**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, resident interview, clinical record review, facility documentation review, and in the course of a complaint investigation, the facility staff failed to ensure 3 residents were free from abuse and/or neglect (Residents #37 and 93, who was abused by Resident #43) in a survey sample of 42 residents. This resulted in harm for Resident #37. The findings included: 1. For Resident #37, the facility staff neglected to provide goods and services to prevent continuing significant weight loss, resulting in severe malnutrition, and an unstageable pressure sore not identified by staff until the wound was first identified with eschar, and unstageable, all resulting in harm. Resident #37 was admitted to the facility on [DATE]. Diagnoses included: hypertension, anemia, arthritis, chronic kidney disease moderate, high cholesterol, heart disease, seizures, and a history of dysphagia. The most recent Minimum Data Set (MDS) assessment was a quarterly assessment with an assessment reference date (ARD) of 9-9-19. Resident #37 was coded with a Brief Interview of Mental Status score of 11 indicating mild to no cognitive impairment and the Resident required extensive assistance, to complete dependence, on staff for all activities of daily living. This included extensive assistance of 1 staff member's physical assistance to eat. The Resident was coded with no aberrant behaviors, and no refusals of care or assistance from staff. This MDS was compared to the previous MDS with an ARD of 7-12-19 which was a 90 day assessment, and the comparison is as below: MDS 7-12-19 - BIMS = 11, at risk for wounds, no current wounds, no preventative measures for wounds, no weight loss, mechanically altered diet, Bed mobility extensive assistance needed, eating extensive assistance needed. MDS 9-9-19 - BIMS =11, at risk for wounds, one current vascular (incorrect identification) wound, pressure reduction devices for chair and bed, for wounds, ointments and dressings for the wound, nutrition management, significant weight loss, mechanically altered diet, Bed mobility extensive assistance needed, eating extensive assistance needed. On 4-15-19, Resident #37 was admitted on a Regular diet with low potassium, regular texture, thin liquids. On 6-25-19 the Resident's diet was changed to Dysphagia ground texture, thin consistency low potassium diet. On 9-11-19 the Resident's diet was again changed to Regular diet puree texture, nectar consistency, for dysphagia. The Resident's diet card was requested from the kitchen and stated the pureed diet with nectar thickened liquids was being served. No mention of the supplement (2 cal supplement 240 ml (milliliters) three times per day, was on the tray card. On 9-15-19 at 12:00 noon, observations and interviews were conducted with the Resident. After introduction, the Resident was asked if we could help him with anything while we were there, and he complained of hunger, and stated he wanted something to eat. He stated his family brought him things and he enjoyed that food. The lunch meal tray did not arrive at the bedside until 12:45 p.m., and at 2:30 p.m., no staff had entered the room to assist the Resident to eat. Surveyor A, and this surveyor looked at the tray which was uncovered, and untouched. We then went to the nursing station to enquire as to how long it would be for the Resident to be fed. The staff stated they were very understaffed, and were unable to use the dining room, and had to close it as they were unable to staff it, so the feeders who would normally be fed there had to be fed in their rooms. They stated that Resident #37 was a self feeder, and independent. At 2:30 p.m., the Resident was again observed and was sitting in bed falling over onto his left side with a small Styrofoam or paper cup containing magic cup supplement, which was an ice cream like substance in his hand. The Resident was licking the inside of the cup to obtain the contents, and the surveyor asked him if he was able to hold the spoon that was on his tray, and he stated not too good, I am so weak now, I just don't have the strength. The Resident picked up the spoon and tried to use it, however, the small amount he was able to get onto the spoon after much effort, fell down onto the bed linens. The rest of the tray was untouched, and no 2 cal supplement was on the tray. At 2:45 p.m., the HR (human resources) Director entered the Resident room to feed him. The surveyors returned at 3:30 pm to find the tray had been left there and the thick pudding consistency portions of food had approximately 2 spoonfuls missing from 2 of the 3 scoops of pureed food. Each of the scoops measured approximately 3 inches by 3 inches circular, and 1/2 inch depth, and had spread out into each other on the plate. The Resident stated I can't eat that stuff, it's awful like cold wet bread. He went on to say I told them when I got here that I can't eat that stuff, and I don't have any trouble eating if I like the food, but they don't listen. On 9-16-19 at 10:00 a.m., another observation was conducted for this Resident by Surveyor C. Surveyor C reported that for the breakfast meal the tray was followed and went into the Resident's room, left uncovered, and removed from the room untouched and returned to the kitchen. On 9-16-19 at 3:00 p.m., the Resident's lunch meal tray was again left untouched, and the Resident was not fed. No supplement was in the room for either meal The ADL (activities of daily living) report was requested and received. The report documented that the Resident was independent with eating for breakfast and lunch every day in September, for 20 of the 32 breakfast and lunch meal opportunities. The 12 meal exceptions where the staff assisted the Resident occurred on the following days; 9-1-19 dependant (fed) for both meals, and consumed nothing for breakfast and 51-75% for lunch. 9-5-19 dependant (fed) for both meals, and consumed 51-75% for both meals. 9-7-19 limited assistance (not fed) for both meals, and consumed nothing for both meals. 9-8-19 limited assistance (not fed) for breakfast, and consumed 26-50%. 9-10-19 limited assistance (not fed) for lunch, and consumed nothing. The behavior portion of the ADL record was also reviewed and revealed at no time did the Resident refuse assistance or care. The other 20 opportunities for staff support with feeding, and the Resident was not fed, occurred on the following days; 9-2-19 The Resident consumed 51-75% both meals 9-3-19 The Resident consumed 26-50% both meals 9-4-19 The Resident consumed 26-50% both meals 9-6-19 The Resident consumed 26-50% at breakfast, and 76-100% at lunch 9-8-19 The Resident consumed 26-50% at lunch 9-9-19 The Resident consumed 76-100% both meals 9-10-19 The Resident consumed nothing for breakfast 9-11-19 The Resident consumed nothing for breakfast, and 76-100% at lunch 9-12-19 The Resident consumed nothing both meals 9-13-19 The Resident consumed 26-50% both meals 9-14-19 The Resident consumed 26-50% breakfast, and 75-100% at lunch 9-15-19 The Resident consumed nothing both meals 9-16-19 The Resident consumed 26-50% for breakfast, nothing for lunch It is notable to mention that on 9-16-19 the Resident's breakfast tray was followed by Surveyor C from delivery by CNA N, to discard, and it was not disturbed, nor did the Resident attempt to consume it. No staff member attempted to assist with the meal, and the tray was simply removed from the room, untouched, and discarded. CNA O documented 26-50% consumed. CNA N (certified nursing assistant) was interviewed, and stated he ate a little of his sherbet cup so I said he ate 25%, however, CNA N did not sign the ADL document, another staff member, CNA O was documented as having fed Resident #37 his breakfast. CNA N was asked if she fed the Resident, and she stated no he can feed himself. CNA N was asked if she had been trained on how to calculate the amount of a meal that a resident consumes, and she stated no. CNA O stated that she only removed the tray, and did not feed the Resident. During this 16 day period from 9-1-19 through 9-16-19, nine different staff members signed the meal consumption record, only 3 of which delivered the meal to the Resident consistently more than one day in the 16 days. The Resident's weight record was requested and revealed that from 7-3-19 until the time of survey on 9-16-19, the Resident had lost 23.4 pounds of weight in less than 12 weeks. Those weights follow: 4-15-19 - On admit 122.4 lbs (pounds) 4-23-19 - 119.2 5-1-19 - 115.2 - weight loss of 7 pounds after admission for 2 weeks. 5-22-19 - 120.2 - weight gain of 5 pounds and stabilizes after 3 more weeks. 6-25-19 - diet modified to ground texture begun, and significant weight loss begins. 6-26-19 - 119.0 7-3-19 - 119.0 7-24-19 - 117.0 7-31-19 - 117.0 8-26-19 - 108.0 9-1-19 - 103.0 9-9-19 - 101.8 9-11-19 - diet modified to pureed texture begun after significant weight loss of 17.2 pounds from 7-3-19 to 9-9-19. 9-16-19 - 95.6 - significant weight loss increased in less than 12 weeks to 23.4 pounds, equaling 20% of the Resident's entire body weight, and 26.8 pounds, since admission. On 9-16-19 at 3:00 p.m., an interview was conducted with the Director of Nursing (DON), and Unit manager RN (registered nurse) D, by surveyors in the conference room. They stated that they were talking to the family, and there were lots of family dynamics, .we want to have a care plan meeting with him and his family, wife, son or brother, that is our next step with him I am aware he is loosing weight. They were asked why it had taken 5 months to get a plan going, and they stated At first his family was bringing in food that he was eating, he doesn't like the pureed texture or the nectar thick liquids. Therapy had been working with him, and he had a FEES study on 9-10-19 that he failed. We have talked with his wife, and his son and brother. He has biological children, a wife and a stepson. He had to go to the hospital for a blood transfusion, and at the hospital his wife refused it. He is his own RP (responsible party). The hospital sent him back to us, and his biological children were upset . Our social worker (name) Employee O was working with him, and his son and daughter got involved and we sent him back, to the hospital, the spouse didn't have his best interest. They were asked why the physician had not talked with the Resident himself and decide a course of action? They stated We discussed the doctor talking to him (the Resident), and we didn't have a social worker as Employee O has been gone about a month and a half ago, and he has lost weight since that. The DON stated I see we need to make a decision and talk to him to see if he wants a peg tube because he doesn't like the pureed texture to maintain his BMI (Body Mass Index). The DON and unit manager continued with, Speech therapy did a swallowing eval, and he didn't do well. They were asked when that occurred as no therapy notes were found in the clinical record. She stated, I don't know, I will get those for you. The family brings in McDonalds, and that he eats. She was asked if he had ever aspirated or been hospitalized , or treated for aspiration pneumonia, or had any respiratory problems, and they stated no. They were asked why the Resident was not being fed by staff who thought he was independent, when his MDS showed he needed extensive assistance from staff to eat since the 7-12-19 MDS which included a seven day look back to 7-5-19. They responded He should be fed. On 9-16-19 at 3:15 p.m., Employee E, the speech language pathologist (ST/SLP) entered the interview in progress in the conference room with surveyors, and with the unit manager and DON. She stated he was on ground meat with pureed solids and the Resident didn't like it so the family requested an upgrade so he would eat, and then the FEES study was ordered on 9-10-19. I asked if there was no problem, or outcome with the regular diet that the family brought in that the Resident did eat, why the change. She stated he needs positioning and encouragement to not aspirate, he is at risk for silent aspiration. She continued he wasn't really eating the ground texture, or anything off of the pureed tray but pudding, oatmeal, and cream of wheat, and that's why the FEES study was done. A bedside swallowing evaluation was done by another speech therapist who was full time here. I am not typically treating most of the time. Her last day was weeks ago, I don't remember how many, we have a new one starting today. Between the last one and this one we have had PRN (as needed) staff and I have been helping treat as well. She was asked if she had assessed or treated Resident #37, and she stated no. The ST notes were again requested. The FEES (Dysphagia systems test) study was requested at 3:15 p.m., during the interview with Employee E, and received at 4:00 p.m. The study documented no diagnoses linked to dysphagia, and documented that the Resident took his medications whole. The document describes the Potential risks to the Resident, and documents that the Resident is at Potential risk for aspiration. Any and all ST notes from Resident #37's time of admission to today were requested again. On 9-16-19 at 4:00 p.m., the Registered Dietician (RD), and Assistant Director of Nursing (ADON) were interviewed by surveyors in the conference room. The current RD stated there had been a lot of turnover in the department and there had been one RD from April to may 2019, and then travel and consultant RD's had come in as needed until mid August 2019 during his significant weight loss, and she herself (employee G) started work in the facility in mid august, and had been there just under a month. Physician's progress notes were reviewed and indicated no weights on the assessments conducted by the physicians. The area in the form for weight were all left blank. There is no indication that the physician's were aware of the significant weight loss from 6-25-10 to 8-29-19. A review of the physician's orders, was conducted from the time of admission to the time of survey. They revealed the following timeline of interventions; 4-15-19 - admission regular diet with thin liquids. - weight 122.4. 4-16-19 - ST, TO (occupational therapy), PT (physical therapy) all evaluate and treat as necessary order entered. 5-2-19 - 2 Cal supplement 120 ml (milliliters) drink twice per day at 8:00 a.m., and 5:00 p.m. - weight 115.2. 6-25-19 - Weight 119.0, which had rebounded from initial admission loss, proving the Resident had no difficulty gaining weight back (for the 2 months and 10 days since admission) while eating a regular diet, and taking a small amount of supplement. During this time there were no problems associated with aspiration. 6-25-19 The diet change to dysphagia ground diet with thin liquids, which the Resident did not like. No other interventions occurred to prevent significant weight loss from 5-2-19 until 8-28-19 when the new RD arrived, and the significant weight loss had already occurred. - weight 108.0 (14.4 pound (10%) weight loss since admission, and an 11 pound weight loss in 2 months.) 7-25-19 through 7-29-19 the Resident had symptoms of illness, and had laboratory blood tests drawn. As a result of those tests it was revealed that the Resident had become dehydrated. Resident #37 then was ordered to receive IV (intravenous) normal saline fluids for dehydration. The infusion was started initially through a peripheral IV in his left wrist, however, the IV was not positioned well and had to be removed, and the staff was unable to replace it, so a specialist nurse was brought in to insert a mid line PICC (peripherally inserted central line catheter) to infuse the fluids. 7-26-19 - Physician's orders, laboratory reports, and nursing/physician progress notes revealed that ADON was aware that the Resident need for help with ADL's has increased. Resident recently ended PT, TO, and ST services. Will continue to monitor for further decline and have therapy screen as needed. 8-27-19 - RD progress note revealed Weight not stable, Spoke with Resident who says that he doesn't like the ordered texture of his food. He reports that he feels like he's lost weight and does feel hungry throughout the day and at bedtime. He is agreeable to drinking 2 cal and trying snacks between meals and at bedtime Orders are then initiated and follow below. 8-29-19 - 2 Cal supplement increased to 240 ml (milliliters) drink twice per day at 8:00 a.m., and 5:00 p.m., magic cup twice per day with lunch and supper, yogurt and apple sauce between meals and at bedtime, were all started - weight 108.0. 9-2-19 - Resident found to have a pressure ulcer to his right lateral ankle directly over the bone, and it was first identified with eschar (Black,dead, necrotic, hard tissue) covering the entire cap over the ankle bone. - weight 103.0. 9-3-19 - Resident lab test resulted for pre-albumin (measures recent dietary intake). Pro-stat protein supplement for wound healing was ordered. 9-9-19 - FEES study (Dysphagia systems test) completed. - weight 101.8. 9-11-19 - Diet changed to pureed with nectar thickened liquids, increase to 2 cal supplement to 3 times per day, and med pass liquid supplement was added for 60 ml three times per day. 9-16-19 - at the time of survey weight was - 95.6. On 9-17-19 at 12:32 p.m., the physician was called on the telephone and asked for an interview. He stated he would come to the facility and look at the chart and let surveyors know about Resident #37. The physician arrived and stated he had looked at the chart, and said the Resident is severely malnourished and doesn't like the texture of the diet. He stated We had speech look at the patient, and they said he isn't able to eat regular food. The family said no to a PEG (Per Endoscopic Gastrostomy) tube, there is nothing else to do. The doctor was asked why was speech therapy was consulted, if the Resident had no signs of aspiration, was not hospitalized or ever suffered from any respiratory illness associated with aspiration, and had been here in the facility for 5 months. He stated that the family was concerned. The doctor was asked why the family was allowed to make decisions for the Resident when the staff made surveyors aware that the family did not have the Resident's best interest at heart. Further, for a Resident, who was alert and oriented, could make his needs known, and was his own Responsible Party (RP). The Resident had not been deemed incompetent, and had the right to make his own decisions. The doctor responded I was not aware of that, and if we let him eat whatever he wants, that's how we get sued. The doctor was then asked why the wound on the Resident's ankle was being called a Vascular ulcer, and he stated it's a pressure sore, and most likely the result of the patient's severe malnutrition. He was asked if he was aware that the RD, ST, and social worker had all been multiple different people (on an as needed basis) with no regular consistency, from June through August in the facility, and that the social worker had been gone for 6 weeks, and a new one was starting that day. He stated no. On 9-17-19 at 5:00 p.m., a Summary Report of Meeting document for the last 2 days of staff huddle meetings was presented to surveyors by the DON. The document described the subject of the meetings to be in regard to Passing trays at meal times, assisting feeders, documenting on amounts eaten. and was signed by those in attendance. This was evidence of training begun by the facility to rectify deficient practice in the meal delivery and assistance system. The comprehensive care plan was reviewed in it's entirety and revealed the following interventions for the weight loss and pressure sore. There were no interventions for hydration, and it was simply placed in with the nutrition (weight loss) hydration plan below; (Weight loss) FOCUS: (name) Resident #37 has the potential for nutrition/hydration imbalance related to hypertension, anemia, chronic kidney disease, history of hyperkalemia, diagnosis of dysphagia. Resident does not like puree texture food. initiated on 4-19-19, revised on 5-5-19, 6-25-19, and 9-13-19. GOAL: Resident will remain adequate nutritional status as evidenced by maintaining weight with no significant weight changes through review date. INTERVENTIONS: (all created and initiated on 4-19-19 immediately after admission) Administer medications as ordered. Monitor/document for side effects and effectiveness. Provide/serve diet as ordered, honoring resident preferences. Monitor intake and record every meal. RD to monitor and follow up per protocol. Weigh per facility protocol. (initiated 6-25-19) No hot liquids for safety. No changes were made to any interventions after the Resident suffered a significant weight loss. The significant weight loss was not care planned, none of the interventions that were initiated for the weight loss were care planned, none of the supplements were care planned, none of the diet changes were care planned, and the need of the Resident to be fed by extensive assistance of staff was not care planned. Most goals are not measurable, and the Residents preferences were not honored. (Pressure sore) FOCUS: (name) Resident #37's pressure ulcer was documented on the care plan on 9-2-19 when the ulcer was identified as a pressure ulcer to right outer heel related to decreased mobility and altered nutrition. On 9-4-19 it was changed to vascular ulcer to the right outer heel. On 9-12-19 it was changed again to vascular ulcer right outer ankle. GOAL: Wound will be free from infection through review date. INTERVENTIONS: (all created and initiated on 9-2-19 at identification) Air mattress. Heel lift boots as tolerated. Resident/family education as needed. (initiated 9-12-19) Supplements as ordered for wound healing (10 days after identification). There was no Hydration care plan initiated, even after the Resident suffered from dehydration requiring IV fluid infusions on 7-25-19. The doctor, and nursing staff identified the wound as a pressure ulcer. None of the supplements for healing are care planned, the heel lift boots application is not measurable and has no guidance for use. No interventions for wound development prevention were present prior to the development of an unstageable pressure ulcer found with eschar upon identification, and likely caused by the Resident's malnutrition, as stated, and diagnosed by the doctor. A wound Observation was conducted on 9-17-19 at 9:30 a.m. with LPN H. The Resident was alert and oriented to person, place, time, and situation. Both legs and the right ankle were exposed, as the Resident was laying partially on his left side, revealing cool, smooth leg skin, with no lesions, scars, scratches, scales nor brawny appearance. There was hair on both legs, no edema, or erythema in either extremity, and the Resident had palpable popliteal (behind the knee), dorsalis pedis (top of foot), and tibial (behind the ankle bone) pulses. The Resident had a brisk capillary refill when the toe nails were depressed, and at less that 1 second blood return. The Resident had no wounds on his heels or shins, and exhibited only 1 wound which was directly on top of the right lateral ankle bone (lateral malleolus). The depth of the pressure ulcer could not be ascertained as the wound was covered by black dead thick necrotic tissue with only the outer circumference beefy red, as the de-vitalized tissue was shrinking leaving an open thin boarder around the circular necrotic wound. There was no slough visible, and no drainage, nor odor to indicate infection. The wound was clean and had a minuscule amount of serosanguineous clear drainage making the edges around the wound shiny. The wound was approximately the size of a 1/2 dollar coin. A Skin Grid Pressure initial assessment document was completed by RN E on 9-2-19 at initial identification of the wound. The document was reviewed and revealed that the wound was a new pressure area, house acquired, risk factors impaired mobility and altered nutrition, unstageable pressure wound, right outer ankle, measured 2.5 cm (centimeters) x 2.2 cm, edges not clearly visible, granulation and eschar present, color red and necrotic, small amount of serous drainage, no odor, peri wound black or hyper-pigmented, no pain, question, does the Resident have a turning and repositioning program in place? answer, no. 5 Physician orders all issued on 9-2-19 after the pressure ulcer was identified, were reviewed and revealed the following: 1. L Elemental Arginine packet for wound healing once per day for 7 days, and was completed at the time of survey. 2. Multivitamin for wound healing one time per day. 3. Pro-stat protein supplement 30 ml one time per day. 4. Zinc Sulfate 220 mg (milligrams) one tablet 1 time per day for wound healing. 5. Cleanse right outer ankle with normal saline, pat dry, apply skin prep to peri-wound, medihoney and calcium (Softens hard dead tissue, and inhibits bacterial growth while absorbing drainage) alginate to wound bed, cover with dry dressing until resolved. Every day shift for wound care. On 9-11-19 a new order was obtained for Santyl collagenase ointment 250 unit/GM (gram) apply to right outer ankle topically every day shift for wound for 14 days. (Enzymatic debriding agent for the removal of dead necrotic tissue), was currently being used during survey. Abuse, neglect policies were requested and received. They revealed that the facility policy described neglect as, failure to provide timely and consistent services, treatment or care to a resident to obtain or maintain a resident's health, safety to comfort: or a failure to provide timely and consistent goods and services necessary to avoid physical harm, mental anguish . The document goes on to say; Examples of neglect include but are not limited to: Failure to provide adequate nutrition and fluids. Accurate and timely reporting of incidents, both alleged and substantiated, will be sent to officials .(within 2 hours for serious injury or within 24 hours if no serious injury). On 9-17-19 at 5:00 p.m., the DON was again asked for ST notes, and none were supplied. At that time, the facility Administrator and Director of nursing were made aware of findings at the end of day meeting. The facility stated they had no further information to provide. COMPLAINT DEFICIENCY 2. For Resident #93, the facility staff failed to ensure that she was not abused by Resident #43. Resident #43 was a [AGE] year old who was admitted to the facility on [DATE]. Resident #43's diagnoses upon admission included Cardiovascular Disease, Anxiety Disorder, Vascular Dementia with Behavioral Disturbance, Unspecified Psychosis, and Diabetes Mellitus -Type 2. The Minimum Data Set, which was a Quarterly Assessment with an Assessment Reference Date of 5/15/19 was reviewed. Resident #43 was coded as having a Brief Interview of Mental Status Score of 8, indicating moderately impaired cognition. In addition, he was coded as requiring 1 person for physical assistance to ambulate. Resident #93 was a [AGE] year old who was admitted to the facility on [DATE]. Resident #93's diagnoses included Unspecified Dementia, Muscle Weakness, and Hypertension. The Minimum Data Set, which was a Quarterly Assessment with an Assessment Reference Date of 9/4/19 was reviewed. Resident #93 was coded as having a Brief Interview of Mental Status Score of 4, indicating severely impaired cognition. On 9/15/19 at 3:15 P.M., an observation was conducted of Resident #43 in his room. He was lying awake on his bed. A Certified Nursing Assistant (CNA L) was providing 1:1 supervision. She stated that Resident #43 was doing well and did not exhibit any inappropriate behaviors. On 9/16/19 at 12:00 P.M., a second observation was conducted of Resident #43. He was sitting in the dining room with CNA L. There were 2 other residents at his table. He sat quietly and did not interact with anyone. On 9/15/19 a review was conducted of facility documentation, revealing a Facility Reported Incident dated 11/28/18. An excerpt read, (Resident #43) was noted by a dietary staff member holding [Resident # 93] with her hands behind her back and stating 'I am not gonna let you go, I'm going to twist your arm off.' Staff intervened and separated them. There were no injuries or further incidents. According to the nursing progress notes, the incident occurred at about 7:30 P.M. The facility submitted a follow-up report on 11/30/18. An excerpt read, (Resident #43) was observed by a dietary staff member who was leaving the kitchen, holding [Resident #93] with her hands behind her back and yelling 'I am not gonna let you go, I am going to twist your arm off. The dietary staff member alerted nursing staff and the two were separated. Both residents were assessed for injuries. There were no injuries noted. Their physician's and Responsible Party's were notified. Resident #43 was seen by the facility's Psychiatric Nurse Practitioner for aggression, and Resident #93 was seen for emotional support by the Psychiatric Nurse Practitioner. On 9/16/19 a review was conducted of Resident #43's clinical record, revealing a care plan. An excerpt read, 4/12/18. Psychosis with auditory hallucinations and paranoia. Behaviors include, but not limited to: resisting care, physical aggression, verbal abuse, talking to self. Monitor/record occurrence of target behavior symptoms .violence/aggression towards staff/others. After the incident on 11/28/18, the care plan was updated. An excerpt read: 11/28/18. [Resident #43] is/has potential to demonstrate abusive behaviors towards staff and residents r/t (related to) dementia. Assess and anticipate needs. Assess coping skills and support system, give as many choices as possible. In addition, Resident #43 was placed on 1:1 supervision at that time. Resident #43's clinical record contained a report by a Licensed Clinical Psychologist. Resident #43 was seen in December 2018, and on 8/23/19. An excerpt read, (Resident #43's) statements regarding his belief that he needs to use violence to defend himself, his paranoid/unrealistic thought process regarding the motivations and intentions of others, and his history of becoming verbally and physically aggressive with residents and staff suggests that [Resident #43] may not be appropriate for this current setting. He needs significant focus on his psychiatric concerns at this time. According to the nursing progress notes, there were multiple preceding incidents earlier in the afternoon on 11/28/18. At approximately 3:30 P.M. Resident #43 was noted to use profane language at staff, including making sexual comments. He also threatened other residents when they walked past him in the hallway, attempting to trip them with his walker or hit them with his belt. Attempted redirection was unsuccessful, and Resident #43 refused to take his medications. During the month of November, 2018, Resident #43 had refused to take his medications about 50% of the time. He was care-planned for refusing to take his medications on 4/17/18. After the incident with Resident #43 on 11/28/18, facility staff monitored her. Resident #93 did not exhibit any physical, mood, or b[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, resident interview, clinical record review, and facility document review, and in the course of a complaint investigation, the facility staff failed to provide treatment and services to prevent and heal pressure sores for one Resident (Residents #37) in a survey sample of 42 Residents, resulting in harm for Resident #37. The findings included; 1. For Resident #37, the facility staff failed to provide adequate nutrition, and preventive devices, and care, for a Resident at risk of developing pressure sores, leading to the development of a pressure sore first identified as an unstageable ulcer with eschar, resulting in harm. Resident #37 was admitted to the facility on [DATE]. Diagnoses included: hypertension, anemia, arthritis, chronic kidney disease moderate, high cholesterol, heart disease, seizures, and a history of dysphagia. The most recent Minimum Data Set (MDS) assessment was a quarterly assessment with an assessment reference date (ARD) of 9-9-19. Resident #37 was coded with a Brief Interview of Mental Status score of 11 indicating mild to no cognitive impairment and the Resident required extensive assistance, to complete dependence, on staff for all activities of daily living. This included extensive assistance of 1 staff member's physical assistance to eat. The Resident was coded with no aberrant behaviors, and no refusals of care or assistance from staff. This MDS was compared to the previous MDS with an ARD of 7-12-19 which was a 90 day assessment, and the comparison is as below: MDS 7-12-19 - BIMS = 11, at risk for wounds, no current wounds, no preventative measures for wounds, no weight loss, mechanically altered diet, Bed mobility extensive assistance needed, eating extensive assistance needed. MDS 9-9-19 - BIMS =11, at risk for wounds, one current vascular (incorrect identification) wound, pressure reduction devices for chair and bed, for wounds, ointments and dressings for the wound, nutrition management, significant weight loss, mechanically altered diet, Bed mobility extensive assistance needed, eating extensive assistance needed. On 4-15-19, Resident #37 was admitted on a Regular diet with low potassium, regular texture, thin liquids. On 6-25-19 the Resident's diet was changed to Dysphagia ground texture, thin consistency low potassium diet. On 9-11-19 the Resident's diet was again changed to Regular diet puree texture, nectar consistency, for dysphagia. A review of the physician's orders, was conducted from the time of admission to the time of survey. They revealed the following timeline of interventions; 5-2-19 - 2 Cal supplement 120 ml (milliliters) drink twice per day at 8:00 a.m., and 5:00 p.m. - weight 115.2. 8-27-19 - RD progress note revealed Weight not stable, Spoke with Resident who says that he doesn't like the ordered texture of his food. He reports that he feels like he's lost weight and does feel hungry throughout the day and at bedtime. He is agreeable to drinking 2 cal and trying snacks between meals and at bedtime Orders are then initiated and follow below. 8-29-19 - 2 Cal supplement increased to 240 ml (milliliters) drink twice per day at 8:00 a.m., and 5:00 p.m., magic cup twice per day with lunch and supper, yogurt and apple sauce between meals and at bedtime, were all started - weight 108.0. 9-2-19 - Resident found to have a pressure ulcer to his right lateral ankle directly over the bone, and it was first identified with eschar (Black,dead, necrotic, hard tissue) covering the entire cap over the ankle bone. - weight 103.0. 9-11-19 - Diet changed to pureed with nectar thickened liquids, increase to 2 cal supplement to 3 times per day, and med pass liquid supplement was added for 60 ml three times per day. The Resident's diet card was requested from the kitchen and stated the pureed diet with nectar thickened liquids was being served. No mention of the supplement (2 cal supplement 240 ml (milliliters) three times per day, was on the tray card On 9-17-19 at 12:32 p.m., the physician was called on the telephone and asked for an interview. He stated he would come to the facility and look at the chart and let surveyors know about Resident #37. The physician arrived and stated he had looked at the chart, and said the Resident is severely malnourished and doesn't like the texture of the diet. The doctor was then asked why the wound on the Resident's ankle was being called a Vascular ulcer, and he stated it's a pressure sore, and most likely the result of the patient's severe malnutrition. The comprehensive care plan was reviewed in it's entirety and revealed the following interventions for the pressure sore. (Pressure sore) FOCUS: (name) Resident #37's pressure ulcer was documented on the care plan on 9-2-19 when the ulcer was identified as a pressure ulcer to right outer heel related to decreased mobility and altered nutrition. On 9-4-19 it was changed to vascular ulcer to the right outer heel. On 9-12-19 it was changed again to vascular ulcer right outer ankle. GOAL: Wound will be free from infection through review date. INTERVENTIONS: (all created and initiated on 9-2-19 at identification) Air mattress. Heel lift boots as tolerated. Resident/family education as needed. (initiated 9-12-19) Supplements as ordered for wound healing (10 days after identification). No interventions for wound development prevention were present prior to the development of an unstageable pressure ulcer found with eschar upon identification A wound Observation was conducted on 9-17-19 at 9:30 a.m. with LPN H. The Resident was alert and oriented to person, place, time, and situation. Both legs and the right ankle were exposed, as the Resident was laying partially on his left side, revealing cool, smooth leg skin, with no lesions, scars, scratches, scales nor brawny appearance. There was hair on both legs, no edema, or erythema in either extremity, and the Resident had palpable popliteal (behind the knee), dorsalis pedis (top of foot), and tibial (behind the ankle bone) pulses. The Resident had a brisk capillary refill when the toe nails were depressed, and at less that 1 second blood return. The Resident had no wounds on his heels or shins, and exhibited only 1 wound which was directly on top of the right lateral ankle bone (lateral malleolus). The depth of the pressure ulcer could not be ascertained as the wound was covered by black dead thick necrotic tissue with only the outer circumference beefy red, as the de-vitalized tissue was shrinking leaving an open thin boarder around the circular necrotic wound. There was no slough visible, and no drainage, nor odor to indicate infection. The wound was clean and had a minuscule amount of serosanguineous clear drainage making the edges around the wound shiny. The wound was approximately the size of a 1/2 dollar coin. A Skin Grid Pressure initial assessment document was completed by RN E on 9-2-19 at initial identification of the wound. The document was reviewed and revealed that the wound was a new pressure area, house acquired, risk factors impaired mobility and altered nutrition, unstageable pressure wound, right outer ankle, measured 2.5 cm (centimeters) x 2.2 cm, edges not clearly visible, granulation and eschar present, color red and necrotic, small amount of serous drainage, no odor, peri wound black or hyper-pigmented, no pain, question, does the Resident have a turning and repositioning program in place? answer, no. 5 Physician orders all issued on 9-2-19 after the pressure ulcer was identified, were reviewed and revealed the following: 1. L Elemental Arginine packet for wound healing once per day for 7 days, and was completed at the time of survey. 2. Multivitamin for wound healing one time per day. 3. Pro-stat protein supplement 30 ml one time per day. 4. Zinc Sulfate 220 mg (milligrams) one tablet 1 time per day for wound healing. 5. Cleanse right outer ankle with normal saline, pat dry, apply skin prep to peri-wound, medihoney and calcium (Softens hard dead tissue, and inhibits bacterial growth while absorbing drainage) alginate to wound bed, cover with dry dressing until resolved. Every day shift for wound care. On 9-11-19 a new order was obtained for Santyl collagenase ointment 250 unit/GM (gram) apply to right outer ankle topically every day shift for wound for 14 days. (Enzymatic debriding agent for the removal of dead necrotic tissue), was currently being used during survey. On 9-17-19 at 5:00 p.m., the facility Administrator and Director of nursing were made aware of findings at the end of day meeting. The facility stated they had no further information to provide. COMPLAINT DEFICIENCY

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. The facility staff failed to maintain water temperatures in a range to prevent burns, scalding and other injuries on 2 of 2 nursing units. On 9/17/19 at 4:22 PM, surveyor F went to the office of the maintenance director. The maintenance director was asked if he checks water temperatures and the maintenance director stated, he checks temperatures daily. Review of his water temperature logs revealed that temperatures are only checked in the kitchen, laundry, lobby and shower rooms. No Resident rooms are checked. When the maintenance director was asked how often he calibrates the thermometer he uses to check temperatures, the maintenance director stated, I haven't ever calibrated it. When the maintenance director was asked about water temperatures he indicated he likes the temperatures to be 110-115, 110 is safe for Residents and 115 stops any bacteria or growth. The maintenance director was asked what temperature is too hot, he stated, anything over 125 degrees when asked the risks, he stated, you risk scalding, especially for Residents. On 9/17/19 at approximately 4:30 PM, surveyor F and the Maintenance Director met with the dietary manager, (Employee D). Employee D stated she calibrates the kitchen thermometers daily. Employee D provided surveyor F with one of her calibrated thermometers. The maintenance director and surveyor F then checked water temperatures using the maintenance thermometer and the kitchen's calibrated thermometer and found the following: * Resident room [ROOM NUMBER]: 124 degrees Fahrenheit using the kitchen thermometer and 122.2 degrees Fahrenheit using the maintenance thermometer. The maintenance director stated, it's hot when asked to touch the water with his hand. * Resident room [ROOM NUMBER]: 123.6 degrees Fahrenheit using the kitchen thermometer and 121.8 degrees Fahrenheit using the maintenance thermometer. The maintenance director stated, it's time for me to get a new thermometer. The maintenance director then asked, does usage effect it? This time of day they are not using a lot of water. * Station 1 shower room: 125.4 degrees Fahrenheit using the kitchen thermometer and 124 degrees Fahrenheit using the maintenance thermometer. When the maintenance director was asked how long it takes for a Resident to get scalded he stated, less than a minute. * Resident room [ROOM NUMBER]: 124.7 degrees Fahrenheit using the kitchen thermometer and 123.5 degrees Fahrenheit using the maintenance thermometer. * Resident room [ROOM NUMBER]: 125.4 degrees Fahrenheit using the kitchen thermometer and 123.6 degrees Fahrenheit using the maintenance thermometer. *Resident room [ROOM NUMBER]: 111 degrees Fahrenheit using the kitchen thermometer and 109 degrees Fahrenheit using the maintenance thermometer. *Resident room [ROOM NUMBER]: 125.2 degrees Fahrenheit using the kitchen thermometer and 123.8 degrees Fahrenheit using the maintenance thermometer. On 9/17/19 at approximately 5:00 PM the facility Administrator and Director of Nursing were made aware of the concern regarding water temperatures. On 9/17/19 at 5:31 PM, during the end of day meeting the facility administrator advised the survey team that the water temperatures had cooled down, they have notified the vendor, had initiated water temperatures and had drained the boiler. Review of the water temperature logs revealed that the water temperatures in the Resident shower rooms and bath rooms ranged temperatures of 112 degrees to 114 degrees from 7/22/19-9/17/19, with the exception of 9/12/19 all of the temperatures were recorded at 100 degrees. Review of the facility policy titled water management plan revealed only information about maintaining temperatures in excess of 108 degrees to prevent the growth and spread of microorganisms such as Legionella. This policy made no reference to acceptable water temperature ranges for Resident use. Access to water at 124 degrees, which was noted in 5 of the areas observed, for 3 minutes can cause 3rd degree burns, according to [NAME], A.R., [NAME] F.C. Jr. (1947). Studies of Thermal Injury: 11. The Relative Importance of Time and Surface temperatures in the Causation of Cutaneous Burns. Am J Pathology, 23, 695-720,. No further information was provided. 2. For Resident #31, the facility staff failed to demonstrate safe use of the mechanical lift while obtaining a weight on 09/16/2019. Resident #31, a [AGE] year old male, was admitted to the facility on [DATE]. Diagnoses included but not limited to dementia, dysphagia, and diabetes. Resident #31's most recent Minimum Data Set with an Assessment Reference Date of 07/15/2019 was coded as a quarterly assessment. Functional status for eating was coded as requiring a one-person physical assist and supervision (oversight, encouragement, or cueing) during meals. Functional status for bed mobility was coded as requiring extensive assistance from staff. Transferring between surfaces was coded as requiring limited assistance from staff. Walking in room was coded as requiring supervision (oversight, encouragement, or cueing) from staff. Mobility devices selected were walker and wheelchair. On 09/16/2019 after 4:52 PM, CNA H, CNA I, and this surveyor entered the room of Resident #31 with the mechanical lift. CNA H and CNA I removed the sling (pad) from the handle bar of the mechanical lift and placed it under Resident #31. CNA H began to raise Resident #31 in the lift. Resident #31's shoulders remained on the bed while his lower torso was being elevated in the sling. This surveyor told CNA H to stop and lower Resident #31 to the bed. CNA H did so and then CNA H and CNA I readjusted the sling under Resident #31, attempting to raise it up further under his back toward the shoulders. CNA H began to raise Resident #31 in the sling and as the sling elevated just above the bed, Resident #31's eyes darted around and he turned his head to the right and reached his right arm out to grab the side rail of the bed. This surveyor told the CNA's to stop and lower Resident #31 to the bed. After completing care for Resident #31 and exiting the room, CNA H stated residents don't have their own pad. CNA I stated she didn't think the pad didn't fit correctly for [Resident #31] but it was the only one she could find. CNA H stated that We don't normally do weights, restorative does it. On 09/17/2019 at 10:44 AM, the DON was notified that this surveyor had to prompt [CNA H and CNA I] to stop when Resident #31 was being raised via mechanical lift for a weight. The DON stated that each resident should have their own pad and that they come in different sizes. The DON also stated that the CNA's should have stopped and readjusted before continuing. When asked why, the DON stated we Don't want him to fall out of the lift. The facility staff provided their policy entitled, Mechanical Lifts and Transfer. The last sentence under the header entitled, Policy documented, Follow manufacturer's recommendations for specific mechanical lift equipment. The facility staff provided the manufacturer's instructions for the mechanical lift. Under the header entitled, Slings it was documented, All slings are size-coded with different colored edge binding or attachment strap coloring .always refer to the label on the sling being used to make sure of its actual safe working load. On 09/17/2019 at approximately 7:00 PM, the administrator and DON had no further information or documentation to offer. Based on observation, staff interview, resident interview, clinical record review, and facility documentation review facility staff failed to ensure Residents were free from accidents and hazards, for 2 residents (Residents #38, and #31) of 42 residents in the survey sample, resulting in harm for Resident #38. In addition, the facility staff failed to maintain water temperatures in a range to prevent burns, scalding and other injuries on 2 of 2 nursing units. The findings included: 1. For Resident #38, the facility staff failed provide the 2 needed staff members for ADL (Activities of Daily Living) care leading to a fall, fracture, and head injury, resulting in harm. Resident #38 was most recently admitted to the facility on [DATE]. Diagnoses included: hypertension, anemia, contractures of the right and left knees, dementia without behavioral disturbances, quadriplegia, peripheral vascular disease, gastrostomy tube for feeding, and high cholesterol. The closest Minimum Data Set (MDS) assessment to the time period associated with the event that injured Resident #38, was a significant change assessment with an assessment reference date (ARD) of 3-18-19. Resident #38 was coded with a Brief Interview of Mental Status score of 0 indicating severe cognitive impairment and the Resident required extensive assistance of 2 staff for bed mobility, and extensive to complete dependence, on staff for all activities of daily living. The Resident was coded with no aberrant behaviors. This MDS was compared to the previous MDS with an ARD of 12-19-18 which was a quarterly assessment. and the Resident was coded as extensive assistance of 2 staff for bed mobility in that assessment as well. The Resident was not interviewable. An initial facility reported incident (FRI) was received in the Virginia Department of Health, Office of Licensure and Certification (VDH/OLC) on 3-4-19 in regard to Resident #38 having a fractured and lacerated finger requiring emergency room hospitalization on 3-3-19. Nursing progress notes were reviewed, and revealed the following course of events; On 3-3-19 at 4:10 p.m. Licensed Practical Nurse (LPN) (I) was called to the Resident's room by Certified Nursing Assistant (CNA) (T). The LPN found the Resident to have a deep laceration to her left pinky finger which measured approximately 1 inch in length, and it was bleeding, and a pressure dressing was applied, and the Resident was sent out to the hospital emergency room via stretcher at 4:50 p.m. On 3-4-19 at 12:50 a.m., the Resident returned with diagnoses of hematoma to right forehead, after a computed tomography (CT) radiology examination , and a bandaged left pinky finger with 8 stitches, also requiring Keflex antibiotic four times a day for 7 days to prevent infection, and a follow up appointment with an orthopedic doctor in 1-2 days. Neurological checks were begun in the facility due to the head injury. Hospital records, and orthopedic follow up documents were reviewed and indicated that the Resident had experienced a head contusion injury (bruised brain) bleeding in the brain which can cause swelling from a fall which also produced an open fracture (bone visible) of the distal phalanx of the little finger. The Resident's care plan was reviewed and revealed a focus for fracture of left pinky finger related to a fall on 3-3-19. The director of nursing was requested to bring all investigation records for March 2019 involving Resident #38. The investigation information was provided, and revealed the following: 3-3-19 Resident #38 experienced a fall with contusion to the brain and an open fracture of the finger requiring hospitalization for CT of the head and sutures and splint to the severely fractured finger. On 3-3-19, and 3-4-19 witness statements were obtained verbally and in written form. The Residents room mate stated that Resident #38 had fallen from bed and CNA (T) and 2 other staff members had picked her up and taken her out of the room. CNA (T) called for LPN (I), who responded to the room, and LPN (I) then called LPN (J) to assist her. The 2 LPN's arrived in the room to assess the injuries. LPN (J) documented that the laceration to the finger was down to the bone/tendon, nail still intact. The other CNA's working with CNA (T) that evening denied being present or any knowledge of the incident. CNA (T) could not name any other staff assisting him when the Resident fell from the bed. On 3-4-19 the Summary of Alleged Incident was completed by the DON (Director of Nursing). The timeline in the document describes that on 3-3-19 at 3:00 p.m. the Resident had no injury. At 4:10 p.m., according to statements LPN (I) was called to Resident #38's room by CNA (T) where she found the Resident with the injury. At 4:50 pm the Resident was sent to the hospital by stretcher. On 3-4-19 at 12:45 a.m., the Resident returned by ambulance with a negative head CT for injury, and 8 sutures to the fractured and lacerated finger which was bandaged now. The summary Conclusion, documented that the injuries were the result of a fall for Resident #38, and the employee (CNA (T) was terminated. The Summary of Alleged Incident report determined that CNA (T) was in the room providing care for Resident #38 alone when the resident was turned by the CNA toward the window and the Resident fell out of the bed. After the Resident was injured other staff were called into the room by CNA (T) to pick up the Resident and send her out to the hospital for treatment of a serious injury. On 9-16-19 the Employee record for CNA (T) was reviewed and revealed documents that described on 1-28-19 the CNA had been counseled for abandoning his post without replacement, and he was terminated on 3-7-19 for injuring a Resident. On 9-17-19 at 5:00 p.m., the facility Administrator and Director of nursing were made aware of findings, at the end of day meeting. The facility stated they had no further information to provide.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. For Resident #31, the facility staff failed to recognize and evaluate a 8.06% weight loss over a 4-day period. Resident #31, a [AGE] year old male, was admitted to the facility on [DATE]. Diagnoses included but not limited to dementia, dysphagia, and diabetes. Resident #31's most recent Minimum Data Set with an Assessment Reference Date of 07/15/2019 was coded as a quarterly assessment. Functional status for eating was coded as requiring a one-person physical assist and supervision (oversight, encouragement, or cueing) during meals. On 09/16/2019, the clinical record was reviewed. According to the weight summary, Resident #31 weighed 172 pounds on admission [DATE]), 177 pounds on 06/26/2019, 171.2 pounds on 08/28/2019 and 157.4 pounds on 09/01/2019 which indicated an 8.06% weight loss over a 4-day timeframe. An active physician's order with a start date of 07/19/2019 documented, Mechanical soft texture, thin consistency, NO STRAWS. MONITOR FOR SIZE AND RATE DURING INTAKE for aphasia [sic]. Aphagia refers to the inability or refusal to swallow. There were no orders for protein/carbohydrate/ high-caloric supplements or fortified foods. The progress notes from 08/01/2019 through 09/09/2019 were reviewed. There were no notes by any service addressing the weight loss documented in the weight summary on 09/01/2019. The care plan was reviewed. A focus entitled [Resident #31] has the potential for nutrition/hydration imbalance r/t [related to] dementia, DM2 [diabetes mellitus 2], dysphagia dx [diagnosis], need for mechanically altered texture diet. A goal associated with this focus initiated on 02/18/2019 and revised on 09/16/2019 documented [Resident #31] will maintain adequate nutritional status as evidenced by maintaining weight with no significant weight changes through the review date. Interventions associated with this focus are as follows: Administer medications as ordered. Monitor/document for side effects and effectiveness. Provide/serve diet as ordered and per resident preference. Monitor intake and record q [every] meal. RD [registered dietitian] to monitor and f/u [follow up] per protocol Weigh per facility protocol. The interventions did not include monitoring for size and rate during intake as indicated in the physician's orders. There was not a focus on the care plan for an actual significant weight loss. On 09/16/2019 at 4:30 PM, an interview with Licensed Practical Nurse F (LPN F) was conducted. When asked about the process when a resident presents with weight loss, she stated, I would re-weigh. She then stated that if it was true weight loss, she would notify the physician, the dietician, and the responsible party. When asked how much weight loss constitutes notifying the physician, she stated, Five to ten pounds. On 09/17/2019 at 10;23 AM, this surveyor observed a restorative aide that routinely weighs residents weigh Resident #31 via wheelchair on the scale and his weight was 158.8 pounds indicative of an overall 7.24% weight loss since 08/28/2019. On 09/17/2019 at 1:34 PM, the medical director was asked if he was aware of Resident #31's significant weight loss. He stated, We discuss it every week in meeting so yes, I think so. When told there were no provider progress notes addressing it, the medical director stated, I will look at it then I have to look at it and exactly the reason, he was doing so well and all of a sudden .I will definitely look at him and get back to you. On 09/17/2019 at 2:45 PM, an interview with Employee G, a registered dietician, was conducted. When asked if she was aware of Resident #31's significant weight loss, she stated she was aware. She went on to explain her process of obtaining a printout of all the residents and their weights. She stated she highlights the residents that need to be re-weighed but Resident #31 was not on the list. Employee G stated, I talked to the nurse about that today. Employee G also stated that she will put in new recommendations for him. When asked what the recommendations would be, she stated that Resident #31 likes milk and ice cream so I was going to add both of those. She stated she would also add juice to the breakfast meal and stated that his wife and daughter bring him snacks as well. The facility staff provided a copy of their policy entitled, Resident Weight. In Section 2 entitled, Weight Procedure it was documented in Part (c) Compare weight to previous weight obtained. If a variance of 5 pounds or more is noted, reweigh resident to verify weight. In Section 6 entitled, Reweight Parameters it was documented, a) A plus/minus of 5 pounds of weight in one week will result in: i) reweight within 24 hours(1) validation with nurse for accurate weight (2) notify IDT [interdisciplinary team]/doctor/family, if indicated. On 09/17/2019 at approximately 7:00 PM, the administrator and DON had no further information or documentation to offer. Based on observation, staff interview, resident interview, clinical record review, and facility documentation review, the facility staff failed to ensure the nutrition and hydration status of 3 residents, (Residents #37, 28, and 31) in a survey sample of 42 residents, resulting in harm for Resident #37. The findings included; 1. For Resident #37, the facility staff neglected to ensure the resident was free from malnutrition and dehydration, resulting in harm. Resident #37 was admitted to the facility on [DATE]. Diagnoses included: hypertension, anemia, arthritis, chronic kidney disease moderate, high cholesterol, heart disease, seizures, and a history of dysphagia. The most recent Minimum Data Set (MDS) assessment was a quarterly assessment with an assessment reference date (ARD) of 9-9-19. Resident #37 was coded with a Brief Interview of Mental Status score of 11 indicating mild to no cognitive impairment and the Resident required extensive assistance, to complete dependence, on staff for all activities of daily living. This included extensive assistance of 1 staff member's physical assistance to eat. The Resident was coded with no aberrant behaviors, and no refusals of care or assistance from staff. This MDS was compared to the previous MDS with an ARD of 7-12-19 which was a 90 day assessment, and the comparison is as below: MDS 7-12-19 - BIMS = 11, at risk for wounds, no current wounds, no preventative measures for wounds, no weight loss, mechanically altered diet, Bed mobility extensive assistance needed, eating extensive assistance needed. MDS 9-9-19 - BIMS =11, at risk for wounds, one current vascular (incorrect identification) wound, pressure reduction devices for chair and bed, for wounds, ointments and dressings for the wound, nutrition management, significant weight loss, mechanically altered diet, Bed mobility extensive assistance needed, eating extensive assistance needed. On 4-15-19, Resident #37 was admitted on a Regular diet with low potassium, regular texture, thin liquids. On 6-25-19 the Resident's diet was changed to Dysphagia ground texture, thin consistency low potassium diet. On 9-11-19 the Resident's diet was again changed to Regular diet puree texture, nectar consistency, for dysphagia. On 9-15-19 at 12:00 noon, observations and interviews were conducted with the Resident. After introduction, the Resident was asked if we could help him with anything while we were there, and he complained of hunger, and stated he wanted something to eat. He stated his family brought him things and he enjoyed that food. The lunch meal tray did not arrive at the bedside until 12:45 p.m., and at 2:30 p.m., no staff had entered the room to assist the Resident to eat. Surveyor A, and this surveyor looked at the tray which was uncovered, and untouched. We went to the nursing station to enquire as to how long it would be for the Resident to be fed. The staff stated they were very understaffed, and were unable to use the dining room, and had to close it as they were unable to staff it, so the feeders who would normally be fed there had to be fed in their rooms. They stated that Resident #37 was a self feeder, and independent. At 2:30 p.m., the Resident was again observed and was sitting in bed falling over onto his left side with a small styrofoam or paper cup containing magic cup supplement, which was an ice cream like substance in his hand. The Resident was licking the inside of the cup to obtain the contents, and the surveyor asked him if he was able to hold the spoon that was on his tray, and he stated not too good, I am so weak now, I just don't have the strength. The Resident picked up the spoon and tried to use it, however, the small amount he was able to get onto the spoon after much effort, fell down onto the bed linens. The rest of the tray was untouched, and no 2 cal supplement was on the tray. At 2:45 p.m., the HR (human resources) Director entered the Resident room to feed him. The surveyors returned at 3:30pm to find the tray had been left there and the thick pudding consistency portions of food had approximately 2 spoonfuls missing from 2 of the 3 scoops of pureed food. Each of the scoops measured approximately 3 inches by 3 inches circular, and 1/2 inch depth, and had spread out into each other on the plate. The Resident stated I can't eat that stuff, it's awful like cold wet bread. He went on to say I told them when I got here that I can't eat that stuff, and I don't have any trouble eating if I like the food, but they don't listen. On 9-16-19 at 10:00 a.m., another observation was conducted for this Resident by Surveyor C. Surveyor C reported that for the breakfast meal the tray was followed and went into the Resident's room, left uncovered, and removed from the room untouched and returned to the kitchen. On 9-16-19 at 3:00 p.m., the Resident's lunch meal tray was again left untouched, and the Resident was not fed. No supplement was in the room for either meal. It is notable to mention that on 9-16-19 the Resident's breakfast tray was followed by Surveyor C from delivery by CNA N, to discard, and it was not disturbed, nor did the Resident attempt to consume it. No staff member attempted to assist with the meal, and the tray was simply removed from the room, untouched, and discarded. CNA O documented 26-50% consumed. CNA N (certified nursing assistant) was interviewed, and stated he ate a little of his sherbet cup so I said he ate 25%, however, CNA N did not sign the ADL document, another staff member, CNA O was documented as having fed Resident #37 his breakfast. CNA N was asked if she fed the Resident, and she stated no he can feed himself. CNA N was asked if she had been trained on how to calculate the amount of a meal that a resident consumes, and she stated no. CNA O stated that she only removed the tray, and did not feed the Resident. The ADL (activities of daily living) report was requested and received. The report documented that the Resident was independent with eating for breakfast and lunch every day in September, for 20 of the 32 breakfast and lunch meal opportunities. The 12 meal exceptions where the staff assisted the Resident occurred on the following days; 9-1-19 dependant (fed) for both meals, and consumed nothing for breakfast and 51-75% for lunch. 9-5-19 dependant (fed) for both meals, and consumed 51-75% for both meals. 9-7-19 limited assistance (not fed) for both meals, and consumed nothing for both meals. 9-8-19 limited assistance (not fed) for breakfast, and consumed 26-50%. 9-10-19 limited assistance (not fed) for lunch, and consumed nothing. The behavior portion of the ADL record was also reviewed and revealed at no time did the Resident refuse assistance or care. The other 20 opportunities for staff support with feeding, and the Resident was not fed, occurred on the following days; 9-2-19 The Resident consumed 51-75% both meals 9-3-19 The Resident consumed 26-50% both meals 9-4-19 The Resident consumed 26-50% both meals 9-6-19 The Resident consumed 26-50% at breakfast, and 76-100% at lunch 9-8-19 The Resident consumed 26-50% at Lunch 9-9-19 The Resident consumed 76-100% both meals 9-10-19 The Resident consumed nothing for breakfast 9-11-19 The Resident consumed nothing for breakfast, and 76-100% at lunch 9-12-19 The Resident consumed nothing both meals 9-13-19 The Resident consumed 26-50% both meals 9-14-19 The Resident consumed 26-50% breakfast, and 75-100% at lunch 9-15-19 The Resident consumed nothing both meals 9-16-19 The Resident consumed 26-50% for breakfast, nothing for lunch During this 16 day period from 9-1-19 through 9-16-19, nine different staff members signed the meal consumption record, only 3 of which delivered the meal to the Resident consistently more than one day in the 16 days. The Resident's weight record was requested and revealed that from 7-3-19 until the time of survey on 9-16-19, the Resident had lost 23.4 pounds of weight in less than 12 weeks. Those weights follow: 4-15-19 - On admit 122.4 lbs (pounds) 4-23-19 - 119.2 5-1-19 - 115.2 - weight loss of 7 pounds after admission for 2 weeks. 5-22-19 - 120.2 - weight gain of 5 pounds and stabilizes after 3 more weeks. 6-25-19 - diet modified to ground texture begun, and significant weight loss begins. 6-26-19 - 119.0 7-3-19 - 119.0 7-24-19 - 117.0 7-31-19 - 117.0 8-26-19 - 108.0 9-1-19 - 103.0 9-9-19 - 101.8 9-11-19 - diet modified to pureed texture begun after significant weight loss of 17.2 pounds from 7-3-19 to 9-9-19. 9-16-19 - 95.6 - significant weight loss increased in less than 12 weeks to 23.4 pounds, equaling 20% of the Resident's entire body weight, and 26.8 pounds, since admission. On 9-16-19 at 3:00 p.m., an interview was conducted with the Director of Nursing (DON), and Unit manager RN (registered nurse) D, by surveyors in the conference room. They stated we want to have a care plan meeting with him and his family, wife, son or brother, that is our next step with him I am aware he is loosing weight. They were asked why it had taken 5 months to get a plan going, and they stated At first his family was bringing in food that he was eating, he doesn't like the pureed texture or the nectar thick liquids. Therapy had been working with him, and he had a FEES study on 9-10-19 that he failed. They were asked why the physician had not talked with the Resident himself and decide a course of action? They stated We discussed the doctor talking to him (the Resident), and we didn't have a social worker as Employee O has been gone about a month and a half ago, and he has lost weight since that. The DON stated I see we need to make a decision and talk to him to see if he wants a peg tube because he doesn't like the pureed texture to maintain his BMI (Body Mass Index). The DON and unit manager continued with, Speech therapy did a swallowing eval, and he didn't do well. They were asked when that occurred as no therapy notes were found in the clinical record. She stated, I don't know, I will get those for you. The family brings in McDonalds, and that he eats. She was asked if he had ever aspirated or been hospitalized , or treated for aspiration pneumonia, or had any respiratory problems, and they stated no. They were asked why the Resident was not being fed by staff who thought he was independent, when his MDS showed he needed extensive assistance from staff to eat since the 7-12-19 MDS which included a seven day look back to 7-5-19. They responded He should be fed. On 9-16-19 at 3:15 p.m., Employee E, the speech language pathologist (ST/SLP) entered the interview in progress in the conference room with surveyors, and with the unit manager and DON. She stated he was on ground meat with pureed solids and the Resident didn't like it so the family requested an upgrade so he would eat, and then the FEES study was ordered on 9-10-19. I asked if there was no problem, or outcome with the regular diet that the family brought in that the Resident did eat, why the change. She stated he needs positioning and encouragement to not aspirate, he is at risk for silent aspiration. She continued he wasn't really eating the ground texture, or anything off of the pureed tray but pudding, oatmeal, and cream of wheat, and that's why the FEES study was done. A bedside swallowing evaluation was done by another speech therapist who was full time here. I am not typically treating most of the time. Her last day was weeks ago, I don't remember how many, we have a new one starting today. Between the last one and this one we have had PRN (as needed) staff and I have been helping treat as well. She was asked if she had assessed or treated Resident #37, and she stated no. The ST notes were again requested. The FEES (Dysphagia systems test) study was requested at 3:15 p.m., during the interview with Employee E, and received at 4:00 p.m. The study documented no diagnoses linked to dysphagia, and documented that the Resident took his medications whole. The document describes the Potential risks to the Resident, and documents that the Resident is at Potential risk for aspiration. Any and all ST notes from Resident #37's time of admission to today were requested again. On 9-16-19 at 4:00 p.m., the Registered Dietician (RD), and Assistant Director of Nursing (ADON) were interviewed by surveyors in the conference room. The current RD stated there had been a lot of turnover in the department and there had been one RD from April to may 2019, and then travel and consultant RD's had come in as needed until mid August 2019 during his significant weight loss, and she herself (employee G) started work in the facility in mid august, and had been there just under a month. Physician's progress notes were reviewed and indicated no weights on the assessments conducted by the physicians. The area in the form for weight were all left blank. There is no indication that the physician's were aware of the significant weight loss from 6-25-10 to 8-29-19. A review of the physician's orders, was conducted from the time of admission to the time of survey. They revealed the following timeline of interventions; 4-15-19 - admission regular diet with thin liquids. - weight 122.4. 4-16-19 - ST, OT (occupational therapy), PT (physical therapy) all evaluate and treat as necessary order entered. 5-2-19 - 2 Cal supplement 120 ml (milliliters) drink twice per day at 8:00 a.m., and 5:00 p.m. - weight 115.2. 6-25-19 - Weight 119.0, which had rebounded from initial admission loss, proving the Resident had no difficulty gaining weight back (for the 2 months and 10 days since admission) while eating a regular diet, and taking a small amount of supplement. During this time there were no problems associated with aspiration. 6-25-19 The diet change to dysphagia ground diet with thin liquids, which the Resident did not like. No other interventions occurred to prevent significant weight loss from 5-2-19 until 8-28-19 when the new RD arrived, and the significant weight loss had already occurred. - weight 108.0 (14.4 pound (10%) weight loss since admission, and an 11 pound weight loss in 2 months.) 7-25-19 through 7-29-19 the Resident had symptoms of illness, and had laboratory blood tests drawn. As a result of those tests it was revealed that the Resident had become dehydrated. Resident #37 then was ordered to receive IV (intravenous) normal saline fluids for dehydration. The infusion was started initially through a peripheral IV in his left wrist, however, the IV was not positioned well and had to be removed, and the staff was unable to replace it, so a specialist nurse was brought in to insert a mid line PICC (peripherally inserted central line catheter) to infuse the fluids. 7-26-19 - Physician's orders, laboratory reports, and nursing/physician progress notes revealed that ADON was aware that the Resident need for help with ADL's has increased. Resident recently ended PT, OT, and ST services. Will continue to monitor for further decline and have therapy screen as needed. 8-27-19 - RD progress note revealed Weight not stable, Spoke with Resident who says that he doesn't like the ordered texture of his food. He reports that he feels like he's lost weight and does feel hungry throughout the day and at bedtime. He is agreeable to drinking 2 cal and trying snacks between meals and at bedtime Orders are then initiated and follow below. 8-29-19 - 2 Cal supplement increased to 240 ml (milliliters) drink twice per day at 8:00 a.m., and 5:00 p.m., magic cup twice per day with lunch and supper, yogurt and apple sauce between meals and at bedtime, were all started - weight 108.0. 9-3-19 - Resident lab test resulted for pre-albumin (measures recent dietary intake). Pro-stat protein supplement for wound healing was ordered. 9-9-19 - FEES study (Dysphagia systems test) completed. - weight 101.8. 9-11-19 - Diet changed to pureed with nectar thickened liquids, increase to 2 cal supplement to 3 times per day, and med pass liquid supplement was added for 60 ml three times per day. 9-16-19 - at the time of survey weight was - 95.6. The Resident's diet card was requested from the kitchen and stated the pureed diet with nectar thickened liquids was being served. No mention of the supplement (2 cal supplement 240 ml (milliliters) three times per day, was on the tray card. On 9-17-19 at 12:32 p.m., the physician was called on the telephone and asked for an interview. He stated he would come to the facility and look at the chart and let surveyors know about Resident #37. The physician arrived and stated he had looked at the chart, and said the Resident is severely malnourished and doesn't like the texture of the diet. He stated We had speech look at the patient, and they said he isn't able to eat regular food. The family said no to a PEG (Per Endoscopic Gastrostomy) tube, there is nothing else to do. The doctor was asked why was speech therapy was consulted, if the Resident had no signs of aspiration, was not hospitalized or ever suffered from any respiratory illness associated with aspiration, and had been here in the facility for 5 months. He stated that the family was concerned. The doctor was asked why the family was allowed to make decisions for a Resident, who was alert and oriented, could make his needs known, and was his own Responsible Party (RP). The Resident had not been deemed incompetent, and had the right to make his own decisions. The doctor responded I was not aware of that, and if we let him eat whatever he wants, that's how we get sued. On 9-17-19 at 5:00 p.m., a Summary Report of Meeting document for the last 2 days of staff huddle meetings was presented to surveyors by the DON. The document described the subject of the meetings to be in regard to Passing trays at meal times, assisting feeders, documenting on amounts eaten. and was signed by those in attendance. This was evidence of training begun by the facility to rectify deficient practice in the meal delivery and assistance system. The comprehensive care plan was reviewed in it's entirety and revealed the following interventions for the weight loss and pressure sore. There were no interventions for hydration, and it was simply placed in with the nutrition (weight loss) hydration plan below; (Weight loss) FOCUS: (name) Resident #37 has the potential for nutrition/hydration imbalance related to hypertension, anemia, chronic kidney disease, history of hyperkalemia, diagnosis of dysphagia. Resident does not like puree texture food. initiated on 4-19-19, revised on 5-5-19, 6-25-19, and 9-13-19. GOAL: Resident will remain adequate nutritional status as evidenced by maintaining weight with no significant weight changes through review date. INTERVENTIONS: (all created and initiated on 4-19-19 immediately after admission) Administer medications as ordered. Monitor/document for side effects and effectiveness. Provide/serve diet as ordered, honoring resident preferences. Monitor intake and record every meal. RD to monitor and follow up per protocol. Weigh per facility protocol. (initiated 6-25-19) No hot liquids for safety. No changes were made to any interventions after the Resident suffered a significant weight loss. The significant weight loss was not care planned, none of the interventions that were initiated for the weight loss were care planned, none of the supplements were care planned, none of the diet changes were care planned, and the need of the Resident to be fed by extensive assistance of staff was not care planned. Most goals are not measurable, and the Residents preferences were not honored. There was no Hydration care plan initiated, even after the Resident suffered from dehydration requiring IV fluid infusions on 7-25-19. On 9-17-19 at 5:00 p.m., the DON was again asked for ST notes, and none were supplied. At that time, the facility Administrator and Director of nursing were made aware of findings at the end of day meeting. The facility stated they had no further information to provide. 2. For Resident #28, the facility failed to ensure that he was offered adequate hydration. Resident #28 was a [AGE] year old who was admitted to the facility on [DATE]. Resident #28's diagnoses included Diabetes Mellitus Type 2, Muscle Weakness, and Hypertension. The Minimum Data Set, which was an admission Assessment with an Assessment Reference Date of 4/22/19 was reviewed. Resident #28 was coded with a Brief Interview of Mental Status Score of 15, indicating no cognitive impairment. He was also coded as requiring set up assistance with meals, and being able to ambulate independently with his wheelchair. On 9/16/19 a review was conducted of Resident #28's clinical record, revealing the following diet order: 4/22/19. Renal diet. Regular texture, Large Portions, Sandwich 3 times a day at meals. On 9/15/19 at 1:40 P.M. an interview was conducted with Resident #28 in his room. His lunch had not been served. He stated that he wanted some apple juice, or something other than water to drink. Other than water there were no beverages in his room. He further stated that the dining room was closed all day on weekends. He complained that his food was late on a daily basis. He had not received an additional beverage to drink because the food tray was always late, and the facility did not ensure that preferred sources of hydration was available between meals. On 9/16/19 at approximately 5:00 P.M., an interview was conducted with the Director of Nursing (DON Employee B). When asked why Resident #28 was unable to receive other sources of hydration, the DON said that the facility had a hydration cart that passed out ice. No further information was received.