**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure a resident maintains acceptable parameters of nutritional status and weight. This affected 1 (R24) of 5 reviewed for nutrition and hydration. R24 did not receive cueing/reminders during meal times per her plan of care and R24 has had a significant weight loss over the last 6 months. Evidenced by: The facility policy, titled, Nutrition Support, dated 5/22/17, states, in part: I. Inadequate Oral Intake A. The Registered Dietician or Nursing staff will offer oral commercial nutrition supplements to residents with inadequate oral intake . III. Initiation of Nutrition Support A. The Physician's Order for nutrition support will be communicated to the Nutrition Services Department by Nursing . R24 was admitted to the facility on [DATE] with diagnoses that include Corticobasal degeneration (neurological degenerative disease that leads to progressive symptoms such as loss of movement, speech difficulties, and cognitive decline) and Parkinsonism (neurological disorder causing tremors, slowed movements, rigidity, and postural instability). R24's Quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) 4/9/25, shows R24 has a Brief Interview for Mental Status (BIMS) score of 10 out of 15 indicating R24 is moderately cognitively impaired. R24's Diet Order states: DIET: General, Meats/all food cut up bite size. ADAPTIVE EQUIPMENT: Large Handled/Built Up utensils, lids on cups. R24's Comprehensive Care Plan states, in part: I have the potential to be at nutritional risk because I have a history of hypertension, chronic kidney disease, insomnia, anxiety, mild cognitive impairment, repeated falls, and constipation. My goal is to: maintain my weight 135 +/- 5 lbs. Goal date: 7/29/25 I need my nurses to: . ask my family to provide my favorite foods and drinks, try to figure out why I'm not eating, ask me about my preferences I need my aides to: . weigh me per nursing order, setup my meal so I can eat, let me take as much time to eat as I need, ask me if I like my meal, offer me something else if I don't like the meal, offer me a snack, I need cueing/reminders to keep eating at meals, cut up foods. I need dietary staff to: provide me with a general diet, foods cut up bite size, food I like to eat, offer me built up silverware. I prefer my hot cereal in a mug. (with extra milk to make it drinkable). (Of note: The intervention I prefer my hot cereal in a mug. (with extra milk to make it drinkable) was added 6/16/25. Prior to this, the intervention for providing built-up silverware was added 4/9/25. No other nutritional care plan changes were made after 01/2025.) R24's Annual Nutrition Assessment, dated 4/11/25 indicates, in part: . Usual Body Weight Range: Care plan weight goal: 135 +/- 5 lbs . Calorie needs: 1247 . Eating Ability: Supervision-Set-up . MNA (Mini Nutritional Assessment): 10, At risk for malnutrition . Monitoring/Evaluation: monitor weights, intakes, s/s (signs and symptoms) of dehydration, labs as available, and will follow up quarterly or sooner if needed . R24's Weight Documentation states, in part: 1/10/25: 137.2 lbs. 6/13/25: 122.6 lbs. (Of note: This indicates a weight loss of 10.64% in less than 6 months). R24's Meal Intake Documentation from 5/17/25 through lunch on 6/17/25 indicates R24 had 89 meal intakes recorded. Of these 89 meals, 42 of these meals indicated R24 ate 50% or less of her entire meal, indicating R24 is only eating 50% of her meal or less for around 47% of her meals. Surveyor was provided with an untitled document that facility staff report is a seating chart for the dining room. This chart indicates R24 usually needs cueing/supervision with meals. Surveyor requested two days of R24's meal cards during survey. Surveyor was provided with R24's meal cards for breakfast, lunch, and supper. These cards do not indicate a date, and do not include R24's recommended dietary supplement. On 6/13/25, a note from the Registered Dietician states, in part: . -11.0% (15.2 lb) in six months . With [Resident's Name]'s gradual weight loss and overall fair intake, will request order for 8 oz Ensure at supper for additional calories and protein. Will continue to monitor weights, intake, and acceptance to nutritional supplement. (Of note: There is no order for this supplement, and it does not appear on R24's meal card). On 6/17/25, Surveyor observed R24 eating breakfast. At 8:16 AM, R24 received her breakfast tray. At 8:19 AM, R24 attempted to take her first bite and dropped half of her spoonful. At 8:24 AM, R24 drops another entire spoonful onto her lap. At 8:30 AM, Surveyor notes R24's hands are shaking, and she is having difficulty bringing the spoon to her mouth. Surveyor also notes R24 has to adjust the spoon angle several times in order to take a bite. At 8:40 AM, R24 drops another spoonful of food onto her lap. At 8:53 AM, R24 attempted to eat a slice of toast, half of the slice was dropped onto her lap and R24 was having difficulty getting the bread into her mouth. At 9:00 AM, Surveyor ended observation and noted R24 was still trying to eat her breakfast. On 6/18/25, Surveyor observed R24 eating breakfast. At 7:56 AM, Surveyor started breakfast observation and R24 had already received her breakfast tray. At 8:06 AM, R24 brought the spoon up to her mouth, and attempted for an entire minute to get food into her mouth. R24 was unsuccessful and slowly put the spoon back down, still full of food. At 8:13 AM, R24 attempts to take another bite, and struggles, missing her mouth several times with the spoon before finally being able to take a bite. At 8:16 AM, R24 brought the spoon to her mouth to attempt to take a bite, missed her mouth several times, then put utensil back down with food still on it. At 8:19 AM, R24 attempts to take another bite, again missed her mouth several times before finally being able to take a bite. On 6/18/25 at 8:45 AM, Surveyor sat with R24 to ask her about breakfast. Surveyor noted R24 was struggling to reach her cup. On 6/18/25 at 8:25 AM, Surveyor interviewed DA C (Dietary Aide). Surveyor asked DA C if there were any CNAs (Certified Nursing Assistants) in the dining room with her. DA C indicates not at the start of breakfast, they usually won't come down until they get all the residents up. Surveyor asked DA C if she assists any residents with cueing or eating. DA C indicates, no, she is not allowed to. On 6/18/25 at 9:17 AM, Surveyor interviewed CNA D (Certified Nursing Assistant). Surveyor asked CNA D if there is usually a CNA assigned to the dining room. CNA D indicates, yes there always is a CNA assigned to assist with feeding. Surveyor asked CNA D how they know which residents need assistance. CNA D indicates the map with the seating chart on it. Surveyor asked CNA D how R24 eats. CNA D indicates she eats pretty good, she doesn't like her built up silverware, so we give her regular silverware, and she needs help with cutting up her food. CNA D also indicates she spills her food sometimes and can't use her left arm so it makes it more difficult for her to eat. On 6/18/25 at 10:15 AM, Surveyor interviewed CNA E. Surveyor asked CNA E if there is usually a CNA assigned to the dining room. CNA E indicates, yes, and that she was assigned but that she didn't get out to the dining room until later because she had to help get a resident up on another hall. Surveyor asked CNA E what time she thinks she was able to get out to the dining room. CNA E indicates around 9:15 AM. Surveyor asked CNA E if it is common that CNAs are late getting out to the dining room in the morning. CNA E indicates yes, because they are trying to get all of the residents up for the day. Surveyor asked CNA E how R24 eats. CNA E indicates she is a slow eater, frequently spills her food, staff always give R24 two sets of silverware, the regular and built-up because she often refuses the built-up silverware, and she has a hard time eating food because she can't use her left arm. CNA E also indicates she did have to cue R24 this morning and helped her by holding her bowl so she could eat. On 6/18/25 at 1:51 PM, Surveyor interviewed CNA F. Surveyor asked CNA F if there is usually a CNA assigned to the dining room. CNA F indicates, yes, and that there are 3 residents who require feeding assistance. Surveyor asked CNA F how R24 eats. CNA F indicates staff have been having to help her more lately and that it is hard for her to get a good grip on the silverware, and she frequently drops her food. On 6/18/25 at 2:01 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B what the expectation is for staff when a resident requires cueing or supervision assistance. DON B indicates, to help cue and supervise that resident. Surveyor asked DON B what the expectation is for CNAs who are assigned to the dining room. DON B indicates, she expects the CNAs to be cueing, supervising, and assisting residents who need assistance. Surveyor asked DON B who monitors resident weights. DON B indicates, numerous people monitor weights, including herself, the two nurse managers, the registered dietician, and the dietary manager. DON B also indicates the electronic medical record creates weight alerts and these are discussed during morning meetings where they try to determine root cause. Surveyor asked DON B who monitors residents' food and fluid intakes. DON B indicates the dietary manager reviews the intakes then sends any changes in intake to the registered dietician. Surveyor asked DON B if registered dietician orders should be placed or sent to the physician for review. DON B indicates, she would have to double check as they are in the process of changing standing orders. Surveyor asked DON B if residents who have a recommendation for Ensure, should have that order placed. DON B indicates only if it is to be given during meal pass, otherwise dietary places the recommendation on the meal card. Surveyor asked DON B how R24 eats. DON B indicates she doesn't know her specifics. Surveyor relayed to DON B that according to the Registered Dietician, R24 has a caloric intake goal of 1247 calories a day, does DON B believe R24 is meeting that nutrition goal according to her meal intake documentation. DON B indicates, no. Surveyor asked DON B what interventions have been put in place to counteract R24 not meeting her intake goal. DON B indicates the facility has offered her assistance with meals and built-up utensils, however R24 often refuses both of those interventions. Surveyor asked DON B if those interventions have been effective at helping R24 meet her caloric intake goal. DON B indicates, no but she is also refusing those interventions. R24 did not receive cueing/reminders during meal times per her plan of care and R24 has had a significant weight loss over the last 6 months.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Example 3 On 6/16/25 at 12:15 PM, Surveyor interviewed R8 who indicated that the ham they were having today, as well as beef and meats in general, are tough. R8 indicated the staff will assist with cutting but they can't help chew it. Based on observation, interview and record review, the facility did not ensure that each resident receives food and drink that is palatable and at a safe and appetizing temperature. This has the potential to affect 4 of 14 sampled residents (R27, R32, R11, and R8). R27 voiced concerns with her food being cold. R11 voiced concerns with food being cold. R32 voiced concerns with food being cold and tough to chew. R8 voiced concerns with meats being tough to chew. Surveyors conducted 2 test trays; both were not palatable. Evidenced by: Facility policy, entitled Infection Control - Preparing and Cooking Foods, last revised 7/20/2016, includes, in part: . Use hot holding equipment that can keep hot foods at 135 degrees Fahrenheit or higher . Cold foods must be maintained at 41 degrees Fahrenheit or below . Example 1 R27 admitted to the facility on [DATE]. R27's most recent Minimum Data Set (MDS), with a target date of 6/4/25, indicates a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R27 is cognitively intact. On 6/16/25 at 11:36 AM, R27 indicated during screening her food is often cold when she eats it. R27 chooses to eat meals in her room and stated her food isn't hot enough when it's delivered. Example 2 On 6/17/25 at 12:16 PM, Surveyor conducted a test tray from room trays on the 200 hallway. Surveyor observed a Certified Nursing Assistant (CNA) deliver the room trays to the hallway on a cart that was not enclosed, plates had cambro bottoms (not heated) and lids, drinks and bowls were covered. After the room trays were delivered, Surveyor took the temperature of the items on the test tray. The temperatures were as follows: Chicago Beef Sandwich (temped the beef on the sandwich) - 113 degrees Fahrenheit Sweet Potato Fries - 104 degrees Fahrenheit Creamy Cucumber Salad - 49 degrees Fahrenheit Fruited Gelatin - 48 degrees Fahrenheit Surveyor tasted the food and hot food was cold. The tray was not palatable and at a safe and appetizing temperature. On 6/18/25 at 12:24 PM, Surveyor interviewed DM G (Dietary Manager) about the food. DM G indicated she would expect the hot food to be hot and cold food to be cold. On 6/18/25 at 12:15 PM, Surveyor conducted a test tray in the facility's main dining room. Surveyor was cutting the country fried pork tenderloin with a fork and knife. Surveyor had to use a lot of pressure to cut the meat. Surveyor had a difficult time chewing the meat, particles got stuck in Surveyor's teeth. This test tray was not palatable. On 6/18/25 at 12:24 PM, Surveyor interviewed DM G about the toughness of the meat. Surveyor asked DM G to cut the meat and DM G indicated the pork was tough to cut. DM G stated they switched food companies recently and were trying different things on the menu. She also stated she would work on figuring out a way to make the meat more tender or take this off of the menu. Example 4 On 6/16/25 at 11:30 AM, R11 reported that food is lukewarm mostly all of the time. Example 5 On 6/16/25 at 3:45 PM, R32 reported that since getting the new food company the food has been rotten. She indicated they could improve the food 100%. She stated that the pork chop was tough as a brick and food is lukewarm. On 6/18/25 at 2:20 PM, Surveyor interviewed NHA A (Nursing Home Administrator) and VP H (Vice President of Health Services). Both indicated policies should be followed, food should be hot enough and meat not hard to chew.

Based on observation, interview, and record review, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This has the potential to affect 34 of 34 residents. Surveyor observed food to have been removed from the original packaging and not dated with an expiration date, an open date, or a use by date. Surveyor observed undated and expired seasoning to be in circulation. Evidenced by: The Wisconsin Food Code 2020 states, in part, at 3-501.17 .(D) A date marking system that meets the criteria stated in (A) and (B) of this section may include: . (1) Using a method approved by the regulatory authority for refrigerated, ready-to-eat, time/temperature control for safety food that is frequently rewrapped, such as lunchmeat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine; (2) Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (A) of this section; (3) Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section; or (4) Using calendar dates, days of the week, color-coded marks, or other effective marking methods, provided that the marking system is disclosed to the regulatory authority upon request .Disposition. (A) A food specified under 3-501.17 (A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in 3-501.17 (A) Except time that the product is frozen; (2) Is in a container or package that does not bear a date or day . Example - Undated food removed from original packaging On 6/16/25 at 10:28 AM, during initial tour of the kitchen, Surveyor and DM G (Dietary Manager) observed in the freezer an opened package of fish fillets out of the original cardboard box without a use by or expiration date. Surveyor and DM G also observed 3 unopened packages of pancakes out of the original cardboard box without dates on them. DM G verified the packages did not have dates and indicated the fish fillets and pancakes should have dates on them. On 6/18/25 at 2:20 PM, Surveyor interviewed NHA A (Nursing Home Administrator) and VP H (Vice President of Health Services). Both indicated they would expect food to be labeled and discarded appropriately. Example - Undated and Expired Seasoning On 6/16/25 around 10:28 AM, during initial tour of the kitchen, Surveyor and DM G observed boxes of beef and chicken bouillon in the dry storage area to not have expiration dates on them. DM G indicated they should have dates on them. Surveyor and DM G also observed an opened container of onion powder in the main kitchen to have a use by date of 6/12/25 (initial tour of the kitchen occurred on 6/16/25). DM G indicated the onion powder was expired and should have been thrown away. On 6/18/25 at 2:20 PM, Surveyor interviewed NHA A and VP H (Vice President of Health Services). Both indicated they would expect food to be labeled and discarded appropriately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that all residents were able to formulate an advance directive, specifically related to code status, for 1 of 19 sampled residents (R5) reviewed for advance directives. The facility does not have R5's advance directives in her medical record. Evidenced by: The facility policy, entitled POLST (Physician Orders for Life Sustaining Treatment)/Advance Directives, dated 2/1/22, states, in part: . Advance Directives: 1. Upon resident move in, the Social Worker will determine if the resident has any advance directives (i.e., Power of Attorney for Health Care, Power of Attorney for Finances). 2. If Advance Directives are not present, the Social Worker will meet with the resident within the first 14 days from arrival to advise them of their right to establish Advance Directives and to offer assistance should they wish to create them. 3. Advance Directives will be reviewed at the initial care conference and the quarterly care conferences. If changes are made to the Advance Directive, appropriate forms will be filled out and signed by the resident. 4. Copies of these documents will be filed in the resident's physical chart as well as updating the hospital records and informing agents of any changes made. R5 was admitted to the facility on [DATE], and has diagnoses that include Alzheimer's Disease, Type Two Diabetes Mellitus and Spinal Stenosis. R5's Quarterly Minimum Data Set Assessment, dated 7/27/22, shows R5 had a Brief Interview of Mental Status (BIMS) score of 3 indicating R5 has severe cognitive impairment. Advance Care Planning (ACP) note by (Physician Name) MD (medical doctor), dated December 3, 2020, states: I have personally examined the patient and have determined that she is unable to receive and evaluate information effectively, and communicate decisions necessary to manage her health care. I recommend that the provisions contained in her Power of Attorney for Health Care be activated. ACP note by (Physician Name) MD, dated December 5, 2020, states: I have personally examined the patient and have determined that she is unable to receive and evaluate information effectively, and communicate decisions necessary to manage her health care. I recommend that the provisions contained in her Power of Attorney for Health Care be activated. R5's Advanced Practice Nurse Prescriber (APNP) office visit note, dated 1/31/22, states, in part: . She has Alzheimer's. Her POA (Power of Attorney) is activated . On 4/29/24 at 3:10 PM, Surveyor interviewed NHA A (Nursing Home Administrator) and asked if R5 has Advance Directives and NHA A indicated yes. Surveyor asked NHA A if she could show documentation of the Advanced Directives to Surveyor. NHA A was unable to locate them in R5's medical record but provided a social service note indicating R5's POA. NHA A also provided two doctor notes recommending POA be activated. Surveyor asked NHA A if R5 has advance directives should they be signed and in R5's medical record and NHA A indicated yes, and they are not. On 4/29/24 at 4:15 PM, NHA A supplied a copy of R5's Advance Directives to Surveyor. NHA A indicated she had just called over to the hospital and received the Advance Directives by fax. NHA A indicated she provided education to the social worker regarding Advanced Directives.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, and facility policy review, the facility failed to develop and implement a baseline care plan within 48 hours of admission that included the minimum healthcare information necessary to properly care for R36's immediate needs related to his mental health diagnosis upon admission for one of three residents (Resident (R) 36) of 15 sampled residents. Findings include: Review of the facility's policy titled, Care Plan, updated 04/1/24, revealed each resident would have a specific plan of care, developed on information gathered from the Minimum Data Set (MDS)/Care Area Assessment (CAA)'s, other assessment tools, resident/family expectations, and physician/therapist orders. The policy stated that the plan of care would be developed through an interdisciplinary approach within 48 hours of resident's admission to the facility, and would contain goals, approaches, and interventions to address the risks, problems, and issues associated with the resident. Review of R36's Electronic Medical Record (EMR) under the Face Sheet tab, revealed R36 was admitted from an acute care hospital to the facility on 3/29/24, with diagnoses which included bipolar depression, post-traumatic stress disorder (PTSD), depression, and anxiousness associated with depression. Review of R36's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/4/24 revealed diagnoses which included bipolar mood disorder, anxiety disorder, and PTSD. The MDS indicated R36 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating intact cognition. Review of R36's EMR under the Physician Orders tab, dated 3/29/24, revealed R36 was administered Lamotrigine (anti-seizure medication) 100 mg (Milligram) tab twice daily for bipolar depression, Prazosin (alpha blocker medication) 1mg capsule once daily for PTSD, Trazodone (anti-depressant medication) 50 mg Tablet once nightly for insomnia associated with depression, Bupropion (anti-depressant medication) XL 300 mg daily for indications of anxiousness associated with depression, and Escitalopram (anti-depressant medication) 20 mg tablet daily for indications of anxiousness associated with depression. Review of the hospital Discharge summary, dated [DATE] and located in the EMR under the Other tab, revealed the hospital physician indicated that R36 has word-finding difficulties at times and has a slower response time given his head injury in August 2023. The discharge summary indicated no tests were pending at discharge, a reference to Consult to Social Services, and restorative services of physical and occupational therapy. The summary included a list of discharge medications to include lamotrigine, prazosin, trazodone, bupropion, and escitalopram. Review of R36's EMR baseline care plan summary under the Care Plan tab with an ARD of 4/4/24 through 4/29/24, had no care planned problems or interventions associated with his psychosocial diagnosis or medications administered for his psychosocial diagnosis. During an interview on 4/29/24 at 11:34 AM, DON B (Director of Nursing), stated that her expectation for R36 upon his admission was that he should have had a care plan from nursing and social services to address his psychosocial needs. She stated that the care plan did not indicate nursing or social services had addressed his psychosocial needs related to his mental illness diagnosis and antipsychotic medications. During an interview on 4/30/24 at 3:00 PM, SW E (Social Worker) stated that she had not addressed R36's psychosocial needs in his care plan because it was not on the list of problems documented by the hospital discharging physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, the facility failed to ensure physician's orders were followed according to professional standards for one resident (R) out of 19 sampled (R16). Specifically, the facility failed to follow physician daily weight orders and orders to check R16's O2 saturation on room air every shift to wean R16 off oxygen. This had the potential to cause R16 not to receive the necessary care for treatment of R16's congestive heart failure (CHF) and the use of unnecessary oxygen. Findings include: Review of the facility's policy titled Weights last reviewed on 4/1/24 states in part, Purpose: To identify and provide nutritional interventions to maintain control of weight loss or gain in residents. Weight will be monitored and assessed to prevent avoidable weight loss and/or weight gain. Procedure: If a resident is determined to be at nutritional risk, they will be weighed weekly, twice weekly, or daily depending upon the assessment of the IDT (interdisciplinary team) during weekly risk meeting. Weights triggering greater than 5lb loss or gain in 1 month/week MD (medical doctor) will be updated along with POA (power of attorney) or guardian. Of note: the facility policy does not address a physician's orders for daily weights for a resident with CHF. Review of the facility's policy titled Oxygen Use and Documentation last reviewed on 4/1/24 states in part, Purpose: To provide guidelines for oxygen use and documentation. Procedure: Oxygen use shall be checked every shift by a nurse. If oxygen is being used, indicate the flow in liters per minute (L/min) in the EMAR/ETAR (electronic medical record/electronic treatment administration record), If oxygen saturation (O2 Sat) checks are done according to the physician's order, note the results in the EMAR/ETAR. R16 was admitted to the facility on [DATE], with the diagnosis that include in part . CHF, atrial fibrillation, cerebral infarction, pleural effusion, type 2 diabetes, and anemia. Review of R16's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/20/24 indicates R16 has a Brief Interview for Mental Status (BIMS) score of 13 of 15, which indicates R16 is cognitively intact. Toileting/hygiene, toilet transfers showering, personal hygiene, upper and lower body dressing are all partial/moderate assistance. R16 is independent with bed mobility. Frequently incontinent of urine and always continent of bowel. MDS also indicates that R16 is on oxygen therapy. R16's care plan states, in part, I have the potential to have cardiovascular problems because I have high blood pressure. I show this by having to take BP (blood pressure) medication. I need my nurses to .monitor my vital signs as needed, observe for effectiveness or adverse side effects . assess heart/lung sounds . monitor my respiratory status and use of O2. I need my aides to notify the nurse if I have SOB (shortness of breath) . if I have an increase in edema to my lower legs or abdomen . check my weight as ordered. Of note: R16's care plan does not address her CHF diagnosis. Physician's orders dated 11/29/23, states in part, Check room air oxygen saturation to wean off oxygen every shift NOC (night) AM (morning) PM (evening). May apply oxygen 1-4 Liters via nasal cannula for respiratory distress or O2 (oxygen) sats below 88% every shift NOC AM PM. Physician's telephone order dated 4/2/24, states in part, 1. Increase Bumex to 2 mg BID (twice daily) for CHF. 2. Daily weights. 3. Monitor lung sounds, update Monday. In review of R16's EMAR, the facility was checking R16's oxygen saturation every shift but was not checking R16's oxygen saturation on room air as ordered. In review of R16's progress note dated 1/7/24 at 12:59 PM, resident was not feeling well this morning. Resident complained of dizziness, skin was pale, maybe almost nauseous. Vitals stable, blood sugar slightly higher than her usual in the morning. Sips of water taken in. I feel like my heart is fluttering around. Some work of breathing noted, oxygen saturations stable. Gave morning medications and instructed resident to take slow breaths and focus on her breathing. Sat resident by the cart with me to keep an eye on her. Resident ate breakfast and was doing ok. Resident also ate lunch and color looked better, also stated she felt a little better but felt off, just don't know why. Will continue to monitor resident. Doing well thus far in the shift. Progress notes dated 1/11/24 at 11:02 AM, 13:27 (1:27 PM), and 22:08 (10:08 PM) states, resident had complaints of SOB this morning. Oxygen saturation levels checked at that time was 92% on 2L of oxygen. Gave resident her morning medications, appeared to be doing ok. Resident was wheeling herself back to her room when she stopped RN (Registered Nurse) in the hallway and state, she felt shaky. Resident was taken down to her room, vitals were taken. Blood pressure on higher side though had morning medications. Pulse was still on higher side for resident though had taken her medications. Oxygen saturations were at 86-88% on 2L(liter) of oxygen. Increased to 4L of oxygen, stable at 93% at 4L, provider called and updated. UA (urinalysis) and labs obtained and sent out for review. Bladder scan done; 57 mL's (milliliters) noted in the bladder post void. Lungs diminished, heart irregular per baseline. Increased edema noted bilaterally to lower extremities and rechecked pulse oxygen. Resident was on 4L of oxygen at 96% saturation level, turned oxygen down to 3L and was stable at 92%. Labs reviewed which were unremarkable, faxed over to provider. Called provider and asked what she would like us to do more for resident. Order to give one time dose extra of 1 mg (milligram) Bumex (diuretic) this afternoon and then to call again later for an update. and Follow up on resident's status per physician request. Residents SOB (shortness of breath) has resolved. Oxygen saturation 94 percent of 4 liters. All other vital signs unremarkable. Slight congestion noted to the lower bases of both lungs. Edema 2+ (plus) pitting to the left lower leg and ankle. +1 edema noted to the right ankle. Resident states she is feeling better, but still feels ill. Progress note dated 1/12/24 at 13:29 (1:29 PM) states in part, . RLL (right lower lobe) continues to have course crackles noted, LLL (left lower lobe) clear and diminished. Edema noted to be 3+ bilaterally in the lower extremities yesterday. Today lower extremities are significantly improved (+1 edema). Work of breathing has improved as well. Skin color is more vibrant than yesterday . Progress note dated 1/16/24 at 10:35 AM states in part, . no complaints with exception of I'm a little short of breath . Progress notes dated 1/20/24 at 13:39 (1:39 PM) states, change in condition: resident not feeling well before lunch. Stated her head felt funny, maybe SOB, idk (I don't know). I just don't feel right. Noted that resident had +2 increased edema to LLE (left lower extremities), crackles noted to LLL. Oxygen saturations at 2L was 89-92%. Result: new orders received and noted. 1/20/24 give one-time extra dose of 1 mg Bumex for increased edema. Progress note dated 1/23/24 at 9:30 AM states in part, resident has +2 pitting edema noted to left ankle and +1 pitting edema to left leg. +1 edema to right leg and ankle. Progress note dated 1/24/24 at 13:33 (1:33 PM) states in part, . edema left sided, has 3+ pitting edema, increased edema noted to LLE in ankle and leg . Progress note dated 1/25/24 at 10:41 AM states in part, . lung sounds fine crackles heard in LLL, right lung is clear and diminished. O2 SAT: 97% (on oxygen) 3L. Progress note dated 1/26/24 at 13:54 (1:54 PM) states in part, . Edema has +2 pitting edema, to the left ankle +1 pitting edema to the right ankle. Lung sounds crackles heard, left lower lobes . Progress note dated 01/27/2024 at 20:58 (8:58 PM) states in part, .edema right sided, has 2+ pitting edema, left sided, has 1+ pitting edema . Progress note dated 3/14/24 at 9:58 AM states in part, . edema: bilateral, pedal edema present . Progress notes dated 3/16/24 at 14:52 (2:52 PM) and 14:53 (2:53 PM) state in part, . Edema: Has 2+ pitting edema, to the left foot/leg right sided, trace of edema noted to the right leg within normal limits . alert but sleepy at this time states that she don't [sic] feel good . physician notified and .new orders received and noted. 3/16/24 give another dose of Bumex 1 mg now and additional one 1 mg in the am and update her on resident condition. Progress notes dated 3/17/24 at 13:51 (1:51 PM) and 13:59 (1:59 PM) state in part, . spoke with on call provider regarding change in condition- resident vitals stable, continues to feel poorly, extra dose of Bumex administered this morning, poor output. Result provider stated that we could send resident out to urgent care, the ER (emergency room), or we can't try another dose of Bumex . [Physician Name] given poor output and unknown kidney function did not feel comfortable to given [sic] another dose of Bumex. Given the last two extra doses of Bumex appeared to not work as well as it has in the past. Result: Ok to send out to ER . and Edema left sided, has 3+ pitting edema, right sided, has +1 pitting edema. Progress note dated 3/18/24 at 13:54 (1:54 PM) states, received verbal report from RN at [Hospital Name]. Weight in the hospital was 148.0, Some medication changes were done. She had a chest ex ray [sic] and a U/A while in the hospital. They report trace bilateral lower extremity edema. Resident has crackles in bilateral bases of her lungs. Progress note dated 3/19/24 at 13:17 (1:17 PM) states in part, resident doing well on this shift today . +1 trace of edema noted to BLE (bilateral lower extremities), +2 edema in left ankle which is more of residents baseline, left lower lobe of lung is diminished though clear, right lower lung has fine crackles present- encouraged to cough and deep breath, encouraged to ambulate as allows. Progress note dated 3/22/24 at 2:34 AM states in part, resident returned to facility from evaluation at [Hospital Name] ER (Emergency Room). Dx (diagnosis) acute diverticulitis, constipation, pleural effusion, right . Progress note dated 3/29/24 at 13:54 (1:54 PM) states in part, Complaint/symptom: shortness of breath or trouble breathing when sitting at rest, Respirations: Rate: 22, regular, O2 Sat: 87% (on oxygen) 2L .Procedure done: oxygen administered at 4 LPM (liters per minute). Progress note dated 4/2/24 at 13:13 (1:13 PM) states in part, .Complaint: cough, nasal congestion . Respirations: Rate: 22 regular .Lung sounds: crackles heard, left lower lobes . O2 SAT: 93% (on oxygen) 4L . Other: uses accessory muscles . encouraged coughing and deep breathing, physician notified, and orders received. Obtained CBC and chest x-ray .chest x-ray impression [sic]: congestive changes with bibasal infiltrates (both lower lobes contain substances that fill the lung i.e., fluids) and effusions (unusual amount of fluid in the lung) .New orders received-daily weights, monitor lung sounds, start 2mg of Bumex BID for CHF, follow up Monday. Progress notes dated 4/8/24 at 9:58 AM, 10:06 AM, and 10:22 AM state in part, .complaint/symptom: cough: hacking .lung sounds: crackles heard, left lobes . O2 SAT: 94% (on oxygen) 3L . and cyanosis is present, in nailbeds bilaterally . fax sent to: attending physician regarding: faxed weights and medication list. Resident continues with crackles to base of left lung. Edema +1 to BLE. Continues to have cough, fatigue, and weakness. Oxygen saturations range from 90-94% on 3-4L of oxygen. Spoke to DON (Director of Nursing) about care conference given gradual decline . No new orders. Provider to evaluate Wednesday during rounds and Note: resident appears to be fatigued and continues to have weakness. Oxygen saturations are stable with supplemental oxygen via nasal cannula. Resident appears to have nonproductive hacking cough. Resident has been noted to have swallowing concerns during meals, speech therapist to evaluate and treat, as necessary. Noted that resident has increased supplemental oxygen needs, resident diuretics have been increased. Noted that resident heart is in poor condition and may continue to gradually decline. Care conference pending for goals of care. Progress note dated 4/8/24 at 13:37 (1:37 PM) states, Daily weight: lbs. (pounds)-did not obtain weight. Review of facility weight log indicates daily weights during these time frames: 1/25/24-1/29/24, 1/31/24, 3/17/24, 3/19/24-3/22/24, 3/24/24-3/25/24, 3/27/24, 3/29/24-4/8/24, otherwise weights were taken weekly. On 4/29/24, Surveyors reviewed electronic medical record (EMAR) for oxygen saturations to be done every shift on room air. EMAR shows oxygen saturations completed every shift on oxygen. Room air oxygen saturations were not completed as ordered. On 4/30/24 at 8:34 AM, Surveyor interviewed RN J (Registered Nurse). Surveyor asked RN J what the facility procedure was for weights. RN J stated, if they are a new resident, they obtain daily weights on same shift for 3 days then we go to weekly weights on bath day. RN J stated the CNA's get the weights. CNA's are told in the morning during report who needs weights done. Weights are brought to nurse and then the nurses chart the weight in the medical record. Changes in weights are communicated on the to do list in electronic charting system. RN J stated she would update the MD (medical doctor) if weight increase of 3#'s (pounds) overnight or 5#'s in a week. The weight increase would be communicated to the Physician, along with assessment (lung sounds, edema, etc.). On 4/30/24 at 8:40 AM, Surveyor interviewed CNA K (Certified Nursing Assistant). Surveyor asked CNA K what the facility procedure was for weights. CNA K stated, nurses inform us on shower day who we need to weigh, if new admit we weigh the first 3 days. If weight is off, we will have to get a reweight. Some people are daily weights. Surveyor asked CNA K if R16 is a daily weight. CNA K stated, R16 is not a daily weight. CNA K stated R16 received daily weights when she returned from hospital but that didn't last but just a couple of weeks. Surveyor asked CNA K how order changes are communicated with nursing staff and what is done with weights once obtained. CNA K stated weights are reported to the nurse and they report any weight changes to the physician and document the weights in the medical record. On 04/30/24 at 8:44 AM, Surveyor interviewed CNA L. Surveyor asked CNA L what the process is for obtaining weights. CNA L stated, weights are usually every week on bath day and given to the nurse to document, reweigh if not within 3 pounds. New admission weights are obtained every day for three days and reported to the nurse. Residents that are a daily weight are communicated during morning report. We get any changes in morning report from RN M. R16 used to be a daily weight but is not currently on daily weights. Surveyor asked CNA L if R16 is always on oxygen. CNA L stated that R16 is always on O2. On 4/30/24 at 8:49 AM, Surveyor interviewed RN I. Surveyor asked RN I what standard of practice the facility for CHF residents. RN I stated, we have standing orders with vital parameters, it's standard to do your assessments, vitals, update PCP (primary care provider), complete any new orders as prescribed and update family. Follow-ups are put into the to do list in the electronic charting system. Surveyor asked RN I, the process for obtaining weights. RN I stated, weights would be daily for three days on admission and are done right away in morning before breakfast. If a resident with CHF has acute changes or medication changes, they would be a daily weight. Surveyor asked RN I who decides the frequency of obtaining weights. RN I stated, the provider decides if someone is a daily weight and/or based on nursing discretion. Weekly weights are done on shower days. The CNA brings the nurse the weight and nurse puts it into the electronic charting system to do list. Surveyor asked RN I if R16 is currently a daily weight. RN I stated that R16 is not a daily weight and has had frequent issues with CHF and medication changes. Surveyor asked RN I who decides whether R16 is a daily or weekly weight. RN I stated, we do daily weights for a week when there is a change to her medication otherwise it is being done by the physician or our discretion. Surveyor asked RN I about R16's oxygen use. RN I stated that R16 is always on O2 and that O2 is being checked every shift. Surveyor asked RN I if staff are checking R16's oxygen saturation on room air or how often room air is being assessed. RN I stated, R16's room air O2 is checked monthly .I think, unless orders state otherwise. We have tried weaning R16 off oxygen and have been unsuccessful. On 4/30/24 at 8:57 AM, Surveyor interviewed RN M. Surveyor asked RN M about the facility process for obtaining weights. RN M stated, we get weights weekly on shower days and the nurses chart the weights in the electronic charting system. The Dietician looks at the weights when she comes in weekly and notifies management staff of any significant changes. We notify the provider of any changes, and we have weight notification sheets we send out to the PCP (primary care provider) if changes are noted. The CNAs obtain weights, and they give the weights to the nurse to chart in the electronic charting system. If a discrepancy exists, we will ask the CNA to get reweight. Surveyor asked RN M what the facility standard of practice is for a patient with a change of condition or CHF. RN M stated that the facility does not use a standard of practice. Surveyor asked RN M if R16 is always on oxygen. RN M stated that R16 is always on oxygen. We tried weening her a while ago she was in therapy but that did not work. She is uncomfortable without her O2. Surveyor asked RN M about R16's physician's orders for oxygen. RN M states I think this stem back to therapy's recommendation. She has had exacerbations. R16 for sure likes to wear her oxygen to sleep. Surveyor asked RN M, should staff be assessing R16's room air oxygen as ordered every shift. RN M stated, yes, we should be checking her O2 on room air, every shift, as the order indicates. We should also be trying to wean her off the O2 as the orders indicated. On 4/30/24 at 9:08 AM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B what standard of practice the facility uses. DON B stated, Healthcare Academy, skills, 8-10 educational modules, and [NAME]. Surveyor asked DON B about the process for obtaining weights. DON B stated, the facility just implemented new procedures last week regarding weights as discrepancies had been noted. Surveyor asked DON B how staff are made aware of who to obtain weights on every day. DON B stated, the nurse would in morning report tell the CNA who needs weights and those show up on the nurses to do list. The CNA gets the weight, brings it to the nurse and the nurse charts it. Surveyor asked DON B where staff would find weight parameters. DON B stated the care plan under nutrition will indicate any weight parameters. The electronic charting system does trigger with any significant weight loss or gain. Surveyor asked DON B how frequently weights are obtained. DON B stated the standard is weekly weights. If they are daily weights, a physician orders them. We have had some issues with no stop dates for daily weights. During the interview with DON B, NHA A (Nursing Home Administrator) stated the goal for obtaining weights is weekly but at a minimum monthly, unless a physician order indicates specific parameters. Surveyor reviewed R16's weight order with NHA A and DON B. NHA A states R16's weights should be done daily unless there is an order to discontinue. Surveyor asked NHA A what the expectation of staff would be for following physician orders. NHA A stated that the expectation would be to follow the physician orders. The facility did not ensure physician's orders were followed for R16's daily weights and oxygen assessment and administration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not ensure that pain management was provided consistent with standards of practice for 1 of 2 residents reviewed (R7) reviewed for pain out of a total sample of 15. R7 has orders for scheduled Tylenol and Tramadol pain medication. R7 has pain in left knee and Polyosteoarthritis. Facility has not been assessing pain with scheduled pain medications to track effectiveness of medications. Evidenced by: The facility policy, entitled Pain Assessment and Monitoring, dated 4/1/24, states, in part: . Purpose: To provide care and services to attain or maintain optimal comfort and pain management from acute and/or chronic medical conditions. Procedure: 1. Evaluate the resident for signs/symptoms that may indicate the need for pain management . 3. Documentation will include, but not be limited to: origin/location, duration, intensity of pain, past relief measures, what precipitated the pain, what relieves the pain, etc. 5. Notify the MD (medical doctor) of any persistent or uncontrolled pain so scheduled pain medications or interventions may be implemented/ordered . 9. Residents receiving scheduled pain medications will be evaluated in the routine documentation. 10. The medical record will have parameters for administration of multiple pain medications . R7 was admitted to the facility on [DATE], and has diagnoses that include unspecified dementia, pain in left knee and Polyosteoarthritis. R7's Quarterly Minimum Data Set (MDS) Assessment, dated 2/7/24, shows R7 has a Brief Interview of Mental Status (BIMS) score of 13 indicating R7 is cognitively intact. Section J indicates R7 has pain frequently, pain intensity is severe, and pain interferes with day-to-day activities frequently. R7's Care Plan, dated 2/5/24, states, in part: . Need/Preference: I like to be comfortable because I sometimes hurt as I have arthritis. I show this by telling you that I have pain. Approach: I need my nurses to: -Ask me if I hurt, offer me pain medication, offer me a warm or cold pack, give me a massage . notify the provider of unrelieved pain. Evaluate need for routinely scheduled medications . Goal: My Goal is to maintain my pain at an acceptable level. Goal Time: thru 5/5/24 . R7's February, March, and April Medication Administration Record (MAR) states, in part: . Acetaminophen 500 mg (milligrams) Tablet Dose Ordered: (2 tablet/1000mg) by mouth twice a day AM PM First Date: 9/22/21 For: Pain . Tramadol HCI (hydrochloride) 50 mg Tablet Dose Ordered: (1 tablet/50mg) by mouth daily AM first date: 1/20/23 For: Pain . Of note: There are no pain ratings/assessments with administration of the acetaminophen and tramadol. R7's nurses' progress notes from May 1, 2024 - March 1, 2024, states, in part: . 4/9/24 @ 3:52:15 PM Pain/Hurting in Last 30 Days: Yes, Scheduled Pain Meds: Yes . 3/12/24 @ 6:34:51 PM Pain/Hurting in Last 30 Days: Yes, Scheduled Pain Meds: Yes . Of Note: No mention of any non-pharmacologic interventions used or pain ratings. R7's last pain assessment dated [DATE], states, in part: . Been on a scheduled pain medication regimen? Yes Received prn (as needed) pain medications? Yes Offered a prn pain med and declined? No Received non- medication? Yes Intervention for pain? (Left blank) Pain Interview: Have you had pain or hurting at any time in the last 5 days? Yes How much of the time have you been experiencing pain or hurting over the last 5 days? Frequently Location of pain: left ribs Description of pain: aching Over the past 5 days, has the pain made it hard for you to sleep at night? Frequently Over the past 5 days, how often have you limited your participation in rehabilitation therapy sessions due to pain? the past 5 days. Over the past 5 days, how often have you limited your day-to-day activities (excluding rehabilitation therapy sessions) because of pain? Frequently Please rate your worst pain over the last 5 days on a zero to ten scale (zero= no pain, 10 = worst pain you can imagine): 07 Please rate the intensity of your worst pain over the last 5 days: moderate On 5/1/24 at 9:49 AM, Surveyor interviewed RN I (Registered Nurse) and asked when one would do a pain assessment. RN I indicated with any acute pain and quarterly with Medicare. RN I indicated pain assessments get completed with administration of prn (as needed) meds. Surveyor asked how one would know if scheduled pain medications were effective and RN I indicated one would only know if residents spoke of pain or use nurse judgement. RN I indicated pain assessments only get completed on prn medications and pain levels are not being charted on scheduled meds. Surveyor asked RN I where a resident's comfort level would be found and RN I indicated it should be in the care plan, Surveyor asked RN I if a resident's comfort level could be found somewhere else other than care plan and RN I indicated not knowing. Surveyor asked RN I who is responsible for completing care plans and RN I indicated DON B (Director of Nursing) or nurse manager. On 5/1/24 at 10:03 AM, Surveyor interviewed DON B and asked if pain assessments/ratings are to be completed with administration of scheduled pain medications. DON B indicated with prn pain meds the computer system is set up to populate a pain assessment with administration. DON B looked on R7's MAR and indicated pain ratings/assessments are only pulling up for prn pain medications. Surveyor asked DON B if staff are completing pain ratings with R7's scheduled Tylenol and Tramadol DON B indicated no. DON B indicated she would expect a follow up on residents' pain levels to be documented within one hour of receiving a scheduled pain medication. Surveyor asked DON B how one would know if the pain medications administered were effective for the resident without pain ratings/assessments and DON B indicated one would not know. Surveyor asked for R7's pain assessments and DON B provided R7's pain assessments from 2/3/24 - 2/21/24. DON B indicated 2/21/24 pain assessment was the last pain assessment completed. DON B indicated pain ratings and follow up pain ratings are not being completed for scheduled pain medication and should be. Surveyor asked where a resident's pain goal would be found, and DON B indicated on the care plan. DON B pulled up R7's Care Plan. Surveyor asked if R7's pain goal was on her care plan and DON B indicated no and it should be. DON B indicated the expectation would be for a resident pain goal to be on the care plan. Surveyor asked DON B if R7's, care plan states to maintain R7's pain level at an acceptable level; what is R7's acceptable level? DON B indicated one would not know. Of note, Surveyor attempted to interview R7 and R7 elected not to speak to Surveyor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, and facility policy review, the facility failed to provide medically related social services for one of three residents (Resident (R) 36) related to his mental health diagnosis and physician recommendation upon admission of 15 sampled residents. Findings include: Review of the facility's policy titled, Care Plan, updated 04/01/24, revealed each resident would have a specific plan of care developed on information gathered from .physician/therapist orders. Review of R36's electronic medical record (EMR) under the Face Sheet tab, revealed R36 was admitted from an acute care hospital to the facility on 3/29/24, with diagnoses which included bipolar depression, post-traumatic stress disorder (PTSD), depression, and anxiousness associated with depression. Review of the hospital Discharge summary, dated [DATE] and located in the EMR under the Other tab, revealed a reference Consult to Social Services . The summary included a list of discharge medications to include trazodone (anti-depressant medication), bupropion (anti-depressant medication), and escitalopram (anti-depressant medication). Review of R36's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/04/24 revealed diagnoses which included bipolar mood disorder, anxiety disorder, and PTSD. The MDS indicated R36 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating intact cognition. Review of R36's Electronic Medical Record (EMR) under the Care Plan tab with an Assessment Reference Date (ARD) of 4/4/24 through 4/29/24, had no care planned problems or interventions associated with his psychosocial diagnosis or medications administered for his psychosocial diagnosis. Review of R36's EMR under the Progress Notes tab, from admission through 4/29/24, social services did not have documentation to address his psychosocial diagnosis or medications administered for his psychosocial diagnosis and needs. During an interview on 4/29/24 at 11:34 AM, DON B (Director of Nursing), stated that her expectation for R36 upon his admission was that he should have had a care plan from nursing and social services to address his psychosocial needs. She stated that the care plan did not indicate nursing or social services had addressed his psychosocial needs related to his mental illness diagnosis and antipsychotic medications. During an interview on 4/30/24 at 3:00 PM, SW E (Social Worker) stated that she had not addressed R36's psychosocial needs in his care plan. She said her focus for R36 was based on the hospital discharge summary problem list located on page one, that did not include a mental illness diagnosis. The SW stated she did not see the physician's reference for social services consult on page three of the hospital discharge summary. The facility did not provide medically related social service consultation per physician orders or address his psychosocial needs as it relates to his diagnoses and medication therapy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure that drug regimens are free of unnecessary psychotropic medications, and that a resident taking a psychotropic medication has a care plan that includes targeted behaviors and side effects for 2 of 5 residents (R32 and R36) reviewed for unnecessary medications. R32 was started on Clonazepam (sedative) for involuntary body movements and Citalopram (antidepressant) for Major Depressive Disorder. R32 does not have a diagnosis for Major Depressive Disorder and the care plan contained no mood or behavior monitoring to assess the effectiveness of these medications or any potential side effects. R36 did not have targeted behavior monitoring. Evidenced by: The facility policy titled, Psychotropic Medication Review and GDR (gradual dose reduction) Reduction, last reviewed 4/01/24, does not include any information on care planning targeted behaviors or monitoring for potential side effects of medications being taken. Example 1 R32 was admitted to the facility on [DATE] with diagnosis that includes in part, other specified anxiety disorders and unspecified involuntary movements. R32's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/20/24 states in part, R32 has a BIMS of 11, indicating moderate cognitive impairment. D0150. Resident mood interview: A. little interest or pleasure doing things, No. B. Feeling down, depressed, or hopeless, Yes-Never or 1 Day. E0100. Psychosis Z. None of the above. E0200. Behavioral Symptoms-Presence and Frequency. All indicate behavior not exhibited. R32 has upper and lower extremity impairment on both sides. Toileting, hygiene, and showering are partial/moderate assistance. Upper and lower body dressing and personal hygiene are supervision or touch assistance. Bed mobility is independent. Transfers are partial to moderate assistance. R32 is always continent of bowel and bladder. On 4/30/24, Surveyor reviewed R32's mood and behavior charting for the period of 1/1/24 through 5/1/24 with no documented behaviors noted. Surveyor reviewed Certified Nursing Assistant (CNA) closet card which includes a section for behavior which is blank. R32's comprehensive care plan states in part . Care plan dated 03/18/2024: I: can't complete my cares on my own. I WANT: to return to my previous living situation. BECAUSE I: Have acute illness, cardiac disease, involuntary movements after my strokes (take clonazepam). Of note, this is the only mention of Clonazepam and there is no mention of Citalopram within the care plan. R32's signed physician orders dated 4/18/24 state in part, Citalopram Hydrobromide 20 mg (milligram) tablet dose ordered: (1 tablet/20 mg) by mouth daily AM (morning). First date 09/27/2023 for Major Depressive Disorder (Major Depression). R32's signed physician orders dated 4/18/24 state in part, Clonazepam 0.5 mg tablet dose ordered: (1 tablet/0.5 mg) by mouth twice a day AM Supper. First date 10/23/23 for Involuntary Body Movements. Social services progress note dated 3/23/24 at 8:27 AM states, quarterly review: R2 is well adjusted to the facility and states that he is happy with his care, room, and roommate. R32 requires reminders of daily activities. His long-term memory is largely intact. There are no mood or behavior concerns. His family is supportive and visit often. R32 requires a level of assist that likely could not be met in a lower level of care setting. He gets along well with staff and other residents and participates in activities of his choosing. He denies any concerns or issues at this time. On 5/1/24 at 8:46 AM, Surveyor interviewed RN S (Registered Nurse). Surveyor asked RN S where staff would be able to find targeted behaviors and potential side effects of medication. RN S states, I would look in the care plan. RN S also states, I wish it indicated what behaviors we are to be looking for. On 5/1/24 at 8:48 AM, Surveyor interviewed RN I. Surveyor asked RN I where staff would be able to find targeted behaviors and potential side effects of medication. RN I states, I usually put them in the to-do list and specify what behavior you are looking for. I am not sure who puts the behaviors in the electronic charting system for the CNAs. Surveyor asked RN I how often they chart behaviors for residents taking psychotropic medications. RN I stated, every shift for someone on an antipsychotic. Surveyor asked RN I if mood, behavior, and side effects should be care planned. RN I stated, for sure. On 5/1/24 at 8:56 AM, Surveyor interviewed CNA L. Surveyor asked CNA L where she documents resident behaviors. CNA L states, there is behavior charting on the kiosk in the electronic charting system. Surveyor asked CNA L how she knows which behaviors to monitor. CNA L states that there are no targeted behaviors on the care plan. The care plan only includes wandering, fall risk, or no male cares. On 5/1/24 at 9:01 AM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B if psychotropic medications should be care planned. DON B states, psychotropic medications should be care planned and added to the to do list in the electronic charting system. Surveyor asked DON B if targeted behaviors should be on the care plan. DON B states, targeted behaviors should be listed on the care plan. Surveyor asked DON B who creates the care plans. DON B states, the admission care plans are done by me and the nurse manager. Surveyor asked DON B how often care plans are reviewed and updated. DON B states, the care plans are reviewed and updated quarterly and as needed. The facility failed to ensure that each resident was free of unnecessary psychotropic medications and that the comprehensive care plan included targeted behaviors and potential side effects of the medications. Example 2 Review of R36's electronic medical record (EMR) under the Face Sheet tab revealed R36 was admitted from an acute care hospital to the facility on 3/29/24, with diagnoses which included bipolar depression, post-traumatic stress disorder (PTSD), depression, and anxiousness associated with depression. Review of R36's EMR under the Physician Orders tab, dated 3/29/24, revealed R36 was administered Lamotrigine (anti-seizure medication) 100 mg tab twice daily for bipolar depression, Prazosin (alpha blocker medication) 1 mg capsule once daily for PTSD, Trazodone (anti-depressant medication) 50 mg Tablet once nightly for insomnia associated with depression, Bupropion (anti-depressant medication) XL 300 mg daily for indications of anxiousness associated with depression, and Escitalopram (anti-depressant medication) 20 mg tablet daily for indications of anxiousness associated with depression. There were no specific orders for monitoring R36's medication side effects or behaviors. Review of R36's EMR under the Care Plan tab indicated his care plan with an Assessment Reference Date (ARD) of 4/4/24 through 4/29/24 had no problems or interventions associated with his psychosocial diagnosis or medications administered for his psychosocial diagnosis. Review of R36's EMR Medication Administration Record (MAR) from his admit date of 3/29/24 through 4/29/24, indicated administration of R36's medications as ordered by the physician but did not indicate monitoring of side effects or behaviors associated with R36's diagnosis or medication administration. During an interview on 4/29/24 at 11:34 AM the Director of Nursing B (DON), stated that the care plan did not indicate nursing or social services had addressed his psychosocial needs related to his mental illness diagnosis and antipsychotic medications. She could not provide documentation from the EMR for R36 to indicate his psychotropic medications had been reviewed or monitored for side effects or behaviors associated with R36's mental health diagnosis or medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure a resident with limited range of motion receives appropriate treatment and services to increase their range of motion and/or to prevent a further decrease in range of motion for 3 of 16 total sampled Residents (R7, R8, R16) and 1 of 1 supplemental resident's (R31). R8 has therapy recommendations for restorative therapy including the [NAME] Med bike four times weekly for twelve minutes and passive range of motion exercises daily that are not being completed. R16 has orders to participate in a walking program twice a day-AM (morning) and PM (evening), CGA (contact guard assist) with four-wheeled walker, wheelchair to follow-distance as tolerated that is not being completed. R31 is on the restorative walking program and the facility does not have documentation to show R31 is being walked. R7 is on the restorative walking program and the facility does not have documentation to show R7 is being walked. Evidenced by: The facility policy titled, Restorative Policy last reviewed 4/1/2024, states in part, Purpose: to promote resident ability. To improve/maintain/regain self-performance or prevent decline in various ADLs (activities of daily living), so that they may adapt and adjust to living as independently and safely as possible. Resident participation is a requirement for all restorative programming except for PRM (passive range of motion) and splint/brace use to prevent contractures. Procedure: programs will be individualized by identifying goals, approaches, and safety areas for that resident. An accumulation of minutes will include explanations, set-up, verbal cuing, supervision, demonstration, clean-up, etc. Changes in ability and/or function will be reported to the unit nurse so that updates/revisions can be made. As a resident's needs and abilities change, the program will be updated. PT/OT/ST (Physical Therapy/Occupational Therapy/Speech Therapy) will communicate to nursing pertinent recommendations for the resident's restorative program and will be added by the nurse manager or the DON (Director of Nursing). A referral to PT/OT/ST will be forwarded as needed for the residents that are showing a decline in ADL function. Example 1 R8 was admitted to the facility on [DATE], with the latest readmission on [DATE]. R8 has diagnoses that include in part . iliotibial band syndrome-right leg, contracture-unspecified hand, unspecified abnormalities of gait and mobility, low back pain, myoneural disorder-unspecified, pain in leg unspecified, osteoarthritis- right and left hand, weakness, vitamin D deficiency, syndrome of inappropriate antidiuretic hormone (SIADH). R8's Significant Change Minimum Data Set (MDS) dated [DATE] indicates R8 has a Brief Interview of Mental Status (BIMS) of 15 indicating that he is cognitively intact. No mood or behaviors noted. Resident has limited range of motion in upper and lower extremities. Resident is dependent on staff for bathing. R8 requires substantial/maximal assist for upper and lower body dressing, personal hygiene, bed mobility, and transfers. Urinary incontinence is not rated and R8 is always incontinent of bowel. On 8/23/23, facility document titled Therapy Communication to Nursing for R8 states in part, start the following therapy: PT. Goal: Restorative program. Recommendation: May use [NAME] med bike (a therapy device that enables patients with restricted mobility a motor driven, and motor assisted leg and/or arm training from a seated position) daily for maintaining leg strength and mobility. Four times weekly for 12 minutes. Will need assistance to set up. Questions, see therapy. On 3/22/24, facility document titled Therapy Communication to Nursing for R8 states in part . start the following therapy: PT. Goal: Range of motion program. Recommendation: See attached exercises. Complete one time a day to maintain mobility and flexibility in lower extremity. Attached exercises include, calf stretch PROM (passive range of motion), hip PROM-flexion-extension, hip PROM-abduction-adduction, and hip PROM-rotation. R8 is to receive [NAME] bike daily for maintaining leg strength and mobility 4 times weekly for 12 minutes. R8's restorative documentation indicates he has not received this treatment over the last 30 days. R8 is to receive PROM daily. Review of R8's restorative documentation indicates that from 3/22/24 to 4/30/24 R8 received restorative PROM 16 times out of a possible 39 times. Example 2 R16 was admitted to the facility on [DATE] with the diagnosis that include in part . Congestive Heart Failure (CHF), atrial fibrillation, cerebral infarction, pleural effusion, type 2 diabetes, and anemia. Review of R16's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/20/24, located in the EMR under the MDS tab, indicated R4 had a Brief Interview for Mental Status (BIMS) score of 13 of 15, which indicated R16 is cognitively intact. Toileting/hygiene, toilet transfers showering, personal hygiene, upper and lower body dressing are all partial/moderate assistance. R16 is independent with bed mobility. Frequently incontinent of urine and always continent of bowel. The MDS also indicates that R16 is on oxygen therapy. On 11/27/23, facility document titled Therapy Communication to Nursing for R16 states in part, Goal: Return to PLOF (prior level of function) and possibly wean from O2. Recommendation: Please resume walking program one to two times a day with four-wheeled walker, CGA (contact guard assist), with wheelchair to follow. Distance as tolerated. Also, can we try to wean O2. She was stable in the low to mid- 90's at rest and with activity on 1L with PT. Physical therapy Discharge summary dated [DATE] at 4:37 PM states, in part, Restorative programs: Restorative program establish/trained=restorative ambulation program. Ambulation program establish/trained: Patient to ambulate with nursing daily distance as tolerated with four-wheeled walker and wheelchair to follow. The Certified Nursing Assistant (CNA) Care Card printed 4/30/24, states in part, Restorative: Walking program twice a day-AM and PMs. CGA with four-wheeled walker, wheelchair to follow-distance as tolerated. R8's comprehensive care plan does not address restorative services that were ordered by physical therapy. R8's restorative documentation from 3/1/24 to 4/30/24, shows R8 was walked on the following dates and times: 3/1/24 at 13:09 (1:09 PM) 3/1/24 at 21:03 (9:03 PM) 3/3/24 at 10:24 AM 3/4/24 at 10:44 AM 3/5/24 at 11:24 AM 3/6/24 at 13:15 (1:15 PM) 3/7/24 at 13:13 (1:13 PM) 3/9/25 at 13:50 (1:50 PM) 3/10/24 at 13:24 (1:24 PM) 3/12/24 at 13:14 (1:14 PM) 3/19/24 at 15:15 (3:15 PM) 3/21/24 at 13:16 (1:16 PM) 3/23/24 at 10:17 AM 3/24/24 at 13:50 (1:50 PM) 3/26/24 at 13:25 (1:25 PM) 3/30/24 at 13:40 (1:40 PM) 3/30/24 at 14:09 (2:09 PM) 4/15/24 at 13:28 (1:28 PM) 4/28/24 at 13:29 (1:29 PM) Of Note: From 3/1/24 through 4/30/24 R1 was walked a total of 19 times out of a possible 122 times. On 4/28/24 at 10:10 AM, Surveyor interviewed R8. Surveyor asked if R8 had any concerns regarding his care in the facility. R8 states, he is supposed to be receiving additional ROM assistance three time a week from staff; however, this is not being done. Surveyor asked R8 if he knew which staff members are supposed to be completing these exercises with him. R8 stated, physical therapy staff told him that nursing staff are supposed to assist him with his range of motion exercises, but no one had been helping him with his exercises. On 4/29/24 at 2:07 PM, Surveyor interviewed R8. Surveyor asked R8 how missing his restorative therapy sessions has affected him. R8 states, if they kept up on therapy, it would help my knees and legs .it's just never been done. Surveyor asked R8 if he ever refuses his restorative therapy exercises. R8 states, no, I always use it. Anything to help me get better, I'm going to do it. On 4/29/24 at 3:49 PM, Surveyor interviewed PTA R (Physical Therapy Assistant). Surveyor asked PTA R who is responsible for completing the restorative and walking programs. PTA R stated that the CNAs (Certified Nursing Assistants) are expected to complete both programs. Surveyor asked PTA R how restorative and walking program orders are communicated to the nursing staff. PTA R stated that she makes three copies of the orders. One copy goes to the Director of Nursing, one copy goes to the charge nurse, usually RN M (Registered Nurse), and the last copy goes to a floor nurse currently on shift. On 4/30/24 at 1:33 PM, Surveyor interviewed CNA C. Surveyor asked CNA C if the facility has a restorative or walking program. CNA C states we have a walking program and its done if we have time. We often can't get through the entire list. ROM is completed with dressing. Surveyor asked CNA C were the restorative program orders/recommendations come from. CNA C states that the restorative orders come from therapy. Surveyor asked CNA C how she knows who is on a restorative program. CNA C states she can ask others and she also keeps a personal cheat sheet as a reminder. Surveyor asked CNA C what she does when someone refuses restorative. CNA C states that she talks to the nurse or OT about anyone that declines. CNA C states that they have a binder that they document walking in, but since Surveyors have arrived in the building, management took away the binder. On 4/30/24 at 13:37 (1:37 PM) Surveyor interviewed RN I (Registered Nurse). Surveyor asked RN I what the procedure is for a resident who shows a decline in function or abilities. RN I states that if it is an acute change, the facility has standing orders for PT/OT/Speech evaluations and that RN I updates the provider to notify them that they are implementing the standing orders. A sheet is completed and given to management notifying them of the implementation of the standing orders. Surveyor asked RN I what staff do with therapy recommendations. RN I states that therapy will write out a communication sheet, 1 sheet goes to the nurse manager who updates the care plan. A copy is made and put into the communication book. Surveyor asked RN I what they do if the resident refuses restorative services. RN I states she talks to the resident about the refusals to attempt to determine a cause and updates the physician. Surveyor asked RN I what the expectation is for staff who can't complete the restorative program to-do list. RN I states that staff should report it to the nurse if they can't get it done and that the nurse should report it to management if they realize it isn't being done. RN I also stated, we really need a restorative aide. Every place I've worked has one and we really need one. On 4/30/24 at 13:45 (1:45 PM) Surveyor interviewed CNA F. Surveyor asked CNA F about the facility restorative program. CNA F states that we walk them and do ROM (range of motion). Surveyor asked CNA F where she finds the restorative program information. CNA F states that the information is on everybody's care plan. Surveyor asked CNA F how she is provided new orders or changes to someone's current restorative program. CNA F states, there may be a note on the desk or with staff report during shift change. Surveyor asked CNA F what she does if she notices someone has a decline in ROM. CNA F states that she notifies a nurse that the resident may need a therapy evaluation. Surveyor asked CNA F about R8's restorative program. CNA F states, R8 has ROM with left arm and leg. Surveyor asked if R8 ever refuses restorative therapy. CNA F states he never refuses ROM therapy. Surveyor asked CNA F what they do if someone refuses restorative therapy. CNA F states, they reapproach in the afternoon and chart any refusals. Surveyor asked CNA F how to perform and complete prescribed exercises. CNA F states, therapy gives us something to follow on what exercises we should do with print out pictures. Surveyor asked CNA F what they do if they are unable to complete restorative therapy with a resident. CNA F states, if it can't get done, I chart not completed because of environment which means i.e., staffing, it happens a lot. On 4/30/24 at 1:54 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B what the process is for conducting the facility's restorative therapy program. DON B states, all the restorative therapy orders are put in through restorative nurse on the electronic charting system. The process was changed in January as we identified an issue with the electronic charting system not triggering staff to chart the restorative program. Communication comes from PT/OT and a copy is given to the floor nurse and all management personnel and added to the to-do list in the electronic charting system. The walking program binder was also added in January. Surveyor asked who is expected to conduct restorative program orders. DON B states, the CNA's are supposed to conduct restorative program orders, whatever the order is whether it be ROM or the walking program. Surveyor asked DON B what the expectations are for CNA's regarding the restorative program. DON B states, if they can't get it done it is to be passed off to the next shift unless the resident refuses. If the resident refuses it needs to be charted as a refusal. Documentation should be completed whether the resident refuses or the ordered activity is completed. Surveyor asked DON B if the expectation is for CNA's to chart in the walking binder, resident walks, and refusals. DON B states, yes. Surveyor asked DON B if she would expect the CNA to notify a nurse if a resident had a noticeable change in ability. DON B states, yes. Surveyor asked DON B if the expectation would be for a CNA to report frequent refusals of restorative orders. DON B states, yes. Surveyor asked DON B if R8 is at risk for a decline in function. DON B states if he continues to refuse and not participate in prescribed exercises with staff. It can be hit or miss with him. Surveyor asked DON B why R8 is at risk for a decline in ROM. DON B states, R8 has refusals, can make inappropriate comments towards staff, can be unpleasant and rude towards staff, and at times expects staff to do everything for him. DON B indicates also has a right-sided neuromuscular disorder. Surveyor asks DON B what interventions are in place to prevent a decline in R8's ROM. DON B states, R8 has a restorative plan but I do not know what that is off the top of my head. Surveyor asked DON B if R8 also has a ROM restorative plan. DON B states yes. Surveyor asked DON B if R16 is at a risk for a decline in function. DON B states yes, based on age and diagnosis. The facility did not ensure that restorative therapy exercises and activities were completed for each resident to maintain current abilities, prevent decline, or to restore baseline abilities. Example 3 R31 was admitted to the facility on [DATE], and has diagnoses that include Atherosclerosis of native arteries of left leg with ulceration of other part of lower leg (a disease that causes the arteries that supply the legs and feet to narrow and harden) and venous insufficiency (improper functioning of the vein valves in the leg, causing swelling and skin changes). R31's Quarterly Minimum Data Set (MDS) Assessment, dated 3/20/24, shows R31 has a Brief Interview of Mental Status (BIMS) score of 15 indicating R31 is cognitively intact. R31's care plan dated 4/19/24, states, in part: . Need/Preference: I can't complete my cares on my own. I want to return to my previous living situation because I have hemiplegia- CVA (cerebrovascular accident)/left side affected. I show this by having a hard time moving getting tired quickly voicing frustration . Approach: I walk with 2 helpers providing more than half the effort follow my restorative walking plan ONCE DAILY 2A (assist) 2 WW (wheeled walker), gait belt, w/c (wheelchair) to follow. Currently tolerates 50-75 feet . R31's Therapy Communication to Nursing Form, dated 12/18/23, states, in part: . Resident is Changes to Plan of Care From the following therapy: PT (Physical Therapy) Goal: Walking Program Recommendations: Please walk 1x/day with 2 persons assist using 2 ww, gait belt, and w/c follow. Currently tolerates 50 -75 feet . Certified Nursing Assistant (CNA) documentation for daily ambulating for March 1, 2024, through May 1, 2024, shows R31 was not ambulated on following dates: 4/23, 4/22, 4/21, 4/19, 4/14, 4/13, 4/10, 4/9, 4/7, 4/6, 4/5, 3/31, 3/29, 3/28, 3/24, 3/21, 3/19, 3/18, 3/16, 3/15, 3/14, 3/13, 3/12, 3/10, 3/7, 3/6, 3/4, and 3/1. This shows R31 did not get ambulated 28 days out of 62 days. Of note: This is not following therapy recommendations for every day. R31's Walking Program Documentation sheets from 3/31/24- 4/29/24 shows R31 walked 2 days out of 30 days. Of note: This is not following therapy recommendations for every day. Example 4 R7 was admitted to the facility on [DATE] and has diagnoses that include Polyosteoarthritis (a joint disease that affects at least five joints simultaneously), Muscle weakness (generalized), and difficulty in walking. R7's Quarterly Minimum Data Set (MDS) Assessment, dated 3/20/24, shows that R7 has a BIMS score of 13 indicating R7 is cognitively intact. R7's Care Plan dated 3/1/24, states, in part: . Need/Preference: I need some assistance with my personal cares because I have poor balance, OA (osteoarthritis), get confused, chronic pain, some limitations. I show this by having a hard moving, being forgetful, trying things on my own . Approach: . I walk with the help of 1 person with gait belt and 4 ww . R7's CNA [NAME], with a print date of 4/30/24, states, in part: . Restorative: Walk with 1 assist FWW (Front wheeled walker), gait belt, with wheelchair to follow AM and PM daily . R7's therapy recommendations, dated 3/9/23, states, Walking: On the unit assist of 1 with 4 ww, gait belt, wheelchair to follow, and o2 (oxygen) on halfway down the hall and back to room two times a day every day. CNA documentation for daily ambulating for 3/1/24 through 4/28/24, shows a total of 61 days R7 should have been ambulated twice a day totally 122 times R7 should have been ambulated. R7 was ambulated only 30 times out of 122 times as per recommendations of therapy. Of note: This is not following therapy recommendations for every day. R7's Walking Program Documentation sheets from 3/31/24- 4/29/24 shows R7 walked 1 time/day x 1 day out of 30 days. Of note: This is not following therapy recommendations for every day. On 4/30/24 at 1:05 PM, Surveyor interviewed PTA R (Physical Therapy Assistant). PTA R indicated R31 is currently working with PT (physical therapy) and PT has recommended R31 to be on walking program for walking one time a day with a walker with 1 assist as tolerated. Surveyor asked PTA R if she would expect the recommendation to be followed and documented and PTA R indicated yes in the walking book at the nurses' station or in the computer. Surveyor asked who is responsible to walk the residents on the walking program and PTA R indicated the CNAs. PTA R indicated therapy would expect the CNAs to be following the walking program for residents on it and documenting. Surveyor asked PTA R if R7 was on the walking program and PTA R indicated yes. PTA R indicated therapy would expect the CNAs to be following the walking program for R7 and documenting as well.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Example 3 On 4/29/24, Surveyor reviewed R2's physician's telephone orders from 1/2/24 through 4/24/24. Surveyor noted that these orders were signed by facility Registered Nurses (RNs), but no physician signatures were present. Example 4 On 4/29/24, Surveyor reviewed R16's physician's telephone orders from 12/1/23 through 4/22/24. Surveyor noted that these orders were signed by the facility RNs, but no physician signatures were present. Based on record review and interview, the facility did not ensure that Physician Orders were signed and dated timely for 4 of 19 residents (R7, R5, R2, R16) and 1 supplemental resident reviewed for physician orders. R5's telephone orders are not signed by a physician. R7's telephone orders are not signed by a physician. R2's physician telephone orders were not signed and dated by a physician in a timely manner. R16's physician telephone orders were not signed and dated by a physician in a timely manner. Evidenced by: The facility policy, entitled Physician Services, dated 4/1/24, states, in part: . Policy: It is the responsibility of Norseland Nursing Home to ensure that physician services are available to the residents of this facility. Procedure: I. Physician Services 483.30 . 3. Physician Visits- The Physician must: a. Review the resident's total program of care, including medications and treatments . c. Sign and date all orders with the exception of influenza and pneumococcal polysaccharide vaccines . Example 1 R5 was admitted to the facility on [DATE], and has diagnoses that include Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), Type Two Diabetes Mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and hyperlipidemia (a condition in which there are high levels of fat particles in the blood). R5's telephone orders from 11/28/24 through 4/23/24 are not signed by a physician. Example 2 R7 was admitted to the facility on [DATE], and has diagnoses that include Interstitial pulmonary disease (a group of disorders that cause progressive scarring of the lung tissue), dementia (a general term for the loss of cognitive functioning that interferes with a person's daily life), and chronic kidney disease (longstanding disease of the kidneys leading to kidney failure). R7's telephone orders from 11/22/24 through 4/24/24 are not signed by a physician. On 4/30/24 at 9:05 AM, Surveyor interviewed RN J (Registered Nurse) and asked what the process is for obtaining a telephone order from a physician. RN J indicated one gets the order over the phone from the physician's nurse or physician and then it goes under physician tab in chart. The nurse who receives the order fills in the physician's name and medication. The order gets entered into the computer system. The carbon copy gets torn off and given to a second nurse to check the order against the order entered into the computer system. The second nurse co-signs physician's order under the co-sign tab. RN J indicated the pink carbon copy goes to the nurse desk until the end of the shift where we make sure it gets communicated to oncoming shift. The physician comes to facility typically once a week and the nurse working with the physician has the physician sign the copy. Surveyor asked RN J who would be responsible for obtaining the physician signature on the copies of the telephone orders and RN J indicated the nurse doing rounds with the physician. Surveyor asked RN J where the carbon copies of the telephone orders go after signature is obtained and RN J indicated not knowing. On 4/30/24 at 9:17 AM, Surveyor interviewed RN I and asked what the process is for obtaining a telephone order from a physician. RN I indicated the nurse taking the telephone order from the physician writes the orders on the slip with the date, resident, date of birth , physician's name and nurse receiving the order. The order then gets entered into the computer system into the MAR/TAR (medication administration record/treatment administration record). A second nurse checks the order and co-signs in computer system. The pink carbon copy goes in a folder at the nurse station for the physician to sign. Surveyor asked RN I where the pink carbon copies go after signed and RN I indicated she was not sure. Surveyor asked if a telephone order is required to be signed by a physician and RN I indicated yes within 7 days. RN I indicated the nurse manager rounding with the physician has the physician sign them weekly on Wednesdays. On 4/30/24 at 9:25 AM, Surveyor interviewed DON B (Director of Nursing) and RN M and asked what the process is for obtaining a telephone order from a physician. RN M indicated the nurse taking the order from the physician or the physician's nurse, puts the order on a Physician Order Sheet or on the Provider Communication Form. The order gets entered into the computer system by the nurse taking the order. A second nurse co-signs after checking the order entered into the computer system to the order on paper. DON B indicated the pink carbon copies go into the resident's thin file where we keep them for 5 years. DON B indicated the pink carbon copies are not signed by a physician; they are used for facility communication only. The carbon copies stay on the nurses 24-hour board for oncoming shifts to see. DON B and RN M indicated physicians never view telephone orders because the orders go into the computer system and physician orders get printed out for the physician to sign on rounds. Surveyor asked if a resident does not get seen one month what happens with telephone order and DON B indicated the order will get signed the next month. Surveyor asked DON B if a telephone order should be signed by a physician and DON B indicated not if it is a verbal order. DON B indicated RN M is responsible for printing physician orders off to be signed when a resident is seen by a physician. If a resident is not seen, they are signed on next visit. On 4/30/24 at 11:10 AM, NHA A (Nursing Home Administrator) indicated to Surveyor it is her expectation telephone orders are to be signed by a physician within 10 days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not establish and 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, this has the potential to affect the total census of facility, 42 residents. The facility allowed staff to return to work too soon after reporting respiratory symptoms and were not requiring staff to be tested for COVID-19 per Centers for Disease Control and Prevention (CDC) guidance. The facility allowed staff to return to work too soon after gastrointestinal (GI) symptoms. This is evidenced by: The facility's policy titled Infection Control Measures for Acute Respiratory Illness Outbreak revised on 10/19/23 states in part .3. Surveillance 1. Monitor staff call- ins and have anyone with COVID like symptoms perform an Antigen test. If the test is negative and the staff member continues to present symptoms, they must wear a mask while working. 2. When an ARI (Acute Respiratory Illness) or COVID-19 outbreak is identified, the facility's Infection Preventionist will maintain and update a line list to organize case information .5. Documentation of testing 1. For symptomatic residents and staff, DON (Director of Nursing) or IP (Infection Preventionist) will document the date(s) and time(s) of the identification of signs or symptoms, when testing was conducted, when results were obtained, and the actions the facility took based on the results .6. Return to work for staff 1. If a staff member has tested positive for COVID-19, they will be required to follow quarantine guidelines as below .Per baseline [Facility Name] functions at a Contingency Staffing level .i. Conventional staffing: 1. At least 10 days since symptoms first appeared or 7 days with two negative tests (if asymptomatic) and 2. At least 72 hours have passed since last fever without the use of fever- reducing medications and 3. Symptoms have improved. ii. Contingency staffing: 1. 5 days with/ without negative test (if symptomatic or mild to moderate illness) and 2. Symptoms have improved . The facility's policy titled Employee Illness no date, states in part .Employees requesting to return to work after a communicable illness will consult with Infection Preventionist/ designee or their supervisor before returning to work .NOTE: these are examples only- See State and updates to Federal Guidance on restrictions for work: .Disease/ Problem: Diarrheal Diseases *Acute Stage (diarrhea with other symptoms) Work Restriction: Restrict from resident contact, contact with the resident's environment, or food handling Duration of Restriction: Until symptoms resolve, 48 hours since last episode (handwritten in). Disease/ Problem: *Norovirus (CDC) Work Restriction: Exclude from Duty Duration of Restriction: If you have symptoms consistent with norovirus infection (per the CDC symptoms include acute onset of vomiting, non-bloody diarrhea, abdominal cramps, nausea, and sometimes a low- grade fever), stay home for a minimum of 48 hours after symptom resolution. Disease/ Problem: Viral Respiratory Infections, Acute febrile Work Restrictions: Consider excluding from care of high-risk residents or contact with their environment during community outbreak of RSV or Influenza. Duration of Restriction: Until acute symptoms resolve, 24 hours fever free (handwritten in) . It is important to note that the facility's policy does not address Viral Respiratory Infections without a fever and does not indicate when an employee has symptoms that they should test for COVID-19. CDC guidance titled Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2 dated 9/23/22 states in part .Test-based strategy: HCP who are symptomatic could return to work after the following criteria are met: Resolution of fever without the use of fever-reducing medications, and Improvement in symptoms (e.g., cough, shortness of breath), and Results are negative from at least two consecutive respiratory specimens collected 48 hours apart (total of two negative specimens) tested using an antigen test or NAAT . https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assessment-hcp.html Surveyor reviewed the facility's Staff Illness Tracking for February 2024, March 2024, and April 2024. Per the documentation, the following staff returned to work too soon and did not perform COVID-19 testing per the guidance, nor did they test for Influenza during the facility's outbreak in February 2024. The documentation is as follows: Date: 2/7/24 Employee Name: CNA L (Certified Nursing Assistant) Unit last worked: 200. Date last worked: 2/6/24. Date of sx (symptoms): 2/6/24 Reason for call- in: Respiratory, Headache, Sinus/ Nasal Congestion Well date: 2/7/24. Return to work: 2/8/24. CNA L's Call-In/ [NAME] Report states that CNA L had migraine, sore throat, headache, and sinus. Date: 2/13/24 Employee Name: RN I (Registered Nurse) Unit last worked: 200. Date last worked: 2/13/24. Date of sx: 2/13/24 Reason for call- in: Diarrhea Well date: 2/14/24. Return to work: 2/16/24. RN I's Call-In/ [NAME] Report states that RN I left the faciity on 2/13/24 at 7:50 AM with diarrhea. RN I returned to work prior to 7:50 AM on 2/16/24. It is important to note that the facility entered an Influenza Outbreak on 2/17/24 that affected 4 residents. Date: 2/20/24 Employee Name: CNA F Unit last worked: 100. Date last worked: 2/15/24. Date of sx: 2/18/24 Reason for call- in: Nausea, Vomiting, Headache, Diarrhea, and Sinus Well date: 2/19/24. Return to work: 2/21/24. CNA F's Call-In/ [NAME] Report states that CNA F had Diarrhea and stomach cramps on 2/19/24. Date: 2/21/24 Employee Name: RN N Unit last worked: both (100 and 200) Date last worked: 2/21/24. Date of sx (symptoms): 2/21/24 Reason for call- in: Respiratory and Sinus Well date: 2/23/24. Return to work: 2/29/24. Surveyor did not receive RN N's Call-In/ [NAME] Report. Date: 2/20/24 and 2/21/24 Employee Name: RT O (Recreation Therapist) Unit last worked: rec therapy. Date last worked: 2/19/24. Date of sx (symptoms): 2/20/24 Reason for call- in: Respiratory and Sinus Well date: 2/21/24. Return to work: 2/22/24. RT O's Call-In/ [NAME] Report states that RT O reported symptoms of pressure in sinuses, exhaustion, sore throat, and congestion. RT O's COVID test was negative, no fever, and RT O was not tested for influenza as this was during the facilities influenza outbreak. Date: 2/27/24 Employee Name: RN I Unit last worked: 100. Date last worked: 2/26/24. Date of sx (symptoms): 2/26/24 Reason for call- in: Respiratory, Cough, Sinus Well date: 2/29/24. Return to work: 3/1/24. Surveyor did not receive RN I's Call-In/ [NAME] Report. Date: 3/5/24 Employee Name: CNA Q Unit last worked: 100. Date last worked: 3/4/24. Date of sx (symptoms): 3/5/24 Reason for call- in: Nausea, Vomiting, Diarrhea Well date: food related. Return to work: 3/6/24. CNA Q's Call-In/ [NAME] Report states that CNA Q had Diarrhea and Nausea/ Vomiting. Date: 3/12/24 Employee Name: DA P (Dietary Aide) Unit last worked: Kitchen. Date last worked: no date listed. Date of sx (symptoms): 3/12/24 Reason for call- in: Nausea Well date: 3/13/24. Return to work: 3/13/24. DA P's Call-In/ [NAME] Report states that DA P had Nausea/ Vomiting, not feeling well, feels like crap. On 4/30/24 at 3:36 PM, Surveyor interviewed RN M, who is also the Infection Preventionist. Surveyor asked RN M how she determines when staff can return to work after calling off with an illness, RN M stated staff have to be 48 hours without nausea and vomiting and have to be 24 hours fever free without a fever reducing agent. Surveyor asked RN M to review the Staff Illness Tracking form. Surveyor asked RN M what CNA L's respiratory symptoms were based off the line list, RN M reported that she believed CNA L had a cough. Surveyor asked if that should have been indicated on the line list, RN M stated yes. Surveyor asked RN M if CNA L called in sick on 2/7/24, how could her well date be 2/7/24 and then her return-to-work date be 2/8/24, RN M stated that she would have to do a better job at recording times. Surveyor asked RN M if RN I should have returned to work on 2/16/24, RN M stated that it depends on RN I's symptoms. Surveyor asked RN M if RN I had been symptom free for a full 48 hours before returning to work, RN M stated RN I should have returned to work on 2/17/24. Surveyor discussed CNA F's call- in with RN M. Surveyor asked RN M if CNA F were symptom free on 2/19/24, if she called in sick on 2/19/24, RN M stated that she would have to check. Surveyor asked RN M about RT O. Surveyor asked RN M if, considering that the facility was in an Influenza outbreak, did RT O get tested for influenza, RN M stated no. Surveyor asked RN M if RT O had 2 negative COVID tests before returning to work, RN M stated that the form does not indicate. Surveyor asked RN M if she would expect that RT O would have been tested for Influenza and have 2 negative COVID tests before returning to work, RN M stated yes. Surveyor asked RN M when CNA Q's well date was, RN M reported that CNA Q indicated that his illness was food related. Surveyor asked RN M, based on CNA Q's symptoms, when should he have returned to work, RN M stated 3/8/24. Surveyor asked RN M if DA P returned to work too soon, RN M stated that the Dietary Manager allowed DA P to return to work, but she should have been off longer. Surveyor asked RN M if the staff member with respiratory symptoms were tested for COVID, RN M stated no. Surveyor asked if she would expect them to have been COVID tested, RN M stated she would not expect COVID testing to be done if they weren't in a COVID outbreak. Surveyor asked RN M if during their Influenza outbreak, would she expect staff with symptoms to get tested for Influenza, RN M stated that a few staff members did get tested. RN M did not provide documentation of staff members that were tested for Influenza. The facility failed to ensure that staff members remained off work for the specified time based on current standards of practice for acute respiratory illnesses and GI symptoms, nor did they require staff to complete testing, when showing signs and symptoms of potential communicable diseases.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Example 2 R19 was admitted to the facility on [DATE] with diagnoses that include, in part: Multiple fractures of ribs, left side .Paroxysmal atrial fibrillation; Epilepsy; Localized edema; Constipation. R19's facility recorded weights are as follows: 12/7/22: 167 lbs 12/16/22: 167.4 lbs 12/28/22: 164.4 lbs 1/3/23: 159.2 lbs 1/10/23: 152.8 lbs 1/17/23: 161.2 lbs 1/24/23: 154.2 lbs 1/31/23: 168 lbs 2/7/23: 169.2 lbs R19's Care Plan includes, in part: I: need some assistance .I eat without help if you set out what I need . I have the potential to: be at nutritional risk. Because I: have a history of constipation, edema, pain, and hypertension. I need my nurses to--- .ask my family to provide my favorite foods and drinks, let me eat uninterrupted, try to figure out why I'm not eating, ask me about my preferences. I need my aides to --- .weigh me per nursing orders .My goal is to maintain my weight +/- 5 lbs . R19's Nurses Notes, include, in part: 1/9/23 at 1:13PM: .Weight: Reviewed Weights Conclusion: 8lb increase in the last 90 days . 1/17/23 at 9:19PM: .Edema: Has no edema present . 1/23/23 at 4:13PM: .Edema: bilateral, has non pitting edema, lower extremities . 1/24/23 at 9:26PM: .Edema: has 1+ pitting edema . 1/26/23 at 10:39AM: .Edema: bilateral, has 2+ pitting edema, lower extremities . 1/30/23 at 1:56PM: .Edema: bilateral, lower extremity edema present . 1/31/23 at 9:37PM: .Edema: has non pitting edema . Of note, no evidence of physician notification regarding weight changes were noted. R19's Re-admission assessment dated [DATE], includes, in part: 12/7/22: .Current diet order: General Weight: 167 lbs Skin Conditions; 1+ pitting edema . Risk Level: 13; 12-14 Normal nutritional status . Summary: .His weight has been stable since admission in the upper 160s. Will need to monitor his weight as past weights have fluctuated between the 150s and 170s on recent admission . Of note, R19's MDS (Minimum Data Set) Indicates Discharge Assessment, return not anticipated on 11/12/22 and entry MDS on 11/23/22. Nutritional notes received from the facility, include, in part: 11/30/22: R19: Flagging for >5% loss in 1 month, >7.5% loss in 3 months, >10% loss in 6 months. Unsure of resident's UBW (Usual Body Weight) because weight has fluctuated between 150s-170s over the last 5 months. Weight on admission this time was between 161-165 lbs. Will continue to monitor weekly. 12/7/22: R19: Flagging for > 5% weight loss in 1 month, >7.5% loss in 3 months, > 10% loss in 6 months. Unsure of resident's UBW because weight has fluctuated between 150'-170's over the last 5 months. Resident working with therapy due to edema. Weight on admission this time was between 161-165lbs. Will continue to monitor weekly. 12-14-22: R19: Flagging for > 5% weight loss in 1 month, >7.5% loss in 3 months, > 10% loss in 6 months. Unsure of resident's UBW because weigh has fluctuated between 150's-170's over the last 5 months. Resident working with therapy due to edema. Weight on admission this time was between 161-165lbs. Per resident, UBW has fluctuated between 150-170. Will continue to monitor weekly. 12-21-22: R19: Flagging for 10.2% gain since October. Weight does appear to have stabilized in the 160's. Weight of 168.4lbs on 12/20. Weight has fluctuated between 150-170's over the last 5 months. Resident is working with therapy due to edema. Per resident, UBW has fluctuated between 150's - 170's. Will continue to monitor. 2-8-23: Flagging for 6.3% gain in 1 month and 10.7% in 4 months (readmission date October). Wt Hx: 2/7/23: 169.2 lbs, 1/31/23: 168 lbs; 1/24/23: 154.2lbs; 1/17/23: 161.2 lbs; 1/10/23: 152.8 lbs; 1/3/23: 159.2 lbs; 12/6/22: 167.4 lbs; 11/2: 173.6 lbs; 10/5/22: 152.8 lbs Nutrition Care Plan: Weights have been fluctuating widely between the 150's and 160's. Will continue to monitor, nursing aware. Of note, per R19's MDS, the most recent admission date is 11/23/22 after a discharge, return not anticipated date of 11/12/22. The Weights recorded prior to 11/23/22 are from a previous stay. Review of provider progress notes for 12/14/22 and 1/25/23 do include documentation regarding review of weights. Review of R19's Physician Orders and standing orders in the paper chart do not reference a weight gain or loss parameter for notification. On 2/9/23 at 1:37PM Surveyor interviewed CNA C (Certified Nursing Assistant) and asked what the process for obtaining Residents weights is. CNA C indicated; Residents get weighed on their shower days. Usually for admissions it's the first 3 days after admission. Surveyor asked CNA C, how she knows if anyone is supposed to be weighed more frequently than their shower day. CNA C indicated, it shows up on our care card and the nurses are good about reminding us of because it shows up on their care list. Surveyor asked CNA C how she knows how the resident should be weighed, for example, Hoyer, wheelchair, standing. CNA C indicated, from experience. Surveyor asked CNA C how she trains new employees to know this information. CNA C indicated, I'm not sure it's written anywhere, but if they use EZ-stand, get EZ-weight, Hoyer scale. I guess it goes by their transfer status. Surveyor asked CNA C after she gets the weight what she does with that information. CNA C indicated; I tell the nurse. Surveyor asked if this is written or verbal. CNA C indicated; I usually just tell them right away, so I don't forget. Surveyor asked CNA C, how she would know if a re-weight was needed. CNA C indicated, from the nurse. Surveyor asked CNA C, if she weighs someone in a w/c how she knows what to subtract for the wheelchair. CNA C indicated, we take the w/c down and weigh it after we take the resident out of the w/c. On 2/9/23 at 1:45 PM Surveyor interviewed RN D and asked what the overall process was for weights in the facility. RN D indicated, weights are obtained on shower days and new admission are done for 3 days in a row to get a good baseline. If there is someone that has CHF (Congestive Heart Failure) or something like that where the doctor wants it monitored, then it's on the to do list in [ECS} electronic health record. Surveyor asked RN D how she gets the resident weights. RN D indicated, verbally from the CNA. Surveyor asked RN D what she does with the weight once she receives it from the CNA. RN D indicated, it goes into [ECS] the electronic health record and the past weights show up when you put it in. Surveyor asked RN D, what would trigger you to ask for a re-weight. RN D indicated, a big weight gain or weight loss. Surveyor asked RN D what she would consider a big gain or loss. RN D indicated, if they are more than 3lbs up or down I would ask for a re-weight. I don't know if that is policy but that's what I would do. Surveyor asked RN D, how she knows when to contact the provider. RN D indicated, after the re-weigh I would be looking at that. Weight gain greater than 2-3 lbs. Weight loss, I've never called on a weight loss because people are here, and they are declining so it's individual. Is it edema, do they have a lot of swelling, are they symptomatic, shortness of breath, lung sounds. Surveyor asked RN D if there is a set parameter for calling with a weight loss. RN D indicated, probably 5 lbs. Surveyor asked if this is documented. RN D indicated; it should be in the nurses notes. On 2/9/23 at 2:17PM Surveyor interviewed DON B (Director of Nursing) and asked who is responsible for contacting the provider with a weight change. DON B indicated; the nurses contact the physician. Surveyor asked if this information should be documented in the nurses' notes. DON B indicated, yes. Surveyor reviewed weights with DON B and asked if she would have expected the provider to be called for the following weights: 1/31/23 - 168 lbs: An increase from 154.2 lbs on 1/24/23. A gain of 13.8 lbs. 1/24/23 - 154.2 lbs: A decrease from 161.2 lbs on 1/17/23. A loss of 7 lbs. DON B indicated, they should have done a re-weight, if it was a true weight loss, yes. Based on interview and record review the facility failed to consult with the physician related to a significant change of condition for 2 of 3 residents (R4 and R19) reviewed for physician notification. The facility did not consult with R4's physician nor notify her APOAHC (Activated Power of Attorney for Health Care) when R4 experienced a 7.48% decrease in her weight on 1/2/23, 6.03% decrease on 1/16/23, 10.67% on 1/24/23 and 9.7% decrease on 1/30/23. R19's provider was not updated timely of his weight loss and gain. This is evidenced by: The facility policy titled, Weights, dated 7/23/13 states, in part, as follows: Purpose: To identify and provide nutritional interventions to maintain control of weight loss or gain in residents. Weight will be monitored and assessed to prevent avoidable weight loss and/or weight gain. Significant Change is defined as: 1 month - 5% weight loss/gain 3 months - 7% weight loss/gain 6 months - 10% weight loss/gain The facility policy titled, Change in Condition/Status Notification, undated, states the Purpose: To have a policy and procedure in place for notification of a resident's physician/practitioner, the Medical Director, and/or responsible party if there is a significant change in the resident's physical, mental, or emotional status Policy: Change in condition: A resident's MD/Practitioner, guardian or responsible party is to be notified of an accident, injury, or adverse change in condition. Procedure: The professional nurse on duty will notify the responsible party in the event of a significant change in condition or stats. Example 1 R4 was admitted to the facility on [DATE] with diagnoses including, but not limited to, Parkinson's disease, diabetes and atherosclerotic heart disease. R4's comprehensive care plan indicates, R4 needs some assistance to complete her ADLs (Activities of Daily Living) Because: I have poor balance and Parkinson's disease. I eat without help if you set out what I need I dine in the main dining room. R4's CNA Care Card documents the following diet order: Mechanical soft (NDD#2) with ground meal - may give pureed for a meal if needed, extra sauces and gravies on foods. R4's Annual MDS (Minimum Data Set), dated 1/18/23, Section K0100, indicates R4 has no swallowing issues and has not experienced a weight loss of 5% or more in the last month or loss of 10% more in the last 6 months. R4 is has an APOAHC (Activated Power of Attorney for Health Care). R4's weights are documented as follows: 11/28/22 144.3 12/19/22 141.9 (-1.66%) *1/2/23 133.5 (10.8 pounds, -7.48%) *1/16/23 135.6 (8.7 pounds, -6.03%) *1/24/23 128.9 (15.4 pounds, -10.67%) *1/30/23 130.3 (14 pounds, -9.7%) * Denotes a significant change On 1/25/23 DON B (Director of Nursing) documented the following WAR (weight at risk): Flagging for 9.2% loss in 1 month and 9.7% loss in 3 months Weight history: 1/24/23-128.9 lbs, 1/16/23-135.6, 1/2/23-133.5 lbs, 12/19/22-141.9 lbs, 10/12/22 - 142.7 lbs, 8/10/22- 140.2 lbs. Nutritional Care Plan: Resident has not been feeling well, she has been noted to be falling asleep at the table during meals, meal intakes have declined, per nursing at WAR meeting today resident is declining in overall status. Currently receiving 8 oz variety Ensure with all 3 meals. On 2/1/23 DON B (Director of Nursing) documented the following WAR (weight at risk): Flagging for 9.5% loss in 3 months. Weight history: 1/30/23 -130.3 lbs, 1/24/23-128.9 lbs, 1/16/23-135.6, 1/2/23-133.5 lbs, 12/19/22-141.9 lbs, 10/12/22 - 142.7 lbs, 8/10/22- 140.2 lbs Nutrition Care Plan: See RD sig change assessment from today's date. Resident has not been feeling well, she has been noted to be falling asleep at the table during meals, meal intakes have declined, per nursing at WAR meeting today resident is declining in overall status. Currently receiving 8 oz variety Ensure with all 3 meals. Speech will be screening resident this week. On 2/8/23 DON B (Director of Nursing) documented the following WAR (weight at risk): Flagging for 9.5% loss in 3 months (-7.1% in 6 months, not sig) Weight history: no new weight this week, 1/30/23 -130.3 lbs, 1/24/23-128.9 lbs, 1/16/23-135.6, 1/2/23-133.5 lbs, 12/19/22-141.9 lbs, 10/12/22 - 142.7 lbs, 8/10/22- 140.2 lbs Nutrition Care Plan: Sig change last week. Resident has not been feeling well, she has been noted to be falling asleep at the table during meals, meal intakes have declined. Currently receiving 8 oz variety Ensure with all 3 meals. Spoke with Speech today and she is working with resident to modify diet appropriately. Also adding 4 oz Ensure BID between meals to help resident meet nutrition needs on days she is sleeping through meals. Will continue to monitor. On 2/1/22 the Dietician documented the following note. R4 continues to receive a carbohydrate-controlled diet with advanced NDDL3 (Level 3 National Dysphagia Diet) textured foods, cut up into bite size pieces and extra sauces with meals. No current reported issues with chewing or swallowing. Speech will be evaluating resident this week due to significant change in status. Resident has own teeth with some missing. She receives small portions, an HS (bedtime) snack, and 8oz Ensure TID (three times a day) with all meals with poor-fair acceptance. Meal intakes have decreased with consistent refusals. Weight has continued to decline. Resident is flagging for 9.5% loss in 3 months. CBW is 130.3 lbs. Will continue to monitor and offer nutrition supplements. Resident is likely not meeting their nutritional needs. Fluid intakes continues to be poor at meals. No reported s/s (signs/symptoms) of dehydration. Resident is likely not meeting their fluid needs. Staff to continue to encourage and offer fluids between meals. Care plan reviewed; no changes made at this time. It is important to note, the facility did not notify R4's Physician or APOAHC (Activated Power of Attorney for Health Care) regarding her significant change in condition (weight loss). On 2/9/23 at 12:06 PM, DON B (Director of Nursing) documented the following progress note: Call placed to attending Physician at 9:00 AM regarding: Order change weight loss noted from WAR meeting, Ensure added between meals remains low intake and increased sleeping. Result: No return call received. On 2/9/23 at 12:50 PM, DON B (Director of Nursing), stated to Surveyor she implemented a new process today Resident Weight Change Communication for WAR (weight at risk) meetings. DON B stated she has not completed the Resident Weight Change Communication for R4. On 2/9/23 at 1:51 PM, Surveyor spoke with DON B (Director of Nursing). Surveyor asked DON B, what is the process for monitoring weights. DON B stated, she has started the WAR (weight at risk) binder and weekly meetings on Wednesdays. DON B stated, our Dietician is here weekly. The Dietician looks at the weights and they and makes her recommendations from that. DON B stated, we're trying to tighten up that system, so we are capturing the weights weekly. The recommendations from Nutrition are started right away. Surveyor asked DO B, when did you implement this WAR process. DON B stated the beginning of January. Surveyor asked DON B, who monitors for weight loss. We discuss this information with the Dietician weekly. Surveyor asked DON B, who monitors for significant weight loss. DON B stated, the Dietician looks at the weights weekly and as a team we look at them weekly. Surveyor asked DON B, when would you expect staff to notify the Physician and APOAHC (Activated Power of Attorney for Health Care) regarding a significant weight loss. DON B stated, that should be done when we are discussing that weekly (on Wednesdays). Surveyor asked DON B, did you or anybody at the facility notify the Physician and APOAHC when R4 started experiencing a significant weight loss. DON B stated, she discussed R4's weight loss with the Physician, however, this conversation is not documented. DON B stated the only documentation the facility has regarding Physician notification is on 1/24/23. Note, the Physician saw R4 on 1/25/23, however, there is no evidence that he was informed of R4's weight loss or reviewed the weight loss during his visit. DON B stated, it wasn't until today that she realized the Physician hasn't made a mention of R4's significant weight loss. DON B stated, we had no other documentation to document that the Physician nor APOAHC was notified when R4 experienced significant weight loss. DON B added, it wasn't until today that I realized he hasn't made a mention of it (significant weight loss) and that's our Medical Director, too. Surveyor asked DON B, should notification to the Physician be documented. DON B stated, yes. DON B stated, she thought the Physician would document this in his note. DON B added, that's why the form (Resident Weight Change Communication) came out because that's obviously not happening. Surveyor asked DON B, when was the APOAHC notified of the wt. loss? DON B stated, 1/25/23. DON B stated, she spoke with R4's APOAHC this morning. Surveyor asked DON B, when a resident has a significant weight loss when should the Physician and APOAHC be notified. DON B stated, the Physician and APOAHC should be notified on those Wednesdays that we meet. Surveyor asked DON B, should the facility document notification to the Physician and APOAHC. DON B stated, yes. Surveyor asked DON B, when should the Physician have initially been notified of R4's significant weight loss. DON B stated, 1/2/23. Note, the Physician was not notified and R4's weight continue to decline. On 2/9/23 at 2:14 PM, Surveyor left a message for MD E (Medical Director). MD E did not return Surveyor's phone call.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility did not ensure that a resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 1 of 5 residents (R15) reviewed for range of motion, of a total sample of 15 residents. R15 did not regularly receive her restorative therapies and the facility did not reassess resident to ensure the program was effective and the resident did not experience a decline in range of motion. Findings include R15 was admitted to the facility on [DATE]. Her most recent MDS (Minimum Data Set), dated 1/25/23, shows a BIMS score (Brief Interview for Mental Status) of 14, indicating R15 is cognitively intact. This MDS also shows R15's primary medical condition to be stroke. R15's care plan states, I can't complete cares on my own because I had a stroke, have poor balance and have hemiplegia .my goal is to: maintain my upper and lower extremity ROM (range of motion) with my current restorative program . Additionally, R15's Plan of Care Summary, dated 8/16/21 states, Passive ROM: RUE (Right upper extremity) use 3# dumbbell for elbow flexion and 2# dumbbell for chest press and overhead press. Follow directions posted in restorative binder. LUE (Left upper extremity) 5 repetitions, LLE (Left lower extremity) 5 repetitions two times a day every day, Goals: Prevent decline in ROM. The facility provided therapy recommendations for R15, which were signed and recommended by therapy staff, stated the following, Goal: To prevent decline and left upper extremity contracture .recommendation: restorative program of passive range of motion to be applied to LUE to prevent contracture .for RUE, use 1 lb dumbbell for bicep curls, wrist curls, and shoulder raises. 2x10. On 2/8/23 at 8:46 AM, Surveyor interviewed R15, who stated that she has not been getting any exercise or therapy in her room. R15 stated that she has trouble moving her left side and attempted to lift her arm up but could only slightly move it at the shoulder (a shrugging motion). While sitting in her bed, R15 looked straight ahead at her picture collage and stated that she would like to move her body more so that she could get stronger and spend more time with them as she pointed at her family pictures. R15 also stated that she has not seen a dumbbell and does not remember using one or where they are. On 2/9/23 at 1:21 PM, Surveyor interviewed CNA G (Certified Nursing Assistant) who stated that she regularly works with R15 and does do range of motion with her, however, stated that it sometimes does not get done due to other resident needs. Additionally, CNA G stated that she was unaware of the exercises R15 was to be doing. On 2/9/23 1:36 PM Surveyor interviewed CNA F, who frequently provides care for R15. CNA F stated that she does do exercises with R15 and a lot of those exercises revolve around doing cares and the resident does not know it, which may be why R15 believes she is not getting any therapy or restorative. CNA F then stated she did not do the dumbbell exercises and has never performed any exercises with R15's weak side (LUE). CNA F also stated that she believes the CNA's at the facility are good at regularly documenting when restorative therapies are being done. At around 2:15 PM, CNA F found Surveyor and stated she had found where the dumbbells were located and showed the Surveyor that they were right behind the nurse's station. The facility's documentation shows R15 did not receive restorative a total of 34 days from November 2022 through 2/7/23 (2/3, 2/1, 1/29, 1/25, 1/24, 1/23, 1/22, 1/19, 1/14, 1/13, 1/11, 1/8, 1/6, 1/5, 12/24, 12/25, 12/21, 12/19, 12/15, 12/10, 12/9, 11/30, 11/27, 11/26, 11/25, 11/23, 11/21, 11/19, 11/13, 11/12, 11/9, 11/7, 11/6, 11/5). On 2/9/23 at 3:38 PM, Surveyor interviewed DON B (Director of Nursing). DON B stated that the facility has some work to do on their restorative program, but that she believes it will be improving greatly in the very near future. Additionally, DON B stated that she was aware that restorative plans for residents were not being reevaluated and assessed to find if residents' range of motion was improving or declining and if plans needed to be updated. DON B stated that currently, a nurse is doing monthly general assessments on residents, which includes a statement that briefly mentions the resident's ADL (Activities of Daily Living) assist level, but does not address range of motion. The facility had therapy recommendations to provide daily upper and lower extremity restorative exercises for R15. Facility staff were not conducting the specified exercises, were not conducting them consistently, and were not assessing the resident's range of motion and if R15's range of motion had improved, declined or if her current restorative plan needed updating.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility must develop policies and procedures to ensure that residents or their responsible party receive risk and benefits of COVID immunizations, are offered the immunization and documented in the medical record whether the immunization was received or declined, this affected 3 of 5 residents (R28, R95, and R31) reviewed for immunizations of 12 sampled residents. R28 did not have the COVID immunizations offered and no documentation. R95 did not have the COVID immunizations offered and no documentation. R31 did not have the COVID immunizations offered and no documentation. This is evidenced by: The facility did not provide a policy and procedure that speaks of COVID immunizations for the residents. Example 1 R28 was admitted to the facility on [DATE]. There is no documentation that R28 was provided education on the risk and benefits of the COVID immunization or that the immunization was offered, received, or declined. Example 2 R95 was admitted to the facility on [DATE]. There is no documentation that R95 was provided education on the risk and benefits of the COVID immunization or that the immunization was offered, received, or declined. Example 3 R31 was admitted to the facility on [DATE]. There is no documentation that R31 was provided education on the risk and benefits of the COVID immunization or that the immunization was offered, received, or declined. On 2/8/23, at 2:24 PM, Surveyor interviewed DON B (Director of Nursing) and asked if R28, R95, and R31 had received education, were offered, received, or declined the COVID-19 immunizations. DON B indicated DON B had recognized on 2/3/23 that was a break in the system with immunizations. DON B indicated the issue was taken to QAPI (Quality Assurance Performance Improvement), but nothing has been started. DON B indicated there should be documentation on education and declination of the COVID-19 immunizations in the residents' medical records and there was not. DON B provided education and declinations signed and dated 2/8/23 for R28, R95, and R31, after Surveyor had asked for the documentation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility must develop policies and procedures to ensure that residents and/or resident responsible party receives education regarding the benefits and potential side effects of the immunization prior to offering the immunization and documentation is noted in the medical record on whether the resident received or declined the immunization, this affected 4 of 5 residents (R28, R95, R31, R5) reviewed for influenza immunizations and 1 of 5 residents (R31) reviewed for pneumococcal immunizations of 12 sampled residents. R28 did not have the influenza immunization and no documentation. R95 did not have the influenza immunization and no documentation. R31 did not have the influenza and the pneumococcal immunization and no documentation. R5 did not have the influenza immunization and no documentation. The facility has not updated their pneumococcal policy regarding the CDC's (Centers for Disease Control) new guidelines on the pneumococcal immunizations. This is evidenced by: The facility policy, entitled Influenza and Pneumonia, dated 2/27/15, states, in part: . PURPOSE: Norseland Nursing Home wants to ensure that each resident and/or their legal representative, receives education on the benefits and potential side effects of the Influenza and Pneumonia Immunizations before they are offered. PROCEDURE: 1. Residents and/or their legal representative will receive education regarding the benefits and potential side effects of the immunizations before they are offered. 2. As appropriate, residents will be offered the opportunity to receive immunizations annually for Influenza and once for Pneumonia unless otherwise indicated by their medical provider. 3. Residents and/or their legal representative have the right to refuse the immunizations. 4. Documentation of the provision of education, and if the resident received or refused the immunization, is all included in the resident's medical record. Example 1 R28 was admitted to the facility 1/21/21. There is no documentation that R28 was provided education on the risk and benefits of the influenza immunization or that the immunization was offered, received, or declined. Example 2 R31 was admitted to the facility on [DATE]. There is no documentation that R31 was provided education on the risk and benefits of the pneumococcal immunization or the influenza immunization or that the immunizations were offered, received, or declined. Example 3 R5 was admitted to the facility on [DATE]. There is no documentation that R5 was provided education on the risk and benefits of the influenza immunization or that the immunization was offered, received, or declined. Example 4 R95 was admitted to the facility on [DATE]. There is no documentation that R95 was provided education on the risk and benefits of the influenza immunization or that the immunization was offered, received, or declined. On 2/8/23, at 2:24 PM, Surveyor interviewed DON B (Director of Nursing) and asked if R28, R95, R31 and R5 had received education, were offered, received, or declined the Influenza and Pneumococcal immunizations. DON B indicated DON B had recognized on 2/3/23 that was a break in the system with immunizations. DON B indicated the issue was taken to QAPI (Quality Assurance Performance Improvement), but nothing has been started. DON B indicated there should be documentation on education and declination of the immunizations in the residents' medical records and there was not. DON B provided education and declinations signed and dated 2/8/23 for R31, R95, and R28, after Surveyor had asked for the documentation. DON B indicated the facility did not have an updated policy on the pneumococcal immunization per CDC guidelines.