**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to complete the Preadmission Screening and Resident Review (PASARR) Level II upon a new qualifying mental health diagnosis for four residents (#112, #286, #288, #42) of 30 residents sampled for PASARR Level II. Findings included: 1. Review of Resident #112's admission Record revealed she was readmitted to the facility on [DATE] from an acute care hospital. Her medical diagnoses included but were not limited to anxiety disorder and bipolar disorder. Review of Resident #112's Preadmission Screening and Resident Review (PASARR), dated 1/19/22, revealed no qualifying mental health diagnosis and no PASARR Level II was required. Review of the Quarterly Minimum Data Set (MDS), dated [DATE] and 3/31/23, and an admission MDS, dated [DATE], Section I, Active Diagnoses, showed psychiatric/mood disorder diagnoses of anxiety disorder and bipolar disorder. Review of the medical record revealed the resident was not assessed for a PASARR Level II. An interview was conducted with the Nursing Home Administrator (NHA) and the Regional Nurse Consultant on 8/02/23 at 11:40 a.m. They confirmed Resident #112 had an incorrect PASARR and would see if the resident had a different one. A follow up interview was conducted with the NHA on 8/02/23 at 12:20 p.m. She confirmed there was no other PASARRs in Resident #112's medical record and no other documents related to PASARR to provide. She confirmed there was a concern related to PASARRs. She said the DON (Director of Nursing) completed the PASARRs and all the nurses had access to the system to complete a PASARR. 2. A review of the admission Record for Resident #286 showed he was admitted on [DATE] with diagnoses to include syncope and collapse, unspecified severity unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. The admission Record did not include any further diagnoses. The PASARR, completed by the acute care facility on 7/26/23, did not show Resident #286 had diagnoses related to mental illness or suspected mental illness with findings based on documented history, medications, and behavioral observations. The review of the medication list from the acute care facility, dated 7/26/23, for Resident #286 showed the resident was ordered Escitalopram 10 milligram (mg) daily (an antidepressant) and Quetiapine 25 mg every night (an antipsychotic). The acute care facility's History and Physical form showed the resident had been admitted on [DATE] and had a past medical history significant for dementia with behavior disturbance. The facility's active Order Summary Report as of 8/2/23 showed Resident #286 had the following physician orders: - Escitalopram Oxalate 10 mg - Give 1 tablet by mouth one time a day for depression, ordered 7/26/23. - Quetiapine Fumarate 25 mg - Give 1 tablet by mouth at bedtime for agitation/anxiety, ordered 7/26/23. A review of Resident #286's Minimum Data Set (MDS) showed a Brief Interview of Mental Status (BIMS) of 3, which indicated severe cognitive impairment. The MDS did not include any active diagnoses of psychiatric/mood disorders. The Medication section of the comprehensive assessment showed the resident had received four days of an antipsychotic and three days of an antidepressant. The Regional Nurse Consultant (RNC) stated on 8/2/23 at 2:35 p.m., [Resident #286's] PASARR should reflect (mental illness) diagnoses. 3. The admission Record for Resident #288 showed the resident was admitted on [DATE] and 7/30/23. The record included diagnoses not limited to unspecified recurrent major depressive disorder. A review of Resident #288's PASARR, completed by an acute care facility on 7/24/23, did not indicate the resident had a mental illness or suspected mental illness based on documented history. 4. A review of Resident # 42's admission Record showed she was admitted to the facility on [DATE], with diagnoses to include but not limited to dysphagia following cerebral infarction, aphasia following other cerebrovascular disease, bipolar disorder, unspecified, major depressive disorder, recurrent, unspecified. A review of Resident # 42's PASARR, dated 6/25/2023, revealed Section I: PASARR Screen Decision- Making, Section A. MI (mental illness) or Suspected MI, did not list Resident #42's mental illnesses. A review of the admission MDS, dated [DATE], Section I- Active Diagnoses showed a Psychiatric/Mood Disorder of depression and bipolar disorder. On 08/01/2023 at 12:00 p.m., an interview was conducted with the Regional Clinical Director. She confirmed Resident # 42's PASARR was inaccurate and should have been revised to accurately reflect her mental disorders. A review of the facility policy titled, admission Criteria, revised December 2016, showed, Our facility will admit only those residents whose medical and nursing care needs can be met. 7. Nursing and medical needs of individuals with mental disorders or intellectual disabilities will be determined by coordination with the Medicaid Pre-admission Screening and Resident Review program (PASARR) to the extent practicable. 8. Potential residents with mental disorders or intellectual disabilities will only be admitted if the State mental health agency has determined ( through the preadmission screening program ) that the individual has a physical or mental condition the requires that level of services provided by the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, and record review, the facility failed to 1. provide treatment and services to maintain or improve functional abilities for activities of daily living for one resident (#112) of two residents sampled and 2. failed to assist with meals and offer alternatives for one resident (#74) of seven residents sampled who required assistance with meals. Findings included: 1. A review of Resident #112's admission Record revealed she was readmitted to the facility on [DATE] from an acute care hospital. Her medical diagnoses included morbid (severe) obesity, cellulitis of left lower limb, type 2 diabetes mellitus, and sciatica of the left limb. An observation and interview were conducted on 7/30/23 at 11:50 a.m. with Resident #112. She was observed lying in bed watching television. She stated her only concern was that when she first came to the facility in January, she was ordered therapy, but she had bilateral sciatic problems with her legs with unbearable pain and she could not participate in therapy. She stated, When you don't participate then they stop giving you therapy. I have a wound on my left leg and that is finally getting better now, and my sciatic nerve pain stopped, and the physicians wrote in their notes that I needed therapy, so I got occupational therapy [OT], but I never got PT [physical therapy]. I need physical therapy to get my arms stronger and build up my muscles so I can transfer myself in and out of my wheelchair, so I can go home. I have asked people if I can borrow the exercise bands or something to strengthen my arms, but no one will let me use them or give me therapy. I don't have to take up their time I can just do it in my bed if they would provide me with the equipment. I just want to go home. A review of Resident #112's Quarterly MDS, dated [DATE], Section C - Cognitive Patterns revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated the resident was cognitively intact. An interview was conducted with the facility's Rehabilitation Director on 8/01/23 at 4:13 p.m. She stated, We saw and screened her [Resident #112] on 6/20/23, no changes in ADLs [activities of daily living] and no change in mobility, no changes in eating or swallowing, no changes in pain, range of motion, sitting and positioning. When we do the screening, we see the patient. She [Resident #112] always says she needs therapy. When we assessed her, she has not had a decline or a change and she's not on therapy load. I can't tell you the last time she was in therapy because I don't have access to the old documentation. What I do know is that based on the quarterly assessment the therapist did not feel the resident would benefit from therapy services. There is recreational exercises that Activities does and the resident should know about that. The Rehabilitation Director confirmed it would be appropriate to start therapy services for someone who wanted to strengthen their arms to help assist in transfers. An interview was conducted on 8/01/23 at 4:26 p.m. with Staff Q, Physical Therapist. She said, I did not talk to the resident at the time of my assessment, but I did talk to the CNA [certified nursing assistant] and the nurse to see if there were any changes in mobility and there was no change. I'm pretty sure she has had OT in the last 6 months to a year and I'm pretty sure they gave her home therapy exercises but, there was no change functionally with her. She's not very mobile. She's rarely out of bed and I know in the past she was getting dressing changes for a wound. She's not highly motivated to get out of bed. 2. A review of the admission Record showed Resident #74 was admitted on [DATE] and 6/14/23. The record included diagnoses not limited to sepsis due to escherichia coli (e.coli), pressure induced deep tissue damage of left buttock, unstageable pressure ulcer of right hip, and type 2 diabetes mellitus without complications. An observation on 7/30/23 began at 12:19 p.m. as the meal cart arrived on the unit. An unknown staff member removed a meal tray from the cart and placed it on the over-bed table for Resident #74. On 7/30/23 at 12:32 p.m., the covered meal continued to sit on the over-bed table with no staff observed entering the room. On 7/30/23 at 12:39 p.m., Resident #74's meal continued to sit on the table without staff entering the room to assist the resident. On 7/30/23 at 12:40 p.m., a staff member entered the resident's room, immediately left the room and shut the door. In an interview on 7/30/23 at 12:41 p.m., the resident said he did not know lunch was there and someone did assist him with his meals. On 7/30/23 at 1:00 p.m., Staff E, Registered Nurse (RN), entered the room and asked if the resident wanted to eat. Staff E lifted the plate cover and identified that it was meatballs and carrots. The resident stated No. Staff E stated the resident's family member brought him a fast food burger. Staff E removed the meal tray and did not offer the resident an alternative. The meal tray had been sitting on the resident's over-bed table for 21 minutes prior to a staff member entering the room then another 20 minutes before another staff member entered the room and asked the resident if he wanted to eat, leaving without offering an alternative. On 7/31/23 at 8:24 a.m., Staff I, Certified Nursing Assistant (CNA) was observed in Resident #74's room. The resident was informed the meal tray was on the over bed table and was asked if he was hungry, which the resident stated no to being hungry or thirsty. The staff member left the room with the meal tray, no alternative was offered. The Minimum Data Status (MDS), dated [DATE], showed Resident #74 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated intact cognition. The MDS showed the resident required extensive assistance from 1-person for eating. The care plan for Resident #74 showed the resident required assist with Activities of Daily Living (ADL) related to multiple factors and staff were to provide assistive devices as ordered/indicated and to encourage and assist with all ADL tasks as indicated, as tolerated by resident, including . meals, (and) personal /oral hygiene, cetera (etc.). The resident was identified as being at risk for alteration nutrition/hydration related to (r/t) diagnosis (dx) of Diabetes Mellitus (DM), wounds (and) infection. The interventions included but not limited to encourage and assist resident .as tolerated for meals and to explain and reinforce to the resident the importance of maintaining the diet as ordered, encourage the resident to comply, explain consequences of refusal, obesity/malnutrition risk factors. The CNA task of eating documentation showed from 7/4 to 8/1/23 Resident #74 was independent with eating after meal set up on 7/4, 7/5, 7/12, 7/13, 7/15, 7/16, 7/17, 721, and 7/29/23. The documentation showed the resident required limited assist from 1-person for meal(s) on 7/5, 7/6, 7/10, 7/12, 7/13, 7/14, 7/16, 7/20, and 7/26/23. The task showed the resident required extensive assist for a meal service from one-person on 7/6, 7/8, 7/9, 7/10, 7/11, 7/12, 7/13, 7/16, 7/17, 7/19, 7/22, 7/25, 7/29, and 7/30/23. The task showed the resident required total dependence from 1-person during meal service on 7/4, 7/5, 7/7, 7/8, 7/9, 7/11, 7/18, 7/20, 7/21, 7/23, 7/24, 7/25, 7/26, 7/27, 7/28, and 7/29/23. The facility provided evidence that menu alternatives of soup of the day, chef salad, yogurt or cottage cheese, seasonal fruit plate, grilled cheese sandwich, tuna or egg salad sandwich, peanut butter & jelly sandwich and deli sandwiches were available and baked sweet potato, hot dog, hamburger, and a baked potato was available if ordered 2 hours prior to the meal. Review of the facility's Activities of Daily Living (ADLs), Supporting policy, revised on March 2018, revealed: Policy Statement Residents will [be] provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Resident who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Policy Interpretation and Implementation 1. Residents will be provided with care, treatment and services to ensure that their activities of daily living (ADLs) do not diminish unless the circumstances of their clinical condition(s) demonstrate that diminishing ADLs are unavoidable. a. The existence of a clinical diagnosis or condition does not alone justify a decline in a residence ability to perform ADLs. .2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: .c. Mobility (transfer and ambulation, including walking); . .e. Dining (meals and snacks) .5. A residence ability to perform ADLs will be measured using clinical tools, including the MDS. Functional decline or improvement will be evaluated in reference to the Assessment Reference Date (ARD) and the following MDS definitions: .d. Extensive Assistance- while resident performed part of activity over the last 7 days, staff provided weight-bearing support. .6. Interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals and recognized standards of practice. 7. The resident's response to interventions will be monitored, evaluated and revised as appropriate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. A review of Resident #40's admission Record showed diagnoses of ataxic gait, unspecified dementia, anemia, essential hypertension, history of falling, sarcopenia, weakness, atherosclerotic heart disease, and other symptoms and signs of concerning food and fluid intake. Review of the active physician orders as of 8/2/23 showed a physician order, dated 01/31/23, showed, Escitalopram Oxalate Tablet 5 mg- Give 5 mg by mouth one time a day for depression give with 10 mg to equal dose of 15 mg. A second physician order, dated 01/31/23 showed, Escitalopram Oxalate Tablet 10 mg- Give 10 mg by mouth one time a day for depression give with 5 mg to equal dose of 15 mg. A third physician order, dated 11/02/22 showed, Buspirone HCI Oral Tablet 5 mg- Give 5 mg by mouth two times a day for anxiety. The Medication Administration Record (MAR) was reviewed for June 2023 and July 2023 and showed Escitalopram Oxalate Tablet 5 mg, Escitalopram Oxalate Tablet 10 mg, and the Buspirone HCI Oral Tablet 5 mg were given per the physician orders. The Quarterly Minimum Data Set (MDS), dated [DATE], showed a diagnosis of dementia but no diagnoses of anxiety or depression in Section I-Active Diagnoses of the MDS. The Quarterly Minimum Data Set (MDS), dated [DATE], showed the medications of antianxiety and antidepressants were administered all seven days during the seven day MDS day look back period. A review of Resident #40's care plan showed a focus diagnosis of dementia, initiated on 1/24/22, with appropriate goals and interventions. The care plan showed a second focus on adverse risks related to the use of antidepressant medications, initiated on 1/24/22, with appropriate goals and interventions. The diagnoses of anxiety and depression as the administration of antianxiety medications were not found on Resident #40's care plan. During an interview on 08/02/23 at 2:25 p.m., the Regional Nurse Consultant (RNC) stated the expectation of the facility was to have a resident diagnosis that corresponded with the medication ordered by the physician. Additional review of the facility policy titled, Medication Utilization and Prescribing-Clinical Protocol, issued 10/14 and revised on 10/2022, showed, Assessment and Recognition 1. When a medication is prescribed for any reason, the physician and staff will identify the indications (conditions or problem for which it is being given, or what the medication is supposed to do or prevent), considering the resident's age, medical and psychiatric conditions, risks, health status and existing medication regimen. Based on observation, interview, and record review, the facility failed to ensure an as needed psychotropic medication was limited to 14 days for one resident (#125) out of six residents reviewed for unnecessary medication. The facility also failed to ensure three residents (#128, #40, and #286) out of six residents reviewed for psychotropic medications had documented corresponding diagnoses for ordered medications. Findings included: 1. Review of Resident #125's admission Record revealed she was readmitted to the facility on [DATE] from hospice. Resident #125's medical diagnoses included but were not limited to senile degeneration of the brain and dementia without behaviors or mood disturbances and anxiety disorder. An observation of Resident #125 was conducted on 7/30/23 at 11:29 a.m. The resident was observed to be clean, lying in bed, with her eyes closed. During an observation conducted on 7/31/23 at 3:50 p.m., Resident #125 was observed to be lying in bed, her eyes were closed, and music was playing in her room. Review of Resident #125's physician orders active as of 8/2/23 revealed an order for Ativan oral tablet 0.5mg to be given every 4 hours as needed for anxiety and agitation which started on 6/21/23 without an end date. Review of Resident #125's admission Minimum Data Set (MDS), Section I - Active Diagnoses, dated 5/6/23, revealed Resident #125 did not have any Psychiatric/Mood Disorders including the resident did not have anxiety disorder. Review of Resident #125's June and July 2023 Medication Administration Record (MAR) revealed the resident received her as needed Ativan 4 times from 6/21/23 to 7/31/23. One of the four Ativan administrations was administered on 7/15/23 at 2:45 p.m. which was 24 days after the medication was ordered. Review of Resident #125's pharmacy recommendation reviews for June 2023 revealed no recommendations. An interview was conducted with the facility's Regional Nurse Consultant on 8/01/23 at 3:29 p.m. She confirmed she reviewed Resident #125's Ativan order and confirmed it was ordered for longer than 14 days and the pharmacist just sent her an email for the July (2023) review and the resident did not have any recommendations. 2. Review of Resident #128's admission Record revealed she was re-admitted to the facility on [DATE]. The resident's medical diagnoses included heart failure, encephalopathy, cognitive communication deficit, cellulitis of left lower limb, morbid obesity (severe) obesity due to excess calorie, sepsis, type 2 diabetes mellitus with diabetic polyneuropathy. Her medical diagnoses did not include depression. Review of Resident #128's physician orders active as of 8/2/23 showed an order which started on 6/11/22 for Duloxetine HCL capsule Delayed Release Particles 60mg (milligrams), give 1 capsule by mouth one time a day for depression. Review of Resident #128's July 2023 MAR showed the resident received her ordered Duloxetine for depression. Review of Resident #128's Quarterly MDS, Section I-Active Diagnoses, dated 4/18/2023, showed the resident did not have any Psychiatric/Mood Disorders including the resident did not have depression. Review of Resident #128's Pharmacist reviews for the month of June 2023 did not show recommendations related to Resident #128 having ordered medications for diagnoses that were not documented. A phone interview was conducted with the facility's Consulting Pharmacist on 8/02/23 at 2:40 p.m. He stated, Residents are reviewed once a month and then if anyone needs a review in between we will do that too. We do look at medications and make sure there are corresponding diagnoses and as needed psychotropics should be limited to 14 days. 3. Review of Resident #286's admission Record showed the resident was admitted on [DATE]. The resident's medical diagnoses included syncope and collapse, unspecified severity unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. The MDS assessment, dated 7/29/23, showed Resident #286 had a Brief Interview of Mental Status score of 3 out of 15, which indicated severe cognition impairment. The MDS showed the resident had an active diagnosis of Non-Alzheimer's Dementia and did not include any psychiatric/mood disorder diagnoses and received 4 days of antipsychotic and 3 days of antidepressant medications. The active Order Summary Report as of 8/2/23 for Resident #286 showed the resident was receiving the following psychotropic medications: - Escitalopram Oxalate 10 milligram (mg) - Give 1 tablet by mouth one time a day for depression; - Quetiapine Fumarate 25 mg - Give 1 tablet by mouth at bedtime for agitation/anxiety. The acute facility's History and Physical report, which showed a date of admission of 7/23/23, indicated Resident #286 had a diagnosis significant for dementia with behavior disturbance. The Physician/Practitioner progress note, dated 7/31/23 at 12:53 p.m., included diagnoses for Resident #286 of vascular dementia (vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety) and showed to continue supportive care. During the observation of medication observation with Staff D, Registered Nurse (RN), for Resident #286, on 7/31/23 at 8:04 a.m., the resident was observed lying in bed, pulling up the blankets that covered from the waist down. The resident informed the staff member to get rid of the five inches of water, lifting up the blankets indicating it (the water) was under there. The behavior monitoring for Resident #286 identified on 7/31/23 during the day shift Resident #286 did not have any episodes of behaviors. The Medication Administration Record (MAR) instructed staff to document behaviors, effectiveness, and non-pharmaceutical interventions. The care plan for Resident #286 indicated the following: - a focus was initiated, on 7/31/23, an identified the resident had a history of exhibiting the following behaviors agitated (and) anxious. The interventions instructed staff to Administer medications as ordered. Monitor/document for side effects and effectiveness. - a focus was initiated, on 7/31/23, an identified the resident was at risk for falls related to impaired mobility, use of psychotropic medications. - The resident uses antipsychotic medications related to (r/t) behavior management and instructed staff to administer antipsychotic medications as ordered by physician. - The resident uses antidepressant medication r/t depression and instructed staff to administer antidepressant medication as ordered by the physician. Staff J, Certified Nursing Assistant (CNA) stated on 8/1/23 at 4:48 p.m., that Resident #286 had no extra confusion noted, had never mentioned sitting in water, and that the resident was constantly dropping the water on the floor and when that happened staff changed the bed. During an interview that started on 8/1/23 at 5:00 p.m., Staff F, Registered Nurse/Unit Manager (RN/UM) reported understanding if a psychiatric consult was requested a Nurse Practitioner would come in. Staff F reported not noticing anything new with Resident #286's confusion. Staff F stated if the resident voiced lying in water that would be a behavior and should be noted on the behavior log. Staff F reviewed the medical diagnoses of the resident and stated the resident had dementia without behavioral disturbances then reviewed the hospital history and physical and identified it indicated the resident had a diagnosis of dementia with behaviors. Staff F reported the resident did not have a psych (psychiatric) consult. On 8/1/23 at 11:22 a.m., the Regional Director of Clinical Services (RDCS) stated the behavior monitoring should be included on the Medication Administration Record (MAR). The policy titled, Medication Utilization and Prescribing - Clinical Protocol, issued 10/14 and revised 10/22, showed the standard was To ensure medications are prescribed and utilized according to State and Federal guidelines. The assessment and recognition showed, When a medication is prescribed for any reason, the physician and staff will identify the indications (condition or problem for which it is being given, or what the medication is supposed to do or prevent), considering the resident's age, medical, and psychiatric conditions, risks, health status, and existing medication regimen. The assessment showed, Symptoms should be characterized in sufficient detail (onset, duration, frequency, intensity, location, etc.) to help identify whether a problem exists or whether a symptom is just a variation of normal. As part of the overall review, the physician and staff will evaluate the rational for existing medications that lack a clear indication or are being used intermittently on a PRN (as needed) basis.

Based on observations, record reviews, and interviews the facility failed to ensure the medication error rate was less than 5.00%. Thirty-five medication administration opportunities were observed and four errors were identified for two residents (#186 and #95) of six residents observed. These errors constituted a 11.43% medication error rate. Findings included: 1. On 7/31/2023 at 8:30 a.m., an observation of medication administration with Staff B, Registered Nurse (RN), was conducted with Resident #186. Staff B dispensed medications scheduled at 9:00 a.m. which included but not limited to the following medications: - Oyster Shell Calcium 500 mg (milligrams) - 3 tablets. During the observation Staff B searched the medication cart, dispensing three Oyster Shell Calcium tablets identifying the tablets contained calcium carbonate. Staff B reported they had contacted the pharmacy this morning about the resident's Sodium Bicarbonate and was told they were out of it, and the physician was notified already. Staff B documented, med not available at this moment, pharmacy notified and MD notified this am, waiting for MD call back for update order. The July 2023 Medication Administration Record (MAR) showed Resident #186 was to receive at 9:00 a.m. on 7/31/23 the following medications: - Calcium Carbonate Oral wafer 500 (200 Ca) mg - Give 3 tablet by mouth every 8 hours for supplement during the observation, which Staff B had documented as given. - Sodium Bicarbonate 650 mg oral tablet (Sodium Bicarbonate (Antacid)) - Give 3 tablet by mouth two times a day for supplement. On 7/31/23 at 10:53 a.m., a review of progress notes and assessments for Resident #186 did not show the physician or pharmacy had been contacted prior to the medication administration observation with Staff B. The Electronic Medication Administration Record (eMAR) notes, dated 07/27 at 5:20 p.m., 07/28 at 8:02 a.m., and 7/29/23 at 5:36 p.m. showed waiting for delivery, 7/30 at 10:45 a.m. not aval (available), and 7/30/23 at 5:49 p.m. called pharmacy will deliver. On 7/31/23 at 5:15 p.m., a list of over-the-counter (OTC) medications was reviewed with Staff R, Staffing Coordinator/Central Supply. Staff R stated she would have to check with the wound care nurse that they knew more about it (available OTC medications). Staff R stated on 7/31/23 at 5:40 p.m. the highlighted items on the OTC list could be ordered. The list identified Sodium Bicarbonate tablets were highlighted and listed as (pharmacy) Do NOT Send. During an interview on 7/31/23 at 5:42 p.m. the Regional Nurse Consultant (RNC) stated the facility would contact the pharmacy for OTCs; would just need authorization from the Director of Nursing (DON) or Nursing Home Administrator (NHA) (for pharmacy) to bill the facility; could also order from supplier. Staff R stated medications only take a couple of days to receive from the supplier. The RNC stated the facility could also go to the nearby pharmacy and buy it if a resident had it ordered and we did not have it. On 8/2/23 at 11:27 a.m., Staff F, Registered Nurse/Unit Manager (RN/UM), stated Oyster Shell Calcium was not the same as Calcium Carbonate and identified it as a name brand Antacid. Staff F stated they could go get some (medication) and should have let her know of the missing medications (regarding Sodium Bicarbonate). On 8/2/23 at 11:29 a.m., Staff H, Wound Care/Registered Nurse (RN) stated not all house stock (OTC) were available. Staff H reported the facility calls the pharmacy if they do not have house stock and requests a form for the DON to sign, then the pharmacy sends it. 2. On 7/31/2023 at 5:17 p.m., an observation of medication administration with Staff C, Registered Nurse (RN), was conducted with Resident #95. Staff C dispensed medications which included: - Ferrous Sulfate 325 milligram (mg) tablet - Multi-Vitamin with minerals tablet - Vitamin D3 25 microgram (mcg) tablet - Calcium + D3 600 mg/10 mcg tablet - Memantine 10 mg tablet - Novolog FlexPen 4 units. Staff C confirmed dispensing 5 tablets. During the dispensing Staff C searched the medication cart and could not find the following medication scheduled to be administered with the above medications: ICaps Oral Capsule (Multiple Vitamins with minerals) - Give 1 capsule by mouth in the afternoon for supplement. Staff C confirmed ICaps tablet was not administered and documented the medication was not available. A review of Resident #95's Medication Administration Record (MAR) identified the resident had a physician order to administer Caltrate +D Plus minerals 600/800 mg-unit. According to the website, https://www.caltrate.com/calcium-supplement-products/600d3-plus-minerals/, Caltrate 600+D3 Plus Minerals contained 600 mg of Calcium and 800 International Unit (IU) of Vitamin D3. Medscape.com indicated that 10 mcg (that was administered) = 400 IU. On 8/2/23 at 11:29 a.m., Staff F, Registered Nurse/Unit Manager (RN/UM) reported ICaps was a (brand name) eye vitamin and mineral supplement. Staff H, Wound Care/RN, reviewed Resident #95's medications and stated the resident had duplicate medications that needed to be reviewed but did not identify the resident did not receive the 800 international units of Vitamin D as ordered. The policy titled, Medication Shortages/Unavailable Medications, undated, showed When medications are not received or are unavailable for the customers, the licensed nurse will urgently initiate action in cooperation with the attending physician and the pharmacy provider. The procedure portion of the policy documented the following: - If a medication shortage is noted at the time of medication administration (Med-Pass), the licensed nurse or certified medication assistant must immediately initiate action to obtain the medication and not wait until the med pass is completed. The policy documented if a medication was noted during normal pharmacy hours a licensed nurse was to notify the pharmacy and speak to the pharmacist to determine the status of the order and if not order, place the order or re-order to be sent with the next scheduled delivery. The facility link may also be utilized to order or re-order. The policy documented if a medication shortage is noted after normal pharmacy hours a licensed nurse obtains the medication from the emergency stock supply and if unavailable, calls the pharmacy and requested to speak the on-call pharmacist. If an emergency delivery is not feasible a licensed nurse contacts the attending physician to obtain orders or directions which may include holding the dose/doses, use of an alternative medication available from the emergency stock supply, and/or change in order (time of administration or medication). Review of document titled, The Medication Dispensing System, undated, showed, All medications will be prepared (blister card, vials, [brand name] box) and administered in a manner consistent with the general requirements outlined in this policy. The procedure identified that prior to Medication Administration staff were to Verify each medication preparation that the medication is the right drug, at the right dose, the right route, at the right rate, at the right time, for the right customer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to provide sufficient staffing to adequately meet the residents' needs for nine residents (#131, #117, #26, #147, #144, #80, #72, #537, and #128) out of 63 residents sampled. Findings Included: 1. On 7/30/2023 at 9:10 a.m., an interview was conducted with Resident #131's family member. The family member said the 11:00 p.m.-7:00 a.m. shift was constantly understaffed, which had an impact on Resident #131 because he was always wet when she visited him in the morning. She said that she visited him before the morning shift started their assigned shift, so she knew that it was the night shift who left the resident wet. A review of the staffing assignment sheet, dated 7/30/2023, revealed Staff K, Registered Nurse (RN) worked as a nurse and a Certified Nursing Assistant (CNA) on the 11:00 p.m.-7:00 a.m. on the Medbridge unit. A review of the staffing assignment sheet, dated 7/31/2023, revealed Staff L, Licensed Practical Nurse (LPN) and Staff K, RN worked as nurses and CNAs from 11:00 p.m.-7:00 a.m. on the Medbridge unit. On 8/1/2023 at 12:00 p.m., an interview was conducted with Staff N, CNA. Staff N said she had been working at the facility for 15 years. She said sometimes they had enough staff and sometimes they did not. She reported she used to help out on 11:00 p.m.-7:00 a.m. shifts, but she stopped because they had a lot of call offs on that shift and it was too much for one CNA to have to work on the unit by themselves. She said last night they only had one CNA on for the 300 hall (Medbridge Unit) for 38 residents. On 8/1/2023 at 1:00 p.m., an interview was conducted with Staff K, RN. She said she worked as a CNA and a nurse for her shift from 11:00 p.m.-7:00 a.m. last night. She said that she and another nurse (Staff L, Licensed Practical Nurse [LPN]) and a CNA divided up the assignment. They gave the CNA 20 residents and both she and the other nurse had nine residents a piece. She said it was hard, but they made it through the night. Review of the CNA Assignment Sheet for 11(p.m.) to 7:00 (a.m.) for the Medbridge Unit showed Staff L, LPN was assigned rooms 301-321, Staff K, RN was assigned rooms 339-349 and 354-356 and Staff O, CNA was assigned rooms 322 - 338 and 357 - 373. and review of the census showed 36 residents on this unit. On 8/1/2023 at 1:38 p.m., an interview was conducted with Staff L, LPN. Staff L reported she worked as a CNA and a nurse last night and the night before due to staff calling out. She said she and Staff K worked as both nurses and CNAs for the whole night on the Medbridge unit. On 8/1/2023 at 1:45 p.m., an interview was conducted with Staff M, CNA. Staff M reported she was not able to provide dining assistance for her residents because they were always working short staffed at the facility. On 8/1/2023 at 4:00 p.m., an interview was conducted with Staff O, CNA. Staff O confirmed that she worked as a full time CNA on the 11:00 p.m.-7:00 a.m. shift on the Medbridge Unit. She confirmed she was the CNA who worked with both Staff L, LPN and Staff K, RN on the 11:00 p.m.-7:00 a.m. shift when they both worked as nurses and CNAs. She said they were short staffed often but she was able to manage her workload. On 08/02/23 at 9:42 a.m., an interview was conducted with Staff R, Staffing Coordinator. Staff R said she determined staffing in the facility by the census, and not by acuity. Whenever there was a call out and she was not in the building, the charge nurse was responsible to make sure there was coverage for the shift. She said they used agency but just for nurses, however after today, they had signed an agreement for agency CNAs. A review of the Facility Assessment, undated, showed: Requirements, Nursing facility will conduct, document, and annually review a facility-wide assessment, which includes both their resident's population and the resources the facility needs to care for their residents. Purpose: The purpose of the assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. Use this assessment to make decisions about your direct care staff needs, as well as your capabilities to provide services to the residents in your facility. Using competency- based approach focuses on ensuring that each resident is provided care that allows the resident to maintain or attain their highest practicable physical, mental and psychological well-being. The intent of the facility assessment is for the facility to evaluate its resident's population and identify the resources needed to provide the necessary person- centered care and services the resident requires. Staffing Plan 3.2 Based on our resident population, acuity of residents and the duties of the day-to-day operations - the following staffing plan is in place to meet those needs. The ratio of registered and license practical nurses to aids shall be sufficient to assure professional guidance and supervision in the nursing care of the residents. 3. During an interview on 07/30/23 at 1:11 p.m., Resident #26 stated the facility needed the staff to answer the call lights faster and not make residents wait long periods of time. Resident #26 stated they had to wait 45 minutes to an hour for someone to come answer the call light. 4. During an interview on 07/30/23 at 11:40 a.m., Resident #147 stated a concern with call light response time. Resident #147 stated the other night, I was so thirsty and put the call light on. Resident #147 stated it took staff over an hour to answer the call light just to get a drink of water. 5. During an interview on 07/30/23 at 12:05 p.m., Resident #144's family member stated the other day he looked for staff and could not find anyone. Resident #144's family member stated he did not know if it was the time of day of the visit but, there was a concern about staffing. A review of the facility's Resident Council minutes showed: -07/17/23- Old Business- Followed up with nursing with call lights and showers. - 07/03/23- Residents report slow call light response at times on 11-7 shift. - 06/05/23- Followed up with nursing regarding all lights. During an interview on 08/02/23 at 9:33 a.m., Staff A, Activities Therapist (AT) stated the Activity Director was charge of Resident Council. Staff A stated based on the Resident Council minutes notes she was not able to identify when the first complaint about call light response times started but would check more into the question since the Activity Director was out of the facility. Staff A stated when a concern was addressed at Resident Council , the Activity Director wrote a grievance immediately and took it to the social services department to take care of. During an interview on 08/02/23 at 10:00 a.m., Staff A stated the first call light concern identified in Resident Council was on 05/08/23. Staff A stated there was a grievance written corresponding to the identified concern made in the Resident Council meeting on 05/08/23. On 8/2/23 at 12:30 p.m., the Resident Council President (RCP) stated the issue, mentioned in the Resident Council minutes, was that call lights were not answered efficiently then clarified that it took staff to long to answer. A review of the facility's Grievance Log showed concerns related to call bell response times. The Grievance Log showed as followed: 05/08/23- Concern of call bell timeliness - Call bells not timely 11-7. 05/22/23- Concern of call bell- Call bell on 11-7 last weekend. Dinner was late last weekend too. 07/03/23 - Concern call bell- Report times call bell is slow. A review of the facility's Grievance Form with facility response was reviewed related to call bell response times. The Grievance Forms showed as followed: - Dated 05/08/23 the grievance showed, slow call light response at times on 11-7 shift (East and West). An in-service was provided to staff regarding call lights and answering call lights timely. Since staff education patients report its better. The in-service was conducted to all staff on 05/11/23 titled Customer Service. - Dated 05/22/23 the grievance showed, long call light response wait times on 11-7 shift and on weekends. An in-service was provided about call light response times. The in-service was conducted on 05/22/23 titled Call Light Response. -Dated 07/03/23 the grievance showed, slowed call light response at times. Occasionally it took a longer time to get a CNA to answer call lights promptly. An in-service was provided on call light response times. The in-service was conducted on 07/10/23 titled Call Bell Response. During an interview on 08/02/23 at 3:10 p.m., the Nursing Home Administrator (NHA) stated staff were educated regarding call bell response times after each grievance related to call bell concerns. 6. An interview was conducted on 7/30/23 at 10:30 a.m. with Resident #80's family member. The family member stated, The only thing they [the facility] can improve on is always having someone available that can help because, if the person that is assigned to you is on break; the staff will say oh, I'm not your nurse, or I'm not your CNA [Certified Nursing Assistant] you have to wait till they get back. [Resident #80] can't use the call light but if I put the call light on, they don't answer that. It's worse on the night shift there's never any one around or at the nurse's station. 7. An interview was conducted on 7/30/23 at 12:00 p.m. with Resident #72's family member. She stated, If you push the call light it will take 30-45 minutes for anyone to even answer the call lights and that's not including the time it takes for them to do what you were calling them in to do. 8. An interview was conducted on 7/30/23 at 10:05 a.m. with Resident #537. She stated, I put my call light on the other night, I forgot what I needed, but I put the call light on and it took them 45 minutes to answer it and I asked the girl why and she said she starts at one end of the hall and works her way down. I told her what if I was having a heart attack? I could be dead by the time she got to me. Review of Resident #537's admission MDS, dated [DATE], Section C- Cognitive Patterns revealed a BIMS score of 15 out 15 indicating the resident is cognitively intact. 9. An interview was conducted on 7/30/23 at 11:25 a.m. with Resident #128, she stated, The only concern I have is I think they have had too many cutbacks. The girls [CNAs] here used to have nine patients, now they each have 11. They are very nice, and I don't let them miss any of my care because I will go out into the hall and just yell until I get what I want. They are very nice, but they just wiz in and out of the rooms because they just don't have the time to spend with anyone like they used to. Review of Resident #128's Quarterly MDS, dated [DATE], Section C- Cognitive Patterns revealed a BIMS score of 15 out of 15 indicating the resident is cognitively intact. 2. The admission Record for Resident #117 identified admission dates of 1/20/22 and 5/31/2023. The record included diagnoses not limited to unspecified anxiety disorder, unspecified dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. On 8/1/23 at 9:41 a.m., during an observation of medication administration, Resident #117 informed Staff S, LPN, of not getting a shower last night and that staff had told the resident they didn't have time. On 8/2/23 at 9:29 a.m., during an interview with Resident #117 she stated the staff were not very nice when giving a shower, they were rushed, and had an attitude. The resident stated when she did not receive a shower the staff would tell her they were too busy. A review of the Minimum Data Set (MDS), dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated intact cognition. A review of the shower day schedule showed Resident #117 was to receive a shower during the 3:00 p.m.-11:00 p.m. shift on Monday and Thursday. A review of the Certified Nursing Assistant (CNA) documentation showed on Monday on 7/3/23 at 2:59 p.m., Resident #117 received a sponge bath, on 7/31/23 at 10:30 a.m., in addition at 9:14 p.m. the documentation indicated the resident had refused.

Based on observation, interview, and record review the facility failed to ensure care plan interventions and physician orders were followed related to implementing contact precautions for one (Resident #347) of three residents sampled. Findings included: On 08/11/21 at 8:40 a.m. an interview with Resident #347 revealed him presenting with confusion and continually saying I can't see . it's so dark in here . where is my wife? . Where am I? Resident #347 had a catheter in place. Prior to entering the Resident's room, no precaution signage was observed on the doorway. A record review of Resident #347's admission Record Report revealed an admission date of 08/03/2021 with medical diagnoses of unspecified injury of the head, legal blindness as defined in the United States of America, and Escherichia Coli (E. Coli). A record review of Resident #347's MDS [Minimum Data Set] 3.0, dated 8/09/21, revealed under Section C- Cognitive Patterns a brief interview for mental status (BIMS) score of 8, indicating cognition problems without behaviors of inattention. Under Section G- Functional Status it was revealed the Resident required extensive assistance of two staff members for transfer and toilet use. Under Section H- Bladder and Bowel it was revealed the Resident has an indwelling catheter. A record review of Resident #347's Clinical Physician Orders revealed an order, start date of 08/04/21 and an end date of 8/13/21 for contact isolation for E. Coli in the urine. A record review of Resident #347's Care Plan revealed a focus area of . Infection of urinary tract: E-Coli, dated 08/04/21. Interventions included contact precautions for E. Coli of the urine and maintain precautions as indicated. An interview and observation were conducted on 08/11/21 at 2:41 p.m. with Staff K, Certified Nursing Assistance (CNA). Staff K, CNA stated Resident #347 was not on any room precautions because . there is nothing on his door. If a resident requires additional personal protective equipment (PPE) to be donned while providing care, then a sign is posted on the door indicating the required additional precautions. Staff K, CNA stated she also worked with the Resident on 08/10/21 and he was not on any precautions then neither. Staff K, CNA stated that if a resident is on contact precautions, then staff should don additional PPE of a gown and gloves when going into the room. Photographic evidence was obtained of Resident #347's doorway without signage indicating the type of precautions required for the room. During an interview on 08/11/21 at 2:46 p.m., Staff A, Licensed Practical Nurse (LPN) stated Resident #347 is not on any precautions. Staff A, LPN reviewed Resident #347's online medical chart and confirmed an active order in place for contact precautions due to E. Coli in the urine. Staff A, LPN looked at Resident # 347's door and said . yea there is no sign on the door. Staff A, LPN stated Resident #347 was admitted from the hospital with a urinary tract infection and for contact precautions additional PPE requirements for entering the room would be a gown and gloves An interview on 08/12/21 at 7:04 a.m. with the Director of Nursing (DON) and Nursing Home Administrator (NHA) revealed for those residents with orders for contact precautions, additional PPE is required of donning a gown and gloves when entering the room. The resident's room should have signage posted on the door indicating to see nurse with the letter of the type of precaution required. An interview on 08/12/21 at 1:50 p.m. with the Infection Preventionist revealed Resident #347 does not have a urine culture to indicate the type of bacterial urinary tract infection. The resident was admitted with orders for contact precautions due to E. Coli in the urine, however, there is no culture to indicate the bacterium requires the precautions. A follow-up interview on 08/13/21 at 5:02 p.m. with the DON confirmed that those residents with physician orders and care plans indicating a type of precaution should be implemented. A policy review of Interdisciplinary Care Planning, updated 03/2018, revealed under section Comprehensive Care Planning Requirements that . The facility must develop and implement a comprehensive person-centered care plan for each patient that includes measurable objectives and timeframes to meet a patient's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment Once the care plan is developed, the staff must implement the interventions identified in the care plan These may include but is not limited to . administered treatments and medications . performing therapies, and . participating in activities with the patient . Interventions identify specific, individualized elements of care, provided y staff, which will help patients achieve their goals. Interventions are the instructions for delivering patient care and allow for continuity of care by staff. Just like goals, interventions are specific and measurable .

Based on observation, interview and record review, the facility did not ensure that the medication error rate was below 5.00%. A total of twenty-seven medications were observed, and fifteen late medications were verified for three (3) (Resident #51, # 295 and #347) of eight (8) residents observed. These late medications constituted a medication error rate of 55.56 percent. Findings included: On 08/11/2021 at 10:07 a.m., an observation was conducted of Staff A, Licensed Practical Nurse (LPN), on the MED Bridge Wing, administering medications to Resident # 51. Staff A, (LPN) was seen administering the following medications: -Amiodarone HCL Tablet 100 milligrams (MG) orally, -Eliquis Tab 5 MG by mouth orally, every 12 hours -Furosemide Tablet 20 MG orally, one time a day -Potassium Chloride ER Tablet Extended Release 10 milliequivalents (MEQ) orally, three times a day -Spironolactone Tablet 50 MG orally, twice daily -Prednisone Tablet 1 MG orally, one time a day Record review of active Physician Orders and the Medication Administration Record (MAR) for Resident #51, revealed that the medications administered to the resident were given late, and scheduled to be administered at 9:00 a.m. On 08/11/2021 at 10:19 a.m., a continued observation of medication administration with Staff A (LPN), was conducted with Resident #347. Staff A, (LPN) was observed administering the following medications: -Ticagrelor Tablet 90 MG orally every 12 hours. -Cefdinir Capsule 300 MG Capsule orally every 12 hours. -Atorvastatin Calcium Tablet 40 MG orally once a day. -Ferrous Sulfate Tablet 325 MG orally one time a day. -Midodrine HCL 10 MG Tablet orally every 12 hours. An immediate interview was conducted with Staff A, (LPN) who was asked if she or anyone else in the facility called the physician to alert him/her the medications were being administered late and for any orders? She stated, My computer went up and down, and I did not know I was supposed to call the physician if the medications were given late. Record review of active Physician Orders and the Medication Administration Record (MAR) for Resident #347, revealed that the medications administered to the resident were given late, and scheduled to be administered at 9:00 a.m. On 08/11/2021 at 10:49 a.m. Staff B, Agency (LPN) was observed administering medications to Resident #295. On the MED Bridge Wing. The following medications were seen administered to the resident: -Amlodipine Besylate Tablet 5 MG orally one time a day. -Duloxetine HCL Capsule Delayed Release Particles 60 MG orally one time a day. -Losartan Potassium Tablet 100 MG orally one time a day. -Metformin HCL Tablet 500 MG orally twice a day. An immediate interview was conducted with Staff B, Agency (LPN) about the medications on her computer screen of the MAR observed to be in red, which denotes a late medication. She stated It's been about time management, I have to stop a lot, there are new admissions, I need to call the Physician prior to giving a medication to them, and then I am agency, and I cannot pull medications from the [name of medication dispensing system] because I have to get another nurse to pull them. I do not have access to it to pull. Staff B, Agency (LPN) indicated she did not have any computer issues that morning that would make medication administration late. Record review of active Physician Orders and the MAR for Resident #347, revealed that the medications administered to the resident were given late, and scheduled to be administered at 9:00 a.m. An interview was conducted on 08/11/2021 at 12:50 p.m., with the Director of Nursing (DON). During the interview she was informed of fifteen medications being administered late to three (3) residents. The DON stated I expect the staff follow policy and give the way the medication is ordered by the physician and written. I would expect that they call the physician to inform them the medication is late. The DON further indicated that she spoke to Staff A, (LPN) who told the DON that she did not have computer issues of going up and down, but rather that her computer was slow. A facility provided policy titled, Medication Administration Times, revision date 08/2018, Page 01 of 02 revealed under Procedure: 2. The Nursing Center may commence medication administration within sixty (60) minutes before the designated times of administration and sixty (60) minutes after the designated times of administration. And under Medication Administration read: Medications are administered in accordance with the following rights of medication administration, right time (including duration of therapy).

Based on observation, interviews, and policy review, the facility failed ensure 1) removal of expired medications from one (Med Bridge Hall) of two medication storage rooms observed; and 2) medications were secured in one (Medication Cart A, East Wing) of five medication carts observed. Findings included: On 8/12/2021 at 3:55 p.m. an observation was made of Medication Cart A located on the East Wing. In the seventh draw from the top of the medication cart was a loose blue capsule. Staff D, (LPN) confirmed the presence of the unsecured medication. On 08/12/2021 at 02:45 p.m., an observation was conducted on Med Bridge Wing's, medication room and medications stored in the refrigerator. During the observation four (4) brown plastic envelopes containing Aplisol 0.1 milliliters (ML) Syringe (PPD), were observed with pharmacy labels that had the resident name, and expiration date located on each one. Observation of two (2) medications found to have expiration date of 08/05/2021 and the other two (2) had expiration dates of 08/04/2021 and 08/08/2021 respectively. Staff C, Registered Nurse (RN) verified the presence of the expired medications Photographic evidence was obtained. On 08/12/2021 at 4:30 p.m., an interview was conducted with the Director of Nursing (DON). She was informed of the observations made, and the DON indicated she knew about the expired medications from Staff C (LPN), and stated, All loose medications must be disposed of in the medication carts, and all medications should be routinely checked by my staff and disposed of as the expiration date approaches. On 08/13/21 at 11:37 a.m. in an interview with the facility Pharmacy Consultant he stated The nurses are aware of the timeframe the medications should be administered. A review of the facility titled, Storage and Expiration Dating of Drugs, Biologicals, Syringes and Needles, with Revision Date 08/2018, Pages 01 to 03, included under Applicability: This section sets for the procedures relating to storage and expiration dates of drugs, biologicals, syringes, and needles, further read: 3. The Nursing Center should ensure that drugs and biologicals: Have not been retained longer than recommended by manufacturer or supplier guidelines. 9. The Nursing Center should ensure that the drugs and biologicals for each resident are stored in their originally received containers. 15. The Nursing Center should destroy or return all discontinued outdated/expired, return or deteriorated drugs or biologicals in accordance with Pharmacy return/destruction guidelines. 16. Nursing Center personnel should inspect nursing station storage areas for proper storage compliance on a regularly scheduled basis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 08/10/21 at 10:40 a.m. an interview with Resident #70 revealed she had voiced her dietary preferences to the facility but was not receiving the correct food items. Resident #70 stated she would receive food items on her tray that she had trouble digesting. A record review of Resident #70's admission Record Report revealed medical diagnoses of urinary tract infection, unspecified fractures, and disorder of the muscle. A record review of Resident #70's MDS [Minimum Data Set] 3.0, dated 06/22/21, revealed under Section C- Cognitive Patterns a brief interview for mental status [BIMS] score of 15; indicating an intact cognition with no behaviors of inattention, disorganized thinking, or altered mental status. Section G- Function Status revealed Resident #70 only required supervision with set-up help only for eating. A record review of Resident #70's CarePlan revealed a focus area of Nutritional status as evidenced by actual/potential weight loss/gain related to specific diet preferences ., created on 6/17/21, with interventions of Food Allergy/Intolerance/Preference: NO PORK, NO BEEF, NO SUGAR, NO SWEET TYPE DESSERTS, NO SAUSAGE/BACON, NO [NAME]/ NO SWEET N' LOW, NO FRIED FOODS . FOLLOW PATIENTS SELECT MENU . Provide diet as ordered . A record review of Resident #70's Nutritional Assessment, dated 6/21/21 revealed on page 6 that . Patient voiced multiple food related concerns, food preferences are in place . Patient reported hx [history] of gastric bypass surgery for weight loss. Patient commended that she avoids certain foods due to gi [gastrointestinal] tolerance . Continue current diet . Honor preferences . A review of Resident #70's meal ticket, dated 08/13/21, revealed under ALLERGIES listed sugar packets or sweet desserts . DISLIKES . gravy . During a meal observation on 08/12/21 at 12:01 p.m. an interview with Resident #70 revealed she was not sure what was on her tray because the meal ticket does not indicate the food items and sometimes, she can not tell what the food item is. At the beginning of the week a selection of meals for the following week is provided and the resident will circle what food item they want. Resident #70 stated she returned her meal selection listing for the week but .apparently they lost the package. An observation of the meal tray revealed a meal ticket placed on the tray without indication of what the food items were. On the meal ticket, Resident #70's allergies and dislikes were listed. An observation of the meal tray revealed a piece of chocolate cake (sweet dessert). Further observation revealed the chicken was covered in a mushroom gravy sauce. Photographic evidence was obtained of the meal tray. During the interview on 08/12/21 at 12:01 p.m. Resident #70 stated she is cognitive enough to not eat the cake, however, . what if they put something like that on a tray for someone that isn't able [cognitive]. Resident #70 stated that while her meal ticket states sweet treat is an allergy, it is more of her preferences to not have the item because she lost over 100 pounds and she prefers to not have the treat on her tray, so she won't be tempted to eat it. On 08/12/21 at 12:24 p.m. an interview with Staff M, Registered Nurse (RN) revealed resident not on a diet restriction are provided a menu with the food items for the following week. The resident circles what food item they want and then that document is given to the dietary department. Those residents that are on a diet restriction are not really given an option menu. Once the resident makes their choices the document goes to dietary and from there the nursing staff does not have any input. If the resident does not like the food item, then they do have the option to ask for an alternative item. The tray ticket will also indicate dislikes and preferences. If a tray has a food item that states allergy then the tray/food item should not be provided to the resident. If the resident gets an item, they dislike they may still be provided with the tray because they may still want the item, especially if they selected it. On 08/13/21 at 1:27 p.m. with the FSD, it was revealed that a resident's allergies are listed on the meal ticket and as the tray line is started, the staff member that is serving the food will be educated on what the resident should be receiving. The FSD said . If the resident says it is an allergy, then it is an allergy . The CNAs' will also double check the meal tray to make sure there is nothing on the tray that should not be there. Based observations, interviews, and record review the facility failed to ensure coordination among departments which resulted in the failure of the facility's food and nutrition services system for accommodation of food choices and preferences for two (Residents #141 and #70) out of six sampled residents. Findings included: 1. Resident #141 was observed during the lunch meal on 08/10/21 at 12:10 p.m. Observation of his lunch tray revealed a plate with an entrée selection, a cup of coffee, a cup of iced tea, a serving of pudding, and a chocolate flavor frozen nutritional treat. The only meal ticket present with the tray revealed the following information: no allergies; nutritional treat supplement; beverages iced tea and water; diet soft & bite-sized (SB6). There was no other information printed on the ticket. Resident #141 said he did not like chocolate and had told the facility, but they said they only had chocolate flavor (for the supplement). He said lunches were generally too heavy and not great but that he had to eat it because he had lost weight. He said he could not identify the food items on his plate and did not know if it was what he had ordered. He said the process for meal selection was he was given a printed menu by facility staff and circled the items he wanted. Photographic evidence obtained. Review of the medical record for Resident #141 revealed he was admitted to the facility on [DATE] with diagnoses that included adult failure to thrive. The Minimum Data Set, dated [DATE] revealed the resident required supervision for eating and had weight loss of 5% or more in the last month. There was no completed Brief Interview for Mental Status (BIMS), or other assessment related to cognition recorded in the MDS, however a social services progress note dated 07/28/21 revealed: Patient is alert and oriented w/ (with) some forgetfulness/confusion. Physician orders revealed enhanced diet soft and bite-sized texture and nutritional treat supplement three times a day for nutrition with meals. The nutrition assessment dated [DATE] revealed the resident was underweight, had involuntary weight loss, and .Recent weight loss proven of 8# (8 pounds)/5.6% since initial admit date .Patient was not responding to questions during visit. An interview was conducted with Staff Q, Dietetic Technician Registered, Certified Dietary Manager (CDM) on 08/12/21 at 2:52 p.m. She confirmed she performed nutrition assessments for residents upon admission to the facility and said, sometimes I get a lot of information and sometimes I don't .almost always my assessment involves food preferences. Regarding food preferences for Resident #141, Staff Q consulted notes in the Electronic Health Record (EHR) and said, he was not responding to questions is what I have in my note. She said she was not aware that he did not like chocolate. She said anyone could communicate resident food preferences to the kitchen and said her process was, I write recommendation sheets which is communicated to the kitchen .I don't know the process for other disciplines. Regarding the chocolate nutritional treat supplement for Resident #141 she said that if the kitchen was sending chocolate, they were probably not aware that the resident did not like chocolate. She said, I don't know what flavors are stocked available weekly. Review of Resident #141's medical record on 08/13/21 revealed an entry dated 08/13/21 7:52 a.m. made by Staff Q: Met with Patient after report that he does not care for chocolate flavors .asked Patient about report of dislike of chocolate and he agreed. Dietary notified of update . Resident #141 was observed during the lunch meal on 08/12/21 at 12:18 p.m. Staff O, Certified Nursing Assistant (CNA) was in the room providing delivery and setup of the meal tray. The tray contained a plate with entrée selection, a covered Styrofoam cup, a dessert item on a plate, and a chocolate flavor nutritional treat supplement. The resident could not identify the items on his tray. Staff O could not identify the items on the tray. The meal ticket on the tray did not list any of the food items and did not list any preferences regarding the nutritional supplement flavor. Staff O said she had noticed the meal tickets had been blank this week and she did not know why. She said normally the tray would come with the printed menu selections that the resident had circled so that the resident could identify their meal items. Staff O said she did not know what had changed. Photographic evidence obtained. An interview was conducted with the facility Dietary Services Director (DSD) on 08/13/21 at 1:27 p.m. He reported the facility had a process in place for select menus for residents to choose their food items and preferences for each meal. He said the kitchen printed a week of menus for each resident, the menus were delivered to each unit nurse's station and the nurse in charge was responsible to ensure the menus were delivered to the residents. He said the residents were to circle their choices and/or alternate preferences. He said after the residents completed their selections, the menus were either delivered to the kitchen by the nursing staff or, I will go and retrieve them from a wall sleeve at each nurse's station. The DSD said that the menus with circled selections made by the residents were transformed to the meal ticket that goes out on the tray .that menu that was circled becomes the ticket and goes back out with the tray. Observations made during survey were revealed and he said, without trying to point any fingers I think sometimes they (residents) may not get the menu or sometimes the menus might not be in their designated spot for us to pick up .the process should be that if I deliver them (menus) to the station then it's in the hands of the person in charge .if we don't get the tickets back then we can't follow what they chose .I think the problem is pretty clear. Regarding dietary staff role in assessing for resident preferences he said, my CDM assesses for resident preferences on admission, as needed, and quarterly. Regarding flavors of frozen nutritional treat supplements, he said, if the preferences are known we will of course honor that. A follow-up interview was conducted with the DSD on 08/13/21 at 2:05 p.m. He confirmed that Resident #141 should have received a select menu and had not received them that week and said, no clear answer as to why he didn't have them with his tray this week .probably because it didn't come back to us .we did not get them in the kitchen. He said, I don't have a checklist to see whose has come back and whose has not, that would be my responsibility, I rely on the staff to do their jobs, it's an imperfect thing. He revealed printed select menu tickets that should have been issued to Resident #141 on 08/13/21 and provided with his trays and confirmed they had not been provided to the resident. The tickets were for 08/13/21 and revealed the special instruction, no chocolate nutrition treats for all meals which did not match the ticket that was observed with Resident #141's tray during the lunch observation on 08/13/21. Review of concern forms filed on behalf of the resident council for June 2021 and July 2021 revealed concerns had been reported about meal preference selections. The concern form dated 06/01/21 revealed the concern, Resident not getting what they circled on menu had been assigned to the DSD for follow up on 06/02/21 and resolution was documented as ongoing meetings with residents would continue and additional follow up was needed. The concern form dated 07/07/21 revealed the concern, Don't always receive what was circled on menu had been assigned to the DSD for follow up on 07/16/21, concern was documented as resolved with the following note: attention to tray cards will continue to improve .spoke w/ (with) members of resident council. Review of facility policy titled Selective Menus dated 11/2020 revealed, Selective menus offer patients the opportunity to make choices in food selection and may improve intake of meals and customer satisfaction. The guidelines included: .Daily selective menus are distributed to patients who will participate in the selective menu program .A list of participating patients may be printed by sorting the patient view in Dietary eKardex by the selective menu column header. This list can be used to check off that a completed select menu has been returned to the kitchen .Completed menus may be dropped off at the kitchen office or a drop off box may be set up at each nursing station for the ease of collection .At the time of meal service, the competed selective menu tray tickets are combined with the non-select menu tray tickets and placed in serving order .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. A tour of the facility east wing was conducted on 08/12/2021 at 05:50 a.m. Prior to entering the unit a double door with a signage STOP was posted. The signage read, MUST HAVE N95 Mask and Face shield Prior to Entering Unit. During the tour, an observation was made of Staff F, RN wearing a surgical mask. The mask was not covering her nose and was loose fitting around her ear. In addition, Staff F was not wearing a face shield. An interview was conducted on 08/12/2021 at approximately 05:51 a.m. with Staff F following the observation. Staff F, RN stated that she is aware of the signage posted, but she is not able to breathe effectively when wearing a N95 mask. She stated that she did not inform the facility of not being able to breathe when wearing a N95 mask. Staff F stated that she was not taking care of the resident on airborne precautions and did not think it was necessary to wear a face shield. On 08/12/21 at approximately 05:55 a.m. Staff E, Dietary Aide was observed entering facility lobby, she had no mask on. Staff E then opened the door to the main entrance of the facility to enter. Staff E was not wearing a mask upon attempt to enter the main entrance. In addition, she was not screened for signs and symptoms of COVID-19 upon entering the facility lobby. In an interview with the Staff E at approximately 5:56 a.m. on 08/12/2021. She stated that she has been working at the facility for a month and had never worn a mask upon entering the facility prior to getting to her assigned department. She stated that she usually does self-screening in the lobby area for COVID-19 but confirmed that this morning she did not. Signage was observed posted on the facility entrance related to cough etiquette, and face mask to be worn upon entrance to facility. On 08/12/21 07:17 a.m. an interview with the facility DON and the NHA revealed the expectation is for staff to wear the appropriate PPE in the designated areas. The DON and NHA stated that they expect staff and visitors to wear a mask upon entering the facility, and to be screened in the lobby area for COVID-19, before entering the main facility area. Based on observation, interview, record review, and Centers for Disease Control and Prevention (CDC) recommended infection control guidelines, the facility failed to ensure infection control practices during an active COVID-19 facility outbreak were followed related to 1) donning of personal protective equipment (PPE) prior to entering designated COVID-19 person under investigation (PUI) rooms (307, 312, and 357); and 2) ensuring all direct care staff wore a well-fitted face mask while inside of the facility on two (300 hall and East Wing) of three hallways observed. Findings included: 1. An observation on 08/12/21 at 5:36 a.m. revealed personal protective equipment (PPE) requirement signage posted on the double entrance doors into the 300-unit hallway. The signage stated an N95 & [and] Face Shield Required Prior to entering unit. Photographic evidence obtained of the signage. Upon entering the 300-hallway unit, an observation on 08/12/21 at 5:37 a.m., revealed Staff G, Certified Nursing Assistant (CNA) entering room [ROOM NUMBER]. Signage posted on the room door stated, AIRBORNE DROPLET PRECAUTION with instructions of Upon Entry into Room: -Gown - Face Shield - N95 Mask. IN Room: -Cleanse Hands - Apply Gloves for Direct Care - Offer Resident a Mask. BEFORE you EXIT Room: -Remove Gown & Gloves -Cleanse Hands. Photographic evidence was obtained. Staff G CNA wore a surgical mask; the staff member did not don an N95 mask or face shield. Upon entering the room, Staff G closed the door. An observation on 08/12/21 at 6:07 a.m., revealed Staff G, CNA walking down the 300-unit hallway without a face shield or N95 mask donned; Staff G, CNA was wearing a surgical mask. During an immediate interview with Staff G, CNA, she stated while working on the 300-unit an N95 mask and face shield are required. She further said upon entering a designated airborne droplet precaution room, the requirements are to don additional PPE of a gown and gloves. Staff G stated she has an N95 mask that the facility provides, which is stored in the front of the facility in a designated brown bag. Immediately following the interview on 08/12/21 at 6:07 a.m., Staff G, CNA was observed entering room [ROOM NUMBER] again which had the AIRBORNE DROPLET PRECAUTION signage still posted on the door and a PPE caddy placed outside the door with gowns. Staff G, CNA was overheard speaking to the resident stating she would be assisting with draining the catheter bag. Staff G, CNA was observed standing inside room [ROOM NUMBER]'s bathroom. Staff G, CNA did not don an N95 mask, face shield, or gown prior to entering the room. Staff G, CNA closed the room door. 2. An observation on 08/12/21 at 5:37 a.m. revealed Staff E, CNA walking in the 300-unit hallway without a face shield, or face mask of any kind covering her nostrils and mouth. Staff E was observed walking behind the nursing station prior to walking down the hallway and entering room [ROOM NUMBER], which had a call light turned on. An observation of room [ROOM NUMBER] revealed signage posted on the room door as AIRBORNE DROPLET PRECAUTION. Photographic evidence obtained. Staff E, CNA did not don any PPE, including a face shield, N95 mask, or gown, prior to entering room [ROOM NUMBER]. Staff E, CNA exited the room and walked back to the 300-unit nursing station. Staff E, CNA began speaking to Staff J, Licensed Practical Nurse (LPN) regarding how to turn off the doorbell alarm. Staff J, LPN provided Staff E, CNA with instructions on how to turn off the alarm prior to walking back to her medication cart. During this conversation, Staff E, CNA did not have on a face shield or face mask of any kind covering her mouth or nostrils. Staff J, LPN did not instruct Staff E, CNA to don the appropriate PPE requirements for the 300-unit hallway. During the continued observation on 08/12/21 beginning at 5:37 a.m., after speaking with Staff J, LPN, Staff E, CNA walked down the 300-unit hallway and entered room [ROOM NUMBER]. Staff E, CNA was overheard talking to a resident. Upon looking into the resident's room, Staff E, CNA was observed standing within 6 ft of the resident and was touching the resident's bed. Staff E, CNA was not wearing a face shield or mask of any kind while interacting with the resident. During an interview on 08/12/21 at 5:45 a.m., Staff E, CNA said sorry . I am doing a million things right now. Staff E stated she was unsure where she placed her face mask, N95 mask, and face shield. She stated she was currently assigned to 12 residents. She said upon arriving to the facility, the night supervisor provided instructions on what the PPE requirements were while working on the 300-unit. She stated she might have left her face shield and N95 mask in the bathroom. Finally, Staff E, CNA stated she went out to her car earlier and must have left her required PPE in the car. During this interview, Staff I, Registered Nurse (RN) was observed watching the interview while standing by a medication cart. 3. An interview on 08/12/21 at 5:52 a.m. with an assigned 300-hallway nurse, Staff I, Registered Nurse (RN), revealed that while working on the 300-unit a face shield and N95 mask are required due to residents that are actively infected with COVID-19. The requirement is that should a staff member be observed on the unit without a face shield or mask, they must be instructed to don the appropriate PPE. Staff I, RN stated he had not seen Staff E, CNA without PPE. An interview on 08/12/21 at 6:00 a.m. with Staff J, LPN revealed the PPE requirements while working on the 300-unit is to have an N95 mask and a face shield on. If a staff member is entering an airborne droplet precaution room, then they are required to don additional PPE of a gown and gloves. Staff J, LPN stated if a staff member were observed without any PPE on such as a N95 mask, surgical mask, or face shield then she would instruct the staff member to don the items and ask them if they needed assistance in finding an N95 mask and face shield. An interview on 08/12/21 at 7:04 a.m. with the Director of Nursing (DON) and Nursing Home Administrator (NHA) revealed there are COVID-19 positive residents in the facility. The PPE requirements for the 300-unit hallway is to always wear an N95 mask and face shield. The employees have personal bags stored in the dining room where they can keep their N95 mask and face shield. Those rooms designated as AIRBORNE DROPLET PRECAUTION are for residents considered to be persons under investigation (PUI) for COVID-19 due to being new admissions who have not been vaccinated for COVID-19. When entering one of these designated rooms, additional PPE of a gown and gloves are required. To ensure staff are wearing their PPE appropriately on the unit, the nurses on the floor are the main line of defense. 4. A record review of COVID-19 PREVENTION Please follow these tips when in our facility, not dated, revealed Maintain Social Distancing . Wear A Mask . A record review of Personal Protective Equipment Usage Guide, dated 06/17/21, revealed under section Mask revealed . N-95 Respirator . WHEN TO USE: Procedure masks or surgical masks are used for center/community staff under universal masking criteria N-95 respirators are used: . When providing care or services within (6) feet of patients with suspected or confirmed COVID-19 in transmission-based precautions including new admissions for quarantine period . Under section Face Shield/Goggles revealed . Full Face Shield . WHEN TO USE: Full-face shields are worn when providing direct care activities where splashes and sprays are anticipated as aerosol generating procedures or prolonged face-to-face or close contact with a potentially infections patient as with any patient in airborne droplet isolation. Must be used when providing care or services within six (6) feet of patients with suspected or confirmed COVID-19 in transmission-based precautions including new admissions for quarantine period . A policy review of Airborne Precautions, dated 07/2021, revealed Special air handling and ventilation required for airborne precautions is not routinely available in centers. Airborne transmission occurs by dissemination of either small [less than or equal to] 5 micron airborne droplet nuclei remaining suspended in the air for long periods of time or dust particles containing the infectious agent. Microorganisms carried in this manner can be widely dispersed by air currents and may become inhaled within the same room or over a longer distance depending on environmental factors . A policy review of Droplet Precautions, dated 07/2021, revealed Droplet transmission involves droplets generated by the individual during coughing, sneezing, and talking or during the performance of certain procedures, such as suctioning. Transmission occurs when droplets containing microorganisms generated from the infected person are propelled a short distance through the air and deposited on the susceptible conjunctiva, nasal mucosa, or mouth. Special handling and ventilation are not required . In addition to standard precautions, the following measures are necessary for droplet precautions . Mask . Wear a mask when within six (6) feet of the patient . Apply mask upon entering the patient room and remove mask upon exiting the patient's room and immediately wash hands with antimicrobial agent or use alcohol-based hand sanitizer. Avoid touching from of mask during removal as it is considered contaminated . Goggles . Wear goggles if likelihood of exposure during care . Remove goggles and immediately wash hands with an antimicrobial agent or use alcohol-based hand sanitizer. Avoid touching front of mask during removal as it is considered contaminated. A review of Centers for Disease Control and Prevention (CDC) Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes, updated March 29th, 2021, under section Personal Protective Equipment, revealed . Facilities should have policies and procedures addressing . Which PPE is required in which situations (e.g., residents with suspected or confirmed SARS-CoV-2 infection, residents placed in quarantine) .? The fit of the medical device used to cover the wearer's mouth and nose is a critical factor in the level of source control (preventing exposure of others) and level of the wearer's exposure to infectious particles. Respirators offer the highest level of both source control and protection against inhalation of infectious particles in the air. Facemasks that conform to the wearer's face so that more air moves through the material of the facemask rather than through gaps at the edges are more effective for source control than facemasks with gaps and can also reduce the wearer's exposure to particles in the air. Improving how a facemask fits can increase the facemask's effectiveness for decreasing particles emitted from the wearer and to which the wearer is exposed . Further review of the CDC Infection Control for Nursing Homes, updated March 29th, 2021, under sub-section Manage Residents with Suspected or Confirmed SARS-CoV-2 Infection [COVID-19], revealed .Residents with suspected or confirmed SARS-CoV-2 infection do not need to be placed into an airborne infection isolation room (AIIR) but should be cared for HCP using an N95 or higher-level respirator, eye protection (i.e., goggles or a face shield that covers the front and sides of the face), gloves, and gown .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure acceptable parameters of nutritional status by failing to identify and address significant weight loss for one (Resident #67) of 4 residents reviewed for nutrition. Findings included: Resident #67 was observed on 11/20/2019 at 11:46 AM self-propelling in her wheelchair in the hallway near the nurse's station. A staff member was overheard redirecting the resident back to her room to eat lunch. At 12:10 PM on 11/20/2019, Resident #67 was observed being served their lunch tray in their room by a Certified Nursing Assistant (CNA) who assisted them with setup. At 5:19 PM on 11/20/2019, Resident #67 was observed in her room with her dinner tray. She stated that she had finished eating. Her completed tray was observed with an empty container of cranberry juice, a sandwich with a few bites taken, and two containers of fruit that appeared untouched. Resident #67 stated that she was not hungry. A review of the medical record for Resident #67 revealed an initial admit date of 09/25/2019, current admission date of 11/07/2019 with diagnoses including dementia, chronic diastolic congestive heart failure (CHF), and chronic kidney disease. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Inventory of Mental Status (BIMS) score of 5 which indicated severe cognitive impairment. Section K of the most recently completed MDS dated [DATE] (discharge/return anticipated assessment) revealed no significant weight loss and no specialized nutrition approaches. A review of the active physician orders revealed the following: no added salt diet, regular texture, add 6-8 ounces fluids to each meal tray start date 09/26/2019; offer snack at bedtime start date 10/04/2019; daily weights, if greater than 2 pound (lb) weight gain in one day or greater than 5 pound (lb) weight gain in one week call medical doctor (MD) or nurse practitioner (NP). A review of the weights for Resident #67 revealed a weight of 121.4 lbs on 9/26/2019, weight of 118.9 lbs on 10/26/2019, and a weight of 110.6 lbs on 11/21/2019. The Resident's weight loss entered the 5% significant loss range on 11/13/2019 when weight was recorded at 115.7 lbs, and a 7.5% change on 11/19/2019 when weight was recorded as 112.2 lbs, utilizing the admitting weight of 121.4 lbs on 09/26/2019. A review of the care plan for the resident revealed focus area, .potential for weight loss/gain related to chf, therapeutic diet, meal intake, age. The care plan goal was for the resident to experience no significant weight change and interventions included, Review weights and notify physician and responsible party of significant weight change. On 11/21/2019 at 9:44 AM, Resident #67 was observed asleep in bed, dressed in a hospital gown. Interview with the Resident's assigned CNA, Staff A, on 11/21/2019 at 9:47 AM revealed the resident had eaten 50% of her breakfast that morning and confirmed that the resident did not have a good appetite. Staff A stated that she provided the resident with cueing, reminders, and encouragement to eat, and offered snacks, which the resident generally did not accept. Staff A reported that the CNA staff were responsible for tracking meal intake and the process was to calculate upon removal of the meal tray and document in the electronic health record (EHR). Staff A stated that Resident #67 was not on any nutritional supplements but that she (Staff A) had brought it up to nursing staff including that morning. A lunch meal observation of Resident #67 was conducted on 11/21/2019 at 12:23 PM. The resident was observed to be eating from her lunch tray in her room and stated that she was enjoying her meal. Items observed on the resident's tray included what appeared to be pork, baked beans, broccoli, a slice of bread, and a slice of pound cake. Photographic evidence of the tray was obtained while the resident was eating and after she had finished eating. Intake was estimated at approximately 25%. A review of Resident #67's meal intake records over the last 30 days was conducted and revealed a steady decline in intake percentage and an increase in meal refusals beginning 11/3/2019 and including the following refusals: dinner 11/3; breakfast 11/5; breakfast and lunch 11/9; all meals 11/16; breakfast 11/19, dinner 11/21. The average intake across meals based on recorded data in the EHR for the date range of 10/24/2019 through 11/21/2019 was 48.8 percent. A review of dietary assessments and progress notes revealed an admission assessment initiated 09/30/2019 and signed by Staff C, Registered Dietician on 10/01/2019. The assessment documentation included the following: diet order for no added salt, regular texture; supplement not applicable (N/A); nutrition problem of inadequate oral food/beverage intake; average meal intake of 26-50 percent; plan for weekly weights; goal of no significant weight change by next review. No other dietary assessments or progress notes were present in the medical record for Resident #67. On 11/22/2019 at 10:31 AM Staff B, Registered Nurse (RN), Unit Manager (UM) was interviewed. She consulted the medical record for Resident #67 and confirmed the weight loss, stating that she thought it was because of her dementia. Staff B reported that the facility dietician reviewed the resident's case but was unable to reveal any assessments or progress notes except for the admission assessment. Staff B confirmed that no nutritional supplements or other interventions were in place for Resident #67. A telephone interview was conducted on 11/22/2019 at 10:44 AM with Staff C, Registered Dietician (RD). She described her general process for addressing weight loss as the following: weekly weight reviews usually on Mondays or Tuesdays, monthly weights, and watching for patterns with weight loss. Staff C reported that weight loss of 5% would trigger her to intervene and additionally that she would usually intervene at a 4lb weight loss. Staff C did not wish to discuss details of Resident #67 over the phone, stating that Staff D, Certified Dietary Manager (CDM) would be able to provide that information. Staff D was interviewed on 11/22/2019 at 10:50 AM. She consulted the medical record for Resident #67 and confirmed that a dietary assessment had been completed for the resident upon admission to the facility. She described the process of intervention sharing between herself and Staff C, the RD, as the following: Staff D, CDM, started all resident assessments upon admission; Staff C, RD, was the decision maker on all clinical aspects/needs/interventions; following the resident's admission dietary assessment, a quarterly and annual assessment was also completed; every Tuesday a weight calculation report was pulled and reviewed for significant weight loss triggering the need for dietary intervention. The CDM revealed the weight calculation report for Resident #67 and confirmed that a significant triggering 5% weight loss had registered on 11/13/2019 and that weight loss had continued through the present time. The CDM consulted the medical record for Resident #67 and confirmed that the only assessment/intervention for this resident had been the admission assessment. Staff D confirmed that no dietary interventions had been started with Resident #67 and should have been. The CDM stated, if I just saw it [significant weight loss] today without you telling me, I would have gone to ask the resident if she would accept a supplement, request orders through Staff B, and flag the Resident on a list for the RD to review/assess. The CDM stated that following the interview she would go directly to Resident #67 and offer a nutritional supplement, flag the case for the RD to review, and update the care plan. On 11/22/2019 at 11:04 AM, the Director of Nursing was informed about the finding. A facility policy regarding nutritional intervention process was requested and the CDM provided a policy titled, Medical Nutrition Therapy and Documentation dated September 2014. The policy revealed the following under the heading Monitoring: Patients are evaluated when changes in condition occur .Monitoring of nutritional status is documented in a nutrition/weight type progress note. Monthly or more frequent monitoring or documentation is suggested for patients who are .experiencing significant weight changes or trends.