**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 residents (Resident #4) observed for infection prevention. The facility failed to ensure Enhanced Barrier Precautions (EBP) were implemented and used when RNA provided wound care for Resident #4. This deficient practice could place residents at-risk for spread of infection. Findings included: Record review of Resident #4's Face sheet dated 02/07/2025 revealed she was a [AGE] year-old woman, with an initial admission date of 02/08/03/2018, with re-admission on [DATE] and with diagnoses which included: Chronic Embolism (a blockage in a blood vessel) and Thrombosis (formation of a blood clot inside a blood vessel, obstructing blood flow) of Unspecified Deep Veins of Left Lower Extremity. Record review of Resident #4's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 15, indicating intact cognition. Further review revealed Resident #4 was assessed as having an indwelling urinary catheter, a colostomy, three stage 2 pressure ulcers, four unstageable pressure injuries and one venous/arterial ulcer. Record review of Resident #4's Care Plan dated last reviewed 04/07/2025 revealed a Problem which included Resident requires Enhanced Barrier Precautions related to wounds, initiated 01/16/2025 and revised 04/07/2025. This problem area included the following interventions: Apply signage outside resident room; initiated 01/16/2025 and EBP used during high-contact resident care activities as applicable, such as: -Dressing -Bathing/Showering -Transferring -Providing hygiene -Changing linens -Changing briefs or assisting with toileting -Device care or use -Wound Care -Other areas determined to require EBP; Initiated 01/16/2025 Observation on 04/28/2025 at 11:07 AM, revealed there was a sign indicating Enhanced Barrier Precautions outside the door to Resident #4's room, and there was a supply of PPE available outside the door/room. Further observation revealed the contracted wound care nurse donned gloves but did not wear a gown while performing wound care for Resident #4. During an interview on 04/28/2025 at 11:30 AM, after the wound care observation, the DON and the Corporate Nurse both agreed that it was their expectation that the contracted wound care nurse wear a gown during the process of wound care. During an interview on 04/28/2025 at 1:00 PM, the DON stated she had called the wound care nurse and educated regarding EBPs. The DON presented written documentation of the education. During a telephone interview with the contracted wound care nurse on 04/30/2025 at 9:45 AM she stated she had received education from the DON regarding the need to wear a gown when providing wound care to a resident who had been placed on Enhanced Barrier Precautions. She also stated: Now that we have been educated, we will follow the protocol. Record review of facility policy titled Enhanced Barrier Precautions, reviewed 03/19/2025 states: Enhanced Barrier Precautions refer to an infection control intervention designed to reduce transmission of multi-drug-resistant organisms that employ targeted gown and glove use during high contact resident care activities. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and glove during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. EBP are indicated for resident with any of the following: -Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO.

Based on observation, interviews, and record review, the facility failed to store food following professional standards for food service safety for one of one kitchen reviewed in that: - Food items were not labeled and/or dated correctly in the walk-in fridge. - Out of date food in the walk-in fridge These failures could place residents who received meals from the main kitchen at risk for food-borne illness. Findings included: Observation on 4/28/2025 at 8:15 am of the walk-in refrigerator reflected the following: - Refrigerated cornbread for stuffing dated 4/22/2025 with no expiration date. - Refrigerated tortillas dated 4/12/2025 with no expiration date. - Refrigerated lunch Meat dated 4/25/2025 with no expiration date. - Refrigerated milk and juice on a tray that was not dated. - Refrigerated tamale pie dated 4/19/2025 with an expiration date of 4/26/2025. - Refrigerated scrambled eggs dated 4/27/2025 with no expiration date. - Refrigerated sausage dated 4/27/2025 with no expiration date. - Refrigerated pancakes dated 4/22/2025 with no expiration date. - Refrigerated gelatine dated 4/20/2025 with an expiration date of 4/26/2025. - Refrigerated coleslaw dated 4/25/2025 with no expiration date. Observation on 4/28/2025 at 8:30 am of the freezer reflected the following: - Frozen beef and chili Burritos red burritos in a bag with a date of 2/25/2025 with no expiration date. - Frozen chicken Breast Fillets in a bag that was dated 4/10/25 with no expiration date. - Froze Hush Puppies in a bag dated 4/25/2025 with no expiration date. - Frozen chicken pieces in a bag dated 4/03/2025 with no expiration date. - Frozen Salisbury steak in a bag dated 3/12/2025 with no expiration date. - Frozen corn dogs in a bag dated 1/31 with no year and no expiration date. During an interview on 4/30/2025 at 9:31 AM DA stated that she tried to check for out of date products in the kitchen daily, DA said that sometimes items get missed. DA stated if she found an item out of date, then she told the DM, and the food was thrown in the trash. DA stated when labeling items in bags the name of the product should be on the bag, the date the item was placed in the bag, and the expiration date put on the bag. DA stated if the bag was not labeled correctly, you would not know what was in the bag. Also, if the date on the bag was not there, the food in the bag could be expired. During an interview on 4/30/2025 at 9:38 AM KC stated she tried to check the kitchen daily for out-of-date product. KC stated if she found food was out of date, she threw the food in the trash. KC stated when labeling items in bag the name of the item should be on the bag, the date it was put on the bag, and the expiration date should be on the bag. KC stated if bags were not labeled and outdated food was served, residents could have gotten get sick from eating the food. During an interview on 4/30/2025 at 9:37 AM DM stated the kitchen should be check daily for out-of-date items. If out of date items in the kitchen are found the item should be discarded. DM stated when Items are placed in a bag the bag should be labeled with the name of the food, the date that the food was put in the bag, and the expiration date of the food in the bag which was three days. DM stated that if items are not labeled or dated correctly then the food could be bad without knowing it. DM said that if out of date food was served to the residents, then the residents for get sick from eating food that was out of date. DM said that she had in-serviced staff on the procedure labeling and checking for food that was out of date. During an interview on 4/30/2025 at 9:55 AM with ADM stated food in the kitchen should be checked regularly for out-of-date products. ADM stated items in the walk-in fridge should be labeled and dated correctly. ADM stated residents could get sick if food was not labeled or dated correctly. Record Review of the facility's undated Food Storage Policy: -All foods shall be dated with the month and year received and shall be rotated on the first in/first out basis upon receipt. Oldest items are to be moved to the front to be used first. -Food shall be purchased in quantities which can be stored properly. Frozen products purchased in larger quantities than needed are divided into appropriate quantities, wrapped, and labeled with the description of the product, the date it was wrapped and placed in the freezer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a resident, who was incontinent of bladder, the appropriate treatment, and services to prevent urinary tract infections, to the extent possible, for 1 of 7 residents (Resident #71) reviewed for catheter care. Resident #71's urinary catheter bag with urine was not anchored to his bed frame and was lying directly on the floor. This failure could place residents at risk of infection. Findings included: Record review of Resident #71's Annual MDS, dated [DATE], reflected Resident #71 was a [AGE] year-old male who was admitted to the facility on [DATE]. He was diagnosed with renal insufficiency (which was a disease that caused poor function of the kidneys,) atrial fibrillation (which was a disease of the heart characterized by irregular and often faster heartbeat,) and coronary artery disease (which was a disease where major blood vessels struggled to send blood, oxygen, and nutrients to the heart muscle.) Section C., Cognitive Patterns reflected Resident #71 had a BIMS Score of 12. A BIMS Score of 12 indicated Resident #71 had moderate cognitive impairment. Section H., Bladder and Bowel reflected Resident #71 utilized an indwelling catheter. Record review of Resident #71's CP reflected a focus area for the resident having utilized an indwelling catheter. This resident was a new admission, 3/11/2024 and the goals and interventions were not yet complete. Record review of Resident #71's order summary report reflected an order, dated 03/14/2024, to provide catheter care each shift, and as needed. Record review of Resident #71's progress notes, dated 3/11/2024, reflected Resident #71's arrival to the facility. Resident arrived with the catheter, which was free from obstruction and draining yellow clear urine. Observation and interview on 03/18/2024 at 10:10 AM revealed Resident #71 lying in bed comfortably watching television. He utilized an indwelling catheter, and the catheter bag was located on the floor next to his bed. The tubing had sufficient slack to reach the resident and there was no visual evidence of urine spilled on the floor or an odor of urine in the room. Resident #71 stated he felt good and that he did not have any concerns with the care he had received since he arrived at the facility on 3/11/2024. He was not aware that his catheter bag was located directly on the floor, and he denied any pain or discomfort in the area of his urinary track system. Interview on 03/20/2024 at 9:10 AM with CNA A revealed she had been a CNA for the last 11 years and had been at the facility for the last two. She stated catheter bag placement was within the scope of practice for the CNAs and that the correct placement of the catheter bag was on the side of the bed, or chair, and lower than the level of the resident's bladder. The catheter bag was placed lower than the level of the resident's bladder, so gravity drained the resident's urine into the catheter bag. The catheter bag was not supposed to be on the floor to protect the catheter bag, and the tubing, from contamination. Contamination of the catheter bag, or tubing, risked spreading to the resident and risked a urinary tract infection. She stated the failure associated with the catheter bag on the floor fell on the last person to provide the resident care or the clip that held the catheter bag to the bed. Interview on 03/20/2024 at 9:26 AM with LVN B revealed she had been an LVN for the last 10 years and had been at the facility for the last 6 months. She stated that CNAs usually emptied the resident's catheter bags during their shifts and reported the urinary output to the nursing staff for documentation. CNA staff was trained to affix the catheter bag to the resident's bed, or chair, lower than the level of the bladder. The catheter bag was not supposed to be positioned on the floor. If the catheter bag was on the floor, the catheter bag, and the tubing, risked contamination. If the contamination reached the resident's body, the resident risked a urinary tract infection. She stated that nursing staff periodically conducted rounds and any observations as such would have been corrected on the spot. Interview on 03/20/2024 at 10:57 AM with the DON revealed she had been an LVN for the previous 10 years and had been an RN for the last 6 months. She recently started working at the facility and she had been the DON for the last 9 days. She stated the correct placement for a catheter bag was on the side of the resident's bed, or chair, lower than the level of the resident's bladder. The bag was not supposed to be on the floor. If a catheter bag was on the floor, the catheter bag was exposed to contamination. If the bag was contaminated, and the contamination reached the resident, the resident risked a urinary tract infection. The failure to keep the resident's catheter bag off the floor was the resident's movements or the clip that affixed the bag to the bed. She did not believe that staff saw the bag on the floor and intentionally left it on the floor. Interview on 03/20/2024 at 11:53 AM with the ADM revealed facility policy for catheter care, specifically stated that the catheter bag was supposed to be kept off the floor for infection control. If the catheter bag was contaminated, it posed a risk of infection to the resident. The ADM stated the failure to keep the bag off the floor rested with staff did not ensure the catheter bag was in its proper location. Record review of the facility's Catheter Care Policy, dated January 2023, reflected a section for infection control. The infection control section indicated staff were to maintain clean techniques when handling or manipulating the catheter, tubing, or drainage bag. Be sure the catheter tubing and drainage bag are kept off the floor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that a resident had appropriate treatment and services to prevent complications of enteral feeding for 1 of 7 resident (Resident #72) reviewed for enteral feeding. Resident #72's peg tube gauze was not changed for 9 days. This failure placed the resident at risk of feeding tube complications and infections. Findings included: Record review of Resident #72's admission MDS, dated [DATE], reflected Resident #72 was an [AGE] year-old male who was admitted to the facility on [DATE]. He was diagnosed with benign prostatic hyperplasia (which was a disease having caused an enlarged prostate,) anemia (which was a health condition having caused fewer red blood cells to carry oxygen throughout the body,) and hypertension (which was a disease effecting the outward pressure on arteries and blood vessel walls.) Section C., Cognitive Patterns, revealed Resident #72 had a BIMS Score of 1. A BIMS Score of 1 indicated Resident #72 had severe cognitive impairment. Section K, Swallowing and Nutritional Status, revealed Resident # 72 had a feeding tube and consumed 51% or more calories and 501 CCs or more fluid each day through tube feeding. Record review of Resident # 72's CP revealed a focus area for tube feeding care, evidenced by Resident #72 having been admitted to the facility on tube feedings, revised on 3/15/2024. The goal, initiated on 3/15/2024, was for the resident's insertion site to be free from signs and symptoms of infection. The intervention for nursing staff, initiated on 3/15/2024, revealed nursing staff was supposed to cleanse tube site with normal saline, place split gauze dressing daily, and monitor for infection at tube site. Record review of Resident #72's Order Summary Reports revealed an order, dated 2/29/2024, to cleanse peg tube site with normal saline and place split gauze dressing daily. Resident #72's Order Summary Reports revealed an order, dated 03/16/2024, to cleanse peg tube site with normal saline and place split gauze dressing daily. Resident #72's Order Summary Reports revealed an order, dated 03/19/2024, to cleanse peg tube site with normal saline and place split gauze dressing daily. Record review of Resident #72's progress note dated 2/26/2024 revealed Resident #72 admitted to the facility with peg tube in place. Interview and observation on 3/19/2024 at 8:03 AM with Resident #72 revealed he had a peg tube insertion on his abdomen and had received nutrition through his peg tube since admission to the facility. The tube insertion site was covered by a split gauze pad to protect the insertion site. The date on the split gauze pad, written in black ink, was 3-10-2024. Resident #72 could not remember the last time staff cleansed, or changed the split gauze pad, at his tube insertion site. With the assistance of an Investigator VI, RN, there was observable pink coloration around the tube insertion site, but no signs of infection. Resident # 72 denied pain or discomfort at the insertion site. Interview and observation on 03/20/2024 at 9:51 AM with LVN C and Resident #72 revealed she had been an LVN for the last 10 years and had been working at the facility for the last 6 months. She stated she had cleansed the tube insertion site for Resident #72 at the beginning of her shift on 3-20-2024 and each new dressing was supposed to be marked with the date it was changed. Observation revealed the date on the split gauze pad was 3-20-2024. She stated the date on the split gauze pad she replaced was dated 3-19-2024. The importance of cleansing the insertion site, and changing the split gauze pad, was to prevent infection. An infection, at a tube insertion site, risked skin breakdown, loss of nutrition, and weight loss. The order to cleanse the insertion site and change the split gauze pad was not entered into the TAR. Interview on 03/20/2024 at 11:13 AM with the DON revealed she had been an LVN for the previous 10 years and had been an RN for the last 6 months. She recently started working at the facility and she had been the DON for the last 9 days. The DON did not speculate on why, or how, Resident #72's dressing was not changed as ordered, but stated the gauze should have been changed daily per the order to prevent the spread of infection. Interview on 03/20/2024 at 11:20 AM with LVN B revealed she cleansed the tube insertion site for Resident #72 and changed the split gauze pad yesterday, 3-19-2024. She stated the date on the gauze pad she changed yesterday, on 3-19-2024, was previously dated as 3-10-2024. She could not explain why the gauze pad had gone 9 days without being changed. She stated the failure to cleanse and change the dressing on the tube insertion site fell on the nursing staff. Interview on 03/20/2024 at 11:41 AM with the ADM revealed the facility had a policy in place to address enteral feedings and skin break down precautions. The ADM stated the failure of the dressing not being changed as ordered fell either on the order not being reviewed, not entered on the TAR, or due to leadership. Resident #72 risked infection and skin breakdown. Record review of the facility's Enteral Feedings Policy, dated January 2023, reflected a section that addressed preventing skin breakdown. The policy stated to keep the skin around the site clean, dry, and lubricated and observe for signs of skin breakdown, infection, and irritation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident clinical condition demonstrated that this was not possible or resident preferences indicated otherwise for one (Resident #17) of eight residents reviewed for nutrition. The facility failed to ensure Resident #17 received all items on her meal ticket as ordered by a regular diet which resulted in inadequate oral intake and weight loss. The facility failed to provide Resident #17 effective interventions to prevent further weight loss. This failure could place residents at risk of further weight loss, malnutrition, and decreased quality of life. Findings included: Record review of Resident #17's face sheet dated 01/30/2023 revealed Resident #17 was an [AGE] year old female admitted to the facility on [DATE] with a diagnoses of Alzheimer's disease (disease that effects the brain and nervous system and results in confusion, memory problems and behavioral issues), congestive heart failure (weakening of heart muscle resulting in the heart not pumping blood as effectively), GERD (condition that causes heart burn), high blood pressure, major depressive disorder (mental disorder characterized by low mood, low self-esteem, loss of interest or pleasure in normally enjoyable activities for at least two weeks) and anxiety disorder with history of hallucinations. Record review of Resident #17's quarterly MDS assessment dated [DATE] revealed Resident #17 had a BIMS score of 11 to indicate moderately impaired cognition. Resident #17 was not noted to have recent weight loss or require a mechanically altered or therapeutic diet. Resident #17 was independent and only required setup help for eating. Record review of Resident #17's care plan dated 11/12/2022 revealed Resident #17 was at risk for weight changes due to depression with fluctuating appetite, diuretic use and GERD. Resident #17 had the goal to maintain stable weight and will exhibit no signs or symptoms of dehydration over the next 90 days. Interventions included: -Labs as ordered. -Monitor for signs and symptoms of dehydration (poor skin turgor, chapped lips, dry skin, dry oral mucosa) Notify MD PRN. -Administer meds as ordered. -Diet as ordered. -Monitor meal percentages. Notify nursing PRN poor intake. -Offer choices of food/drink with each meal as able. -Quarterly drug review. -Weigh monthly. Review of Resident #17's weight record dated 01/29/2023 revealed: 01/20/2023 143.6 lbs -6.1% change in 30 days, -8.1% in 3 months, -10.25% in 6 months 12/01/2022 152.8 lbs 10/06/2022 156.2 lbs 07/06/2022 160.0 lbs In an interview on 01/29/2023 at 8:45 AM, Resident #17 stated the food at the facility was okay and that she was picky eater. She stated she felt like she lost weight recently because she had not been eating as much. She said she was unsure of how much weight she lost, but her clothes were looser. In an observation on 01/30/2023 at 7:23 AM, Resident #17's breakfast tray contained one piece of toast, a cup of coffee, a cup of milk, a cup of orange juice and a bowl of hot cereal. Record review of Resident #17's tray card dated 01/30/2023 revealed the following regular diet/regular texture and the menu included choice of juice, choice of cereal, scrambled eggs, sausage patty, toast, margarine, jelly, milk, coffee and water. In an interview on 01/30/2023 at 7:30 AM, CNA B stated Resident #17 will not eat much for breakfast and prefers a light breakfast. She stated Resident #17 preferred only a piece of toast or two biscuits for breakfast. She stated Resident #17 was offered the additional food including eggs and sausage in the past and refused to eat it. She stated Resident #17 was particular about the food she ate and would only eat a salad for lunch and then ate a bigger dinner. In an interview on 01/30/2023 at 7:50 AM, Resident #17 stated she only wanted to eat toast and coffee for breakfast. She did not like to eat a big breakfast and would not eat the eggs or sausage if it was brought to her. She liked eating a salad for lunch and then she would eat dinner. She said she was particular about food and had always watched what she ate closely and like to eat healthy. When asked what she thought caused the weight loss, she did not know but maybe she had been eating less. She said the facility did offer other food to her if she did not like what was served. She said she was not offered a health shake or other supplement to stabilize her weight. She said before she was admitted to the facility, she would drink a [NUTRITION SUPPLEMENT] shake every day. She said she would drink a health shake/supplement if offered one by the facility. In an interview on 01/30/2023 at 7:58 AM, CNA C stated Resident #17 ate only what she wanted to eat and had her preferences. He stated she was offered more food or different food by the kitchen to encourage intake but she would not eat it . He stated she had been very depressed over the holidays and would not come out of her room. He said they tried to encourage her to eat whatever she wanted and she would not eat much. He said he was not sure if her doctor was notified. In an observation on 01/30/2023 at 8:15 AM, Resident #17 was weighed standing up on the scale and her weight was 138.8 pounds. From 01/20/2023 her weight decreased another 4.8 pounds. Record review of Resident #17's RD Weight Variance Note dated 01/20/2023 revealed Resident #17 had a 6% decrease in her weight in 30 days and 8.1% decrease in 90 days. Her intake was noted at 76-100% some and <50% on occasion. Her estimated needs were 1488 kcal , 65-79 g protein, 1964 cc fluid. The summary noted: Resident with no real changes to eating behaviors and no skin issues presents with weight loss this month. Staff noted that had a very rough few weeks over the holiday season with increased depression. She did not come out to the dining room for two weeks during that time, but intake only marginally changed. Resident is not a big breakfast eater and has a chef salad every day at lunch and then the menued dinner. Resident also does not drink milk or consume ice cream type foods. Resident also is not a snacker. At this time continue nutrition POC (Plan of Care) as resident declines other intervention. Goal: Adequate oral intake to support stable weight during admission. RD will monitor and follow up as needed. In an interview on 01/30/2023 at 8:30 AM, the DON stated she and other staff routinely offer Resident #17 snacks, alternate foods and supplements to increase her intake and Resident #17 refused all of them. When asked if there was documentation to prove the offering of supplements or additional food, she said she would have to check. When asked if Resident #17's doctor was notified of her weight loss she said she would have to check because it was not documented in Resident #17's clinical record . When asked if any interventions were put into place by the RD after she was evaluated on 01/20/2023, she said no because Resident #17 refused previous interventions including supplements. She said the RD saw every resident quarterly or if there was a significant change and the RD would then make recommendations. She said the physician would be notified of a significant change and any additional orders would be implemented. She said she was not aware of any new orders for Resident #17 in regards to her recent weight loss. In an interview on 01/30/2023 at 8:45 AM, the DM stated Resident #17's food preferences were for a light breakfast of either two biscuits or a piece of toast. She said Resident #17 wanted a salad for lunch and then ate a regular dinner. She stated they offer her additional food and snacks and she declines them. She stated when Resident #17 was depressed over the holidays they offered any food that she would eat. She said she offered to run to any restaurant to pick up her favorite food and Resident #17 declined outside food as well. She stated Resident #17 did not like milk drinks and therefore did not like health shakes so they did not offer health shakes when her intake was low. In an interview on 01/30/2023 at 9:00 AM, Resident #17's RP stated Resident #17 suffered from depression every year this time of year like clockwork and had a history of losing weight when depressed. She stated Resident #17 also stopped eating sweets in the last few months and told Resident #17's RP that she did not like sweet food or desserts anymore. She said they used to bring Resident #17 pastries when they visited and now Resident #17 will not eat them anymore. She stated she thought Resident #17's tastes had changed. She said she was not notified by the facility about the weight loss. She said she was not aware of any changes the facility made for Resident #17 to stabilize her weight. She said she did not know if Resident #17 was offered a supplement and refused it. She said Resident #17 drank [NUTRITION SUPPLEMENT] daily when she lived independently, so she would assume Resident #17 would drink one now. In an interview on 01/30/2023 at 9:17 AM, the RD for the facility stated she believed Resident #17 had the weight loss due to depression over the holiday period. She said the staff reported to her Resident #17 stopped coming out of her room for two weeks over the holidays and stopped eating in the dining room. She said Resident #17 had improved since that time and the RD said she thought Resident #17's intake improved with her eating in the dining room now. She stated Resident #17 was health conscious with what she ate and chose to eat a salad every day for lunch and liked a lighter breakfast of biscuits or toast . She stated she did not ask for weekly weights after the significant weight loss was noted on 01/20/2023. She stated she only had residents who were underweight and continuing to lose weight weighed weekly or residents under 100 pounds. She said they did not have a specific protocol or policy for weight loss that would include weekly weights. When asked about interventions put into place after the significant weight loss was noted, she said no specific intervention was put into place because Resident #17 would refuse the interventions including a health shake, med pass supplement, fortified food or snacks. She said she knew staff at the facility had offered snacks and health shakes and Resident #17 refused them. When asked if there was documentation of what was offered or if the information was in Resident #17's care plan she said she did not know. She said information on what was offered to Resident #17 for weight loss would be in the EMR. She said she did not update a resident's care plan when weight loss occurred, the MDS Coordinator was in charge of updating a resident's care plan with interventions. She did not notify the doctor of Resident #17's weight loss and said the nurse would be in charge of notifying the doctor. She did not ask about or recommend an appetite stimulant for Resident #17. In an interview on 01/30/2023 at 9:43 AM, LVN A stated Resident #17 was particular about the food she ate and did not eat junk food. She said she liked her breakfast to only be two biscuits or a piece of toast. She said they could offer more food and she would refuse additional food. She stated Resident #17 only ate a salad for lunch because it was preference and then ate a regular dinner. She stated Resident #17 was depressed over the holidays which likely caused her intake to decrease. She stated she felt like Resident #17 was eating more now because she ate in the dining room again. She said for two weeks over the holidays Resident #17 refused to leave her room. She said they would offer her snacks or more food and Resident #17 would decline. She said she was not sure if a health shake or other supplement had been offered to Resident #17. In an interview on 01/30/2023 at 11:04 AM, the ADMIN stated Resident #17 was very particular about what she ate and how she dressed. She stated Resident #17 liked to take good care of herself including eating a healthy diet. She said Resident #17 eats what she wants when she wants. In a follow-up interview on 01/30/2023 at 11:42 AM, the DON stated she spoke with Resident #17's PCP and he ordered an appetite stimulant to prevent further weight loss. She said they would offer Resident #17 a health shake and if she drank it, she would have the PCP order health shakes twice per day for Resident #17. In an interview on 01/30/2023 at 11:58 AM, the PCP for Resident #17 stated he rounded on Resident #17 last week and was given Resident #17's current weight, but he was not notified of the significant change for her previous weight in December 2022. He stated he ordered an appetite stimulant today and will monitor her weight closely for the next 60 days. He stated he requested the RD re-evaluate her as well. He said Resident #17 did not suffer a decline as a result of the weight loss or develop skin breakdown. The PCP thought the weight loss was related to depression over the holidays which resulted in decreased appetite. Record review Resident #17's EMR dated 07/01/2022 - 01/30/2023 did not reveal additional documentation regarding Resident #17's weight loss or interventions that were tried by the facility. Record review of Resident #17's Dietary Progress notes written by the DM dated 08/04/2022 revealed CDM (Certified Dietary Manager) spoke with resident about her likes and dislikes. She is on a regular diet, regular texture and thin liquids at this time. No concerns voiced. She enjoys two biscuits or toast for breakfast and a bowl of cream of wheat. Review of Nutrition (Impaired)/Unplanned Weight Loss - Clinical Protocol Policy dated September 2017 revealed the staff will report to the physician significant weight gain, anorexia and weight loss before ordering interventions . The physician will review for medical causes of weight gain, anorexia and weight loss before ordering interventions . the staff and physician will identify pertinent interventions based on identified causes and overall resident condition, prognosis, and wishes . The physician will authorize appropriate interventions, as indicated.

Based on observation, interview and record review, the facility failed to ensure expired/discontinued medications were removed and destroyed for 1 of 1 medication storage rooms reviewed for medications. The facility failed to remove two bottles of expired Famotidine from the medication storage room. This failure could place all residents at an increased risk of receiving expired medications resulting in adverse health consequences. Findings include: Observation on 01/29/2023 at 10:00 AM of the medication storage room with the DON in attendance revealed two bottles of Famotidine (used to treat stomach ulcers) 20 mg with expiration dates of 12/2022. Interview on 01/29/2023 at 10:05 AM the DON stated, I don't know for sure if the potency of the drug is affected. She further stated she had recently looked at all the medications in the storage room and wasn't sure how those were missed. Interview on 1/30/2023 at 11:19 AM the ADMIN stated it was a requirement to not have expired medications available to give to the residents. Review of the facility policy dated 2007 and titled Disposal of Medications reflected Outdated medications shall be destroyed. The director of nursing and consultant pharmacist will monitor for compliance with federal and state laws and regulations regarding the disposal of medications.