Based on observation, interview, and record review, the facility failed to protect one resident (Resident #1), in a sample of seven residents, from physical abuse by another resident, (Resident #3), who had a history of aggressive behaviors. Staff failed to separate the residents and sufficiently monitor Resident #3 after he/she had initially verbally assaulted Resident #1. Resident #3 was able to return to the dining area and physically assault Resident #1. Resident #1 received scratches and had a large clump of hair pulled from his/her scalp. The facility census was 117. Review of the facility policy, Resident's Rights, dated (revised) 07/05/23, showed the facility must protect and promote rights of each resident, including freedom from verbal, sexual, mental and physical abuse, corporal punishment and involuntary seclusion. Review of the facility policy, Abuse and Neglect, dated (revised 06/12/24), showed the following: -Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish, which can include staff to resident abuse and certain resident to resident altercations; -The facility will take steps to prevent mistreatment while the investigation is underway; -Residents who allegedly mistreat another resident will be removed from contact with the resident during the course of the investigation. The accused resident's condition shall be immediately evaluated to determine the most suitable therapy, care approaches, and placement considering his or her safety, as well as the safety of other residents and employees in the facility. 1. Review of Resident #1's face sheet, undated, showed he/she had a legal guardian. Review of the resident's care plan, dated 08/07/24, showed no issues with behavioral symptoms, verbal or physical, directed at others. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument, completed by the facility staff, dated 08/09/24, showed the following: -Cognitively intact; -Diagnoses included hallucinations (perceptual experiences in the absence of real external sensory stimuli) and delusions (misconceptions or beliefs that are firmly held contrary to reality); -No behavioral symptoms, verbal or physical, directed at others; -Use of antipsychotics (a medication to help reduce psychotic symptoms like hallucinations, delusions, and disordered thinking), antianxiety, and antidepressant medications. During an interview on 09/04/24 at 11:40 A.M., the resident said the following: -A couple of days ago, he/she was frustrated that Resident #3 was in the hallway outside his/her room, and on the facility resident phone for a long period of time, when he/she (Resident #1) had expected a call from his/her family; -He/She asked Resident #3 to get off the phone and Resident #3 became angry, started yelling at him/her, threw the phone down and then called him/her (Resident #1) a bad name; -The activity director was in the dining room and told Resident #3 to go to his/her room to calm down and he/she did, but he/she did not stay there; -He/She walked into the dining room and Resident #3 came up to him/her and threw his/her shoulder into him/her (Resident #1), scratched his/her neck and pulled a clump of his/her hair out; -The activity director and another staff person responded to the incident and shielded him/her with her arms, while another staff pulled Resident #3 off him/her; -The activity director took him/her to her office for the afternoon and Resident #3 stayed on the unit; -He/She was upset and afraid after Resident #3 attacked him/her; -He/She and Resident #3 were still on the same unit but avoided each other now. Observation on 09/04/24 at 11:45 A.M. showed the following: -Resident #1 had a mildly red, linear scratch on the back of his/her neck, measuring approximately six inches in length and less than two millimeters in width; -The resident had a clump of brown hair wrapped up in a paper towel in his/her pocket that measured about the size of a half-dollar; -The resident had a small area of baldness along the left side of the scalp, and it measured about two inches in width by two inches in length. During an interview on 09/11/24 at 11:30 A.M., the resident's legal guardian said Resident #1 did not have a history of verbal or physical aggression towards other residents. 2. Review of Resident #3's face sheet, undated, showed he/she had a legal guardian. Review of the resident's electronic medical record showed a Pre-admission Screening and Resident Review Level Two (PASARR II), dated 08/30/23, showed the following: -The resident was discharged from a previous skilled nursing facility due to aggression and the facility filed charges and a restraining order against him/her; -The resident was unable to live in a less-restrictive environment at this time for his/her safety and the safety of others, he/she required 24-hour supervision; -Diagnoses included major depressive disorder, bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), generalized anxiety disorder, and post-traumatic stress disorder (PTSD, a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event); -The resident's legal guardian said the resident had a history of aggressive behaviors when he/she was frustrated or when he/she felt his/her needs were not being met; -Behaviors to be addressed in the nursing facility plan of care included attention seeking behaviors, irritability, anxiety, outbursts, and per hospital records, history of aggressive behavior when the resident is frustrated or when he/she felt his/her needs were not being met. Review of the resident's baseline care plan, dated 08/12/24, showed no documentation regarding behaviors, interventions or PASARR II recommendations related to the resident's behaviors. Review of the resident's admission MDS, completed by the facility staff and dated 08/25/24, showed the following: -Cognitively intact; -Diagnoses included hallucinations and delusions; -No behavioral symptoms; -Use of antipsychotic, antianxiety and antidepressant medications. During an interview on 09/04/24 at 1:10 P.M., the resident said the following: -A couple of days ago, he/she was on the phone in the hallway when Resident #1 accused him/her of being on the phone for too long and it made him/her (Resident #3) mad; -He/She had problems in the past of acting out when he/she was mad; -He/She might have cussed at Resident #1, he/she was not sure; -The facility staff told him/her to go to his/her room and he/she did for maybe 15 minutes and then he/she went to the dining room; -Resident #1 hit him/her first on the chest when he/she went to the dining room, so he/she pulled Resident #1's hair; -A staff person pulled him/her off Resident #1 and told him/her (Resident #3) to go to his/her room; -Staff put him/her on 1:1 monitoring (one staff monitored the resident exclusively) and stayed with him/her for a little bit; he/she was not sure how long; -He/She was still on the same unit as Resident #1 and he/she just stayed away from Resident #1 now. During an interview on 09/04/24 at 2:15 P.M., the activity director said the following: -On 09/02/24, around 9:30 A.M., she was in the dining room when Resident #3 began yelling and cussing at Resident #1 because Resident #1 complained Resident #3 had been on the resident phone for too long; -She and another staff member told Resident #3 to calm down because Resident #3 was yelling and cussing at Resident #1, and she (the activity director) told Resident #3 to go to his/her room; -Resident #3 started yelling and cussing at her (the activity director) and another staff member, while Resident #3 walked to his/her room; -She thought the situation was resolved because Resident #3 went to his/her room, staff did not follow Resident #3 to his/her room and did not stay with him/her; -Resident #3 returned to the dining area in a few minutes and used his/her shoulder to shove Resident #1 and then started to pull Resident #1's hair; -She called a code green (indicating additional staff were needed due to a resident was a threat to himself/herself or to others) when Resident #3 was physically aggressive towards Resident #1; -She and Licensed Practical Nurse (LPN) A separated the residents; she put her arms around Resident #1 because Resident #3 was still pulling at Resident #1's hair; -LPN A pulled Resident #3 off Resident #1; -She took Resident #1 to her office and off the unit for the afternoon so Resident #1 could calm down; -Resident #1 was initially teary and told her he/she was in shock, but then Resident #1 said he/she was calmer and he/she went back to the unit later in the afternoon; -Resident #3 remained on the unit; she (the activity director) was not sure if staff stayed with Resident #3 after the incident occurred; -She was aware of Resident #3's history of aggression. During an interview on 09/18/24 at 8:40 A.M., LPN A said the following: -On 09/02/24, Resident #3 was on the phone in the dining room (of the 400-500-600 unit) when Resident #1 started complaining because he/she wanted to use the phone; -He/She did not remember what the residents said to each other, but he/she knew the residents were in an argument by the tone of their voices; -He/She told the residents to separate, and the activity director took Resident #1 off the unit and LPN A told Resident #3 to go to his/her room; -He/She could not remember if any other staff went with Resident #3 to his/her room; -Resident #1 returned to the unit with the activity director, he/she could not remember how long Resident #1 was gone; -Resident #3 came out of his/her room and was not calmed down yet, LPN A could not remember how he/she knew Resident #3 was not calm; -Resident #3 went up to Resident #1 and pushed him/her and then pulled his/her hair; -LPN A and another staff member got in between Resident #1 and Resident #3 to separate them, but he/she could not remember which staff helped him/her separate the residents; -He/She could not remember if a code green was called; -Resident #1 was taken off the unit by the activity director again and LPN A thought Resident #3 was taken to his/her room by a certified nurse assistant (CNA), he/she could not remember; -He/She did not think Resident #1 and Resident #3 had any physical injuries but he/she could not remember if he/she did a physical assessment of the residents; -If he/she had done a physical assessment of the residents, he/she would have documented the assessment in the electronic medical record (EMR); -He/She could not remember if he/she documented the events that occurred between Resident #1 and Resident #3 in the EMR; -He/She could not remember if he/she reported the events that occurred between Resident #1 and Resident #3 to administration; -He/She was not sure if the verbal exchange between Resident #1 and Resident #3 was abuse since he/she did not actually hear what was said; -He/She said physical altercations between residents would be considered resident-to-resident abuse. During an interview on 09/11/24 at 2:15 P.M., the resident's legal guardian said the following: -The resident had a long history of aggression that could be unprovoked; -The facility should have been aware of the resident's past behaviors of aggression and poor coping skills; -It was important for the facility to include in the resident's care plan, his/her history of aggressive behavior when frustrated. During an interview on 09/04/24 at 3:45 P.M., the director of nurses (DON) said the following: -She was not aware of the verbal or physical altercation that occurred between Resident #1 and Resident #3 on 09/02/24; -She was aware of Resident #3's history of aggression and poor coping skills, but was not aware if Resident #3 had any behaviors at the prior facility before the resident's arrival in the last couple of weeks; -She would have expected staff to separate the residents and provide protection for Resident #1 when Resident #3 began to verbally assault him/her; -If staff had provided a 1:1 with Resident #3 when he/she was verbally aggressive, it may have prevented the physical assault of Resident #1; -The residents involved should have been separated while an investigation of the incident took place. During an interview on 09/04/24 at 5:30 P.M., the administrator said the following: -She was aware that there was a verbal altercation between Resident #1 and another resident on 09/02/24; -She thought Resident #1 left the unit with the activity director after the verbal altercation with Resident #3; -She was not aware that Resident #3 physically attacked Resident #1; -She was aware that Resident #3 had a history of aggression; it was in his/her PASARR II; -If staff had provided a 1:1 with Resident #3 when he/she was verbally aggressive with Resident #1, it may have prevented the physical assault of Resident #1 by Resident #3; -The residents involved should have been separated while an investigation of the incident took place. #MO00241466

Deficiency Text Not Available

Based on observation, interview and record review, the facility failed to assess three residents (#19, #47, and #115) for the ability to consent prior to having sexual relations and failed to protect one resident (Resident #47) from sexual abuse by a resident (Resident #115). Resident #47 reported feeling worthless, having a flashback, and fear of contracting STDs (Sexual Transmitted Diseases). A sample of fourteen residents was selected for review. The facility census was 115. Review of the facility's Sexual Activity/Abuse and Neglect Policy, last reviewed 4/18/22, showed the following: -The purpose of this policy is to ensure the facility provides protective oversight and care for all residents requesting to engage in sexual activity/intercourse while at the same time protecting their rights; -Residents that are wishing to engage in sexual activity/intercourse will be allowed to participate in these activities as long as both parties consent and have the ability to consent. Non-consensual acts and acts that impact negatively on the resident community, such as public displays, shall not be allowed; -Determination of ability to consent: -a. If the resident has a guardian or a physical and/or cognitive impairment, an assessment should be completed to determine the resident's ability to consent. This assessment will be completed by the Interdisciplinary Care Team (ICT), with the assistance of the resident's physician and/or psychiatrist as needed. The assessment shall include an awareness of the relationship including awareness of who is initiating the relationship, identity of the other person, and comfort level with sexual intimacy, the ability to avoid exploitation including the resident's values and ability to refuse unwanted advances; and an awareness of potential risk associated with the relationship, including STDs or pregnancy, if applicable, or reaction if the relationship ends; -The resident's guardian (if applicable) will be invited to provide their guidance/opinion to the ICT. Family members may be involved in the assessment as appropriate; -b. All documentation regarding the resident's ability to consent shall be maintained in the resident's medical file and, if appropriate, in the resident's care plan; -Residents will be assessed for the capacity to consent to sexual activity if they have a history of sexual activity, have indicated that they wish to engage in sexual activity, or if the facility or guardian otherwise believes that they should be assessed. All residents do not need to be assessed. Residents will be reassessed as needed; -If a resident has been deemed to be unable to consent to sexual activity, the resident will be told that they are not permitted to engage in sexual activity; -Employees will not allow sexual activity to take place unless both residents have been deemed to have the capacity to consent; -If non-consensual sexual activity occurs, the abuse and neglect policy will be followed. Review of the facility's Abuse and Neglect Policy, last reviewed 1/05/23, showed the following: -Sexual abuse is non-consensual contact of any type with a resident. Sexual abuse includes, but is not limited to, the following: a. Unwanted intimate touching of any kind especially of the breasts or perineal area; b. All types of sexual assault or battery, such as rape, sodomy, and coerced nudity; This also includes failure to intervene or attempt to stop or prevent non-consensual sexual activity or performance between residents; -The facility is committed to protection of our residents from abuse by anyone including, but not limited to, Facility staff, other residents, consultants, volunteers, and staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals; -As part of the resident social history assessment, staff will identify residents with increased vulnerability for abuse or who have needs and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals, and approaches which would reduce the chances of mistreatment for these residents. Staff will continue to monitor the goals and approaches on a regular basis; -Residents who allegedly mistreat another resident will be removed from contact with the resident during the course of the investigation. The accused resident's condition shall be immediately evaluated to determine the most suitable therapy, care approaches, and placement considering his or her safety, as well as the safety of other residents and employees in the facility. Review of the facility's Covenant Guidelines, dated 10/12/22, showed the following: -Residents residing on Station 2, after administrative approval, may visit other residents of the same gender with the approval from staff working the unit and that of the roommate in the room being visited as long as there are no guardian limitations and charge nurse is aware. Door must be open while visiting and the light on if dark; -Any and all visits in other resident rooms/stations will be determined by guardian limitations before the ICT makes a determination for approval. ICT to review and make recommendations to the guardians if they feel the resident has displayed appropriate behaviors during a set time frame to be determined by the ICT; -Residents who have legal guardians will follow all legal guardian imposed limitations as outlines in their individualized plan of care; -All guidelines were discussed with a committee of residents, staff, a guardian, and the ombudsman. The guidelines were voted on by the residents, with the majority being the final decision. All limitations may be modified by an individual resident's guardian should there be the need; -These covenants are not negotiable, and are put into place and enforced for the safety of the residents/staff and the facility. 1. Review of Resident #47's Pre admission Screening and Resident Review Level Two (PASARR II), dated 7/05/13, showed the following: -Diagnoses included mood disorder (a mental health condition that primarily affects your emotional state), impulse control disorder (a group of behavioral conditions that involve an inability to control impulses and behaviors), bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), adjustment disorder (an emotional or behavioral reaction to a stressful event or change in a person's life), major depression (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy), mixed personality disorder (the occurrence of traits of more than one personality disorder), borderline personality disorder (a mental illness that severely impacts a person's ability to manage their emotions), and mild mental retardation (deficits in intellectual functions pertaining to abstract/theoretical thinking); -The resident communicates without problem/expresses self well; -Cognitively the resident does not make good decisions and cannot follow complex directions; -He/She had a cooperative, childlike manner which he/she was guarded, easily frustrated, and easily distracted; -The resident required monitoring, 24 hours per day supervision and support due to limited intellectual disability, impaired judgement, and history of being taken advantage of; -He/She required redirection for inappropriate behaviors and support for increased anxiety; -The resident would benefit from short term nursing facility level of service for stabilization of mood; -If admitted to a nursing facility, he/she would need implementation of systematic plans to change inappropriate behavior, medication therapy/monitoring to change inappropriate behavior or alter manifestations of psychiatric illness, provision of structured environment, and development of personal support networks. Review of the resident's care plan, dated 7/09/22 showed the following: -The resident has a guardian to assist in decision making due to mental illness (dated 7/09/22); -Ensure guardian wishes are followed (dated 7/09/22); -Encourage resident to participate in social situations and monitor interactions with others (dated 7/09/22); -Resident can be childlike in demeanor. Review of the facility's guardian limitations report dated 12/22/23, showed the resident must follow covenant guidelines. Review of the resident's progress notes dated 2/11/24 at 1:52 P.M., showed the following: -The resident was noted to hold hands and be flirtatious with a peer. The resident was educated on proper friendly boundaries and not having guardian permission for relationships; -The resident acknowledged understanding and said he/she would be friends until guardian approves otherwise with no signs and symptoms of pressure or distress from peer; -Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), and Resident Care Coordinator aware. Review of the resident's care plan, revised on 2/21/24 showed the following: -The resident experienced flirtation with a peer and needs reminding to maintain platonic friendship and refrain from physical touching, kissing, hand holding, etc.; -He/She needs reminders not to enter peers' rooms without invitation or staff permission and was not to be on the 400 hall or a hall that he/she does not live on. Review of the resident's medical record from admission date to 1/2/24, showed no assessment for the resident to consent to sexual activity. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/20/24, showed the resident was cognitively intact. During an interview on 4/24/24 at 11:41 A.M. and 4/25/24 at 10:24 A.M., the resident said the following: -He/She thought Resident #115 had been admitted to the facility around 1/2/24; -He/She had been in a relationship with Resident #115 for about two months; -He/She told Resident #115 he/she was thinking of moving closer to his/her family and Resident #115 told him/her he/she did not want him/her to move as he/she truly liked him/her as a friend, but liked him/her more as a lover; -He/She had performed oral sex on Resident #115 two times, once after supper and once before lunch, and both times the act took place in Resident #115's room; -Resident #115 came to his/her room and asked him/her to give him/her oral sex, so they went to Resident #115's room; -He/She had agreed to perform oral sex, but told Resident #115 he/she did not want to complete the act. Resident #115 held his/her head in place so he/she could not move and did it anyway; -His/Her guardian told him/her he/she could not be in a relationship with Resident #115 or anyone else; -This all occurred after supper and right before shift change; -The second time he/she gave Resident #115 oral sex it happened the same way, even though he/she had asked him/her not to complete the act, Resident #115 did not listen and did it anyway without his/her permission; -The second occurrence happened after the 1:30 P.M. smoke break, when staff were outside with smokers; -He/She did not want to give Resident #115 oral sex a second time, but he/she wanted to keep him/her as a friend and felt obligated to give him/her oral sex; -He/She said Resident #115 said this was their little secret and he/she should not tell anyone what they are doing. -After the second time he/she gave Resident #115 oral sex, Resident #115 was in his/her bed and Certified Nurse Aide (CNA) E walked into the room; -CNA E told them if they want to be in each other's rooms, they knew the rules and the door should be open and reminded them if it was night the light had to be turned on; -The reason he/she waited so long to talk about it, he/she did not know he/she could get into trouble. He/She did not want to get Resident #115 into trouble; -He/She told the DON he/she wanted to be tested for STDs; -He/She did not have any physical injuries, but has had a flash back and woke up the night before sweating. He/She said he/she was dreaming and when he/she woke up he/she felt worthless. Review of the resident's written statements for the facility, dated 4/21/24, showed the following: -The resident had sexual relations with Resident #115; -Resident #115 forced him/herself on him/her by making the resident give him/her oral sex; -Both residents were caught by CNA E; -The resident told the Administrator about the incidents which happened in late January early February; -The resident told the Administrator he was worried about getting AIDS. During an interview on 4/26/24 at 11:09 A.M., CNA E said the following: -The day Residents #47 and #115 were caught sitting on Resident #115's bed, the door was closed and when he/she opened the door he/she found the two residents sitting on Resident #115's bed, staring into each other's eyes and he/she reminded them to keep things in the friend zone; -He/She left her job around 3/15/24 and management had a meeting with Resident #47 and #115's guardian and there was no consent obtained at that time for a physical relationship. During an interview on 4/24/24 at 1:33 P.M., the resident's Caseworker D said the following: -The facility had reported Resident #47 had been forced to perform oral sex on another resident back in January; -He/She did not feel the resident had the mental capacity to be in a relationship. During an interview on 4/30/24 at 2:41 P.M., the resident's legal guardian C said the following: -He/She was not aware the resident and Resident #115 had been in a relationship; -In order for him/her to consent for the resident to be in a relationship, he/she would have needed to have had a conversation with the facility on an as needed basis when these issues arise. Review of the resident's Capacity to Consent to Sexual Activity Form, dated 4/22/24, showed the following: -The resident could not say what level of sexual intimacy he/she would be comfortable with; -The resident did not have the capacity to say no to uninvited sexual contact; -The resident could not describe how he/she would react when the relationship ended; -The resident had been assessed, for the purpose of determining whether he/she is capable of understanding the purpose, nature, risks, benefits, and alternatives (including nonparticipation) in giving consent, making a decision about participation, and understanding that the decision about participation in the sexual activity, otherwise entitled: Capacity to Consent to Sexual Activity; -On the basis of this examination the evaluator arrived at the conclusion that this participant clearly lacks this capacity at this time; -The resident signed the document along with the evaluator, the ADON and the Social Services Director (SSD). 2. Review of Resident #115's PASARR II, dated 11/15/23, showed the following: -Diagnoses included oppositional defiant disorder (a type of behavior disorder. It is mostly diagnosed in childhood in which individuals show a pattern of uncooperative, defiant, and hostile behavior toward peers, parents, teachers, and other authority figures), attention-deficit hyperactivity disorder (ADHD) (neurodevelopmental disorders usually first diagnosed in childhood and often lasts into adulthood in which individuals have trouble paying attention or controlling impulsive behaviors (may act without thinking about what the result will be or be overly active), borderline intellectual functioning (a group of people who function on the border between normal intellectual functioning and intellectual disability), bipolar disorder, autistic disorder (a neurological and developmental disorder that affects how people interact with others, communicate, learn, and behave), moderate intellectual disabilities, intellectual disability moderate to severe (Individuals with moderate intellectual disability possess basic communication skills and can maintain self-care, often with some degree of support. Those with a severe intellectual disability exhibit considerable developmental delays), pervasive developmental disorder (characterized by delays in the development of social and communication skills), learning disorder, developmental disorder of scholastic skills (include dyscalculia (difficulty learning arithmetic) but also dyslexia (a condition of neurodevelopmental origin that mainly affects the ease with which a person reads, writes, and spells, typically recognized as a specific learning disorder in children), mood disorder, Post Traumatic Stress Disorder (PTSD) (a real disorder that develops when a person has experienced or witnessed a scary, shocking, terrifying, or dangerous event), disruptive mood dysregulation disorder (condition in which children or adolescents experience ongoing irritability, anger, and frequent, intense temper outbursts), and impulse control disorder with recurrent self-harm; -He/She needs nursing facility placement due to behavioral difficulties and/or mental illness symptoms requiring 24 hour monitoring/management; -His/Her individual limitations include intellectually disability, poor insight/judgment, and limited interpersonal support system; -His/Her individual strengths include guardianship in place and he/she is able to make his/her wants/needs known; -He/She needs a structured environment in order to assess and plan for the level of supervision required to prevent harm to his/herself or to others; -He/She requires ongoing assessment of mood, thought process and behaviors for early recognition of changes to promote early intervention and proactive modifications to plan of care. Review of the facility's guardian limitations report dated 12/22/23, showed the resident was to follow covenant guidelines. Review of the resident's care plan, dated 2/03/24 and revised 2/20/24, 4/23/24 and 4/24/24, showed the following: -Problem: The resident has a history with extensive psychiatric history, including oppositional defiant disorder, ADHD, bipolar disorder, depression, anxiety, suicidal ideation with attempts of self-harm, moderate to severe intellectual disabilities including autism (varying with hospitalizations and placements), PTSD, with symptoms including anxiety, labile mood, hopelessness, worthlessness, loss of appetite, fearfulness, aggressive and assaultive behavior, paranoia, perseveration, defiance, poor concentration, lack of insight and poor judgement (dated 2/03/24); -Problem: The resident has manifestations of behaviors related to his/her mental illness that may create disturbances that affect others. These behaviors include hypersexuality, seeking sexual relationship from peers (dated 2/20/24); -Intervention: He/She continues to be advised to refrain from physical contact intimacy. Discussed alternatives including masturbating privately and seeking assist to procure device to aid in such if desired. Review of the resident's progress notes, dated 2/11/24, showed the resident was noted to hold hands and be flirtatious with a peer. Resident educated on proper friendly boundaries and not having guardian permission for relationships. Resident acknowledged understanding and states will be friends until guardian approves otherwise with no signs or symptoms or pressure or distress from peer. Review of the resident's admission MDS, completed by facility staff, dated 2/14/24, showed the resident had moderately impaired cognition. Review of the facility clinical census, dated 3/17/24, showed the resident was moved to another hall. Review of the resident's progress notes dated 4/01/24 at 1:04 A.M., showed the resident attended 7:30 P.M. supervised smoke break and when finished he/she went to common area to sit at a table with peer (Resident #19). The resident got up from the table a couple of minutes later, and approached the peer at the same table. The resident leaned over and kissed the peer on the lips. Staff immediately intervened and educated resident on facility guidelines of no physical contact with other peers. DON, Administrator. and guardian notified. Review of the resident's progress notes dated 4/06/24 at 4:11 A.M., showed the resident became upset when redirected from peer, and became belligerent. Staff counseled the resident on guidelines and the resident walked away. The resident then friended a new peer. Was seen chatting and following new peer. Review of the resident's facility acquired written statement dated 4/21/24, showed the following: -He/She and Resident #47 were having sex, kissing, making out and were caught by CNA E in his/her bed together; -He/She and Resident #47 engaged in oral sex and kissed behind the building; -The sexual acts were done out of love; -He/She has a new boy/girlfriend and Resident #47 was jealous and has been trying to cause problems with his/her new relationship. During an interview on 4/24/24 at 12:15 P.M. and 4/25/24 at 11:38 A.M. and 12:14 P.M., the resident said the following: -He/She was not currently in a physical relationship, but he/she was in an emotional relationship with Resident #19; -He/She used to be boy/girlfriend with Resident #47; -He/She did not force Resident #47 to have oral sex, it was consensual and happened many times in each of their rooms; -He/She had oral sex with Resident #47 about two to three months ago; -He/She did not have permission from his/her guardian to have a relationship with anyone; -He/She started a relationship with Resident #19 about one month ago and had oral sex, but now cannot do anything until guardians give them permission. Review of the Resident's Capacity to Consent to Sexual Activity Form, dated 4/22/24, showed the following: -The resident was not aware of who was initiating sexual contact; -The resident could not state what level of sexual intimacy he/she would be comfortable with; -The residents' behavior was not consistent with formerly held beliefs/values; -The resident could not describe how he/she would react when the relationship ended; -The resident had been assessed, for the purpose of determining whether he/she is capable of understanding the purpose, nature, risks, benefits, and alternatives (including nonparticipation) in giving consent, making a decision about participation, and understanding that the decision about participation in the sexual activity, otherwise entitled: Capacity to Consent to Sexual Activity; -On the basis of this examination, the evaluator arrived at the conclusion that this participant clearly lacks this capacity at this time; -The resident signed the document along with the evaluator, the ADON and the SSD. During an interview on 4/24/24 at 1:43 P.M., the resident's legal guardian A said the following: -He/She was not aware Resident #115 was in a physical relationship; -He/She did not think the resident understood what it meant to be in a healthy relationship as he/she does not believe the resident ever witnessed a healthy relationship; -The issue with giving permission for a relationship never came up for Resident #115. 3. Review of Resident #19's PASARR Level II dated 9/07/18 showed the following: -Diagnoses included: Mood disorder, impulse control disorder, schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions which include delusions (false beliefs), hallucinations (seeing or hearing things that don't exist), unusual physical behavior, and disorganized thinking and speech.), PTSD, adjustment disorder, ADHD, major depressive disorder (when an individual has a persistently low or depressed mood, decreased interest in pleasurable activities, feelings of guilt or worthlessness, lack of energy, poor concentration, appetite changes, agitation, sleep disturbances, or suicidal thoughts.) (MDD), schizoaffective disorder (a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania), bipolar disorder, borderline personality disorder, developmental delay, history of traumatic brain injury (a sudden injury that causes damage to the brain); -Historical symptoms or behaviors included seeing a psychiatrist around the age of seventeen due to depression, auditory and visual hallucinations following the death of his/her adopted father. He/She was hospitalized around the age of twenty due to suicidal ideation. He/She has attempted suicide several times in the past. He/She has self-mutilating behaviors with numerous scars on lower legs where he/she cut, burned, scratched, or otherwise hurt him/herself. He/She has chronic suicidal ideation's as he/she hears voices telling him/her to kill him/herself, paranoid thoughts, and elopement from facility; -He/She has had numerous hospitalizations for depression and suicidal ideations; -He/She requires secured/behavioral unit; -His/Her thought process/cognitive status included poor concentration, poor judgement, tangential (a communication disorder in which the train of thought of the speaker wanders and shows a lack of focus, never returning to the initial topic of the conversation), disorganized, short term memory deficit, and poor insight; -His/Her manner was cooperative and childlike; -He/She requires a nursing facility due to ongoing for safety, medication, medical and psychiatric monitoring and requires ongoing medical management and review of medications; -He/She does not make good or safe decisions. Review of the resident's care plan, initiated 5/23/22 and revised on 4/29/23, showed the following: -Problem: PASRR showed the resident had a history of behavioral challenges that require protective oversight in a secure setting. He/She began experiencing hallucinations at seventeen after the death of his/her adopted father. He/She experienced auditory and visual command hallucinations as well as suicidal and homicidal ideation. He/She has a history of suicide attempts. He/She also practiced self-mutilation by cutting self, leaving numerous scars. He/She has a diagnoses of schizoaffective and mood disorder, anxiety, major depression, and psychosis (dated 5/23/22); -Problem: The resident has a history of PTSD. PTSD affects the resident symptoms and may flare up without any known trigger. Alterations in reactivity from the traumatic event, including aggressiveness, and self-destructive behavior. Intrusion or persistently re-experienced stressors in at least one of the following ways: recurrent memories, traumatic nightmares, flashbacks, prolonged distress following traumatic reminders, significant physical symptoms after exposure to stressors. The resident states he/she was bullied in school, physically and emotionally. Triggers include loud noises, accusing him/her of doing things and unwanted touching (dated 4/29/23). Review of the facility's guardian limitations report, dated 12/22/23, showed the following: -The resident must follow covenant guidelines; -The resident may not have any relation with opposite sex peers. Review of the resident's quarterly MDS, completed by facility staff, dated 3/03/24, showed the resident was cognitively intact. Review of the resident's progress notes, dated 4/01/24 at 1:20 A.M., showed the following: -Resident attended 7:30 P.M. supervised smoke break, and when finished, went to common area and sat at a table with peer. A couple of minutes later, the peer (Resident #115) got up from table and kissed this resident. Staff immediately intervened and educated resident on facility guidelines of no physical contact with other peers. DON and Administrator notified. Left message on voicemail for guardian. Review of the resident's guardian email, dated 4/03/24 at 9:16 A.M. and 4/03/24 at 12:48 P.M., showed the following: -The email was sent to the SSD; -The guardian would like to make the facility aware of this guardian directive. The resident is not to be in a relationship with anyone (male or female). Relationships always cause him/her to become confused and when they end he/she becomes suicidal. The resident can have friends, but no romantic relationships. There should be no public display of affection between the resident and another resident. Review of the resident's progress notes, dated 4/06/24 at 5:34 A.M., showed the resident became upset at staff for redirecting him/her away from another peer. Resident became verbally aggressive, but was easily redirected. During an interview on 4/24/24 at 11:31 A.M., 4/24/24 at 4:08 P.M. and 4/25/24 at 11:46 A.M. and 12:16 P.M., the resident said the following: -He/She had consensual oral sex in Resident #115's room about one and a half weeks ago; -He/She can only be with Resident #115 in the dining room and on smoke breaks; -He /She can kiss and hold hands with Resident #115; -He/She just wanted to do a favor for Resident #115, because he/she said he/she was horny. Review of the resident's Capacity to Consent to Sexual Activity Form, dated 4/22/24, showed the following: -The resident's behavior was not consistent with formerly held beliefs/values; -The resident did not realize that the relationship may be time limited due to placement of male/female on unit was temporary; -The resident could not describe how he/she would react when the relationship ended; -The resident had been assessed, for the purpose of determining whether he/she is capable of understanding the purpose, nature, risks, benefits, and alternatives (including nonparticipation) in giving consent, making a decision about participation, and understanding that the decision about participation in the sexual activity, otherwise entitled: Capacity to Consent to Sexual Activity; -On the basis of this examination the evaluator arrived at the conclusion that there was doubt about this participant's capacity at this time and further evaluation was necessary; -The resident signed the document along with the evaluator, the ADON and the SSD. Observation on 4/24/24 at 4:02 P.M. showed Resident #115 knocked on the resident's door while the surveyor interviewed the resident. Resident #115 was not supposed to be allowed on the hall as he/she did not live on the hall. During an interview on 4/24/24 at 1:57 P.M. and 5/01/24 at 12:21 P.M., the resident's legal guardian B said the following: -He/She did not want Resident #19 to have any relationships; -He/She felt the resident did not have the capacity to consent to a relationship of any kind; -There had been times in the past when Resident #19 has been in a relationship and when it ended he/she was taken to the hospital for suicidal ideations; -He/She felt the resident could not handle any breakup without it causing suicidal ideations; -He/She emailed a directive to the facility on 4/03/24 stating the resident could not have a boy/girlfriend relationships; -The resident does not know what a relationship was because he/she has never been in a loving relationship; -The resident can be easily taken advantage of by anyone dealing with anything, for example, there were other residents who were trying to get his/her coloring books and pencils and a fight would ensue; -When he/she spoke with the resident on the phone he/she had told him/her that he/she had a boy/girlfriend and he/she told him he/she did not agree and that he/she knew what could happen if/when the relationship ended; -He/She sent the email on 4/03/24, because the resident told him/her he/she was in love with another resident; -His/Her family member called after speaking with the resident to report he/she was afraid the resident was going away with Resident #115 to another family 's home in another city; -He/She then contacted the resident and told him/her he/she could not have a relationship with anyone; -He/She felt romantic relationships could cause the resident to harm him/herself as the resident does not handle his/her feelings very well when relationships come to an end; -He/Sh

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one resident (Resident #13) with a mental health disorder, in a review of 13 sampled residents, received individualized treatment and services to meet his/her psychosocial needs. The resident had a history of alcohol use, impulsiveness, self-mutilation, and multiple suicide attempts. On 8/3/23, the resident cut himself/herself and swallowed batteries. Staff believed the resident's behavior was a result of staff confiscating contraband (chewing tobacco and cigarettes) after the resident returned to the facility after attending church. On 11/5/23, staff reported the resident was upset when staff confiscated chewing tobacco, cigarettes and two bottles of alcohol-based hand sanitizer upon the resident's return from attending church. The resident also presented with signs/symptoms of alcohol consumption. On 11/12/23 and 11/13/23, the resident refused his/her medications and reported to staff he/she was upset about not having hand sanitizer. On 11/19/23, the resident was restricted from going to church and cut his/her forearms multiple times with a razor blade, requiring sutures. The resident denied this was a suicide attempt, however, reported he/she cut himself/herself because he/she was not allowed to go to church. The facility failed to develop and implement meaningful behavioral health interventions specific to the resident to address the resident's alcohol use, impulsiveness, and self-mutilation to prevent episodes of self-injurious behavior and harm. The facility census was 111. Review of the facility's Behavioral Emergency Policy, last revised on 1/5/23, showed the following: -If the resident exhibits extreme behaviors such as suicidal, homicidal, self-mutilation, elopement, or resident to resident altercations the following steps will occur: 1. The licensed nursing staff/team leader/Resident Care Coordinator (RCC)/nursing administration will assess the resident who is exhibiting such behaviors, ensuring that safety of the resident and others is the first priority. A one-to-one monitoring of the resident will be initiated immediately; 2. The Director of Nurses or Designee and the Administrator or Designee and Regional Director will be notified regarding assessment findings. The Director of Operations or Chief Operating Officer will review the resident ' s plan of care with the Regional Director and Administrator/Designee and will determine if the resident ' s needs can continue to be met safely or whether the resident continues to be appropriate for placement at the facility. The licensed nurse/Team Leader/RCC will follow direction from the Management Team Member on call, Resident Care Coordinator and the Administrator or Designee; 3. The guardian will be notified at this time and imposed limitations may be placed on the resident, including hospitalization or other specific directives; 4. The physician will be notified of the licensed nurse/Team Leader/RCC assessment and orders will be followed; 5. If the Management Team Member on call and Administrator or Designee decide that the resident ' s needs cannot continue to be safely met, or that the resident is not appropriate for placement at the facility, the physician will be notified by the licensed nurse requesting for a psychiatric evaluation at this time an immediate discharge notice may be sent with the resident. 6. The Administrator/DON/designee will complete an Administrative Investigation within 24 hours of the behavioral emergency. This may include a PRN (as needed) Interventions Form and notification of state agencies in the event that criteria are met. 7. The Licensed Nurse will document the behavioral emergency in the medical record by utilizing the BIRPEEEE documentation guidelines: a. B=Behavior Emergency-define 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; 8. Documentation of the Behavior Emergency in the Administrative Investigation will 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 behaviors 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. 1. Review of Resident #13's Preadmission Screening and Resident Review (PASRR) Evaluation (a federally mandated screening process for individuals with serious mental illness and/or intellectual disability/developmental disability related diagnosis who apply or reside in a nursing facility regardless of the source of payment. The screening assures appropriate placement of persons known or suspected of having a mental impairment and also that the individual needs of mentally impaired persons can be, and are, being met in the appropriate placement environment), completed 11/19/09, showed the following: -Diagnoses included schizoaffective disorder, bipolar disorder (brain disorder that causes changes in a person's mood, energy, and ability to function), borderline personality disorder (characterized by severe mood swings, impulsive behavior, and difficulty forming stable personal relationships), and anxiety; -History of self-mutilation, multiple suicide attempts, impaired interpersonal and social functioning, and impulsiveness; -Binge drinks when in the community; -Avoids interpersonal relationships and is socially isolated; -Recommend that client be in a safe, secure environment and have support for emotional issues, provided with an opportunity for increased interaction via small groups. Would benefit from counseling for grief-loss adjustment. Also needs monitoring for safety due to smoking in areas not designated, impulsive behavior, self-mutilation, and multiple suicidal attempts. (Review of the resident's medical record showed no documentation of a more current PASRR.) Review of the resident's face sheet, showed the following: -The resident's original admission date was 1/13/10; -The resident was his/her own responsible party; -Diagnoses included major depressive disorder (mood disorder that interferes with daily life), bipolar disorder, borderline personality disorder, schizophrenia, and anxiety disorder. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/3/23, showed the following: -Cognitively intact; -No behaviors directed toward self or others; -Independent with ambulation. Review of the resident's care plan, last updated 7/27/23, showed the following: -Problem: Coping; -Determine the resident's coping methods. Coping skills included music, outside time, smoking, religion/church, and watching the news. -Encourage participation in self-calming behaviors such as breathing exercises, meditation or guided imagery; -Encourage times of rest and relaxation between care activities; -Provide reassurance to resident. -Problem: The resident had a long history of mental illness; -He/She enjoyed attending local church and regularly went with a staff member; -He/She wished to attend the following spiritual activities: church service (in the town where the facility was located). -He/She will attend church as he/she feels like. -Problem: Risk for harm self-directed or other directed behavior potentially causing harm, mood disorders, psychotic disorder. The resident has exhibited self-harm behavior related to not receiving monies from his/her family member's passing (11/2022); -Hourly face checks; -Encourage the resident to verbalize cause for aggression; -Monitor for cognitive, emotional or environmental factors that may contribute to violent behaviors; -Monitor for signs/symptoms of agitation; -Offer acceptable alternatives to unacceptable situation; -The resident will be placed on intensive monitoring when necessary; -Utilize diversion techniques as needed. -Problem: The resident has a long history of mental illness and frequent psychiatric hospital admissions. The resident's current diagnoses are schizoaffective disorder, bipolar disorder, borderline personality disorder and anxiety. The resident has a history of self-mutilation, multiple suicide attempts and impulsiveness; -Behavior modification programs as needed; -Interdisciplinary team and guardian (the resident did not have a guardian) involvement as necessary; -Long-term psych management and counseling if needed; -One-on-one interventions as needed; -Pharmaceutical interventions as needed; -The resident enjoys attending a local parish church and regularly goes with a staff member. Review of the resident's incident note, dated 8/3/23 at 8:52 P.M., showed the following: -The resident came back from church with numerous items, chew, cigarettes on his/her person; -He/She came up to the staff at approximately 6:00 P.M. stating he/she cut himself/herself and swallowed batteries; -The staff sent the resident to emergency department via ambulance. Review of the resident's Registered Nurse (RN) Investigation, dated 8/3/23, showed the following: -On 8/3/23, the resident reported he/she swallowed batteries and cut himself/herself. The resident had superficial cuts on his/her arm. Orders received to send to the hospital; -The resident attended church earlier in the day and returned with chewing tobacco and cigarettes. The items were secured at the nurses station and the resident was advised he/she could use those items in accordance with facility safety and smoking policies. The resident was unable to identify the utensil used to cut himself/herself saying, I don't know. It's not deep. No sharp objects were found including but not limited to razors, CDs, glass or cans. During an interview on 12/4/23 at 1:15 P.M., the Director of Nursing (DON) said the following: -On 8/3/23, the resident walked up to the nurses station and said he/she swallowed batteries because he/she wanted to; -She thought the resident swallowed the batteries because the staff took the contraband away from the resident upon returning to the facility; -The resident used a piece of the surgical masks to cut himself/herself; -The staff were educated not to leave surgical masks or N95 masks in the trash cans the residents have access to unsupervised. Review of the resident's medical record showed no evidence staff identified the root cause for the resident's self-harm or resident-specific interventions to address the incident and to prevent future incidents of self-harm, including cutting. Review of the resident's admission note, dated 8/17/23, showed the following: -Screening: Does the resident currently or have a history of a substance use or been diagnosed with substance use disorder: Yes. Substance of choice: alcohol. Frequency of use: Daily. -Education/Notification : Safety concerns - recent suicidal ideology. Review of the resident's progress notes, dated 8/20/23 (Sunday), showed the day shift reported the resident was verbally aggressive towards staff but was easily redirected. No behavioral issues noted this shift. (Review showed no evidence staff attempted to identify the root cause of the resident's verbal aggression on 8/20/23.) Review of the resident's care plan, updated on 8/23/23, showed the following: -The resident has a psychosocial well-being problem related to inability to meet role expectations and ineffective coping skills. The resident has self-harming behaviors such as cutting and recently swallowed batteries; -Consult with pastoral care, social services and psych services; -Encourage participation in activities and outings; -Provide activities calendar; -Increase communication between resident/family/caregivers about care and living environment. Explain all procedures and treatments, medication, results of labs/tests, condition, all changes, rules, options; -Monitor/document resident's usual response to problems: Internal - how individual makes own changes, External - expects others to control problems or leave to fate or luck; -When conflict arises, remove residents to a calm safe environment and allow to vent/share feelings. (Review of the resident's care plan showed no specific interventions identified to address the resident cutting himself/herself or swallowing batteries.) Review of the resident's mental status exam, dated 9/15/23, showed the following: -The resident was seen for follow up visit for medication management. The resident was recently in the hospital for depression. The resident reports his/her mood is all right; -Staff report no behavioral issues; -Resident denies self-harm. Nurses notes reports when resident gets upset, he/she refuses his/her human immunodeficiency virus (HIV; an infection that attacks the body's immune system) medications (3/16/23); -Symptoms of illness included conscious desire to inflict self-harming behaviors. Reports he/she will kill himself/herself when he/she doesn't get his/her own way by refusing to take his/her HIV medications; -Assessment: Education and support provided. Zyprexa (an antipsychotic medication) and Seroquel (an antipsychotic medication) have helped manage psychosis (a collection of symptoms that affect the mind, where there has been some loss of contact with reality). Monitor mood, behavior and side effects of medications. Review of the resident's nurse note, dated 9/24/23 at 3:43 P.M., showed the following: -The resident returned from church and agreed to contraband check; -The staff found three cans of chew hidden behind belt in waistband; -The resident gave the staff the contraband without outbursts or behaviors; -The staff smelled alcohol on the resident's breath without signs or symptoms of distress. Review of the resident's care plan showed no documentation staff addressed the resident's alcohol use. Review of the resident's annual MDS, dated [DATE], showed the following: -The resident was cognitively intact; -He/She was independent with all activities of daily living; -No behaviors directed toward self or others. Review of the resident's progress note, dated 10/8/23 at 2:01 P.M., showed the following: -The resident returned to the facility at 12:24 P.M.; -His/Her eyes were red, speech slurred, drowsy affect, and odor of alcohol; -He/She denied drinking alcohol, but admitted to going to the liquor store; -The nurse advised the resident of line-of-sight requirement for protective oversight; -The resident declined to remain in common area, so one-on-one supervision initiated; -The resident said he/she would like to nap, so the staff monitored the resident every 15 minutes for eight hours for safety. Review of the resident's care plan showed no documentation staff addressed the resident's alcohol use. Review of the resident's nurse note, dated 10/22/23 at 12:45 P.M., showed the resident returned to the facility and agreed to personal search. The staff found multiple cans of chew and multiple packs of cigarettes on the resident's person and hidden chew in beltline and pocket. Review of the resident's mental status exam, dated 10/28/23, showed the following: -The resident was seen today for a follow up visit for chart review, interval history and medication management. The resident reports, I'm all right. I'm getting an iPad.; -Assessment: Education and support provided. The resident instructed if he/she feels suicidal to notify staff. Continue facility supportive plan of care and current medications. Continue to monitor mood, behavior and side effects of medications. Review of the resident's October 2023 Medication Administration Record (MAR) and progress notes showed no evidence the resident refused to take his/her medications, including his/her HIV medications. Review of the resident's behavior note, dated 11/5/23 at 1:33 P.M., showed the following: -The resident returned to the facility and agreed to personal search for contraband; -The Director of Nursing (DON) and certified nurse aide (CNA) checked the resident finding multiple cans of chew tucked in his/her beltline attempting to hide cigarettes, the lighter the staff sent him/her, and two bottles of alcohol-based hand sanitizer; -The resident had signs and symptoms of alcohol consumption by alcohol on breath, sweaty, lethargic, and very tired appearance; -The resident said he/she did not consume any alcohol while on leave of absence. During an interview on 12/1/23 at 8:59 A.M., the Assistant Director of Nursing (ADON) said the following: -The staff searched the resident for contraband upon his/her return to the facility on [DATE]; -The staff found contraband items and took the items from the resident to put in a secure area; -The resident yelled at him/her (ADON) when she confiscated hand sanitizer from the resident which was an unusual behavior for the resident. The staff felt threatened with the resident's behavior. During an interview on 12/12/23 at 2:05 P.M., the Administrator said the following: -The resident brought hand sanitizer into the building and admitted to drinking it on the way back to the facility from church on 11/5/23; -The resident had an increase in behaviors towards others following 11/5/23 when the resident returned to the facility with the smell of alcohol and had the bottles of hand sanitizer taken away from him/her. Review of the resident's progress notes, dated 11/12/23 (Sunday) at 3:45 P.M., showed the resident refused his/her noon medications. The staff educated the resident on importance of taking medications as prescribed. The resident verbalized understanding, but continued to refuse. Review of the resident's Medication Administration Record (MAR), dated 11/12/23, showed the resident refused the following medications scheduled for the noon medication pass: -Clonazepam (a sedative used to treat anxiety and panic disorder) 0.5 milligrams (mg), give one tablet three times a day related to bipolar disorder; -Hydroxyzine HCL (an antihistamine used to treat anxiety) 25 mg, give one tablet three times a day related to anxiety disorder. Review of the resident's progress notes, dated 11/12/23 at 6:18 P.M., showed the following: -The resident was not compliant with medications; -The staff attempted to redirect and educate the resident on the importance of staying medication compliant. The resident did not take medication. The medication was destroyed, and the staff notified administration. Review of the resident's MAR, dated 11/12/23, showed the resident refused the following medications scheduled for the evening medication pass: -Benztropine mesylate (an anti-tremor medication) 0.5 mg, give one tablet in the evening related to dysthymic disorder (mild, but long-lasting form of depression); -Prazosin HCL (an antihypertensive medication also used to manage/treat nightmares) 2 mg, give one capsule at bedtime related to nightmare disorder (sleep disorder characterized by recurrent nightmares that cause significant distress); -Quetiapine fumarate (an antipsychotic medication) 200 mg, give two tablets in the evening related to schizophrenia; -Trazodone HCL (an antidepressant medication) 100 mg, give one tablet in the evening related to insomnia (sleep disorder in which you have trouble falling and/or staying asleep); -Olanzapine (an antipsychotic medication) 5 mg, give one tablet two times a day related to schizophrenia; -Clonazepam 0.5 mg, give one tablet three times a day related to bipolar disorder; -Hydroxyzine HCL 25 mg, give one tablet three times a day related to anxiety disorder. Review of the resident's medical record showed no documentation the facility identified the root cause for the resident to refuse his/her medications on 11/12/23 (Sunday) or interventions implemented to address the root cause. Review of the resident's MAR, dated 11/13/23, showed the resident refused the following medications during the morning medication pass: -Fluoxetine HCL (an antidepressant medication) 20 mg, give two tablets in the morning related to major depressive disorder; -Triumeq (antiviral combination) 600-50-300 mg, give one tablet one time a day for HIV; -Olanzapine 5 mg, give one tablet two times a day related to schizophrenia (second missed dose); -Clonazepam 0.5 mg, give one tablet by mouth three times a day related to bipolar disorder (third missed dose); -Hydroxyzine HCL 25 mg, give one tablet by mouth three times a day related to anxiety disorder (third missed dose). Review of the resident's progress notes, dated 11/13/23 at 11:28 A.M., showed the following: -The resident refused all morning medication and stated he/she did not want them. (The resident's morning medications included the medication to treat HIV); -The staff notified the Administrator, DON, ADON, and resident care coordinator (RCC); -The resident was self-guardian, so staff educated the resident on health factors of refusing medication. Review of the resident's MAR, dated 11/13/23, showed the following for the noon medication pass: -The resident did not receive his/her scheduled morning medication; -The resident refused clonazepam 0.5 mg (fourth missed dose) and hydroxyzine HCL 25 mg (fourth missed dose). Review of the resident's progress notes, dated 11/13/23 at 1:05 P.M., showed the resident continued to refuse all medications. (The resident did not receive his/her medication to treat HIV.) Review of the resident's MAR, dated 11/13/23 showed the resident did not receive his/her morning or afternoon medications (including his/her medication to treat HIV) and refused the following medications during the evening medication pass: -Benztropine mesylate 0.5 mg, give one tablet in the evening related to dysthymic disorder; -Prazosin HCL 2 mg, give one capsule at bedtime related to nightmare disorder; -Quetiapine fumarate 200 mg, give two tablets in the evening related to schizophrenia; -Trazodone HCL 100 mg, give one tablet in the evening related to insomnia; -Olanzapine 5 mg, give one tablet two times a day related to schizophrenia; -Clonazepam 0.5 mg, give one tablet three times a day related to bipolar disorder; -Hydroxyzine HCL 25 mg, give one tablet three times a day related to anxiety disorder. Review of the resident's progress notes, dated 11/13/23 at 9:07 P.M., showed the following: -The resident refused bedtime medications; -The certified medication technician (CMT) spoke with the resident and was able to convince the resident to take the medications; -The resident said he/she was upset about not having hand sanitizer. Review of the resident's November 2023 MAR showed no documentation the resident received any of his/her scheduled medications on 11/13/23 Review of the resident's medical record showed no documentation of interventions implemented to address the root cause of the resident's refusal to take his/her medications, including not having hand sanitizer. Review of the resident's progress notes, dated 11/19/23 at 10:29 A.M., showed the following: -The resident's peers found the resident in his/her room bleeding profusely from his/her arms and upper left hand; -The resident said the behavior was in response to not being able to attend church services this day due to inappropriate behavior during a previous outing. (No specific documentation in the note to identify the inappropriate behavior from previous outing); -The staff found two thin razor blades on the resident's person. Review of the resident's RN Investigation, dated 11/19/23, showed the following: -On 11/19/23, the resident was noted to have blood coming from both of his/her outer forearms. The right forearm with two 1-inch long lacerations; the left forearm with three 1-inch long lacerations; and left hand with two 2-inch lacerations. The resident said he/she did this because he/she wasn't allowed to go to church today. When asked what he/she used to cut himself/herself, the resident said nothing. Small metal pieces were noted on the bedside table; -The resident was sent to the emergency department for evaluation and treatment with sutures needed. Review of the emergency department nurse documentation, dated 11/19/23, showed the following: -Emergency medical services (EMS) state the resident cut both forearms at the health care center where he/she lives. He/She has attempted this in the past. -Facility staff states the resident said he/she cut his/her forearms because he/she was not allowed to go to church because of bad behavior. Also reports he/she likes to drink hand sanitizer. Review of the emergency department physician documentation, dated 11/19/23, showed the following: -The resident was brought from care facility after cutting himself/herself because he/she was upset because they would not allow him/her to go to church. The resident said he/she did not try to kill himself/herself although he/she did say he/she wanted to hurt himself/herself at the facility, but denies it was a suicidal attempt and denies current suicidal ideations; -The resident has cut himself/herself before and has a history of depression. The resident's symptoms currently are mild in nature; -Laceration #1: right anterior distal forearm. Length: 3.5 centimeters (cm). Sutures: Five subcutaneous sutures (suture placed immediately below the top layer of the skin); -Laceration #2: left anterior distal forearm. Length: 2.5 cm. Sutures: Five subcutaneous sutures; -Laceration #3: left distal anterior forearm. Length: 3 cm. Sutures: Seven subcutaneous sutures; -Laceration #4: left distal anterior forearm. Length: 3 cm. Sutures: Five subcutaneous sutures; -Laceration #5: left distal anterior forearm. Length: 2 cm. Sutures: Two subcutaneous sutures. During interviews on 12/1/23 at 9:42 A.M. and 12/4/23 at 9:00 A.M., the resident said the following: -On 11/19/23, the staff did not allow him/her to go to church and it made him/her feel depressed. He/She was upset and cut himself/herself with a razor. He/She was not trying to commit suicide; -He/She got the shaving razor out of the trash can in his/her main hallway on 11/19/23 when he/she could not go to church. He/She took the razor blade out of the shaving razor to cut himself/herself; -He/She would tell the staff when he/she was upset about something, but did not tell anyone prior to cutting himself/herself on 11/19/23, because it was the staff who would not let him/her go to church. During interview on 12/4/23 at 9:08 A.M., Licensed Practical Nurse (LPN) A said he/she did not remember the interventions in place to prevent the resident from self-harm. During an interview on 12/12/23 at 10:45 A.M., Certified Medication Technician (CMT) C said the following: -He/She did not know the reason why the resident swallowed batteries on 8/3/23, but the resident was on every 15-minute checks; -Prior to 11/19/23, the staff performed more frequent face checks and 1:1 based on how grouchy the resident was at the time; -On 11/19/23, the staff implemented intense monitoring of every 10 to 15-minute checks when the resident was upset about not being allowed to go to church; -The staff documented and educated the resident when he/she refused to take medication and sent a message to the DON or department head, who would notify the physician; -The resident listened to gospel music, read the Bible, and watched television as coping mechanisms. During interviews on 12/1/23 at 8:59 A.M. and 10:55 A.M., the ADON said the following: -He/She thought the resident drank the hand sanitizer; -The staff told the resident on 11/19/23 that he/she could not go to church for his/her safety, then the resident cut himself/herself; -The resident refused to take medication when he/she became upset. Staff discussed with the resident how not taking medication was hurting him/her and not the staff; -Some interventions in place to prevent the resident from self-harm was talking with the resident, going to church, streaming service for church service, one-on-one attention, prayer with the Administrator, and speaking to a parent via phone. During interviews on 11/29/23 at 9:40 A.M., 12/5/23 at 1:15 P.M. and 12/12/23 at 1:43 P.M., the DON said the following: -The resident made threats of harming himself/herself in the past when he/she did not get his/her way. Most of the time, the resident refused to take his/her medications; -If staff told the resident, no, then the resident would refuse to take medications; -The staff reported the resident's refusal to take medication and an administration staff would discuss it with the resident; -The resident was not always on 15-minute check, however on 11/19/23, the resident was on the 15-minute checks because he/she was unable to go to church; -The face checks were not documented because the resident was not on one-on-one; -On 11/19/23, the resident used a shaving razor to cut himself/herself. The resident did not tell staff where he/she got the shaving razor; -The resident said he/she was mad about not being able to go to church; -The resident's coping skills included the implemented interventions of listening to music on a portable CD player, prayer in the morning, watching television, watching his/her tablet, and smoking; -She expected the resident's care plan to be updated with interventions to address the resident harming himself/herself on 8/3/34 and then again on 11/19/23. During an interview on 1/3/24 at 10:09 A.M., the Administrator said the following: -He did not expect the staff to implement additional measures when the resident returned with contraband on 8/3/23, because the staff had already searched the resident and the resident did not say anything to the staff taking away the contraband; -He expected staff to implement interventions to address the resident after he/she cut himself/herself and swallowed batteries on 8/3/23. He thought the interventions were implemented; -He expected the staff to identify the root cause for the resident's behavior and implement interventions to specifically address the root cause to prevent further incidents after 8/3/23. The intra-disciplinary team met with the resident to speak about the resident's actions and staff implemented one-on-one supervision for at least four hours (not documented) upon the resident's return from the hospital; -The resident was impulsive, and the staff could not have prevented the resident from harm at all times, because the resident did not voice or demonstrate any behaviors; -The resident was his/her own person and consumed alcohol outside the facility; -The ADON and members of the church offered the resident rides to church, which the resident agreed to go but would leave to walk back alone; -The Administrator and Director of Nursing disagree with the statement that the resident became very upset and yelled because it was never reported to them and they had not witnessed the resident ever yell or become upset when staff took contraband from the resident; -The resident became frustrated about being caught with contraband, but never verbally yelled; -He did not remember why the resident refused his/her medications on 11/12/23; -The resident refused to take his/her medications for various reasons, such as, if the resident had a bad phone call from the family, the resident did not receive money from a parent's death, etc.; -The resident usually refused to take medications for a day or two, but the staf

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure weights were monitored weekly after a significant weight loss was identified as directed in the facility policy, failed to provide interventions as ordered by the physician to prevent weight loss, failed to re-evaluate interventions to prevent weight loss for effectiveness, failed to monitor the meal and supplement consumption as directed in the facility policy, failed to update the resident's care plan to reflect the resident's current orders/interventions as directed in the facility policy, and failed to ensure dental needs were identified and actions taken to prevent further weight loss for one resident (Resident #21), who had a 14.5% significant weight loss, in a review of 31 sampled residents. The facility census was 108. Review of the facility's policy, Weight Loss, last revised 2/26/21, showed the following: -Maintain acceptable parameters of nutritional status, such as body weight and protein level, unless the resident's condition demonstrates that this is not possible; -The following parameters for weight loss require physician notification, legal guardian and or the resident's responsible party, the dietitian. The information and notifications will be documented in the resident's record. -Interventions shall also be documented: -5% weight loss in 30 days: will involve physician notification, possible orders for dietary supplement, dietitian may be notified; -7.5% weight loss in three months: requires physician notification, dietitian to consult, and any orders to increase dietary intake, supplements etc; -10% weight loss in six months: requires physician notification, dietitian to consult, and any orders to increase dietary intake, supplements to be increased, changed etc.; -The dietitian can be consulted at anytime. Ensure that documentation with recommendations are charted after any consultation with physician or dietitian; -Nursing staff will follow all recommendations and physician orders. Laboratory results such as serum albumin levels will be called to the primary physician and the dietitian will be notified of the results; -Residents with concerns for weight loss will be weighed as ordered by the physician and at least weekly. Weight loss issues will be addressed in the quality assurance (QA) meetings and will be added to the quality assurance and performance improvement (QAPI) report monthly. -The Assistant Director of Nurses (ADON) or designee will follow-up to ensure that weight losses meeting above parameters are followed and that the physician and dietitian are consulted; -Snack times and snack intake sheets will be filled out; -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; -QAPI meeting will address offering other food choices and different types of snacks that continue to meet the residents required nutritional diet/intake, this should 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; -If a resident triggers for a weight loss or gain, the resident will be placed on weekly weights and weights will be monitored by the Resident Care Coordinator (RCC)/ADON/Director of Nursing (DON) until stable. 1. Review of Resident #21's annual Minimum Data Set (MDS), a federally mandated assessment instrument, dated 11/24/17, showed the resident was edentulous (no natural teeth or tooth fragments). Review of the resident's care plan for weight loss, last revised 4/14/21, showed the following: -The resident has a current diet order for a regular diet and regular liquid; -Goal: Will continue to maintain current nutritional status; -The resident has unplanned/unexpected weight loss related to poor food intake; -The resident often falls asleep while eating; cues and reminders provided; -Goal: The resident will consume two of three meals/day; -Give the resident supplements as ordered; -Alert nurse/dietitian if not consuming on a routine basis; -If weight decline persists, contact physician and dietician immediately; -Labs as ordered. Report results to physician and ensure dietician is aware; -Monitor and evaluate any weight loss. Determine percentage lost and follow facility protocol for weight loss; -Monitor and record food intake at each meal. (The resident's Care Plan did not indicate if the resident had dentures or was edentulous as identified on the MDS, dated [DATE]). Review of the resident's weight record showed the resident's weight on 7/1/21 was 177 pounds (lbs). Review of the resident's Physician's Order Sheet, dated 7/6/21, showed the resident was on a regular diet with pureed texture. Review of the resident's weight record showed the following: -On 8/5/21, staff documented the resident weighed 178 lbs and 171 lbs (both weights were recorded for this date); -On 9/7/21, the resident weighed 170.4 lbs Review of the resident's Dietitian Note, dated 9/9/21, showed the following: -The resident remains on a pureed diet; -The resident continues to eat well with 76-100% of most meals consumed; -Labs 9/2/21: Total protein (measures the total amount of two classes of proteins found in the fluid portion of your blood, low value can indicate liver, kidney disease, and/or malnutrition) 5.7 low (normal range is 6.0 to 8.3 grams per deciliter (g/dL)), albumin (a protein made by the liver, lower value may indicate malnutrition, liver disease, kidney disease, or an inflammatory disease) 2.9 low (normal range is 3.5 to 5.5 g/dL), hemoglobin A1C (Glycated hemoglobin is a form of hemoglobin that is chemically linked to a sugar, measures your average blood sugar levels over the past 3 months) 7.9% high (target should be 7.0 - 7.5%); -Height: 68 inches; -September 2021 weight: 170 lbs; down 8 lbs in one and three months, and down 5 lbs in six months; -No recommendations at this time; -Will continue to follow and be available as needed. Review of the resident's admission MDS dated [DATE], showed the following: -Moderate cognitive impairment; -Diagnoses included chronic obstructive pulmonary disease (chronic respiratory disease), diabetes mellitus (inability to regulate blood glucose), atrial fibrillation (abnormal heart rhythm), and Parkinson's disease (a progressive nervous system disorder that affects movement); -Weight 170 lbs; -Required supervision with eating; -No swallowing issues; -No significant weight loss or gain; -No oral/dental issues. (The MDS was not not marked as edentulous.) Review of the resident's Physicians Orders Sheet, dated 9/24/21, showed the resident was on a regular diet, regular texture. Review of the resident's Dietary Manager note, dated 10/25/21, showed the following: -The resident is on regular diet with super cereal (a recipe that combines different ingredients and nutrients that when combined, makes a high-calorie, nutritious, and fortified cereal, fortified is to add nutrients not normally there) at breakfast; -His/Her weight was 172 lbs; -There are no concerns at this time. Will follow up. Review of the resident's care plan, progress notes, dietician notes or physician's orders showed no documentation the resident was to receive super cereal as indicated in the dietary manager's note dated 10/25/21. Review of the resident's weight record showed the resident's weight on 10/27/21 was 161.8 lbs (a significant weight loss of 10.2 lbs/5% weight loss in one month, and 15.2 lbs/8.5% weight loss in three months). Review of the resident's medical record showed no documentation staff notified the resident's physician or the registered dietician of the resident's significant weight loss as directed by facility policy. Review showed no documentation the resident's goals or interventions to prevent weight loss were re-evaluated or revised and no new interventions to prevent weight loss were implemented. Review showed no evidence staff added weekly weights to the resident's plan of care as directed in facility policy following a weight loss. Review of the resident's weight record showed the resident's weight on 11/29/21 was 158 lbs (a weight loss of 3.8 lbs since 10/27/21). Review of the resident's Dietitian Note, dated 11/29/21, showed the following: -The resident's diet changed 9/24 from a pureed diet to a regular diet, thin/regular liquids continued; -The resident has been having a variable intake, eating 0-100% of meals per documentation; -The resident remains on Remeron (antidepressant medication that can also stimulate appetite) for appetite; -Labs: 10/1/21: Albumin 3.1 low; -November 2021 weight: 158 lbs., down 8 lbs in one month, a 4.8% weight loss; down 20 lbs in three months, an 11.2% weight loss; down 16 lbs in six months, a 9.2% weight loss. -No recommendations at this time; -Will continue to monitor intake, weight and labs and will be available as needed. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -Weight 158 lbs, significant weight loss; -No swallowing issues; -No oral/dental issues. (The MDS was not marked as edentulous). Review of the resident's weight record showed the resident's weight on 12/14/21 was 156 lbs. Review of the resident's Dietitian Note, dated 12/30/21, showed the following: -The resident remains on a regular diet, continues to have a variable food intake, eating 0-100% of meals; -The resident needs encouragement at times to eat; remains on Remeron for appetite; -Labs: 12/2/21: Albumin 3.3 low, ALT (alanine aminotransferase test is a blood test that checks for liver damage) 3 low (normal range is 7 to 56 U/L (units per liter), in the elderly, low ALT levels may indicate an aging liver, declining kidney function, or poor nutrition), Hgb A1c 7.0% high; -December 2021 weight: 158 lbs, no change in one month; down 12 lbs in three months, a 7.1% weight loss; down 20 lbs in six months, an 11.2% weight loss; -No recommendations at this time. Will continue to follow and be available as needed. Review of the resident's Dietary Manager note, dated 1/7/22, showed the following: -The resident is on a regular diet with super cereal for breakfast and limited starch diet; -The resident's weight is down to 158 lbs; -He/She has spoken to the resident and he/she has not been eating well at all; -He/She asked the resident if he/she could buy him/her a burger from the local diner, and the resident said, no; -Facility staff are working on getting the resident to eat again. Will follow up. Review of the resident's care plan and physician's order showed no documentation directing staff to provide the resident with super cereal and a limited starch diet as indicated in the dietary managers note, dated 1/7/22. Review of the resident's weight record showed the resident's weight on 1/12/22 was 156 lbs. Review of the resident's Dietitian Note, dated 1/14/22, showed the following: -The resident remains on a regular diet; continues to have a variable intake; continues to eat 0-100% of meals; -Nursing reports he/she isn't even snacking like he/she usually does; -The resident remains on Remeron for appetite; -Labs: 1/7/22: Albumin 3.3 low, Hgb A1c 7.8% high; -January 2022 wt: 156 lbs, down 2 lbs in one month; down 10 lbs in three months, a 6.0% weight loss; down 21 lbs in six months, an 11.9% weight loss; -Weight loss has slowed. No recommendations at this time; -Will continue to monitor intake, weight and labs and will be available as needed. Review of the resident's medical record showed he/she was discharged to the hospital on 2/10/22. Review of the resident's hospital lab report, dated 2/10/22, showed the resident's albumin was 2.5 low and total protein was 5.9 low (normal range is 6.0 to 8.3 grams per deciliter (g/dL) or 60 to 83 g/L). Review of the resident's Hospital Discharge summary, dated [DATE], showed the following diagnoses: -Bacterial pneumonia (infection of the lung); -Septic shock (widespread infection causing organ failure and dangerously low blood pressure); -Urinary tract infection from e.coli (bacteria found in the bowel); -Moderate malnutrition (lack of sufficient nutrients in the body); -Moderate dehydration (dangerous loss of body fluid caused by illness, sweating, or inadequate intake); -Acute kidney injury. Review of the medical record showed the resident returned to the facility on 2/14/22. During an interview on 5/26/22 at 10:21 A.M., the Dietary Supervisor (DS) said the nursing staff sent a pink communication sheet to the dietary department on 2/14/22 for the resident's readmission. The pink slip said the resident was on a mechanical soft diet, it did not have any nutritional supplements listed. That was the last communication he/she received regarding the resident's diet. Review of the resident's weight record showed the resident's weight on 2/15/22 was 152 lbs (a weight loss of 4 lbs since 1/12/22). Review of the resident's Physician's Order Sheet, dated 2/16/22, showed orders for a regular diet, mechanical soft chopped meat texture, thin/regular consistency, house supplement two times daily, and super cereal with breakfast. Review of the resident's care plan showed no documentation staff updated the care plan with the resident's weight loss, new diet orders, or new interventions to prevent further weight loss. Review of the resident's medical record showed no documentation staff implemented weekly weights as directed by facility policy following weight loss. Review of the resident's annual MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -New signs and symptoms delirium, fluctuates; -Diagnoses added included pneumonia, respiratory failure with hypoxia (insufficient oxygen), malnutrition, urinary tract infection, multi-drug resistant organism (MDRO), septicemia (septic shock), -Weight 152 (10.59% wt loss since September 2021), significant weight loss, not on physician prescribed plan; -No swallowing issues; -No oral/dental issues, (not marked edentulous). -Required limited assistance with eating. Review of the resident's Dietitian Note, dated 2/22/22, showed the following: -The resident was sent out to the hospital on 2/10/22, and was readmitted on [DATE]; -The resident's diet changed on 2/16/22 from a regular diet to a mechanical soft diet with chopped meat. Thin/regular liquids remain the same; -The resident also started on super cereal with breakfast and house supplements two times daily on 2/16/22; -The resident to use built-up silverware; -The resident continues to have a variable intake, needs encouragement to eat at times; -The resident remains on Remeron; -February 2022 weight: 152 lbs, down 4 lbs in one month, down 6 lbs in three months, down 26 lbs in six months, a 14.6% weight loss; -No recommendations at this time since supplements and fortified food just initiated. Will continue to follow and be available as needed. Review of the resident's weight record showed the resident's weight on 3/14/22 was 147 lbs. Review of the resident's Physician's Orders, dated 3/23/22, showed Lasix (a diuretic) 40 milligrams two times daily for edema for 21 days. Review of the resident's Dietitian Note, dated 3/25/22, showed the following: -The resident remains on a mechanical soft diet with chopped meat, thin liquids, house supplement two times daily, and super cereal with breakfast; -The resident remains on Remeron; -Labs: Sodium level 146 high (high sodium level can indicate dehydration), albumin 2.5 low, Hgb A1c 6.5% high; -March 2022 weight: 147 lbs., down 5 lbs in one month, a 3.3% weight loss; down 11 lbs in three months, a 7.0% weight loss; down 23 lbs in six months, a 13.5% weight loss. -Discussed resident in monthly weight meeting held yesterday; -The resident had a room move and has been doing better lately, eating better per nursing; -The resident will sometimes drink his/her nutritional supplements and sometimes will refuse them; -The resident also was started on Lasix due to edema (swelling caused by excess fluid trapped in your body's tissues); -No recommendations. Will continue to monitor intake, weight and labs and will be available as needed. (Review of the resident's Physician Orders showed the Lasix was started on 3/23/22 after the resident's weight of 147 on 3/14/22.) Review of the resident's meal consumption log, dated 4/17/22-4/30/22, showed staff documented two out of approximately 39 meals. (Review of the medical record showed no evidence staff documented any other meal consumption or nutritional supplement consumption as directed by facility policy.) Review of the resident's weight record showed the resident's weight on 4/21/22 was 142 lbs. Review of the resident's Dietitian Note, dated 4/25/22, showed the following: -The resident remains on a mechanical soft diet with chopped meat and thin liquids, house supplement two times daily, and super cereal with breakfast; -The resident eating 26-75% of most meals; -The resident remains on Remeron; -Labs: Albumin 3.1 low; -April 2022 weight: 142 lbs, down 5 lbs in one month; down 14 lbs in three months, a 9.0% weight loss; down 24 lbs in six months, a 14.5% weight loss; -No recommendations at this time. Will continue to follow and be available as needed. Review of the resident's meal consumption log, dated 5/1/22-5/17/22, showed staff documented two out of approximately 50 meals. (Review of the medical record showed no evidence staff documented any other meal consumption or nutritional supplement consumption as directed by facility policy.) Review of the resident's Physician's Order Sheet, dated May 2022, showed a regular diet, mechanical soft chopped meat texture, thin/regular consistency, house supplement two times daily, and super cereal with breakfast. Review of the resident's diet order on the dietary order list, provided by the dietary manager, dated 5/16/22, showed the resident was on a regular, mechanical soft texture diet, with super cereal at breakfast, limit starch and cold cereal. (The dietary order list did not include the nutritional supplement two times daily or chopped meat texture as ordered by the physician.) During an interview on 5/16/22, at 1:15 P.M. and 5/17/22 at 9:15 A.M., the resident said the following: -He/She had lost weight; -He/She tried to eat what he/she could, but the meat was nasty; -They grind up my meat to mush; it is supposed to be cut up small but it is mushy; -Dietary staff grind up his/her meat because the housekeeper threw away his/her dentures over a year ago, and he/she doesn't have any teeth; -He/She does not know why staff grind up his/her meatloaf, riblets, and sausage. He/She can eat those meats without dentures, and they wouldn't be mushy; -If staff want to cut up his/her meat, it would be okay, but they grind it to mush; -He/She does not like green beans, but staff always give him/her green beans; -The only snack he/she gets is at bedtime; -He/She got nutritional shakes back in the Fall when he/she was on a pureed diet, but hasn't had them since; they were good; -Until a few months ago, he/she got super cereal for breakfast, but now he/she gets cold cereal. He/She got burnt out on super cereal and wanted corn flakes or fruit loops; -No one has made a dentist appointment for him/her to get new dentures; -Staff have not asked about his/her teeth, or why he/she doesn't like the meat; -Staff just say, you need to eat. Observation on 5/16/22, at 12:10 P.M., showed the following: -The resident sat in his/her wheelchair at the dining room table; -Staff served the resident a soft beef taco, canned tomatoes, potatoes with green beans, apple cobbler, and one small glass of an orange drink; -The resident consumed his/her taco, cobbler, and half of his/her orange drink; -Staff did not serve the resident a nutritional supplement, and served the resident green beans which he/she did not like (per interview with the resident) and did not eat. During an interview on 5/16/22, at 1:30 P.M., Certified Nurse Assistant (CNA) F said he/she didn't know the resident ever had dentures; the resident was edentulous. He/She didn't know if the resident had any weight loss. He/She didn't think the resident had weight loss because the resident didn't get any nutritional supplements. Observation on 5/17/22, at 8:15 A.M. showed the following: -The resident sat in his/her wheelchair at the dining room table; -The resident's meal tray was in front of him/her; -The tray contained a serving of ground sausage, a bowl with milk remaining, a few scrambled eggs, and a small amount of purple fluid in cup; -Staff did not serve the resident super cereal or a nutritional supplement with his/her breakfast. During an interview on 5/17/22, at 8:15 A.M., the resident said, look my sausage is not cup up, it is mush. Observation on 5/17/22 at 8:15 A.M. showed the resident's sausage was ground to pieces smaller than the size of rice, almost pureed texture. The resident did not consume his/her sausage. Observation on 5/17/22, at 12:05 P.M., showed the resident received ground pulled pork for the lunch meal. Staff did not serve the resident a nutritional supplement with his/her meal. During an interview on 5/17/22, at 11:05 A.M., Licensed Practical Nurse (LPN) J said the following: -He/She was not sure if the resident was currently on weight loss monitoring; -The resident has had issues with weight loss over the last year; -The resident did not get nutritional supplements at this time. During an interview on 5/17/22, at 4:10 P.M., the Resident Care Coordinator (RCC) said the following: -He/She did not know if the resident's dentures were missing; he/she just thought the resident did not wear them; -The resident has had weight loss issues over the last year; -He/She was not sure where the resident was on weight loss or interventions. He/She had been working on the night shift, and was not able to attend the weight loss meetings; -He/She did not know if the resident was getting nutritional supplements and super cereal; -The DON and ADON have been monitoring the resident's weight loss. Observation on 5/18/22, at 7:50 A.M.-8:11 A.M., showed the following: -The resident sat at the dining room table in his/her wheelchair; -Staff served the resident scrambled eggs, ground sausage, coffee cake, corn flakes, grape juice, 2% milk, and a nutritional supplement; (Staff did not serve the resident super cereal as directed in the physician's orders and the resident's meal ticket.) -The resident held up his/her nutritional supplement and said, I love theses shakes. I haven't had them in months. During an interview on 5/19/22, at 4:10 P.M., CNA K said the following: -He/She did not think the resident was a weight loss concern; -The resident did not get any nutritional supplements or anything special (for weight loss); -There was no list of residents with weight loss, the charge nurses just verbally told the aides who needed extra help or the residents with weight loss; -He/She didn't know if the resident ever had dentures, but the resident did not have them now. During an interview on 5/19/22, at 4:25 P.M., the DON said the following: -She reviews all residents' weights monthly; -The resident had significant weight loss, and continued to lose weight, but was not losing weight as fast as before. -She reviews residents of concern weekly with the interdisciplinary team, makes recommendations or notifies the dietitian if residents have continued weight loss; -The interdisciplinary team and the dietitian monitor residents with significant weight loss/gain: 5% one month, 7.5% three months, or 10% six months; -Staff weigh residents with a significant weight loss/gain weekly; -She expected staff to give nutritional supplements and fortified foods as ordered; -Nursing staff monitor to ensure the nutritional supplements/interventions were given/completed; -She was not sure why staff did not weigh the resident weekly or why staff did not give the resident super cereal or nutritional supplements; -Dietary orders should match the physician ordered diets; -She did not know the resident had missing dentures. She just thought the resident did not wear his/her dentures. During an interview on 5/26/22, at 10: 21 A.M., the Dietary Supervisor said the following: -The resident hates his/her mechanical soft diet. The resident does not like anything but a regular diet; -The resident did not like the ground meat he/she was to receive; -She was not aware the resident's diet order was for chopped meat and not ground meat; -She did not know the resident's dentures were missing; she just thought the resident did not wear them; -The nursing staff review the residents' weights, but she was not sure how often; -She participated in the monthly review of weights, and recommendations were made then; -The resident was discussed, he/she had a lot of weight loss, but had slowed down on the amount he/she was losing; -The registered dietitian looked at residents' weights every month; -Some of the diet orders on the residents' physician's orders sheet did not match the pink communication sheets he/she received, so the dietary department did not have the same orders that were on the resident's physicians orders; -The resident did not get the nutritional supplements because it was not on the order dietary had; -He/She did not know why the resident did not get his/her super cereal. Staff were expected to send super cereal and cold cereal with the resident's breakfast meal. During an interview on 5/26/22, at 1:12 P.M., the Registered Dietitian (RD) said the following: -Chopped meat should be cut small and not ground; -She did not know the resident's meat was being ground; -She expected the facility staff to carry through with physician orders and RD recommendations for residents with weight loss; -By the facility's policy, residents who trigger for significant weight loss/gain were to be weighed weekly; -Consumption tracking is important for residents with weight loss because it helps to make meaningful recommendations; -The Dietary Supervisor was expected to audit the dietary orders comparing them to the physician's orders monthly and to clarify any discrepancies; -Staff were to give nutritional supplements and fortified foods as ordered; -The facility should contact her if any interventions to prevent weight loss were not effective or a reason cannot be carried through so another recommendation could be made. The facility had not contacted her about the resident; -Resident #21 cycles and has times he/she does better and times he/she does not do as well, so the approach changes often with him/her; -The resident triggered for significant weight loss every month since October 2021 and an over 10% weight loss in six months; -Tracking the resident's meal consumption and supplements/fortified foods helps to ensure his/her nutritional needs are being met. During an interview on 6/2/22, at 10:32 A.M., the administrator said the following: -He expected staff to follow the dietitian's recommendations and physician's orders; -If fortified foods or supplements were ordered, the resident should receive them; -If a diet order says chopped meat, the meat should be chopped and not ground; -When there were new diet orders or dietary supplement orders, he expected nursing and dietary staff to get together and make sure all their orders match; -He expected staff to weigh residents with significant weight loss weekly; -If a resident with significant weight loss continues to lose weight, then staff should meet and come up with something else to try or to figure out why the resident is still losing weight, and they should document that; -He was not aware of the resident's lost dentures.