**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to maintain acceptable parameters of nutritional status and failed to provide nutritional interventions in a timely manner for 1 of 2 sampled residents reviewed for nutrition (Resident #23). The findings included: Review of the facility's policy titled, Weight Management, dated 06/2021, included the following: Residents will have their weight obtained on admission, re-admission and monthly or at a frequent determined by the interdisciplinary team or provider. Definitions: Significant weight change- As defined in RAI Manual is any unplanned weight change of 5% change over 1 month, 7.5% over 3 months or 10% change over the past 6 months. Procedure: 4.The case associate and or Medication Aide obtains the weight and documents the weight into Touchscreen and or in myUnity. 5. Once weights have been entered into the EMR (Electronic Medical Record), the licensed nurse reviews myUnity's Resident Weight Report/and or Weight Changes +Report for residents obtained on the last day of the Month for any of the following weight changes: a.5 percent (5%) change over 1 month b.7.5 percent (7.5%) change over 3 months or c. 10 percent (10%) change over the past 6 months. 7.When a significant weight change is identified the following will occur: a. PA/CS: The licensed nurse or designee notifies the Dietitian of any resident with a weight change of 5 pounds from the previous weight or a significant weight change. 11. Guest/residents with significant weight change should be discussed in High Risk Rounds/Utilization Review. 12. When a significant weight change is identified, the guest/resident plan of care will be reviewed, evaluated and revised, as applicable, to reflect interventions to support the guest/resident goals and preferences after medical consideration and interdisciplinary discussion. Record review for Resident #23 revealed that the resident was admitted to the facility on [DATE] with diagnoses to include: Alzheimer's Disease, Major Depressive Disorder, Atrial Fibrillation, and Dementia. Review of Section C of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #23 had a Brief Interview for Mental Status (BIMS) of 00, which indicated that he was severely cognitive impaired. Review of Section GG of the same MDS revealed Resident #23 was dependent on staff assistance for eating/nutrition and all his Activities of Daily Living (ADLs). In addition, review section O revealed Resident #23 was not on the Hospice care program. Review of the Physician's Orders showed Resident #23 had orders dated 10/24/24 for ascorbic acid (vitamin C) 500 mg tablet daily, Vitamin B-12 500 mcg tablet daily, diet: Pureed, Nectar Thick Liquid, continuous; Barrier Cream, apply barrier cream to buttocks 3 times daily and as needed. Review of the Physician's Orders showed Resident #23 had orders dated 12/03/24 for Calcium 600 + Minerals 600 mg (as carbonate) 200-unit tablet daily and on 12/30/24 for cholecalciferol (vitamin D3) 1,250 mcg (50,000 unit) tablet Every 1 Week. Review of the Holistic Care Plan dated 01/29/25 under Nutritional Status documented Resident #23 enjoys eating in the dining room and requires Puree diet with double portions. Care Plan approaches were to provide prescribed diet at every meal; honor food preferences as able; staff to assist with meals as needed; offer fluids throughout the day; encourage oral intake; weigh as prescribed and monitor weights. During an observation conducted on 04/15/25 at 12:09 PM Resident #23 was in the dining room, lunch tray was set on the table and the MDS coordinator assisted the resident, however, the consistency of the food was not pureed and was not the correct lunch tray for Resident #23. At 12:18 PM an observation of Resident 23's tray with correct consistency and appeared to have double portions. Resident #23 was observed opening his mouth wide and eating 100% of his lunch. At this time an interview was conducted with the MDS coordinator, who stated Resident #23 has a good appetite and eats 100% of his meals most of the time. During a second dining observation on 04/16/25 at 12:24 PM, Resident #23 was in the dining room for lunch and was assisted by a Certified Nursing Assistant (CNA) and was eating well. The meal ticket was reviewed and stated double portions. A review of Resident #23's weight log showed that the following weights were recorded: on 10/28/24 upon admission he was at 134.90 pounds, on 02/04/25 he was at 127.00 pounds (7.9 pounds weight loss), and on 04/01/25 he had an additional 6-pound weight loss. This showed a 10.30 percent weight loss from 10/28/24 to 04/01/25. During an interview conducted on 04/16/25 at 10:58 AM with Staff A, Licensed Practical Nurse (LPN), who stated she has worked at the facility for 4 years. She stated the facility does not have a restorative CNA and the CNA assigned to the resident would do the monthly weights. Staff A stated the CNA then would document the weights in the computer and the nurses and the dietitian have access to see the residents' weights. She also stated that weights are done monthly at the beginning of the month unless there's a physician's order for a specific timeline to obtain the resident's weight. Staff A stated she would report any weight changes to the Assisting Director of Nursing (ADON) and then the dietitian will come in and follow up with the resident. Record review of the dietitian nutrition note dated 10/29/24 showed Resident #23's Ideal Body Weight (IBW) was 69 kg (152.1 pounds) and current body weight (BW) was 61 kg (134.90 pounds) with recommendation to continue to follow up per protocol. At this time, no Body Mass Index (BMI) was calculated and no documentation that Resident #23 was at risk for weight loss. Record review of the dietitian nutrition follow up note dated 01/23/25 stated Resident #23 is tolerating puree diet well and staff has reported about 100 percent intake of meals. In addition, she reviewed the weights from 10/28/24 to 01/04/25, however, the dietitian only looked at the weight for 12/04/24 and 01/03/25 and noted Resident #23 has had a small weight decline (2.3 percent weight loss x 1 month), which is not significant. The interventions were to continue to monitor oral intake, body weight and skin integrity, with a goal for weight stabilization. Further review of the chart revealed no nutritional interventions or supplements were ordered at this time. Record review of the dietitian note dated 04/13/25 for Resident #23 evaluation due to recent weight loss of 3.4 percent in a month. She reviewed the last 3 months of Resident #23's weight history and noted the weight loss as not significant. She mentioned Resident #23 is currently on supplements including Vitamin E, Vitamin D3, Calcium with minerals, Vitamin C, and Vitamin B12. She also noted that Resident #23 is considered at risk for weight loss and overall decline due to current medical status. The interventions were to continue monitoring closely, weight trends, and skin integrity. No additional interventions were ordered to address the weight loss. In addition, the dietitian did not review the complete weight history (10/28/24 to 04/01/25). At this time Resident #23 had a weight loss trend of 13.9 pounds since admission which indicated a 10.30 percent weight loss from 10/28/24 to 04/01/25. An interview conducted on 04/16/25 at 12:35 PM with the General Manager for Dining, who stated staff members such as nursing, dietitian and even herself can add a food preference to the residents' chart. She stated these preferences are part of the meal ticket and printed on the Dining Details report daily. She reviewed Resident #23's preferences and noted the double portions preference was entered by the ADON on 11/12/24. During an interview conducted on 04/16/25 at 12:59 PM with the Clinical Dietitian, who stated she has been at the facility since September 2024 and works Part-time at least 20 hours a week. She stated she would receive an email with new admissions, and she usually completes the nutritional assessment within 3 days. For the Long-Term Care (LTC) residents, she conducts assessments quarterly, unless she is requested by family, or if the resident is losing weight. She noted that weight loss is considered if the resident has lost 5 percent in a month, 7.5 percent in 3 months and 10 percent in 6 months. She stated that during her assessments she utilizes her clinical knowledge, low BMI, any wounds the resident may have or if poor intake to assess the resident for risk of weight loss. She noted that a normal BMI is 18.5-25 and under 18.5 is considered excessive weight loss. She stated the facility does offer fortified foods, for breakfast is oatmeal, and the other meal is mashed potatoes to add more calories for the residents who are underweight. She then stated that the residents in this community are usually underweight. She also stated if a resident is losing weight, she would immediately put interventions in place such as Ensure or Glucerna (for diabetic residents) supplements, then fortified foods, the last resort is an appetite stimulant (with a physician's order) and continue evaluation. In addition, she stated she receives the monthly weight changes report via email. The report will include residents that are losing weight and percentage change in 30 days, 90 days and 180 days. At this time, the dietitian was asked to review Resident #23's weight history from admission date and was asked to calculate the weight loss and if it is significant. The dietitian stated, yes it looks significant, let me look at the weights again. She then stated, I missed that. I did not look back to 6 months, only until 02/01/25. She then stated that she was not aware Resident #23 was getting double portions for his meals. A side-by-side review of the clinical monthly weight changes report she received revealed that Resident #23 has a significant weight loss and again she stated, I missed that. Furthermore, the Clinical Dietitian also acknowledged that the current BMI for Resident #23 is 18.4 which indicates that Resident #23 is underweight by 0.1. An interview was conducted on 04/016/25 at 3:00 PM with the ADON and the Director of Nursing (DON). The ADON stated she spoke with Resident #23's son on 11/12/24 and she added double portions as preferences as per the son. In addition, the care plan would note this food preference change and the dietitian was notified. They both stated that the interdisciplinary team (ADON, DON, Social Services, MDS, Activity Manager) holds weekly high-risk rounds, the dietitian does not attend these meetings however, she receives email updates with the monthly weight changes report. ADON also stated that they identified a weight loss for Resident #23 and immediately notified the Clinical Dietitian by email on 04/08/25. Then the High-Risk meeting was conducted on 04/10/25. She acknowledged that the dietitian documentation was done on 04/14/25 and she did not address the significant weight loss. ADON also stated she is the one to update the care plans, however, the dietitian did not advise any recommendations for her to update the nutrition care plan. At this time both ADON and DON acknowledged all findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews, the facility failed to honor the resident's choice regarding the name that the resident preferred to be called by, as conveyed on the day of admission, and as documented in the resident's records, for 1 of 2 sampled residents (Resident #10), reviewed for choices. The findings included: A review of Resident #10's records revealed that the resident was admitted to the facility on [DATE] with diagnoses of Major depressive disorder, Dementia, unspecified severity with other behavior disorders, and Generalized anxiety disorder. Record review of Resident #10's care plan, dated 01/04/24, related to Engagement and Socialization, documented that the resident had a preferred first name that was different than her legal name. The care plan specified that the resident should be called by her preferred name. The preferred name was entered incorrectly on this care plan. Record review of Resident #10's Initial Physical Therapy Evaluation and Care Plan, dated 12/30/23, documented Resident #10's preferred name in the Precautions Section. An interview was conducted on 01/17/24 at 5:15 PM with Staff B, Certified Nursing Assistant (CNA), in D Hall. When asked what she called Resident #10, Staff B answered, I call her Ms. (legal first name). An observation on 01/18/24 at 9:39 AM revealed Resident #10 being assisted at the sink in her room by Staff G, Physical Therapy Assistant (PTA). While talking to Resident #10, Staff G consistently used the resident's legal first name instead of her preferred name. A phone call interview was conducted with the representative of Resident #10 on 01/19/24 at 10:05 AM. Resident #10's representative stated that, She's never been called (legal first name). Not even as a child. Resident #10's representative reported that on the day of admission she personally informed the facility's physician, the Director of Nursing (DON), the resident's CNA and the Director of Rehabilitation, that they should call Resident #10 (preferred name). She stated, I wanted them to know that it could help them in her care. The representative for Resident #10 also informed the interviewer that she wrote and placed the sign seen in Resident #10's room that says, Call Me (preferred name), on the day of admission. Photographic Evidence Obtained An interview was conducted on 01/19/24 at 10:28 AM, with Staff C, CNA, in Resident #10's room, regarding the sign beside the resident's bed with written instructions. The sign said, Call Me (preferred name). Staff C reported that, We use both names. Her daughter wrote that, because saying (preferred name) calms her. We use (preferred name) to calm her down. An interview was conducted on 01/19/24 at 10:34 AM, in the Rehabilitation Gym with Staff D, Certified Occupational Therapy Assistant (COTA). Staff D reported, She (Resident #10) prefers to be called by (preferred name) Staff D added that the preferred name was, .established in her initial evaluation. An observation on 01/19/24 at 10:45 AM in the dining room, revealed Resident #10 seated with a group led by Staff E, Activity Assistant. Staff E introduced Resident #10 by her surname, rather than her documented preferred name. An interview was conducted on 01/19/24 at 11:12 AM, in D Hall, with Staff F, Registered Nurse (RN). Staff F was asked how she called Resident #10. Staff F replied that she calls Resident #10, Miss (surname), or (nickname), which is the resident's legal first name shortened. An interview was conducted on 01/19/24 at 2:15 PM, in the Rehabilitation Gym with Staff G, PTA. When asked about Resident 10's name, Staff G reported that, Her preference is (preferred name), but I call her (legal first name). I forget. An observation on 01/19/24 at 2:24 PM revealed Staff E, Activity Assistant, entering Resident 10's room. Staff E knocked on Resident #10's door and said, Hi, Ms. (surname). During an interview with the Director of Nursing (DON) in the conference room, on 01/19/24 at 3:03 PM, the DON was asked how she called Resident #10. The DON replied, How do I refer to her? Ms. (surname)?

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the facility failed to ensure care and services for the prevention of Urinary Tract Infections (UTIs) or other complications for 3 of 3 sampled residents who had an indwelling urinary catheter. Nursing staff failed to maintain proper positioning and securing of the catheter tubing for Residents #24 and #45, and failed to educate Resident #38 of the risks of refusing to follow-up with a urology consult and discontinue use of the indwelling urinary catheter. The findings included: Review of the policy Urinary Catheters dated 06/2021 documented, Procedure: 1. Catheter Care . c. Use of proper infection control practices regarding hand washing, catheter care, tubing and the collection bag will be followed at all times. h. Maintain unobstructed urine flow. i. Catheter tubing, bag or spigot cannot touch the floor. 1) Review of the record revealed Resident #24 was admitted to the facility on [DATE] and was ordered an indwelling urinary catheter on 11/14/23 for urinary retention with obstruction. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 1, on a 0 to 15 scale, indicating the resident was severely cognitively impaired. This MDS also documented the resident was dependent upon staff for all Activities of Daily Living (ADLs). During an observation on 01/17/24 at 11:13 AM, the collection bag for the resident's indwelling urinary catheter was noted in a dignity bag hooked to the low bed, with the tubing lying directly on the floor. Sediment was noted in the tubing leading to the drainage bag (Photographic Evidence Obtained). Observation of the resident's thigh revealed the catheter was stretched tightly from the resident's adult brief. A second observation on 01/17/24 at 4:52 PM revealed the indwelling urinary catheter tubing directly on the floor again (Photographic Evidence Obtained). On 01/17/24 at 5:15 PM, Staff B, Certified Nursing Assistant (CNA), was asked about the tubing on the floor and agreed it should not be there. Upon further observation of the resident, the CNA identified an anchor on the innermost aspect of the resident's right thigh, but the catheter was not in the clamp of the anchor. The CNA confirmed the anchor was for the catheter tubing, but when the CNA placed the catheter into the clamp, she failed to do so at the Y connection (a place on the catheter for obtaining a urine sample and used for proper securing) that would keep the catheter from pulling. The CNA was asked if the catheter was secure, and the CNA demonstrated how it moved freely in the clamp on the anchor. At 5:33 PM, the Clinical Manager was asked to assist the CNA, and the catheter was properly placed into the anchor and urinary drainage bag was replaced. An observation of care for Resident #24 was made on 01/18/24 at 10:35 AM with Staff C, CNA, assisted by Staff A, CNA, for positioning of the resident. Proper indwelling catheter and peri-care (personal care) was observed. Upon completion of the care, the CNA covered the resident and stated she was done. The surveyor asked the CNA to observe the catheter at the anchor. When asked what was wrong, the CNA did not know. The catheter was hooked in the anchor in such a way that the catheter was kinked so that urine would not be able to flow freely into the collection bag. The indwelling catheter bag was noted on the floor. When asked what happened, the CNA stated it fell. When asked what she needed to do, the CNA stated she needed to clean it off. The Assistant Director of Nursing (ADON) was brought into the room and notified of the findings. The ADON provided education to the CNA, assisted the CNA on proper catheter positioning, and changed out the indwelling catheter collection bag. 2) Review of the record revealed Resident #45 was admitted to the facility on [DATE] and had an indwelling urinary catheter upon admission. The resident had the indwelling urinary catheter placed prior to admission for inability to void. Review of the current MDS assessment dated [DATE] documented the resident had a BIMS score of 15, on a 0 to 15 scale, indicating the resident was cognitively intact. This MDS also documented the use of an indwelling urinary catheter. A progress note dated 01/12/24 documented Resident #45 went to the urologist, who placed him on an antibiotic for three days. During an interview with Resident #45 on 01/16/24 at 3:34 PM, Staff B, CNA entered the resident's room and proceeded to empty the indwelling urinary catheter leg bag. The CNA donned gloves but failed to don a gown as per their Enhanced Barrier Precautions (EBP), utilized by the facility to protect the resident from infection. The catheter was not anchored in any way and was noted to be stretched tightly down the resident's leg. After the CNA left the room, when asked about the anchor, Resident #45 stated when he first got it (the catheter), they were careful about putting the tube in the anchor, but it comes out. A cloth/Velcro type anchor secure device was noted on the resident's thigh, but not being used. When asked if the urinary catheter was pulling, the resident stated, Now that you mention it . yes. When asked if staff routinely clean the catheter each shift or daily, the resident stated, sometimes they clean it, but would not specify. During an observation on 01/17/24 at 11:57 AM, Resident #45 had just returned from therapy. The resident's urinary catheter leg bag was noted, the tubing was not anchored, and the tubing was taunt (Photographic Evidence Obtained). The urinary catheter tubing was visible to all staff as the resident was wearing shorts. A washcloth was noted over the collection bag as per the resident's request, but part of the catheter was visible along with the unused anchor. On 01/18/24 at about 11:30 AM, the ADON was shown the photo of the lack of catheter anchor for Resident #45 and agreed with the concern. On 01/19/24 at 10:58 AM, when asked who was responsible for ensuring the urinary catheters were properly secured, the Clinical Manager stated it was the nursing teams responsibility, which included the CNAs, nurses, and managers. 3) During an interview on 01/16/24 at 10:51 AM, when asked why she had an urinary catheter, Resident #38 stated, I couldn't walk to the bathroom. They wanted to take it out last week, I think, but I told them no. Think I will ask them to take it out this week or next. When asked if she was aware of the risks of long-term catheter use, the resident stated she knew she could get an infection, but was unaware of any other risks such as difficulty returning back to a normal urinary function, damage to the bladder or urinary tract, or any other possible complication. Review of the record revealed Resident #38 was admitted to the facility on [DATE], transferred back to the hospital on [DATE] related to surgical complications, and returned to the facility on [DATE]. Review of the physician orders revealed an order dated 11/28/23 for a urology consult related to urinary retention. Further review of the record lacked any evidence of this consult. During an interview on 01/17/24 at 4:04 PM, Staff F, Registered Nurse (RN) and usual day shift direct care nurse for Resident #38, stated she was unaware of a urology consult. The Infection Preventionist (IP), who was at the nurses' station at the time of the interview, stated Resident #38 has canceled two urology appointments. When asked if they had attempted to discontinue the catheter, the IP stated they had, but was unable to locate any documentation in the medical record as to when and the outcome. When asked why Resident #38 still had the indwelling catheter, the IP stated, Because the resident chooses not to have the Foley cath (catheter) discontinued. The IP volunteered that at one point the urinary catheter came out, and when asked what happened, the IP stated the resident wanted it back, so they did, but again was unable to provide any supporting documentation of this or the urology consult. During an interview on 01/17/24 at 4:22 PM, when asked about the urology consult for Resident #38, the Central Supply/Transportation/Scheduling person stated she made an appointment with a urologist when the 11/28/23 order came through. The Scheduler stated the appointment was made, but at that time the resident was not able to walk yet, and refused to go to the appointment or have the urinary catheter taken out. The Scheduler, who was also a Licensed Practical Nurse (LPN), stated she educated the resident, who stated she didn't care. When asked if she documented anything anywhere, the Scheduler stated she doesn't do clinical anymore, so she doesn't document in the record, but that she told the nurse. The Scheduler was unable to locate and provide any information about the first appointment at that time. The Scheduler stated that again this month, when she noted the resident was now up and about, she made a second urology appointment for 01/11/24, and provided an Appointment form that documented the appointment for 01/11/24 at 10 AM. The Scheduler stated when she went to remind the resident the day before the appointment, Resident #38 stated she had called and canceled the appointment herself. When asked what she did at that point, the Scheduler stated she spoke with the nurse again. Review of the working nursing schedule for 01/10/24 and 01/11/24 revealed Staff F, RN, was again the resident's direct care nurse. During an interview on 01/17/24 at 4:38 PM, the RN stated she was not made aware that Resident #38 canceled her second urology appointment. The RN stated if she had known she would have educated the resident, called the family if appropriate, notify the physician, and make a note in the record. On 01/19/24 at 11:05 AM, when asked if they had any further information related to the urology consult for Resident #38, the Director of Nursing (DON), stated she reached out to the physician who stated she knew about the canceled urology visit. A side-by-side review of a physician note dated 01/12/24 documented, Urinary retention - Foley catheter medically necessary. Encouraged resident to follow up with urology - Pt (patient) refused. This note, along with the medical record, lacked any documented evidence of education to Resident #38 of the risks of prolonged use of an indwelling urinary catheter.