Deficiency Text Not Available

Deficiency Text Not Available

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately transcribe physician orders received from a transferring facility upon admission to the facility for one resident (Resident #18), in a review of 18 sampled residents. The resident admitted with physician orders to receive medications to treat anxiety and depression, and did not receive the medications for 14 days. The resident reported experiencing depressed mood and significant mood fluctuations as a result of not receiving the medication. The facility census was 56. Review of Drugs.com on 06/05/25 showed the following: -Buspar is an anti-anxiety medicine that affects chemicals in the brain that may be unbalanced in people with anxiety; -Take Buspar exactly as prescribed; -If switching anxiety medication, the resident may need to slowly decrease the dose of the other medication rather than stopping suddenly; Some anxiety medications can cause withdrawal symptoms when you stop taking them suddenly after long-term use; -Depakote affects chemicals in the body that may be involved in causing seizures; also used to treat manic episodes related to bipolar disorder (manic depression); -Do not stop using this medicine without physician's advice; stopping suddenly may cause a serious, life-threatening type of seizure; -Take exactly as prescribed. Review of the facility policy, admission Process, Assignment of Primary Diagnosis, revised on 12/01/22, showed the following: -A Licensed/Registered Nurse will ensure that all admission paperwork, including physician orders and medications are followed; -All physician orders are noted and followed per policy. Review of the facility policy, Transcription of Orders/Following Physician Orders, revised 05/18/24, showed the following: -The purpose of this policy is to outline procedures in accurately transcribing physician's orders and to ensure that all physician orders are followed. To ensure a process is in place to monitor nurses in accurately transcribing and following physician orders. -Upon receiving a physician's order via telephone, fax, written order, verbal order, transcribed order or other, it will be documented in residents' electronic medical records in the orders section; -Clarification of physician orders will be obtained if the order is either unclear or the nurse is uncomfortable in implementation of the physician orders. 1. Review of Resident #18's referral packet, dated 03/03/25, showed the following: -The resident had a physician's order for Buspar HCL (a medication used to treat anxiety disorder) tablet 5 milligram (mg), give one tablet twice daily for anxiety (original order dated 02/12/25); -The resident had a physician's order for Depakote (a medication used to treat seizure disorder that is also used to treat mood disorders) tablet delayed release 125 mg, give one capsule one time a day for depression (original order dated 02/12/25). Review of the resident's admission record showed the following: -He/She admitted to the facility on [DATE]; -His/Her diagnoses included post-traumatic stress disorder (PTSD; a mental health condition that can develop after experiencing or witnessing a traumatic event that involves actual or threatened death, serious injury, or a threat to physical integrity), major depressive disorder (a mental health condition characterized by persistent feelings of sadness, emptiness, and a loss of interest or pleasure in activities), anxiety disorder (a group of mental health conditions characterized by excessive and persistent worry or fear that is disproportionate to the actual threat or situation), and borderline personality disorder (a personality disorder characterized by a pattern of unstable relationships, self-image, and emotions, leading to difficulties with interpersonal relationships, impulsivity, and self-harm). Review of the resident's progress notes, dated 03/26/25 at 7:06 P.M., showed Licensed Practical Nurse (LPN) A documented the following: -The resident arrived to the facility at 4:00 P.M. via facility transportation; -He/She arrived with his/her medications from his/her previous facility; -His/Her orders were put into the electronic health record. Review of the resident's physician's orders, dated March 2025, showed no documentation staff transcribed the orders for Buspar HCL and Depakote upon the resident's admission to the facility. Review of the resident's Medication Administration Record (MAR), dated March 2025, showed the following: -No documentation the resident received Buspar on 3/26/25 through 3/28/25; -No documentation the resident received Depakote on on 3/26/25 through 3/28/25. Review of the resident's progress notes, dated 03/28/25 at 2:10 P.M. showed the resident told the Social Services Director (SSD) that he/she had not received all of his/her medications. During an interview on 05/29/25 at 12:40 P.M., the SSD said the following: -The resident reported to her that he/she had not been getting some of his/her medications, and she reported it to the charge nurse (LPN A) right away; -The resident seemed more depressed; the resident was in a new facility and it was much smaller, in a more rural area than the resident expected, and the resident said there was nothing to do. Review of the resident's MAR, dated March 2025, showed the following: -No documentation the resident received Buspar on 03/29/25 through 03/31/25; -No documentation the resident received Depakote on 03/29/25 through 03/31/25. Review of the resident's physician's orders, dated April 2025, showed no documentation staff transcribed the orders for Buspar HCl and Depakote received upon the resident's admission to the facility. Review of the resident's MAR, dated April 2025, showed the following: -No documentation the resident received Buspar on 04/01/25 through 04/08/25 (a total of 14 days); -No documentation the resident received Buspar on 04/01/25 through 04/08/25 (a total of 14 days). Review of the resident's psychiatric note, dated 04/09/25, showed the following: -The resident presented as guarded and displayed limited engagement; -He/She reported experiencing depressed mood and significant mood fluctuations; -He/She expressed concern about not receiving his/her previously prescribed medications, specifically Buspar and Depakote, which he/she said were effective for him/her at his/her previous facility; -His/Her guarded presentation suggests underlying distress; -Given his/her reported history and current symptoms, the following medications were restarted: Buspar 5 mg by mouth twice daily for anxiety and depakote sprinkles 125 mg, two capsules at bedtime for mood stabilization and depressive symptoms. Review of the resident's physician orders, dated April 2025, showed the following: -Buspar HCI oral tablet 5 mg, give one tablet by mouth two times a day related to major depressive disorder (order dated 04/09/25); -Depakote oral tablet delayed release 125 mg, give two capsules by mouth at bedtime related to major depressive disorder (order dated 04/09/25). During an interview on 05/19/25 at 2:00 P.M., the resident said the following: -He/She didn't receive Depakote or Buspar for several weeks after he/she first arrived at the facility; -He/She had behaviors and depressed mood because of not receiving his/her medications; -He/She told staff about the missing medications and they did nothing about it. During an interview on 06/03/25 at 8:28 A.M., LPN A said the following: -He/She entered the physician orders the resident brought with him/her into the electronic medical record; -He/She wasn't aware the resident was missing any orders for medications; -The resident nor the SSD reported to him/her that any medications were missing; -The resident had not reported any increased depression. During an interview on 06/03/25 at 10:57, the Assistant Director of Nursing (ADON) said the charge nurse (LPN A) was responsible for ensuring the admission paperwork, including the physician orders for the resident's medications, were entered and followed. During an interview on 05/21/25 at 2:25 P.M., the Medical Director said the following: -Buspar or Depakote should not be be stopped abruptly; -If the resident was on the medications at another facility, both of the medications should be continued upon admission; -If there was any question or discrepancy in orders, he would have expected the nurse to call him to clarify.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure staff treated residents with dignity and respect for four residents (Residents #1, #2, #3, and #6) in a review of nine sampled residents. Residents described staff as being rude, disrespectful and were loud, snappy, and yelled at them. Others described staff as talking down to them, scolding them and making them feel stupid while others said staff mocked and made fun of them, calling them a liar, and making them feel terrible, angry, frustrated, and not like home. The census was 56.Review of the facility policy, Resident's Rights - Missouri, last revised 7/2023 showed the following:-A resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. The facility must protect and promote rights of each resident, including each of the following rights:- The resident has the right to voice grievances without discrimination or reprisal. Such grievances include those with respect to treatment which has been furnished as well as that which has not been furnished;-A resident has the right to be free from verbal, sexual, mental, and physical abuse;-A resident is treated with consideration, respect, and in full recognition of his/her dignity and individuality. 1. Review of Resident #3's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, completed by the facility, dated 06/10/25, showed the following:-Cognitively intact;-Ability to understand others and to be understood;-No delirium, no psychosis, and no behaviors;-Feeling down, depressed, hopeless two to six days;-Feeling bad about self, like a failure or have let self or family down seven to eleven days. Review of the resident's care plan, last revised 07/08/25, showed the following:-Diagnoses included anxiety disorder (persistent worry) and major depressive disorder (serious mood disorder);-Resident has manifestations of behaviors related to his/her mental illness that may create disturbances that affect others;-Acknowledge the resident's concerns. During an interview on 07/15/15 at 12:54 P.M., the resident said the following:-One (unnamed) staff speaks to him/her like he/she was five years old; -It made him/her feel like a child and like he/she had been scolded;-Licensed Practical Nurse (LPN) C was horrendous and had a horrible bedside manner;-LPN C yelled, cursed, and targeted residents; -LPN C was always disrespectful when speaking to him/her and others; -He/She had observed/heard Nurse Assistant (NA) D talk down to Resident #4 when the NA yelled, Why did you pee yourself again? You know better! This happened in the hallway; he/she was the only witness to this incident;-The Administrator had called him/her a liar; -It made him/her feel terrible. 2. Review of Resident #1's annual MDS, dated [DATE], showed the following:-Ability to understand others and to be understood;-Cognitively intact;-No delirium;-No psychosis, no behaviors. Review of the resident's care plan, last revised 05/28/25, showed the following:-Diagnoses included major depressive disorder and anxiety;-Monitor, document, report any signs of depression including hopelessness, anxiety, sadness, verbalization or tearfulness, loss of pleasure and interest in activities, risk to harm self or others. During an interview on 07/15/25 at 10:20 A.M., the resident said the following:-Staff in general could be rude and disrespectful;-NA D was loud and snappy at times;-All staff talked to resident like they were stupid;-Some staff yelled and mocked him/herself and other residents; -He/She had not reported as he/she would be threatened, and it would be held against him/her; -Staff treatment of residents upset him/her and made him/her feel like he/she was in a concentration camp, not a home;-LPN C was the worst of all. 4. Review of Resident #2's annual MDS, dated [DATE], showed the following:-Cognitively intact;-Ability to understand others and to be understood;-No delirium;-No psychosis, no behaviors;-Feeling down, depressed, hopeless two to six days;-Feeling bad about self or like he/she was a failure or has let self or family down seven to eleven days. Review of the resident's care plan, last revised 07/15/25, showed the following:-At risk for impaired social interaction and ineffective coping skills related to bipolar diagnosis;-Emotional distress triggered by overwhelming emotions or feelings or memories;-Allow time to vent with staff of any concerns or feelings;-Provide opportunities for expression of feelings related to situational stressors. During an interview on 07/15/25 at 12:45 P.M., the resident said the following:-Staff, including the administrator, yelled and cursed at him/her and other residents; -LPN C was the worst by far. LPN C mocked and made fun of residents. LPNC will make accusations and laugh at residents making sure they could hear him/her. -LPN C had just done this to him/her;-Staff had called him/her a liar; -It made him/her angry and frustrated;-Everyone had reported staff treatment, but nothing changed. 5. Review of Resident #6's quarterly MDS dated [DATE] showed the following:-Moderately impaired cognition;-No delirium, no psychosis. During an interview on 07/15/25 at 9:55 A.M., the resident said about two weeks ago, he/she overheard and witnessed Certified Medication Technician (CMT) B yell at a resident in the dining room. CMT B could have an attitude. This made him/her feel upset for the other resident and him/herself. 6. Review of Resident #5's admission MDS, dated [DATE], showed the following:-Cognitively intact;-Ability to understand others and to be understood;-No delirium, no psychosis;-Feeling down, depressed, hopeless two to six days;-Feeling bad about self, like a failure or has let self or family down seven to eleven days. Review of the resident's care plan, last revised 07/15/25, showed his/her diagnoses included generalized anxiety disorder. During an interview on 07/15/25 at 12:40 P.M., the resident said the following:-Staff talked down to residents like they were children; -He/She had experienced it by many staff;-The worst was LPN C. 7. During an interview on 07/15/25, an anonymous staff member said the following:-A lot of residents had reported they were afraid to ask CMT B for anything due to his/her reaction to them;-CMT B talked down to residents and was aggressive;-One resident said CMT B was aggressive and he/she would not ask this staff for anything because of the way CMT B spoke to and treated him/her and other residents. He/She would refuse to take his/her medications from CMT B;-He/She had never reported this to anyone because he/she was afraid to lose his/her job. 8. During an interview on 07/17/25 at 2:18 P.M., the Director of Nursing said the following:-Staff should speak to residents in an appropriate tone, professionally and respectful;-Staff should not curse at or in front of residents;-Staff should not mock residents or talk down to them like they are toddlers;-No residents/staff had reported incidents of staff mistreatment to him/her; -Residents should not be fearful of retaliation;-Staff receive resident rights and abuse/neglect training with orientation and quarterly, or more often. During an interview on 07/17/25 at 2:30 P.M., the Administrator said the following:-Staff should speak to residents with dignity and respect. They have been in-serviced on this multiple times;-Staff should not curse at residents or in front of them;-Staff should not mock, yell or talk down to residents like they are toddlers;-Resident #3 had complained of LPN C talking to him/her like he/she was a toddler this morning; -All staff are given a copy of resident rights and abuse/neglect policy upon hire, and they sign they have reviewed and understand. 1588544

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement behavioral health interventions to ensure the physical and psychosocial well-being of two residents (Resident #1 and #2), in a review of four sampled residents. Staff identified Resident #1, who had diagnoses of anxiety and depression, had a language/communication barrier and became agitated when unable to communicate effectively and was not aggressive unless provoked. The facility failed to identify meaningful interventions to address the root cause of the resident's behaviors, and the facility did not ensure an effective means for the resident to communicate his/her needs which resulted in increased agitation. On 2/24/24, the resident became agitated when unable to have a second slice of pizza. Staff administered a medication (that was not ordered to treat the resident's anxiety) to treat the resident's agitation. Staff failed to identify the root cause of the resident's behavior and develop interventions to address the root cause. On 3/9/24, the resident was involved in a physical altercation after Resident #2 (roommate) would not move from the doorway as Resident #1 entered the room. Resident #2 pushed Resident #1 which resulted in Resident #1 hitting Resident #2 multiple times in the head and upper body. During evaluation at the hospital on 3/9/24, Resident #1 reported Resident #2 had exposed himself/herself and performed self-sexual activities in front on him/her and attempted multiple times to touch him/her and his/her possessions afterwards. This made Resident #1 very upset. Resident #1 felt uncomfortable around Resident #2 and as a result became agitated. Resident #1 was placed on an antipsychotic medication for agitation and sleep. Prior to the incident on 3/9/24, staff identified Resident #2 took Resident #1's belongings, which upset Resident #1, however, no interventions were implemented to prevent further incidents. Staff identified Resident #2 instigated incidents and provoked other residents. The facility failed to identify meaningful interventions to address the resident's behaviors directed towards other residents. Staff discussed imposing interventions with the resident's increased behaviors, including setting limits on activities the resident enjoyed. The facility census was 60. Review of the facility policy, Initial Psychosocial History, last reviewed/revised on 1/19/22, showed the following: -Purpose of the policy was to ensure that a comprehensive social history was completed on all residents. The social history was imperative to provide key information to develop an individualized plan of care that addressed the resident's physical, mental, and psychosocial well-being; - The social services director (SSD) would complete the initial psychosocial history on all residents within 72 hours of admission, excluding weekends and holidays; -The facility would recognize that each person was unique and were entitled to basic rights. The SSD would adopt a holistic perspective by recognizing that each resident had individualized needs that interplay to a positive wellbeing which included social, psychological, physical, and spiritual; -The initial psychosocial history form included identifying information, family and relationships, occupational and educational history, marital history, activities of daily living skills and preferences, psychosocial assessment, socialization and support systems, legal history, admission to facility, medical and psychiatric history, special considerations, and discharge planning; -The SSD, to ensure a holistic approach, would also review and include pertinent information in the initial psychosocial history from the PASARR (if applicable), nursing assessment, history and physical, resident interview, and family/guardian interview; -Once the initial psychosocial history was completed, the SSD would meet with the administrator and/or the director of nursing (DON) to communicate findings, discuss plan of care needs and ensure all immediate care needs were met; -Each weekday morning, the SSD would bring completed initial psychosocial history forms or a list of completed in the electronic medical record (EMR) to the morning meeting and review with the interdisciplinary team (IDT) to address development of the individualized plan of care. Review of the facility's policy, Behavioral Emergency, dated 1/5/23, showed the following: -Purpose of the policy was to provide safe treatment and humane care to the resident in a behavioral crisis, to ensure that the resident was not being coerced, punished, and disciplined for staff convenience; -The guardian would be notified and imposed limitations may be placed on the resident, including hospitalization or other special directives; -Documentation of behavior emergencies would include evaluation of the resident's behavior, including consideration for precipitating events or environmental triggers, and other related factors in the medical record with enough specific detail of the actual situation to permit underlying cause identification to the extent possible, not identifying or attempting to identify the root causes of the behavior and not revising the plan of care with measurable goals and interventions to address the care and treatment for a resident with behavioral and/or mental/psychosocial symptoms; The licensed nurse would document the behavioral emergency in the medical record by utilizing the BIRPEEEE documentation guidelines a) B = Behavior; define the behavior; b) I = intervention; document interventions, note behavior emergency policy and document interventions from the behavioral emergency policy; c) R = Reaction/Response; document reaction and response of resident after interventions; d) P = Plan; continue current plan of care, continue observation/monitoring of resident; e) E = Evaluation; f) E = Evaluation; g) E = Evaluation; h) E = Evaluation. 1. Review of Resident #1's level one Preadmission Screening and Resident Review (PASARR), a screening process for individuals prior to admission into a nursing facility to determine if they have a serious mental illness and/or intellectual disability/developmental disability, dated 12/11/20, showed the following: -Recent medical incidents included a Grade II left temporal (highly associated with memory skills. Left temporal lesions result in impaired memory for verbal material) meningioma (meningioma is a tumor that grows from the membranes that surround the brain and spinal cord, called the meninges) status post craniotomy (is the surgical removal of part of the bone from the skull to expose the brain) with residual effects including altered mental status; -His/Her primary language was Spanish; -He/She was oriented to person and place; -His/Her memory was fair; -Diagnoses included anxiety disorder, depressive disorder, malignant (cancerous) neoplasm of the cerebral meninges, and aphasia following cerebral infarction (stroke); -Medication regimen included duloxetine (antidepressant medication) and trazodone (anti-anxiety medication); -He/She showed no signs of mental illness; -He/She had not received intensive psychiatric treatment in the previous two years. Review of the resident's hospital records, dated 12/20/23, showed the resident's medical history included peripheral artery disease ( the narrowing or blockage of the vessels that carry blood from the heart to the legs), stroke, resection of meningioma, altered mental status, aphasia (loss of ability to understand or express speech, caused by brain damage), and encephalomalacia ( is a localized softening of the substance of the brain, due to bleeding or inflammation); Review of the resident's face sheet showed the following: -He/She was admitted to the facility on [DATE]; -He/She was his/her own responsible party. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment to be completed by the facility, dated 1/8/24, showed the following: -The resident was admitted to the facility on [DATE]; -Cognition was not documented; -He/She had no speech; -He/She was understood; -He/She understood others; -No psychosis or behaviors affecting others. Review of the resident's care plan, dated 1/3/24, showed the following: -He/She had a communication problem related to aphasia and language barrier; -He/She would be able to make basic needs known by sign language daily; -He/She would maintain current level of communication function by how, with what assistance i.e., making sounds, using appropriate gestures, responding to yes/no questions appropriately, using communication board, and writing messages; -Allow him/her time to respond, repeat as necessary, do not rush him/her; -Request clarification from him/her to ensure understanding; -Ask yes/no questions if appropriate; -Use simple, brief, and consistent words/cues; -He/She was able to understand English, but responded using sign language; -He/She had a diagnosis of aphasia related to stroke; -Allow resident time to process and understand what was being said to him/her and allow time to answer; -Give him/her alternate communication options; pen and paper and/or communication board; -He/She had impaired coping; -Ensure him/her to verbalize feelings regarding fear and/or anxiety. (The care plan did not identify any other coping skills for the resident.) (Review of the resident's care plan showed no documentation regarding behaviors or agitation directed towards others.) Review of the resident's medication administration record (MAR), dated 1/1/24 to 1/31/24, showed no documented behaviors for this time frame. Review of the resident's physician's orders, dated February 2024, showed the following: -Monitor for behaviors every shift; -Hydroxyzine (antihistamine medication used also to treat anxiety) 25 milligrams (mg), give one tablet every six hours as needed (PRN) for itching; -Duloxetine (an antidepressant medication) 60 mg, give one capsule daily for depression. Review of the resident's nursing progress note, dated 2/24/24 at 1:25 P.M., showed the resident was very upset at lunch due to not being able to have a second slice of pizza. He/She become very angry and started yelling and threw his/her plate at the wall. The nurse attempted to calm him/her down, but other staff came and started to talk to him/her also. The resident became angrier and swiped drinks off the table onto the floor. Staff assisted him/her to leave the dining room to calm down. The resident become physically aggressive with staff and sat on the floor in the doorway. The nurse convinced the resident to go to his/her room and calm down. The resident sat on his/her bed and apologized. A PRN dose of hydroxyzine was administered, and the resident later fell asleep. No other behaviors were noted. Review of the resident's MAR, dated February 2024, showed the following: -Hydroxyzine 25 mg tablet; one tablet every six hours as needed for itching; -Staff administered hydroxyzine 25 mg on 2/24/24 at 1:25 P.M. (Staff administered hydroxyzine for the resident's behaviors and not for itching as indicated in the resident's physician's orders.) -Monitor for behaviors every shift; -There were no behaviors documented from 2/1/24 to 2/29/24. Review of the resident's medical record showed no documentation staff attempted to identify the root cause of the resident's behavior on 2/24/24 or developed interventions to address the root cause for the resident's behavior. Review of the resident's progress notes, dated 3/9/24 at 7:44 A.M., showed at approximately 6:20 A.M., a code green (code used to alert staff for behavioral event and need for intervention) was called for a resident-to-resident altercation. Staff reported they saw the resident punching Resident #2 because he/she was mad over a phone charger. The resident tossed his/her coffee filled cup on the floor. He/She was sent to the hospital for further management and care. Review of the resident's hospital medical records, dated 3/9/24, showed the following: -admitted to the emergency room with chief complaint of moderate aggression; -He/She presented to the emergency department complaining of aggression with a one-day onset. He/She presented from the nursing home where he/she reportedly got into a physical altercation with another resident, striking him/her. The resident had been having progressively worsening issues with aggression according to the nursing home staff; -Exam showed no gross motor deficits, no neurological deficits, and he/she was alert and oriented to person, place, and time; -He/She was calm and cooperative; -He/She was a non-English speaking and had the additional impediment of previous stroke causing significant aphasia. Attempted to converse with the resident using a translator and were unable to get any kind of significant information from him/her besides the fact that someone was messing with his/her phone charger; -Social services assessment showed he/she reported that he/she had been in an argument with his/her roommate over a phone charger that he/she believed the roommate took from him/her. He/She hit his/her roommate. He/She had a history of a stroke and had trouble with communicating, but was able to understand. The facility reported that he/she was getting upset more often and this was the first time that he/she had hit anyone. The facility reported that he/she had gotten upset because they ran out of pizza and he/she threw his/her plate across the room and started picking arguments with other residents. The facility reported no mental health history and he/she was not on medications for mental health; -Psychiatric consult note: the resident was a poor historian due to not able to speak English, stroke history, and intellectual disability. He/She used gestures, signs, and talked gibberish. He/She denied previous psych history. He/She said his/her roommate exposed himself/herself in front of him/her and attempted to touch him/her multiple times. He/She felt uncomfortable around him/her and as a result became agitated. Recommendation included to start Seroquel (antipsychotic medication) 25 mg every bedtime for agitation and sleep; -It had eventually come out that the roommate was performing self-sexual activities in front of him/her and then trying to grab his/her possessions afterwards. This made the resident very upset; -Telepsychiatry recommended initiation of Seroquel 25 mg at bedtime which was added to the resident's discharge orders; -Discharge instructions included to take Seroquel 25 mg one tablet daily at bedtime, and to continue all other medications as directed by the originating prescriber. Review of the resident's nursing progress note, dated 3/9/24 at 11:00 A.M., showed that upon his/her return from the hospital, he/she was moved to the behavioral unit and placed on 15-minute safety checks. Education was provided to the resident on facility policies and peer-to-peer contact, as well as appropriate behavior and coping mechanisms. Review of the resident's care plan showed no documentation staff updated the resident's care plan with coping mechanisms and/or interventions to address aggressive behaviors after the altercation with Resident #2 on 3/9/24. Review of the facility's investigation, dated 3/11/24, showed the following: -On 3/9/24, the Director of Nursing (DON) and the Administrator were notified of a resident-to-resident altercation between the resident and Resident #2. It was stated that the altercation started in the bedroom of the two residents; -Staff on duty witnessed the resident (Resident #1) trying to enter the room, but was unable to due to Resident #2 sitting in his/her wheelchair in front of the doorway. The resident attempted to go around Resident #2 and accidentally stepped on Resident #2's foot; -Resident #2 become visibly upset, yelling, cursing, and pushed the resident causing him/her to fall onto the bed; -The resident got up and started to hit Resident #2 multiple times in the head and upper body; -When Resident #2 was asked what had happened, he/she stated that he/she pushed the resident for stepping on his/her foot and the resident hit him/her; -The resident was sent to the hospital for evaluation and treatment; -Care plan interventions included residents were separated in different locations of the building for safety, psychological evaluation, and treatment, placed on 15-minute safety checks, and education was provided to the resident on facility policies and peer to peer contact, as well as appropriate behavior and coping mechanisms. Review of a resident contract signed by the resident, dated 3/11/24, showed that he/she agreed to not have any verbal or physical altercations with fellow residents. Failure to abide by this contract would lead to limitations being placed for him/herself or being discharged to another facility. Review of the resident's MAR, dated 3/1/24 to 3/31/24, showed the following: -Seroquel 25 mg; one tablet at bedtime related to anxiety disorder was started on 3/11/24 (order was obtained from the hospital on 3/9/24); -Staff documented Seroquel 25 mg; one tablet at bedtime was administered on 3/11/24. During an interview on 3/12/24 at 10:30 A.M., the Administrator said the following: -The resident had never had physical behaviors since he/she was admitted ; -The resident could understand English, but had difficulty making himself/herself understood; -The resident becomes frustrated when he/she is unable to understand, but had never been aggressive; -There was an incident last weekend when he/she became upset when staff did not understand him/her, and he/she threw his/her plate and coffee on the floor; -The resident was roommates with Resident #2 , but Resident #2 could not communicate well with Resident #1. The resident attempted to maneuver around Resident #2 who was blocking the doorway to their room. The resident ended up on Resident #2's foot. Resident #2 become upset and pushed the resident, and he/she fell on the bed. The resident then got up and struck Resident #2. The resident was sent to the hospital and returned with new order for Seroquel; -The resident was moved in with Resident #2 approximately a week ago because they both had problems with their previous roommates; -Earlier in the week, prior to the altercation, the resident said Resident #2 had touched his/her personal belongings and he/she did not like Resident #2 touching his/her personal belongings. Review of the resident's medical record showed there was no evidence to show staff implemented interventions to address Resident #2 touching Resident #1's personal belongings prior to the altercation on 3/9/24. During an interview on 3/12/24 at 11:10 A.M., Certified Nurse Assistant (CNA) A said the following: -On 3/9/24, he/she came out of another room when he/she saw the resident step on Resident #2's foot as he/she tried to maneuver around Resident #2 who was blocking the doorway. Resident #2 shoved the resident on the bed and the resident jumped up and struck Resident #2.; -He/She was unaware of any previous issues between the two residents; -The resident was not usually aggressive. Observation of on 3/12/24 at 1:00 P.M. showed the resident lay in his/her bed calmly listening to music on his/her phone. He/She appeared happy as evidenced with smile on his/her face. During interview with the resident on 3/12/24 at 1:00 P.M., showed it was difficult to communicate due to the communication barrier. He/She pointed to his/her scar on his/her head to show where he/she had previous surgery. He/She picked up his body spray and sat it back down and responded yeah yeah yeah when asked if someone had taken his/her body spray. He/She responded yeah yeah yeah when asked if it was his/her previous roommate (Resident #2). During an interview on 3/12/24 at 4:00 P.M., Certified Medication Technician (CMT) B said the following: -The resident spoke minimal English and communicated by using his/her hands; -The resident became frustrated because others didn't know what he/she was trying to communicate; -He/She had not seen the resident be physically aggressive. During an interview on 3/12/24 at 4:01 P.M., the Maintenance Director said the resident was mellow until provoked, then he/she would become agitated. During an interview on 3/12/24 at 4:15 P.M., the Care Plan Coordinator said the following: -The resident only became physically aggressive if he/she was provoked; -He/She had never seen the resident lash out for no reason; -The resident was normally quiet and kept to himself/herself in his/her room. During an interview on 3/13/24 at 1:00 P.M., Licensed Practical Nurse (LPN) C said the following: -On 2/24/24, the resident was sitting at the dining room table with a peer who had received more pizza. The resident was told there was no more when he/she had asked for more. The resident became frustrated, staff tried to redirect and calm him/her down, but only made him/her more agitated; -He/She administered hydroxyzine because it could also be used for anxiety; -The resident had a language barrier. The resident did not have a problem understanding, but had difficulty communicating to others what he/she wanted; -The resident was usually nice and tried to keep to himself/herself; -He/She noticed a behavior one time and that was because another resident had instigated the issue; -The resident attempted to get out of the room, but his/her roommate Resident #2 was blocking the doorway. The resident accidentally stepped on Resident #2's toes which caused Resident #2 to become angry and he/she pushed the resident on the bed. The resident got up and struck Resident #2; -Resident #1 went to the hospital and was evaluated by psych; -The hospital reported to him/her that the resident said Resident #2 had performed self-sexual behaviors in front of Resident #1 and then Resident #2 wiped his/her hands on Resident #1, all of which he/she reported to management staff; -Resident #1 did not communicate Resident #2's inappropriate sexual behavior to the facility staff; -Resident #2 was known to be an instigator and cause problems; -Resident #1 and Resident #2 should not have been roommates because of Resident #2's history with other roommates and/he she reported that to management staff, but the resident's remained in the same room; -Resident #2 would accuse Resident #1 of taking his/her stuff, when it was Resident #1's stuff that Resident #2 had originally taken. During an interview on 3/14/24 at 2:30 P.M., the administrator said she was unaware that Resident #2 had performed self-sexual behaviors in front of Resident #1 and then Resident #2 wiped his/her hands on Resident #1. She felt like Resident #1 would have told staff if that had occurred. She was aware Resident #1 did not like Resident #2 touching his/her belonging and would make Resident #1 upset when Resident #2 touched his/her things. She spoke with Resident #2 and explained that he/she could not bother other resident's belongings and Resident #2 said he/she would not do it again. During an interview on 3/14/24 AT 7:40 A.M., Registered Nurse (RN) D said the following: -The resident had aphasia and spoke Spanish which caused difficulty understanding and being understood; -The resident's communication barrier caused difficulty between the resident and most of the staff; -The resident was easily irritated which could be caused from staff and/or other peers not understanding him/her; -The facility did not know much about the resident's history due to the communication barrier. -The resident was involved in an altercation with a peer and was sent to the hospital for physical aggression. He returned from the hospital with a new order for Seroquel to calm him/her down and aid with sleep. During an interview on 3/13/24 at 10:00 A.M., the Social Services Director said the following: -The resident's primary language was Spanish, but he/she could understand English; -There was an incident between the resident and the Dietary Manager approximately one month ago. The resident wanted more coffee and he/she started yelling. Not sure if the communication barrier caused the resident's increased agitation, but it could have played a role in it; -The root cause of the resident's behaviors was his/her communication skills; -Overall, she had not seen the resident be aggressive. The resident was normally smiling and appeared happy/cheerful; -The facility was working on being able to meet the resident's psycho-social needs. The resident tried to tell his/her story, but she could not understand him/her. -The resident was admitted directly from a hospital after his/her former facility refused to let him/her return. She did not know any other details regarding the resident. During an interview on 3/14/24 at 11:00 A.M., the Dietary Manager said the following: -The resident had an episode in the dining room when he/she wanted something and wanted it immediately; -The resident seemed frustrated a lot and she was not sure if the resident's actions were due to inability to understand, to be understood, or a behavior; -The resident became frustrated when trying to communicate and would use the gesture to forget it when he/she could not communicate what he/she wanted/needed. During an interview on 3/14/24 at 12:15 P.M., the resident's physician said the following: -The facility did not provide him/her with any of the resident's medical history; -He would expect the facility to reach out to the previous facility and obtain the resident's history and/or background before accepting the resident so they could have better knowledge about the resident's needs; -The resident had a history of a head injury and spoke Spanish. It was unclear how much the resident understood; -The resident was usually calm when he saw the resident; -The resident was in an altercation recently with a peer and was sent to the emergency room. The resident saw tele psych and was recommended that he/she start on Seroquel. It was reported that the resident appeared agitated on a frequent basis. He did not feel that the resident needed the medication due to the degree of provocation. The Seroquel was continued to prevent further incidents of aggression. During an interview on 3/26/24 at 3:25 P.M., the Director of Nursing said the following: -The resident's communication was quite different. The resident made up his/her own sign language which made it difficult for staff to understand him/her and for him/her to understand the staff; -Staff should have contacted the physician for an order to administer the hydroxyzine for increased anxiety/agitation and not take it upon themselves to administer without contacting the physician first. The physician may have recommended some other intervention. During interview on 4/10/24 at 2:13 P.M., the Administrator said the following: -The resident was started on Seroquel on 3/11/24 after the incident with Resident #2; -The resident's diagnosis for Seroquel use was anxiety; -The root cause of the resident's behavior on 3/9/24 was that Resident #2 provoked him/her by shoving him/her; -The root cause of previous incidents involving the resident and behaviors was due to his/her communication barrier. 2. Review of Resident #2's Preadmission Assessment and Resident Screening (PASARR), a federally mandated screening process for individuals with serious mental illness and/or intellectual disability/developmental disability. , dated 9/6/22, showed the following: -His/Her diagnoses included major depressive disorder, recurrent severe psych features, adjustment disorder (is an emotional or behavioral reaction to a stressful event or change in a person's life) with depressed mood, alcohol-induced mood disorder, stimulant abuse with stimulant-induced mood disorder, antisocial personality disorder, opioid use, meth dependence, alcohol intoxication abuse, and cannabis use; -His/Her estimated intellectual function level was average; -He/She had a history of a closed traumatic brain injury (TBI) with loss of consciousness (an injury to the brain from external mechanical force), post-traumatic stress disorder (PTSD, is a disorder that develops in some people who have experienced a shocking, scary, or dangerous event) secondary to TBI; -History of withdrawn, depressed, suspicious and paranoid, anxiety, abnormal thought process. Oriented to person, place and situation but not time, impaired procedural, and situational memory. Required guardianship and had a history of incarceration; -Multiple previous psychiatric treatments, including incarceration, hospitalizations, and outpatient; -Aggressive/assaultive behaviors included fire setting, yelling, and cursing when frustrated; -Required physical assistance with toileting, personal hygiene, bathing, and dressing/undressing; -Use of wheelchair, unassisted; -He/She was open and honest with others and would curse when he/she got frustrated; -He/She felt worthless; -He/She had thoughts about hurting and/or killing himself/herself in the past when he/she was not seeing his/her children. He/She thought he/she would be better off dead; -He/She had thoughts about hurting or killing someone only when people threatened him/her; -Assessment and implementation of behavioral support plan included monitoring of behavioral symptoms and provision of behavioral support; -Medication therapy and monitoring services included psychiatric follow up to prescribe and manage medications; -Provide for individual personal space; -Establish consistent routines; -Provide schedule of daily tasks/activities; -Provide instructions at the individual's level of understanding; -Assess and plan for the level of supervision required to prevent harm to self or others; -Safety plan to address potential risk to self or others, -Plan should identify clear steps that would be taken to support the individual during a crisis, specify who to contact for assistance, how staff should work together with individual during the crisis, as well as identify when the physician, emergency medical services, and/or law enforcement should be contacted; -Personal support should include to assess and plan for meaningful socialization and recreational activities to diminish tendencies toward isolation, withdrawal, etc. Review of the resident's face sheet showed he/she was admitted to the facility on [DATE]. Review of the residents quarterly MDS, dated [DATE], showed the following: -Staff did not complete the areas to assess the resident's cognitive pattern or mood; -The resident had no behaviors in the previous seven days. Review of the resident's care plan, last revised on 1/9/24, showed the following: -He/She had a behavior problem related to his/her disease process, resisting care, and having altercations with peers; -Administer medications as ordered, anticipate, and meet the resident's needs; -Caregivers to provide opportunity for positive interaction and interaction. Stop and talk with him/her when passing by; -If reasonable, discuss the resident's behavior and explain/reinforce why behavior was inappropriate and/or unacceptable to the resident; -He/She had decreased activity involvement related to immobility and physical limitations; -Establish and record the resident's prior level of activity involvement and interests by talking with the resident, caregivers, and family on admission and as necessary. (Review showed no documented interventions to meet his/her psychosocial needs, no documentation to address meaningful socialization and recreational activities to diminish tendencies toward isolation, withdrawal, etc., and to provide for individual personal space as indicated on the resident's PASARR, and no documentation to address how staff were to respond when the resident had behaviors directed towards others.) Review of the resident's quarterly M

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #42's weight record showed the following: -January 153 lbs.; -February 150 lbs. Review of the resident's significant change in status MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Diagnosis of diabetes(disease inhibits the production of insulin that controls blood sugar), and dysphagia (difficulty swallowing) -Requires extensive physical assistance of one staff member for eating; -Mechanically altered diet; -Weighs 150 pounds (lbs.) -Triggered nutrition risk, will proceed with care plan. Review of the resident's care plan, dated 2/27/19, showed it did not address the resident's nutrition risk. Review of Nutritional Notification, dated March 2019, showed; -The resident weighed 145 lbs; -Significant weight loss of 5 lbs in one month; -Mechanical soft diet; -Legal guardian notified and physician signed. Review of the resident's weight record showed the following: -March 145 lbs.; -April 144 lbs. Review of the Registered Dietitian Nutrition assessment, dated 4/9/19 showed the following: -Diagnosis of dysphagia; (difficulty swallowing) -Diet order consistency mechanical soft; -Needs supervision, feeds self; -Edentulous (no teeth or dentures); -Difficulty swallowing; -Lab values include 11/9/18, 3.4 (low)L albumin; -Medications included multivitamin and hydrochlorothiazide (diuretic medication). Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Diagnosis of diabetes, and dysphagia; -Requires limited physical assistance of one staff member for eating; -Mechanically altered diet; -Weighs 143 lbs. Review of the resident's weight record showed the following: -May 143 lbs.; -June 142 lbs.; -July 141 lbs.; -August 139 lbs.; -September 137 lbs.; -October 135 lbs. Review of the resident's physician's order sheet, dated November 2019, showed a diet order for mechanical soft consistency, plate guard, and spoon with built up handle to assist with maintaining food on plate. Review of the resident's quarterly MDS dated [DATE], showed the following: -Severe cognitive impairment; -Diagnosis of diabetes, and dysphagia; -Requires limited physical assistance of one staff member for eating; -Mechanically altered diet; -Weighs 135 lbs.; -Weight loss not on physician prescribed weight loss plan. Review of the resident's care plan showed it did not address the resident's weight loss. Review of the resident's dietitian notes dated 11/15/19 showed the resident with insidious (proceeding in a gradual, subtle way but with harmful effects) weight loss and recommended health shakes two times daily with lunch and supper. Review of the resident's weight record showed the resident weighted 133 lbs in November. Review of the resident's physician's order sheet, dated 11/19/19, showed the resident started a health shake twice a day with lunch and supper. Review of the resident's weight record showed the resident weighted 130 lbs in December. The record showed the resident had weight loss every month, and did not include weekly weights. Review of the resident's care plan showed it did not address the resident's weight loss. Review of the resident's medical record showed no documented meal intake. Continuous observation on 12/9/19 from 12:35 P.M. to 1:21 P.M., showed the following: -The resident sat in a wheelchair in the main dining room at the dining room table; -His/Her left hand was contracted (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints); -At 12:35 P.M. staff served the resident a sandwich, mashed potatoes, green beans, orange slices and water. The resident had a plate guard, and regular silverware rolled in a napkin; -The resident consumed his/her sandwich and tried to unroll his/her silverware with his/her contracted left hand and his/her right hand, and did not get the silverware unrolled; -At 12:40 P.M. the resident scooped mashed potatoes with his/her fingers while DON talked to him/her and did not assist him/her with his/her silverware; -At 12:51 P.M. staff brought the resident a built up spoon, the resident did not have a fork; -At 12:54 P.M., staff served the resident a small glass milk or supplement; -The resident's plate guard opening was directly in front of the resident, the resident could only access the left side of his/her plate; -The resident attempted to load green beans on his/her spoon, and the green beans fell off his/her spoon before the resident could get the spoon to his/her mouth, he/she did not eat his/her green beans; -The resident could only reach the mashed potatoes on the left side of the plate, and scraped small bits of mashed potatoes on the plate guard; -At 1:04 P.M. LPN A put the resident's oranges in the center of his/her plate; -The resident continued to try to reach the mashed potatoes holding the end his/her built up spoon with the spoon straight down to get around the bowl of oranges; -At 1:10 P.M. the resident got one orange on his/her spoon to his/her mouth, the oranges fell off his/her spoon with several attempts; -At 1:19 P.M., the resident brought an empty spoon to his/her mouth 13 times when he/she attempted to eat his/her oranges; -Oranges were on the resident's lap, the table, and on his/her plate where they fell of his/her spoon; -The DON said to the resident, Are you just drinking the juice? and laughed; -The resident consumed his/her sandwich, 3/4 of his/her mashed potatoes, and two drinks of his/her supplement. Continuous observation on 12/10/19 from 12:17 P.M. to 1:00 P.M., showed the following: -The resident sat In a wheelchair in the main dining room at the dining room table; -His/Her left hand was contracted; -The restorative nurse aide (RNA) served the resident spaghetti with the plate guard opening on the side of the plate toward the center of the table, a bowl of fruit, and cake; -The staff gave the resident a built up spoon; -The resident tried to load spaghetti on his/her spoon but the long noodles slid off his/her spoon; -At 12:26 P.M. the resident attempted to load his/her spoon with the spoon upside down, food fell off his/her spoon; -At 12:28 P.M. the resident scooped spaghetti noodles up on his/her plate guard and picked up the noodles from his/her plate with his/her mouth; -At 12:34 P.M. the resident had noodles all over his/her lap, noodles hung off the table, and hung off of his/her plate; -The resident continued to pick up spaghetti noodles with his/her mouth off the plate guard; -At 12:50 P.M. LPN A turned the resident's plate guard so the resident could reach his/her food; -A staff member cut up the resident's spaghetti noodles and told the resident to feed himself/herself; -The resident said, No I'm tired, the staff member gave the resident one bite and walked away; -At 12:55 P.M. the resident started to eat with his/her fingers. During an interview on 12/10/19, at 12:21 P.M., the resident said the following: -It was hard to eat spaghetti with a spoon; -The noodles kept falling off his/her spoon; -It was hard to eata [NAME] of foods with a spoon so he/she usually doesn't eat much of the food. During an interview on 12/12/19, at 2:13 P.M., certified nurse assistant (CNA) I said: -Staff lets the resident try to feed himself/herself and if he/she can not staff feed him/her after the other residents are finished eating; -When the staff serves the resident spaghetti, green beans or items hard to load on a spoon, staff should cut them up because he/she only has a spoon; -If the resident struggles for a while staff do not warm up his/her plate; -The resident had not lost weight that he/she knew of; -The resident does not usually drink his/her drinks; -The resident does not get a supplement that he/she was aware. During an interview on 12/12/19, at 2:19 P.M., RNA said the following: -If the resident needs assistance staff assist him/her with eating; -If the resident has spaghetti or long foods, staff should cut the food up smaller or get him/her a fork; -The plate guard should have the opening towards the resident; -The resident has had weight loss, and gets a house supplement, but he/she does not drink it; -He/She must not have paid attention when he/she put the resident's plate guard facing the center of the table. During an interview on 12/12/19, at 3:07 P.M., LPN A said: -The resident feeds himself/herself with encouragement; -The resident has a plate guard, and a built up spoon; -Staff are expected to cut up spaghetti and items if not easy to pick up with a spoon; -Staff assist the resident depending on how many residents are there that need help; -Staff assist the resident when get they are finished with everyone else; -The opening of the resident's plate guard should be on the right side facing towards the resident; -She was not sure if the resident has had any weight loss. During an interview on 12/12/19 at 10:01 A.M. and 12/17/19, at 10:41 A.M., the DON said the following: -Resident #42 was being monitored on weekly weights; -Resident #42 has a built up spoon but he/she did not know why the resident did not have a built up fork; -Staff should cut up foods hard to pick up with a spoon, but staff usually feed Resident #42 at the end of the meal; -A fork would be more suitable for Resident #42; -She thought staff do consumption logs to track what the residents eat, but she cannot find it; -She was not sure if staff complete consumption logs any more; -She was not sure how the facility tracked how much residents eat; -She monitors the resident's weights monthly; -If a resident triggers for weight loss their weight is monitored weekly and interventions to prevent weight loss are added to their care plan or a new order is added; -The registered dietitian (RD) comes in and looks at the resident's weights; -The RD makes the recommendations, and sends them to her; -She sends the RD recommendations to the physician for approval. Based on interview and record review, the facility failed to maintain acceptable parameters of weight for two residents (Resident #32 and Resident #42 ), in a review of 17 sampled residents. Resident #32 experienced a weight loss of 38.8 pounds between June 2019 and November 2019. The resident continued to lose an additional 5.4 pounds from November 2019 to December 2019 for a total of 26% weight loss since admission to the facility. Resident #42 had insidious (proceeding in a gradual, subtle way but with harmful effects) weight loss, with a weight loss every month for a total of 23 pounds from January 2019-December 2019,a 155% weight loss. The facility failed to document meal intake per their policy and to implement new interventions timely to prevent further weight loss. The facility also failed to offer one resident dependent on staff for accessing fluids and with a history of hospitalization for dehydration (Resident #32) sufficient fluid intake to maintain proper hydration and health. The facility census was 59. 1. Review of the facility policy Weight Loss revised 4/6/2017 showed the following: Purpose: To ensure that all residents maintain acceptable parameters of nutritional status, such as body weight and protein level, unless the resident's condition demonstrates that this is not possible; Procedure: -The following parameters for weight loss require the physician to be notified, intervention for maintain or gaining weight, and dietician to consult on an as needed basis to ensure that proper nutritional guidelines are followed; -5% weight loss in 30 days will involve physician notification and possible orders for dietary supplement, the dietician may be notified; -7.5% weight loss in three months requires physician notification, dietician to consult and any orders to increase dietary intake, supplements, etc.; -10% weight loss in six months requires physician notification, dietician to consults, and any orders to increase dietary intake, supplements to be increased, changed etc.; -The dietician can be consulted at anytime, ensure that documentation with recommendations are charted after any consultation with the physician or dietician; -The nursing staff will follow all recommendations and physician orders, laboratory results such as serum albumin (low levels seen in inflammation, shock, malnutrition, and conditions where protein is not proper absorbed) levels will be called to the primary physician and the dietician will be notified of the results; -Residents with concerns for weight loss will be weighed as ordered by the physician and at least weekly, any weight loss issues will be addressed in weight loss meetings and will be added to the QA monthly. The ADON or designee will follow-up to ensure that weight losses meeting above parameters are followed and that the physician and dietician are consulted; -If the resident is refusing his/her meal or portions of his/her meal/snack then alternative foods will be offered to ensure that adequate intake is provided to the resident. The weight loss meeting will address offering other food choices and different types of snacks that continue to meet the residents required nutritional diet/intake. This should also be added to the resident care plan; -Accurate documentation of intakes on both meal sheets and snack sheets must be completed by the nursing staff. These sheets will be monitored by the Director of Medical Records for completeness; It will be the Resident Care Coordinator (RCC) or designee of each unit's responsibility to ensure that these sheets are being accurately completed; -Residents who have concerns for weight loss will be discussed in the meetings held weekly, this will involve reviewing intakes of both meals and snacks, and interventions for increasing nutritional intakes, the care plan coordinator will address concerns in the care plan as needed; -All residents weights will be monitored on a monthly basis as a minimum. If the resident triggers for a weight loss or gain, the resident will be placed on weekly weights. The facility will delegate the same licensed nurse/restorative aide/designee to consistently weigh the residents to ensure weight information accuracy. This process will be overseen by the RCC, dietary manager and Director of Nursing (DON). Review of the facility policy Hydration revised 4/6/17 showed the following: Purpose: The purpose of this policy is to ensure that a hydration program is in place in each facility, to monitor hydration of residents and to define clinical symptoms of dehydration. The policy will also address assessment of residents at risk for dehydration and put a plan in place to identify nursing interventions including an interdisciplinary team approach in addressing the resident who is at increased risk for dehydration or the resident that requires special assistance or special monitoring of fluid intake; Procedure: Dehydration occurs when the output of water exceeds water intake. Dehydration may result in deprivation of water, excessive loss of water and electrolyte imbalances. The following may be associated with dehydration:1. Recentt rapid weight loss; 2. Dry mucosal membranes including eyes/mouth; 3. Change in mental status; 11. Dizziness, lethargy, weakness, frequent falls; 12. Change in ability to carry out activities of daily living (ADLs); 13. Increase in combativeness/confusion; If resident has symptoms of dehydration the nurse should assess, care plan and document issues that could be causing the dehydration including: 1. Decreased fluid intake or increased output; 2. Change in mental status; 3. Weight loss of 3-5 pounds within 30 days; 5. Use of medications that promote excessive urination or affects sodium/potassium; Clinical conditions and factors that may increase the risk for dehydration: 1. Dementia or cognitive impairment; 5. Dependence on staff for eating or drinking; 6. Use of medications that can cause dehydration (e.g. diuretics); 11. Previous episodes of dehydration; 12. Difficulty or painful swallowing; 17. Chronic comorbidities (e.g. stroke, diabetes, congestive heart failure); Procedures to ensure decreasing the risk of dehydration:1. Fluidss will be passed every two hours with the exception of meal times and night shift. The night shift staff will ensure that fresh water is passed during the shift and ice water will be changed with clean containers; 2. One to one assistance will be provided to residents who require special assistance in consumption of fluids. This will include residents that depend on staff for assistance in consuming fluids, resident that require increased monitoring due to increased risk for aspiration, and special considerations in the consistency of fluids; 3. Accurate fluid intake and output being recorded on residents who are at risk for dehydration; 4. Assessment of residents at risk for dehydration including addressing care plans, physician involvement, dietician involvement, and documentation to show positive interventions to decrease risks for dehydration; 5. Monitoring diagnoses and medications that can contribute to increased risk for dehydration; 6. Review of residents who are on fluid restrictions including laboratory studies focusing on kidney function and electrolyte imbalance; 7. Monitoring changes in vital signs and body weight; Procedure for distribution of drinking water: c. Monitor residents who are not allowed to have water at bedside in room, ensure that correct consistency and amounts are provided to residents every two hours excluding meals and night shift. Review of the undated facility policy Nutrition Monitoring showed the following: Policy: Each resident's response to nutrition care is monitored; Monitoring included the following activities: 1. Recording the resident's percent consumption of food at each meal and the percent consumption of nutrition products; 2. Reviewing the resident's therapeutic regimen including the appropriateness of food and nutrition products and the administration route weekly; 3. Drawing conclusions and communicating them to those responsible for the resident's care; 4. Documenting conclusions and interdisciplinary conference results in the medical record; 5. Reassessing and revising the resident's nutrition therapy; 6. Reviewing residents who are not receiving adequate intake every 2-3 days. 3. Review of Resident #32's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/26/19 showed the following: -Severely impaired cognitive skills for daily decision making; -No behaviors; -No rejection of care; -Required supervision with set up help only for eating; -169 pounds; -No weight loss; -No teeth; -Received diuretic seven of the last seven days; -Diagnoses of anemia, hyperkalemia, dementia, anxiety, depression, schizophrenia and COPD. Review of the resident's weight record for 2019 showed the following: -June 168.8 pounds; -July 165 pounds. Review of the resident's care plan dated 7/1/19 showed the following: -Resident has a diagnosis of dementia and has poor insight, poor judgment and poor decision making skills; -He/she has a legal guardian; -He/she has no natural teeth. He/she has dentures but chooses not to wear them; -Diet as ordered: pureed with nectar thick liquids; -Noncompliant with nectar thick liquids; -The care plan did address the risk for dehydration due to multiple psychiatric diagnoses and diuretic usage; -The care plan did not address the risk of weight loss due to having no natural teeth and receiving a mechanically altered diet and liquids and a history of non-compliance with the diet and liquids. Review of the resident's weight record for 2019 showed August weight of 160 pounds. Review of the resident's quarterly MDS dated [DATE] showed the following: -Moderately impaired cognition; -Inattention present, fluctuates; -No behaviors; -No rejection of care; -Was independent with eating requiring set up help only; -154 pounds; -Weight loss of 5% or more in the last month or loss of 10% or more in the last six months-not on physician prescribed weight loss regimen; -Received diuretic seven of the last seven days. Review of the resident's care plan updated 9/25/19 showed the following: -Resident non-compliant with diet and stealing food off other residents' plates; -Education provided about aspiration risks. Review of the resident's Certified Nurse Aide (CNA) care plan dated 9/30/19 showed the following: -Diet-pureed; -No fluid restriction; -Honey thickened liquids; -Weekly weights; -Assistive devices: dentures; -Hydration program every two hours. Review of the resident's weight record for 2019 showed the following: -September 154 pounds; -October 149 pounds; -November 130 pounds. Review of the resident's dietary notes dated 11/15/19 at 4:35 P.M. showed the following: -Resident initially admitted on [DATE], was sent out to hospital for pneumonia on 10/18/19, was readmitted on [DATE]; -Resident at nutrition risk due to schizophrenia, dementia, COPD, major depressive disorder, anxiety disorder, hyperlipidemia and significant weight loss; -Resident on a pureed diet, no added sodium and nectar thickened liquids, double hot cereal with breakfast and cottage cheese with a magic cup with lunch and supper; -Resident has a poor appetite, does not like the pureed food, needs encouragement to eat; -Height 73 inches, November weight 130 pounds, down 19 pounds in one month, at 12.8% weight loss; down 30 pounds in three months, an 18.8% weight loss; down 39 pounds in five months since initial admit; -Weight loss is unplanned and not desirable; -Body mass index (BMI) 17.2-underweight weight range, resident is 71% of ideal body weight (IBW); -Labs and medications noted which includes Remeron (antidepressant medication) and Megace (appetite stimulant) both started on 11/12/19 for appetite; -Recommend adding med pass supplement-120 cc twice daily at this time due to weight loss; -Will continue to follow and be available as needed. Review of the resident's fluid intake showed the following: -12/1/19: 960 cc; -12/2/19: 960 cc; -12/3/19: 960 cc; -12/4/19: 780 cc. Review of the resident's nurses' notes dated 12/5/19 at 12:55 A.M. showed the following: -Last evening (12/4/19) resident fell around 7:45 P.M. when he/she attempted to get out of his/her wheelchair and fell; -Resident then complained of pain to ribs and right hip, resident was able to move extremities freely, was assisted up to his/her bed, at 8:55 P.M. notified on call practitioner, he/she gave order for chest x-ray and x-ray of the hip tomorrow; -Called guardian and he/she said to go ahead and send the resident to the hospital; -At 9:30 P.M. ambulance here and transported resident to hospital. Review of the resident's nurses' notes dated 12/5/19 at 4:36 A.M. showed at this time he/she called the hospital to check on resident, he/she was admitted with dehydration. Review of the resident's hospital discharge notes showed the following: -Discharge diagnosis dehydration; -On 12/4/19 Blood urea nitrogen (BUN)( blood test done to see how well kidneys are working. If your kidneys are not able to remove urea from the blood normally, your BUN level rises. Heart failure, dehydration, or a diet high in protein can also make the BUN level higher) 49.0 (8.4-25.7 mg/dl normal), creatinine (a chemical waste product in the blood that passes through the kidneys to be filtered and eliminated in urine) 1.79 (0.72-1.25 mg/dl normal), bilirubin (measures the amount of bilirubin in your blood. Test used to help find the cause of health conditions like jaundice, anemia, and liver disease) 2.1 (0.2-1.2 mg/dl normal), albumin 3.0 (3.4-4.8 mg/dl normal); -12/6/19 BUN 28.0, creatinine 0.79. Review of the resident's hospital physician note dated 12/5/19 showed the following: -Weight loss greater than 10% in six months, greater than or equal to 20% in 12 months, 43% x eight months; -Body fat: severe depletion; -Muscle mass: severe depletion; -Meets severe malnutrition criteria; -Outcome summary: nutrition. Resident presents with severe chronic malnutrition present on admission. Resident reports he/she has a good appetite which Registered Nurse (RN) confirms. Despite good appetite, resident is noted with 70 pound/43% unintentional weight loss over the last eight months and is observed to have severe bilateral muscle wasting and subcutaneous fat loss. RN reports he/she was scheduled for a PEG tube (a tube passed into a patient's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate) placement on December 3rd. Review of the resident's physician's orders dated 12/6/19 showed the following: -Diet: pureed; nectar thick liquids; -Ensure twice daily between meals; -Megace 40 milligrams (mg) by mouth twice daily; -Remeron 30 mg by mouth at bedtime. Review of the resident's fluid intake for 12/6/19 was 360 cc. Review of the resident's weight record on 12/6/19 showed a weight of 124.8 pounds. Review of the resident's care plan revised 12/6/19 showed the following: -readmitted [DATE] with dehydration and severe malnutrition; 1. Refer to dietitian; 2. Diet at ordered: pureed with nectar thick liquids; 3. Offer snacks that he/she likes; 4. Supplements as ordered; 5. Offer gastrointestinal (GI) consult for PEG tube. Review of the resident's fluid intake showed the following: -On 12/7/19: 960 cc; -On 12/8/19: 960 cc; -On 12/9/19: 960 cc. Observation on 12/9/19 at 10:31 A.M. in the resident's room showed the following: -The resident sat on the side of the bed rocking back in forth in attempt to stand; -The resident's eyes were sunken with a hollow appearance, his/her cheeks were sunken in; -The resident demonstrated continuous lip smacking and tongue rolling; -The resident's lips were covered with a white sticky appearing substance; -The resident's tongue appeared dry; -No fluids were available for this resident in the room. Review of the resident's physician progress note dated 12/10/19 showed the following: -Weight loss; -Adult failure to thrive; -He/She is still waiting for gastric feeding tube. Observation on 12/10/19 at 8:48 A.M. in the resident's room showed the following: -The resident lay in bed; -The resident demonstrated continuous lip smacking and tongue rolling; -The resident's eyes were sunken with a hollow appearance, his/her cheeks were sunken in; -The resident's lips were covered with a white sticky appearing substance; -The resident's tongue appeared dry; -No fluids were available for this resident in the room. Observation on 12/10/19 at 9:07 A.M. in the hallway showed the following: -The resident sat in his/her wheelchair; -The resident demonstrated continuous lip smacking and tongue rolling; -The resident's eyes were sunken with a hollow appearance, his/her cheeks were sunken in; -The resident's lips were covered with a white sticky appearing substance; -The resident's tongue appeared dry; -Various staff members passed the resident in the hallway. Staff did not offer the resident any fluids. Observation on 12/10/19 at 12:10 P.M. in the dining room showed the following: -The resident sat in his/her wheelchair at the dining room table; -The resident propelled him/herself across the room and asked the surveyor for some coffee with creamer; -The resident's lips were covered with a white sticky appearing substance; -The resident's tongue appeared dry; -The resident said, I'm thirsty and I want something to drink; -The resident propelled him/herself back to the table; -No staff offered fluids. Observation on 12/10/19 from 12:12 P.M. to 12:32 P.M. in the dining room showed the following: -The resident sat in his/her wheelchair at the table; -Two other residents at the table drank bottles of soda; -Staff served the resident's tablemates lunch; -At 12:32 P.M. the resident sat in his/her wheelchair at the table; -Staff served the resident's lunch tray which included 180cc chocolate milk, 240 cc water and 240 cc orange colored drink; -The resident immediately picked up the milk and started drinking. Review of the resident's fluid intake dated 12/10/19 showed intake of 960 cc. Review of the resident's medical record showed no documented meal intake. Observation on 12/11/19 at 6:12 A.M. in the resident's room showed the following: -The resident sat up on the side of his/her bed rocking back and forth with his/her hands outstretched; -CNA E and CNA F provided personal care to the resident's roommate; -The resident demonstrated continuous lip smacking and tongue rolling; -The resident's tongue appeared dry; -The resident's eyes were sunken with a hollow appearance, his/her cheeks were sunken in; -The skin on the resident's arms was covered with white, scaly dry skin; -The resident's scratched at his/her hands and arms; -The resident's yelled out Nurse, nurse!; -The resident eventually laid back down in bed; -No fluids were available for the resident in the room. -At 6:43 A.M. CNA E and CNA F assisted the resident from his/her bed to the wheelchair; -CNA E and CNA F toileted the resident and provided pericare; -The resident demonstrated continuous lip smacking and tongue rolling; -The resident's mouth and tongue appeared dry; -The resident's eyes were sunken with a hollow appearance, his/her cheeks were sunken in; -Staff did not provide or offer fluids; -No fluids were available in the room for the resident. Observation on 12/11/19 at 7:50 AM showed the following: -The resident propelled him/herself in his/her wheelchair to the dining room; -The resident demonstrated continuous lip smacking and tongue rolling; -The resident's mouth, lips and tongue appeared dry; -The resident's eyes were sunken with a hollow appearance, his/her cheeks were sunken in; -The resident told the surveyor he/she was hungry and thirsty; -The resident propelled him/herself to the dining room table; -No fluids were available for the resident at the dining room table. Observation on 12/11/19 from 08:02 to 8:44 A.M. in the dining room showed the following: -At 8:02 A.M.thee resident sat in his/her wheelchair; -Staff served the resident's breakfast which including a bowl of oatmeal, bowl of pureed French toast., 240 cc milk, 180 cc orange juice, 120 house supplement and no water; -The resident began taking a few bites without assistance and drank fluids; -Three staff sat at the table fed other residents; -The resident continued to take bites occasionally, pushed him/herself back away from table, and rolled back and forth in his/her wheelchair; -An unknown CNA placed sweetener on the resident's oatmeal; -The resident pushed him/herself back from the table; -The resident asked the CNA for scrambled egg and toast and said he/she didn't want to eat the oatmeal and French toast; -At 08:23 AM the resident pushed him/herself away from the table; -The resident drank 120 cc orange juice and 120 cc supplement; -The dietary manager (DM) told the resident he/she could have egg and toast but they would have to be ground up; -At 8:38 AM to 8:44 A.M. staff served the resident a bowl of pureed eggs and sausage; -The resident asked staff for chocolate milk and staff provided; -The resident did not eat any eggs or sausage; -The resident drank a few drinks of the chocolate mi