDS) 3.0 assessment, dated 05/01/23 revealed the resident had severe cognitive impairment with a Brief Interview for Mental Status of three out of 15. The assessment revealed the resident required extensive assistance from two staff for bed mobility, transfers and toilet use, extensive assistance from one staff for dressing, supervision from staff for eating, and limited assistance from one staff for personal hygiene. The resident had no impairment to the upper or lower body and used a walker. The MDS assessment revealed Resident #67 was 61 inches in height and weighed 113 pounds; had no swallowing issues, weight loss, or dental problems. The resident was at risk for pressure ulcer development and had one unstageable deep tissue injury on admission located on the coccyx. Review of Resident #67's physician progress notes revealed no evidence the resident was assessed/seen by a physician and/or other designated healthcare provider on behalf of the physician during the resident's stay, with the exception of 04/25/23 when a history and physical was completed. Review of Resident #67's treatment administration records dated 05/01/23 to 05/13/23 revealed the resident's 24-hour fluid intakes were documented to range from 360 ml to 600 ml during this time period. Review of Resident #67's occupational therapy note dated 05/12/23 at 1:44 P.M. revealed Certified Occupational Therapy Assistant (COTA) #203 was not able to keep the resident's attention to task due to the resident falling asleep and confusion. COTA #203 took the resident to nurse's station completing communication with nursing pertaining to resident status. The resident was not unable to participate in therapy session this date secondary to mental status and lethargy. The note indicated nursing was looking into a possible urinary tract infection (UTI). Record review revealed no evidence of any assessment or additional follow up on 05/12/23 related to the resident possibly having a urinary tract infection. Review of Resident #67's nursing progress notes, dated 05/12/23 through 05/13/23 revealed no evidence the physician was notified of the resident's change in condition reported by COTA #203. Review of Resident #67's health status progress note, dated 05/14/23 at 11:58 A.M. and authored by LPN #151 revealed the resident was in the dining room with family for lunch and not acting like herself. She had increased confusion, lethargy, and low blood pressure (91/64). The family requested the resident to be sent to the ER for evaluation where she was admitted . Review of the fire department patient care record form for Resident #67, dated 05/14/23 revealed the fire department arrived (on 05/14/23) to the facility at 12:02 P.M., arrived at the resident's bedside at 12:03 P.M., departed the facility at 12:16 P.M., arrived at the (hospital) destination at 12:22 P.M., and transferred the resident at 12:25 P.M. The call from the facility was for an [AGE] year-old requiring transport to hospital. Upon arrival, fire department staff found a patient sitting in a chair with her family. The family stated she was not acting like herself. The patient did answer several of the questions asked of her but not all. The patient was complaining about her (bake?) being sore. Checked vitals while sitting and family stated the last time the resident was known to be feeling well was last Friday. The resident's vital signs were obtained which showed a blood pressure of 84/56 (hypotensive), pulse 90 (tachycardic) per minute, respirations 16 per minute, and pulse ox (oxygen saturation) of 96%. Review of Resident #67's hospital emergency room documentation dated 05/14/23 from 1:35 P.M. to 2:52 P.M. revealed the resident presented to the emergency room with complaints of altered mental status. The patient was sent from nursing home for lethargy. The resident's daughter was at bedside to assist with the history as patient did not answer questions. Family stated the patient was normally verbal and could walk; however noticed today she was just lying in bed and staring up. Patient would occasionally complain of having left hip pain. History was limited secondary to patient not answering questions. The resident's general appearance was chronically ill appearing, cachectic (a general state of ill health involving marked weight loss and muscle tone) and appeared very dehydrated on exam. The patient's mucus membranes were dry. The resident had a Grade 2 pressure ulcer over the sacrum; her skin was warm and dry with poor skin turgor. The patient would respond to painful stimuli but not verbal stimuli, would move all four extremities if agitated. The resident's blood pressure initially was hypotensive with a pressure of 70/30 (normal 120/80). The ER gave patient a fluid bolus to determine if her (blood) pressure was responsive. The patient does have a history of congestive heart failure, but it was felt the patient needed the intravenous fluids to tolerate the prescribed intravenous fluid orders. The patient was very thin and required the physician's vigilant attention to prevent deterioration (sepsis, hypotension). Review of the hospital admission notes, dated 05/14/23 revealed the resident was admitted to the hospital with diagnoses including toxic metabolic encephalopathy related to acute kidney injury, sepsis, urinary tract infection likely due to poor oral intakes and severe protein calorie malnutrition with temporal wasting, rib exposure with a body mass index under 19, and a Stage II pressure ulcer to the left buttocks. On 05/24/23 at 11:30 A.M. interview with ADON #120 revealed there was no documentation assessing the resident on 05/12/23 or 05/13/23. The ADON revealed the resident was skilled and should have had documentation completed at least once a day. ADON #120 revealed the resident was ordered a COVID test, laboratory testing including a Complete Blood Count (CBC) and Basic Metabolic Profile (BMP) on 05/11/23 without any indication or documentation why it was ordered. The resident was also ordered a chest x-ray on 05/11/23 that indicated possible fluid overload, however there was no documentation to support the order or assessment of the resident after receiving the x-ray results. ADON #120 revealed she did not believe Resident #67 had a change of condition on 05/12/23 or 05/13/23; however there was no documented evidence to support the resident's condition except a phone interview that was completed on 05/24/23 with LPN #151 and after the above concerns that had been identified by the State survey agency. On 05/24/23 at 12:33 P.M. interview with Resident #67's family, Family Member #199 revealed she rode in the squad on 05/14/23 to the emergency room (ER) with Resident #67. The family member stated when the squad transferred Resident #67 to the bed in the emergency room the emergency room (ER) nurse looked at Resident #67's skin and reported the resident had a bad pressure ulcer on her buttocks. During this interview and a subsequent interview on 05/31/23 at 2:19 P.M. Family Member #199 reported she had visited the resident in the facility on 05/12/23. On 05/14/23 when visiting, the family member felt the resident was confused and lethargic and asked the nurse to assess the resident. The resident's blood pressure was low, and she had asked the nurse to transfer the resident to the emergency room . The facility nurse reported to her (Family Member #199) and the ambulance driver Resident 67's had been like this for three days and had not eaten or consumed fluids. On 05/24/23 at 1:16 P.M. interview with STNA #124, STNA #188, and LPN #153 with RRD #197 revealed the STNA staff reported they did not include fluids as part of their meal intake documentation. The LPN reported she only documented on the treatment administration record (TAR) the fluids nursing staff administered. The STNA and LPN confirmed they do not calculate or document the fluids dietary provided. RRD #197 reported she was not aware staff were not monitoring or documenting the fluids dietary was providing on the meal trays. She thought 25% of the meal intakes staff were recording under the task tab in the EMR include fluids provided at mealtime. The RRD reported all residents, no matter the diagnosis, should have fluid monitoring. Nutritional intakes were more important than solid intakes. During the interview, RRD #197 verified Resident #67 was not receiving adequate fluids while in the facility especially given the admitting diagnosis to the hospital on 05/14/23. On 05/25/23 at 11:36 A.M. interview with COTA #203 revealed Resident #67 was more confused and lethargic (on 05/12/23) so she took the resident back to the nurse's station to report the change of condition to the nurse. COTA #203 stated the nurse thought the resident had a urinary tract infection (UTI). The COTA was unable to recall who the nurse was she reported the resident's condition to. On 05/25/23 at 12:45 P.M. interview with STNA #114 revealed she provided care to Resident #67 during the resident's stay. STNA #114 revealed the resident was confused but could let you know her needs. The resident would ask for fluids; however, since she was on a fluid restriction the nurses would have to provide fluids to the resident. STNA #114 revealed STNA staff did not monitor or document resident fluids intakes. The STNA indicated the resident was a tiny bony lady and required encouragement to eat, drink, and even to get out of bed. On 05/25/23 at 1:36 P.M. interview with Resident #67's primary care physician, who was also the facility medical director, Medical Director #196 revealed he was not aware of the resident's condition change over the last few days of her stay until the time of this interview. On 05/31/23 at 10:09 A.M. interview with Manger of Clinical Service #195 confirmed the physician had only seen Resident #67 once during her stay at the facility and that was on 04/25/23 when he performed the resident's history of physical. This deficiency represents non-compliance investigated under Complaint Number OH00142901.

Based on medical record review, resident interview, staff interview, and facility policy review, the facility failed to adequately monitor resident nutritional status and health. This affected four (Residents #7, #39, #41, and #59) of five residents reviewed for nutrition. The census was 71. Findings Include: 1. Record review revealed Resident #7 was admitted to the facility on [DATE]. Her diagnoses were acute of chronic right heart failure, atrial fibrillation, generalized edema, low back pain, disorder of bone density, constipation, enterococcus as the cause of diseases, urinary tract infection, and hypertension. Review of her Minimum Data Set (MDS) assessment, dated 10/02/22, revealed she was cognitively intact. Review of Resident #7 weights revealed the following weights and dates in which significant change occurred: 08/08/22 (139.1 pounds), 09/01/22 (115.4 pounds), 10/02/22 (112.2 pounds), and 11/01/22 (121 pounds). Review of Resident #7 progress notes, dated 09/01/22 to 11/01/22, revealed no documentation to support the resident, resident's representative, not resident's physician were notified of the significant weight changes. Also, there was no documentation in the progress notes to support re-weights were taken to confirmed the significant weight change. Review of Resident #7 care plan, dated 09/01/22, revealed an intervention that meal substitutes are to be offered if the resident refuses her meal. Review of Resident #7 meal intake documentation, dated August 2022, September 2022, November 2022, December 2022, and January 2023, revealed a total of 66 meals that were either refused or not documented as being refused or consumed. There was no documentation to support these substitutes were offered as well. Interview with Licensed Practical Nurse (LPN) #178, LPN #203, and State tested Nurse Aide (STNA) #124 on 01/19/23 at 8:20 A.M., 8:27 A.M., and 8:40 A.M. stated the aides typically take the resident weights; but the nurses will help as well. They are to be done at least once a month. STNA #124 stated she is told by the nurses if there is a weight that is to be done daily or weekly, the morning of when it should be completed. They take a piece of paper around with them to get the weights, document on that paper, and then give the paper to the nurse to enter the weights into the electronic medical record (EMR). LPN #178 and LPN #203 confirmed the EMR will alert them if there is a significant weight change entered into the medical record. They will either tell the aide to retake the weight because of the significant change (on the same day the significant weight change is noted), or contact the dietitian/diet tech to inform them, and then take directive from them about the next steps. New weights will be added to the EMR when a re-weight is completed. If not in the medical records, no evidence it was completed. Interview with Dietary Tech (DT) #200 on 01/19/23 at 10:15 A.M. stated she will visit the facility once a week to review all significant weight changes and dietary concerns. She also confirmed she will review the EMR a few times a week to see if there are any significant changes that need addressed. She will also expect the nursing staff to call her with any significant changes, including significant weight changes. If they don't inform her (which she admitted the notifications to her from nursing staff could be better), she looks at the weights a couple times per week to determine if there are any concerns. She would expect to have a re-weight done within 24 hours, and then report back to her with that re-weight to verify it was accurate. She stated Resident #7 has congestive heart failure, so her weights can significantly change. She confirmed she would want to be notified of significant changes to her weight, due to her congestive heart failure. She confirmed there were no documented re-weights and should have been. 2. Record review revealed Resident #39 was admitted to the facility on [DATE]. Her diagnoses were atrial fibrillation, type II diabetes, obstructive and reflux uropathy, hypothyroidism, hyperlipidemia, osteoporosis, major depressive disorder, squamous cell carcinoma of skin, difficulty walking, osteoarthritis, and anxiety. Review of her MDS assessment, dated 10/05/22, revealed she had a mild cognitive impairment. Review of Resident #39 weights revealed the following weights and dates in which significant change occurred: 06/07/22 (149 pounds), 07/01/22 (136.6 pounds), and 08/02/22 (129 pounds). Review of Resident #39 progress notes, dated 07/01/22 to 08/04/22, revealed no documentation to support the resident, resident's representative, not resident's physician were notified of the significant weight changes. Also, there was no documentation in the progress notes to support re-weights were taken to confirm the significant weight change. Review of Resident #39 care plan, undated, revealed an intervention that meal substitutes are to be offered if the resident refuses her meal. Review of Resident #39 meal intake documentation, dated July 2022, September 2022, October 2022, November 2022, and December 2022, revealed a total of 69 meals that were either refused or not documented as being refused or consumed. There was no documentation to support these substitutes were offered as well. Interview with Dietary Tech (DT) #200 on 01/19/23 at 10:15 A.M. confirmed Resident #39 lost significant amounts of weight and no reweighs completed. She confirmed Resident #39 should have been re-weighed timely, and the significant changes should have been reported to her. 3. Record review revealed Resident #41 was admitted to the facility on [DATE]. His diagnoses were hemiplegia and hemiparesis, aphasia, chronic respiratory failure, pneumoconiosis, unspecified severe protein-calorie malnutrition, chronic embolism and thrombosis, epilepsy, atherosclerotic heart disease, peripheral vascular disease, contracture of right hand, squamous cell carcinoma, anxiety disorder, major depressive disorder, hyperlipidemia, and other chest pain. Review of his MDS assessment, dated 10/21/22, revealed he had a significant cognitive impairment. Review of Resident #41 weights revealed the following weights and dates in which significant change occurred: 07/01/22 (199 pounds), 08/02/22 (178.2 [pounds), 09/01/22 (188.6 pounds), 10/02/22 (188 pounds), 10/18/22 (200.4 pounds), 10/23/22 (191.3 pounds), 11/04/22 (177.8 pounds), and 11/10/22 (173 pounds). Review of Resident #41 progress notes, dated 07/01/22 to 11/30/22, revealed no documentation to support the resident, resident's representative, not resident's physician were notified of the significant weight changes. Also, there was no documentation in the progress notes to support re-weights were taken to confirm the significant weight change. Interview with Dietary Tech (DT) #200 on 01/19/23 at 10:15 A.M. confirmed Resident #41 lost significant amounts of weight and no reweighs completed in a timely manner. She confirmed Resident #41 should have been re-weighed timely, and the significant changes should have been reported to her. Interview on 01/19/23 at 3:13 P.M., with DT #200 and the Director of Nursing (DON) confirmed that re-weights should be taken within 24 hours of the significant weight being identified in the medical records. They both confirmed they do not have a significant weight change policy, including when to take re-weights. They both confirmed that meal substitutions and snack offerings should be documented in the medical records. They confirmed they could not find any for the above residents. Interview with DT #200 on 01/23/23 at 9:38 A.M. confirmed they do not have any re-weights for the residents. She also confirmed that the physician should be notified of significant weight change within 24 to 48 hours. All documentation should have a date as to when notifications were made, either on the weight log (hand written) or in the EMR. Review of facility Change of Condition policy, dated April 2013, revealed the unit supervisor or charge nurse will notify the resident, physician, and guardian/interested family member of all changes and of any other situations requiring notification. The person doing the notification may document all notification. 32801 4. Record review revealed Resident #59 was admitted to the facility on [DATE] with diagnoses including palliative care, diabetes, end stage renal disease, hypothyroidism, chronic obstructive pulmonary disorder, and disorder of lipoprotein metabolism. Interview on 01/17/23 at 9:25 A.M., with Resident #59 reported her weight loss was due to she doesn't like a lot of the food the facility serves. She doesn't like the smell of broccoli and cauliflower; however, the staff keeps putting it on her plate. Resident #59 reported she has told staff several times she did not like those items and they keep sending them on her meal tray. Review of Resident #59's diet history/food preference dated 09/24/22 revealed the resident was 63 inches tall, usual body weight was 165, weight was steady, and no issues with chewing or swallowing. She drank one Glucerna daily at home and disliked peas. The residents' likes were beef, chicken, and vegetables. The resident's breakfast preference were biscuits and gravy, scrambled eggs, toast, French toast, pancakes, bacon, potatoes, and orange juice. The information was provided by the resident. Review of Resident #59's meal tickets dated 01/19/23 revealed the resident's diet was regular, dislikes peas, likes were chicken, turkey, beef, and 2% of milk. For breakfast she likes fried eggs and gets a mighty shake for all three meals. Review of Resident #59's weights revealed on admission the resident weighed 166 pounds. On 10/02/22 Resident #59's weight was 148.4, which indicated a 17.6-pound weight loss. There was no evidence the resident was re-weighed to check the accuracy of the weight loss. On 11/08/22 Resident #59's weight was 149.3. There was no evidence the resident was weighed in December 2022. On 01/01/23 the resident weighed 138.8, which indicated a 10.5-pound weight loss from November. There was no evidence the resident was re-weighed to check the accuracy of the weight loss. The resident had a 27.2-pound weight loss from 09/24/22 to 01/01/23. Review of Resident #59's admission minimum date set (MDS) dated [DATE] and quarterly MDS dated [DATE] revealed the resident was set up for meals and ate independently, no swallowing disorders, and no significant weight loss noted. The 01/01/23 quarterly MDS indicated the resident was on a therapeutic diet. Review of Resident #59's dietary notes dated 10/13/22 revealed the resident's current weight was 148.4 pounds with a body mass index (BMI) of 26.4 indicating she was overweight. The resident had a 10.6 percent weight loss since 09/24/22. Her meal intakes ranging 0-100%. Recommend changing house supplements to 120 milliliter (ml) three times daily between meals to encourage better meal acceptance. Review of Resident #59's dietary note dated 01/02/23 revealed the resident's current weight was 138.8 and her BIM was 24.6. The resident had 16.4% weight loss in four months. Meal intakes are usually 25-50%. The resident was independent with meals. The resident was on a regular diet. Her diet liberalized at this time to offer more variety of food in diet. The resident is a high nutritional risk. Her needs are not being met as related to inadequate by mouth intakes. The resident was at risk for continued unavoidable significant weight loss and decline in nutritional status related to inadequate protein-energy intakes and limited food acceptance as evidence by poor to fair meal intakes. Recommend six ounces might shakes with meals to offer 600 calories and 18 grams of protein. Monitor weights, labs, by mouth intakes. The goal will remain comfortable and tolerate least restrictive diet consistency. Review of Resident #59's current orders dated 01/2023 revealed on 10/13/22 the physician ordered house supplements 120 ml three times daily between meals and on 01/03/23 mighty shakes with meal. There was no evidence of an order for weights. The resident was ordered a regular diet. Review of Resident #59's meal intakes dated 12/26/22 to 01/23/23 revealed the resident had refused 17 meals and the majority of the intakes were 1-50%. There was no evidence the resident was offered a substitute when she refused the meal. Review of Resident #59's potential for alternation in nutrition and hydration plan of care related to BMI (25-29.9 overweight status), hypertensive heart and chronic kidney disease without heart failure, stage five chronic kidney disease, type two diabetes, osteoarthritis, depression, gout, anxiety, depression, chronic obstructive pulmonary disease, and hospice palliative care. Intervention included the resident would remain comfortable and tolerate least restrictive diet consistency, coordinate care with hospice, honor food preferences as able, invite resident to foods related activities, monitor labs as ordered, offer meal substitutes when food are refused, provide meals and supplements as ordered, and weights as ordered. Review of Risk Assessment form titled Provider Services Nutrition Recommendation Physician Notification of Significant Weight Changes dated 10/19/22 revealed on 10/18/23 (future date that has not occurred yet) Resident #59's family was notified of weight change. The physician signed the notification form on 10/19/22 indicating the resident had a decrease of 10.6% since 09/24/22. Review of Risk Assessment form titled Provider Services Nutrition Recommendation Physician Notification of Significant Weight Changes dated 01/06/23 revealed on 01/06/23 the physician signed the notification form indicating the resident had a decrease of 16.4% since 09/24/22. Interview on 01/19/23 at 11:49 A.M. with Dietary Technician (DT) #200 , Dietician #201, and Dietary Manager (DM)#160 revealed the DM reported he had spoken to the resident two weeks ago and reviewed her preferences, however he did not document the interview because there was no changes. The DT #200 reported she had not spoken to the resident, however felt her assessment was sufficient without speaking to the resident to ask her input on her weight loss. The DT #200 reported she doesn't know if staff had re-weighed the resident with noted weight loss on 10/02/22 and 01/01/23 or if the resident was weighed in December. She only reviews the weights that are documented in the electronic medical record. The Dietician reported she believes the admission weight was inaccurate due to it was hard to believe the resident had lost that much weight in that short period of time. The Dietician reported the DT should speak to residents as part of her assessment. Interview on 01/19/23 at 11:58 A.M., with Hospice Aide #202 revealed the Resident #59 had voiced complaints of food all the time to her. She had reported the residents' concerns to the staff; however, food concerns were not addressed. Interview on 01/19/23 at 3:13 P.M., with DT #200 and the Director of Nursing (DON) revealed the resident weight was correct on admission. There was no evidence the resident was re-weighed within 24 hours for accuracy of weight loss on 10/02/22 or 01/01/23. There was no evidence the facility weighed the resident in December 2022. The DON reported hospice residents were weighed monthly. There was no evidence the physician or hospice was notified in the medical record, however the DON reported she may have evidence the physician was notified on her risk assessment documentation (not part of the medical record). The facility doesn't have a policy on weighing residents and the facility just follows best practice. Interview on 01/23/23 at 9:37 A.M., with DT #200 reported the physician should have been notified of Resident #59's weight loss in 24-48 hours. DT #200 reviewed the risk assessment forms, which are not part of the medical record, indicated the physician was not notified of the 17.6-pound weight loss on 10/02/22 until 10/19/22 and the additional 10.5-pound weight loss on 01/01/23 the physician was not notified until 01/06/23, which was not timely. There was no evidence the Resident was weighed in December 2022. DT #200 reported she had went and spoke to the Resident on 01/19/23 to update her preferences and the resident had told her she did not like broccoli, cauliflower, rice, green beans, and soups. The DT confirmed the new intervention for both noted weight loss was supplements (house and might shakes). The resident was receiving six supplements a day and when she spoke to the resident the resident wanted to continue the supplements due to, she liked them. The DT reported she was working remotely from another facility on 01/02/23 when she had completed the resident's assessment, however she was in the building on the 5th but did not interview the resident. The floor staff/DON should notify hospice of weight loss, however there was no documented evidence that hospice was notified, but hospice should be reviewing the residents record at least monthly. The facility called hospice to see if they had obtained weights, however it appears the weight information was obtained from the facilities records on 11/28/22. Review of the best practice for weight loss undated revealed significant weight loss or trending insidious with loss should be documented timely, within 7 days. Assess resident's ability to eat independently and adequacy of nutrient intake. Notify the physician for significant unplanned weight changes. Consider risk factors that may contribute to weight loss. Intervention was to utilize food first. Liberalized diet, fortified foods, choice of meals/snack, increase portion size of favorite food or consider small portions, restorative dining, increased assistance at meal, therapy and pharmacy consults, appetite stimulants, and nutritional supplementation between meals.

Based on record review, review of resident fund management services authorization agreement form, interviews, and policy review the facility failed to obtain written authorization to manage residents' funds. This affected two (Resident #33 and #35) of six residents reviewed for personal funds. Findings include: 1. Record review revealed Resident #33 was admitted to the facility on [DATE] with diagnoses including heart and kidney failure. Review of Resident #33's resident fund management services authorization agreement to handle funds undated revealed there was an X for the resident's signature. There were two witnesses, however, the witnesses were facility staff. Interview on 01/17/23 at 3:26 P.M. and 01/18/23 at 8:27 A.M., with the Business office Manager (BOM) #187 revealed the resident and his sister refused to sign the fund authorization form and she was afraid the resident would throw the checks in the trash, so she took his mail and deposited the checks into a personal funds account. The BOM #187 verified she did not have permission to open the resident's mail. The witnesses on the authorization forms were staff members and they did not witness the resident place the X in the resident signature place. BOM #187 had them sign the form not in the presence of the resident. The resident was not signing the checks, BOM #187 was using the facility's stamp to deposit the checks into the personal funds account with the bank. The BOM #187 reported last week the resident's family had gone off on her for taking the checks and depositing them into the personal funds account. The resident was wanting the checks deposited in his personal bank. BOM #187 told the resident's family that they would have to call each company to have the checks directly deposited into his personal account. Two days later the resident's family member came back to her office but she was on the phone. The sister waited a few minutes and then stormed off. Resident #33 was his own person. Interview on 01/18/23 at 1:25 PM with Resident #33 revealed he did not give the facility permission to open his mail. He knew the checks were to be delivered to the facility and he would not throw them away. He refused to sign the resident agreement form and they told him he did not have a choice and if he didn't sign, he would need to put an X on the form. He did not understand why they needed an X. He wanted his money directly deposited into his personal account not the facility's account. 2. Record review revealed Resident #35 was admitted to the facility on [DATE] with diagnoses of dementia, psychosis, mental disorder, depression, anxiety, and Alzheimer's disease. Review of Resident #35's resident fund statements dated 01/01/22 to 12/31/22 revealed the resident had an active account and the balances ranged from $3,588.38 to $5,468.71. Review of Resident #35's resident fund management services authorization agreement to handle funds dated 01/10/23 revealed there was an X for the resident's signature. The two witness signatures were staff members. There was no evidence an agreement was obtained prior to 01/10/23. Interview on 01/17/23 at 4:28 P.M., with the BOM #187 revealed there was not a resident fund management service authorization agreement obtained when Resident #35's account when it was open. Last week BOM #187 had the resident place an X on the agreement form, even though the resident had dementia and was not competent to sign the agreement. The two witnesses who signed the agreement on 01/10/23 were staff members of the facility. Review of the facility's policy titled Foundations Health Solution Policy and Procedure dated 12/10/21 revealed the nursing facility shall establish and maintain a system that ensures full, complete, and separate accounting of each resident's Personal Needs Allowance (PNA) account funds. All residents with trust funds must have a trust fund authorization before an account can be established. Authorizations must be kept in an orderly fashion for easy access and auditing purposes.