WASHINGTON COUNTY NURSING HOME

INITIAL COMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility's general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a). The campus has a total of four (4) buildings, each building is a one story Type V (111) construction having 10 beds. The facility is protected throughout by a National Fire Protection Association (NFPA) 13 automatic fire suppression systems. The attic space, mechanical and screen porch are equipped with and protected by a dry-piped automatic sprinkler system and is classified as Fully Sprinklered. The Emergency power system for all four (4) buildings is provided by a 200 kw, 208-volt. diesel powered generator located in a separate building on the campus. Each building is equipped with two (2) automatic transfer switches and remote annunciator panel. The facility was constructed in 2016 and is license for 40 beds. This re-certification survey conducted on May 30, 2023 was for compliance with the National Fire Protection Association, (NFPA 101) Life Safety Code (2012) Chapter 19, "Existing Health Care Occupancies". The deficiencies cited were discussed with the Administrator and Maintenance Director during the exit conference conducted at the end on-site survey.

STANDARD is not met as evidenced by: Based on observation and staff interview during the survey, it was determined that the facility failed to maintain marking of means of egress in accordance with Life Safety Section 7.10. This deficient practice could affect all residents, staff and visitors in the area if code compliant exit signage is not provided for building egress. This was evidence by the following. Facility failed to provide proper exit signage in the Dinning Room, directional arrows were pointing in the wrong direction. Life Safety Code 19.2.10.1. Means of egress shall have signs in accordance with section 7.10. The directional indicator shall be located outside of the Exit legend, not less than 3/8 in. (1cm) from any letter. The directional indicator shall be of a chevron type. The directional indicator shall be identifiable as a directional indicator at a distance of 40 ft. (12.2m). A directional indicator larger than the minimum established in this paragraph shall be proportionately increased in height, width and stroke. The directional indicator shall be located at the end of the sign for the direction indicated. The Director of Maintenance acknowledge the lack of exit signage condition during the tour of the facility.

STANDARD is not met as evidenced by: Based on observation and staff interview during the survey, it was determined that the fire resistance rating of smoke barrier walls were not maintained in accordance with Life Safety Code Section 19.3.2.1 This deficient practice could affect all residents in all smoke compartment by allowing the spread of fire and smoke to the adjoining compartments. This was evidenced by the following:Unsealed penetrations in the fire rated walls in the Electrical and Data room where not sealed to maintain the 1-hour fire resistance rating of the fire barrier, as required. Life Safety Code Section 19.3.2.1 requires that the smoke barrier wall be constructed in accordance with Section 8.3, and shall have a fire resistance rating of not less than ½ hour. Section 8.3.2 requires that the barrier be continuous through concealed spaces. Section 8-3.1.1 requires, in part, that the space between piping penetrations. The Maintenance Director acknowledge the penetrations during a tour of the facility.

A licensure survey was completed on 5/15/23 to 5/17/23. One deficiency was cited.

Based on observations, record review and interviews, the facility failed to implement appropriate nutritional interventions for one (#26) out of 20 sample residents to maintain acceptable parameters of nutritional status. Resident #26, age 90, was admitted to the facility on 1/13/23 with diagnoses of heart failure, type 2 diabetes mellitus, chronic obstructive pulmonary disease (COPD), peripheral vascular disease, history of falling and anxiety. Resident #26 sustained a weight loss of 10.6% (20.5 lbs) from admission on 1/13/23 through 1/31/23, which was considered significant. According to Resident #26's nutrition care plan, pertinent interventions initiated 3/4/23 included to monitor, record and report to the physician as needed any signs and symptoms of malnutrition such as significant weight loss and obtain and monitor lab/diagnostic work as ordered. Report results to the physician and follow up as indicated. Resident #26's labwork, dated 2/17/23, revealed his Albumin was 2.8 (ranges 3.4-5) indicating it was low. Review of the physician progress notes revealed no documentation of the resident's significant weight loss and poor nutritional status. There was no documentation on expected or unplanned weight loss, or updated care plan goals and interventions. The dental care plan was initiated on 2/22/23 (six weeks after Resident #26 admission) revealed he was edentulous and chose not to wear dentures. Pertinent interventions included to consult with the dietitian and change the resident's diet (regular diet) if chewing/swallowing problems were noted; encourage to eat meals, and observe for any difficulty with chewing and swallowing. Findings include: I. Facility policy and procedure The Weight Monitoring Policy, dated October 2022, was provided by the nursing home administrator (NHA) on 5/17/23 at 2:48 p.m. The policy read in pertinent part, "Based on resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident's preferences indicate otherwise."The facility will utilize a systemic approach to optimize a resident's nutritional status. This process includes:a. Identifying and assessing each resident's nutritional status and risk factorsb. Evaluating/analyzing the assessment informationc. Developing and consistently implementing pertinent approachesd. Monitoring the effectiveness of interventions and revising them as necessaryDocumentation:a. The physician should be informed of a significant change in weight and may order nutritional interventionsb. The physician should be encouraged to document the diagnosis or clinical conditions that may be contributing to the weight loss c. Meal consumption information should be recorded and may be referenced by the interdisciplinary care team as neededd. If the interdisciplinary care team desires to explore specific meal consumption information for a resident, the Registered Dietician, Dietary Manager, or the nursing department may initiate this process." II. Resident #26 Resident #26, age 90, was admitted on 1/13/23. According to the May 2022 clinical physician orders (CPO), the diagnoses included heart failure, type 2 diabetes mellitus, chronic obstructive pulmonary disease (COPD), peripheral vascular disease, history of falling and anxiety. The 2/26/23 facility significant change in status assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score 13 out of 15. No behaviors or rejection of care were documented. He required extensive assistance of two staff with bed mobility and transfers, extensive assistance of one person with dressing, toilet use and personal hygiene and supervision with eating. He was continent. He sustained two or more falls with no injuries since admission. Section K (Swallowing/Nutrition Status) revealed the resident height was 71 inches (five foot 11 inches) and weight was 177 pounds. Loss of weight was documented as not on physician prescribed weight-loss regimen. The resident complained of difficulty with swallowing. Section L (Oral/Dental Status) documented no natural teeth. He received an antianxiety, anticoagulant, antibiotic and diuretic medications. The 1/20/23 facility admission assessment revealed the resident's weight was 191 pounds, no weight loss and he did not complain of difficulty with swallowing. III. Resident interview and observations Resident #26 was interviewed on 5/15/23 at 2:23 p.m. He said he was not eating much because he did not have an appetite and could not chew. He said he had no teeth. Resident #26 was observed in the dining room, during the lunch meal on 5/15/23, 5/16/23 and 5/17/23. Each meal he took a few bites of food and consumed approximately 25%. Resident #26 was interviewed on 5/17/23 at 12:40 p.m. He said he was unable to chew the meat (BBQ pork rib) and had difficulty swallowing it. He said the staff did not offer him different food choices. IV. Record review A. Nutritional care plan The nutritional care plan, initiated 1/22/23, documented, "Elder (resident) has unintentional weight loss." Interventions included: Invite the resident to activities that promote additional intake. Monitor/record/report to MD (physician) PRN (as needed) s/sx (signs/symptoms) of malnutrition (initiated on 3/4/23). Obtain and monitor lab/diagnostic work as ordered, report results to MD (physician) and follow up as indicated. Offer alternative meal choices as needed. Provide and serve supplements as ordered, Magic cup BID (two times a day) (initiated 3/4/23). Provide, serve diet as ordered, monitor intake and record q (every) meal. RD (registered dietitian) to evaluate and make diet change recommendation PRN (as needed). B. Dental care plan The dental care plan, initiated 2/22/23, documented, "Elder is edentulous. He has dentures, but chooses not to wear them saying that he eats fine without them." Interventions included: Diet as ordered. Consult with dietitian and change if chewing/swallowing problems are noted. Encourage him to eat meals and offer snacks, observe for any difficulty with chewing and swallowing his food related to edentulous status. C. Physician orders -RCS/CC (reduced concentrated sweets/carbohydrate control) diet, regular texture; -Magic cup (nutritional ice cream supplement), two times a day for weight loss, order date 2/2/23; and,-Lasix oral tablet 80 mg (Furosemide) (diuretic), give one tablet by mouth one time a day related to heart failure. D. Resident #26's weights The Hospital Summary, dated 1/13/23, revealed the resident's weight on 1/9/23 was 94.5 kg (207.9 lbs). Resident #26 weights were documented in the medical record as follows:-On 1/13/23 the resident weighed 192 lbs (15.9 lbs difference from the hospital weight obtained the same day);-On 1/17/23 the resident weighed 182.5 lbs (9.5 lbs or 5% weight loss);-On 1/31/23 the resident weighed 171.5 lbs (20.5 lbs or 10.5% weight loss);-On 3/14/23 the resident weighed 176.7 lbs; and, -On 5/3/23 the resident weighed 176 lbs. E. Nutritional progress notes On 1/22/23 the RD documented: "Attended weekly weight meeting on 1/19/23 via phone ...Diet RCS/CC. Eating 56% average/day. Skin intact. Edema: none noted. No new recommendations. Continue current interventions."-The RD note did not document the weight difference from the hospital (15.9 lbs). No edema was noted with the resident being on diuretic medication. No nutritional interventions were put in place with the resident's weight loss and on average poor intake. On 1/28/23 RD documented: "Attended weekly weight meeting on 1/26/23 via phone ...Diet RCS/CC. Eating 54% average/day ...Weight 1/24/23 182.5 lbs ...Skin intact. Edema: none noted. No new recommendations. Continue current interventions."On 2/2/23 interdisciplinary team (IDT) note revealed: "(Resident) is on weekly weight monitoring related to new admission with weight loss. Elder states he has difficulty swallowing at times and in the past has had his esophagus dilated. Appointments are being made regarding this. (Physician) is aware of weight loss and stools are being heme tested. His average PO (oral) intake is 46% and his average daily fluid intake is 789 ml. He accepted one snack and refused two meals. Magic cup has been ordered and elder will be offered one twice daily. Continue current interventions and weekly monitoring."On 2/4/23 RD documented: Attended weekly weight meeting on 2/2/23 via phone. Following weekly r/t (related to) new admission, weight loss. Diet RCS/CC. Eating 46% average/day ... Edema: none noted. Recommendation: Magic cup BID (two times a day). Continue current interventions."-The resident had 20.5 lbs weight loss on 1/31/23 and a supplement was not offered until 2/2/23 when the resident had consistent poor intake. The resident was on diuretic medication with no edema noted in the RD documentation. On 2/23/23 IDT note revealed: "(Resident) is on weekly weight monitoring related to weight loss. His average PO (oral) intake is 56% and his average daily fluid intake is 1029 ml. He accepted two snacks and did not refuse any meals ...He accepted 11 out of 14 Magic Cup administrations. Continue current interventions and weekly monitoring."On 2/24/23 RD documented: "Attended weekly weight meeting on 2/23/23 via phone. Following weekly weight loss. Diet: RCS/CC. Eating 56% average/day. Supplements: Magic cup BID (two times a day). Accepted 11 out of 14. Magic cup provides 260 kcal/9 gm protein per serving. Fluids: Average of 1029 ml of fluid/day from meals/supplement, plus additional water in room. Weight: 2/21/23 167 lbs. BMI: 23.3-within normal limits for height. c/o (complained of) difficulty swallowing ...Edema: none noted. Recommendation: none at this time. Continue current interventions. Continue to follow weekly until weight stabilizes."-The interdisciplinary team and the RD failed to address the resident's swallowing difficulty that was noted when he was having significant weight loss. The resident was not evaluated for different food consistency, mechanical soft diet. F. Laboratory report The 2/17/23 labwork report revealed Albumin level 2.8 (low) (reference range 3.4 - 5.0) -The interdisciplinary team and the RD failed to address the resident's low Albumin level. G. Meal intakes Meal intake records/amount eaten, were reviewed for January 2023 and May 2023 revealed the documented food consumed by Resident #26 averaged approximately 50%.-However, per observations (see above) the resident ate approximately 25% for three lunch meals and per staff interviews (see below) the resident often did not eat much (25-50%) and refused at times. H. Physician notes Review of the physician notes, dated 2/16/23 and 3/21/23, revealed no documentation related to Resident #26 significant weight loss, difficulty swallowing and low Albumin level. V. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 5/17/23 at 11:27 a.m. She said she knew the resident well since his admission. She said she worked with Resident #26, usually five days per week. She said the resident did not eat well at any of his meals. She said he never finished his meals and frequently he had just a few bites. She said most of his meal intake was 26% to 50% and occasionally he refused to eat. She said the resident was on a regular diet. She said the resident's weekly weights were documented on the weights sheet and given to the nurse who would record the weights in the resident's electronic medical record. CNA #2 was interviewed on 5/17/23 at 12:43 p.m. She said she worked with the resident since his admission and knew him well. She said the residentwas independent with eating however he did not eat much of his meals. She said the resident ate very little, he liked sweets. She said she was not aware the resident had difficulty swallowing his food. The NHA and the director of nursing (DON) were interviewed on 5/17/23 at 1:30 p.m. The NHA said the RD was a contractor not a full time employee and was coming to the facility every couple of weeks. She said the RD attended the weights meeting by calling on her phone. The DON said Resident #26 experienced a significant weight loss after his admission however his weight stabilized after a few weeks. She said the interdisciplinary team did not review the resident's medications during the weights meeting. She said the resident's physician was contacted after each meeting, however she was not aware the physician did not document the resident's significant weight change. She said the RD and the IDT were aware of Resident #26's difficulty chewing and swallowing, however she did not realize his diet texture change was not addressed as well as a swallow evaluation. She said the resident's low Albumin level was not addressed during the weights meeting and no other interventions and supplements were taken under consideration. She said she would provide staff training to ensure all residents' food intake was documented accurately. The RD was not available for an interview and did not return a phone call.

A recertification survey was completed from 5/15/23 to 5/17/23. Two deficiencies were cited.

An Emergency Preparedness survey was conducted from 5/15/23 to 5/17/23. No deficiencies were cited.

Based on observations, record review and interviews, the facility failed to implement appropriate nutritional interventions for one (#26) out of 20 sample residents to maintain acceptable parameters of nutritional status. Resident #26, age 90, was admitted to the facility on 1/13/23 with diagnoses of heart failure, type 2 diabetes mellitus, chronic obstructive pulmonary disease (COPD), peripheral vascular disease, history of falling and anxiety. Resident #26 sustained a weight loss of 10.6% (20.5 lbs) from admission on 1/13/23 through 1/31/23, which was considered significant. According to Resident #26's nutrition care plan, pertinent interventions initiated 3/4/23 included to monitor, record and report to the physician as needed any signs and symptoms of malnutrition such as significant weight loss and obtain and monitor lab/diagnostic work as ordered. Report results to the physician and follow up as indicated. Resident #26's labwork, dated 2/17/23, revealed his Albumin was 2.8 (ranges 3.4-5) indicating it was low. Review of the physician progress notes revealed no documentation of the resident's significant weight loss and poor nutritional status. There was no documentation on expected or unplanned weight loss, or updated care plan goals and interventions. The dental care plan was initiated on 2/22/23 (six weeks after Resident #26 admission) revealed he was edentulous and chose not to wear dentures. Pertinent interventions included to consult with the dietitian and change the resident's diet (regular diet) if chewing/swallowing problems were noted; encourage to eat meals, and observe for any difficulty with chewing and swallowing. Findings include: I. Facility policy and procedure The Weight Monitoring Policy, dated October 2022, was provided by the nursing home administrator (NHA) on 5/17/23 at 2:48 p.m. The policy read in pertinent part, "Based on resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident's preferences indicate otherwise."The facility will utilize a systemic approach to optimize a resident's nutritional status. This process includes:a. Identifying and assessing each resident's nutritional status and risk factorsb. Evaluating/analyzing the assessment informationc. Developing and consistently implementing pertinent approachesd. Monitoring the effectiveness of interventions and revising them as necessaryDocumentation:a. The physician should be informed of a significant change in weight and may order nutritional interventionsb. The physician should be encouraged to document the diagnosis or clinical conditions that may be contributing to the weight loss c. Meal consumption information should be recorded and may be referenced by the interdisciplinary care team as neededd. If the interdisciplinary care team desires to explore specific meal consumption information for a resident, the Registered Dietician, Dietary Manager, or the nursing department may initiate this process." II. Resident #26 Resident #26, age 90, was admitted on 1/13/23. According to the May 2022 clinical physician orders (CPO), the diagnoses included heart failure, type 2 diabetes mellitus, chronic obstructive pulmonary disease (COPD), peripheral vascular disease, history of falling and anxiety. The 2/26/23 minimum data set (MDS) significant change in status assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score 13 out of 15. No behaviors or rejection of care were documented. He required extensive assistance of two staff with bed mobility and transfers, extensive assistance of one person with dressing, toilet use and personal hygiene and supervision with eating. He was continent. He sustained two or more falls with no injuries since admission. Section K (Swallowing/Nutrition Status) revealed the resident height was 71 inches (five foot 11 inches) and weight was 177 pounds. Loss of weight was documented as not on physician prescribed weight-loss regimen. The resident complained of difficulty with swallowing. Section L (Oral/Dental Status) documented no natural teeth. He received an antianxiety, anticoagulant, antibiotic and diuretic medications. The 1/20/23 MDS admission assessment revealed the resident's weight was 191 pounds, no weight loss and he did not complain of difficulty with swallowing. III. Resident interview and observations Resident #26 was interviewed on 5/15/23 at 2:23 p.m. He said he was not eating much because he did not have an appetite and could not chew. He said he had no teeth. Resident #26 was observed in the dining room, during the lunch meal on 5/15/23, 5/16/23 and 5/17/23. Each meal he took a few bites of food and consumed approximately 25%. Resident #26 was interviewed on 5/17/23 at 12:40 p.m. He said he was unable to chew the meat (BBQ pork rib) and had difficulty swallowing it. He said the staff did not offer him different food choices. IV. Record review A. Nutritional care plan The nutritional care plan, initiated 1/22/23, documented, "Elder (resident) has unintentional weight loss." Interventions included: Invite the resident to activities that promote additional intake. Monitor/record/report to MD (physician) PRN (as needed) s/sx (signs/symptoms) of malnutrition (initiated on 3/4/23). Obtain and monitor lab/diagnostic work as ordered, report results to MD (physician) and follow up as indicated. Offer alternative meal choices as needed. Provide and serve supplements as ordered, Magic cup BID (two times a day) (initiated 3/4/23). Provide, serve diet as ordered, monitor intake and record q (every) meal. RD (registered dietitian) to evaluate and make diet change recommendation PRN (as needed). B. Dental care plan The dental care plan, initiated 2/22/23, documented, "Elder is edentulous. He has dentures, but chooses not to wear them saying that he eats fine without them." Interventions included: Diet as ordered. Consult with dietitian and change if chewing/swallowing problems are noted. Encourage him to eat meals and offer snacks, observe for any difficulty with chewing and swallowing his food related to edentulous status. C. Physician orders -RCS/CC (reduced concentrated sweets/carbohydrate control) diet, regular texture; -Magic cup (nutritional ice cream supplement), two times a day for weight loss, order date 2/2/23; and,-Lasix oral tablet 80 mg (Furosemide) (diuretic), give one tablet by mouth one time a day related to heart failure. D. Resident #26's weights The Hospital Summary, dated 1/13/23, revealed the resident's weight on 1/9/23 was 94.5 kg (207.9 lbs). Resident #26 weights were documented in the medical record as follows:-On 1/13/23 the resident weighed 192 lbs (15.9 lbs difference from the hospital weight obtained the same day);-On 1/17/23 the resident weighed 182.5 lbs (9.5 lbs or 5% weight loss);-On 1/31/23 the resident weighed 171.5 lbs (20.5 lbs or 10.5% weight loss);-On 3/14/23 the resident weighed 176.7 lbs; and, -On 5/3/23 the resident weighed 176 lbs. E. Nutritional progress notes On 1/22/23 the RD documented: "Attended weekly weight meeting on 1/19/23 via phone ...Diet RCS/CC. Eating 56% average/day. Skin intact. Edema: none noted. No new recommendations. Continue current interventions."-The RD note did not document the weight difference from the hospital (15.9 lbs). No edema was noted with the resident being on diuretic medication. No nutritional interventions were put in place with the resident's weight loss and on average poor intake. On 1/28/23 RD documented: "Attended weekly weight meeting on 1/26/23 via phone ...Diet RCS/CC. Eating 54% average/day ...Weight 1/24/23 182.5 lbs ...Skin intact. Edema: none noted. No new recommendations. Continue current interventions."On 2/2/23 interdisciplinary team (IDT) note revealed: "(Resident) is on weekly weight monitoring related to new admission with weight loss. Elder states he has difficulty swallowing at times and in the past has had his esophagus dilated. Appointments are being made regarding this. (Physician) is aware of weight loss and stools are being heme tested. His average PO (oral) intake is 46% and his average daily fluid intake is 789 ml. He accepted one snack and refused two meals. Magic cup has been ordered and elder will be offered one twice daily. Continue current interventions and weekly monitoring."On 2/4/23 RD documented: Attended weekly weight meeting on 2/2/23 via phone. Following weekly r/t (related to) new admission, weight loss. Diet RCS/CC. Eating 46% average/day ... Edema: none noted. Recommendation: Magic cup BID (two times a day). Continue current interventions."-The resident had 20.5 lbs weight loss on 1/31/23 and a supplement was not offered until 2/2/23 when the resident had consistent poor intake. The resident was on diuretic medication with no edema noted in the RD documentation. On 2/23/23 IDT note revealed: "(Resident) is on weekly weight monitoring related to weight loss. His average PO (oral) intake is 56% and his average daily fluid intake is 1029 ml. He accepted two snacks and did not refuse any meals ...He accepted 11 out of 14 Magic Cup administrations. Continue current interventions and weekly monitoring."On 2/24/23 RD documented: "Attended weekly weight meeting on 2/23/23 via phone. Following weekly weight loss. Diet: RCS/CC. Eating 56% average/day. Supplements: Magic cup BID (two times a day). Accepted 11 out of 14. Magic cup provides 260 kcal/9 gm protein per serving. Fluids: Average of 1029 ml of fluid/day from meals/supplement, plus additional water in room. Weight: 2/21/23 167 lbs. BMI: 23.3-within normal limits for height. c/o (complained of) difficulty swallowing ...Edema: none noted. Recommendation: none at this time. Continue current interventions. Continue to follow weekly until weight stabilizes."-The interdisciplinary team and the RD failed to address the resident's swallowing difficulty that was noted when he was having significant weight loss. The resident was not evaluated for different food consistency, mechanical soft diet. F. Laboratory report The 2/17/23 labwork report revealed Albumin level 2.8 (low) (reference range 3.4 - 5.0) -The interdisciplinary team and the RD failed to address the resident's low Albumin level. G. Meal intakes Meal intake records/amount eaten, were reviewed for January 2023 and May 2023 revealed the documented food consumed by Resident #26 averaged approximately 50%.-However, per observations (see above) the resident ate approximately 25% for three lunch meals and per staff interviews (see below) the resident often did not eat much (25-50%) and refused at times. H. Physician notes Review of the physician notes, dated 2/16/23 and 3/21/23, revealed no documentation related to Resident #26 significant weight loss, difficulty swallowing and low Albumin level. V. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 5/17/23 at 11:27 a.m. She said she knew the resident well since his admission. She said she worked with Resident #26, usually five days per week. She said the resident did not eat well at any of his meals. She said he never finished his meals and frequently he had just a few bites. She said most of his meal intake was 26% to 50% and occasionally he refused to eat. She said the resident was on a regular diet. She said the resident's weekly weights were documented on the weights sheet and given to the nurse who would record the weights in the resident's electronic medical record. CNA #2 was interviewed on 5/17/23 at 12:43 p.m. She said she worked with the resident since his admission and knew him well. She said theresident was independent with eating however he did not eat much of his meals. She said the resident ate very little, he liked sweets. She said she was not aware the resident had difficulty swallowing his food. The NHA and the director of nursing (DON) were interviewed on 5/17/23 at 1:30 p.m. The NHA said the RD was a contractor not a full time employee and was coming to the facility every couple of weeks. She said the RD attended the weights meeting by calling on her phone. The DON said Resident #26 experienced a significant weight loss after his admission however his weight stabilized after a few weeks. She said the interdisciplinary team did not review the resident's medications during the weights meeting. She said the resident's physician was contacted after each meeting, however she was not aware the physician did not document the resident's significant weight change. She said the RD and the IDT were aware of Resident #26's difficulty chewing and swallowing, however she did not realize his diet texture change was not addressed as well as a swallow evaluation. She said the resident's low Albumin level was not addressed during the weights meeting and no other interventions and supplements were taken under consideration. She said she would provide staff training to ensure all residents' food intake was documented accurately. The RD was not available for an interview and did not return a phone call.

Based on observation, records review and interviews, the facility failed to adequately monitor the resident for unnecessary psychotropic medications needed to provide effective and person-centered care for one (#19) of five residents reviewed for use of psychotropic medication out of 20 sample residents. Specifically, the facility failed to for Resident #19:-Ensure staff monitored the resident for effectiveness of antidepressant medication therapy since the resident was prescribed two antidepressant medications with one being used for a diagnosis of insomnia;-Ensure staff identified depressive target behaviors; -Ensure staff accurately monitored the resident for depressive target behaviors and hours of sleep for the antidepressant being used for insomnia; and, -Ensure staff monitored the resident for her response to antidepressant medication. Findings include:I. Facility policyThe Use of Psychotropic Medication, undated, was received on 5/16/23 from the nursing home administrator (NHA), which read in pertinent part:"Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s)." "The effects of the psychotropic medications on a resident's physical, mental, and psychosocial wellbeing will be evaluated on an ongoing basis such as:-Upon physician evaluation;-During the pharmacist's monthly medication regimen review;-During MDS (minimum data set) review and;-In accordance with nurse assessment and medication monitoring parameters consistent with clinical standards of practice, manufacturer's specifications, and the resident's comprehensive plan of care. "The resident's response to the medication(s), including progress towards goals and presence or absence of adverse consequences, shall be documented in the resident's medical record." II. Resident statusResident #19, age 68, was admitted on 9/1/21. According to the May 2023 computerized physician orders (CPO), the resident's diagnoses included hypertension, sleep apnea, depression, anxiety and epilepsy. The 4/2/23 minimum data set (MDS) assessment revealed the resident had no cognitive impairments with a score of 15 out of 15 on the brief interview for mental status (BIMS) assessment. The resident was independent with all activities of daily living. III. Resident interview and observationResident #19 was interviewed on 5/15/23 at 10:12 a.m. Resident #19 said she had bad depression and she felt sad a lot of the time. She said she was depressed since moving into the facility and had chronic pain. She said she took medication for depression and she had been able to see a behavioral health specialist but did not feel her depression had improved. The resident fell asleep twice while speaking during the interview. IV. Record reviewA review of the May 2023 computerized physician orders (CPO) revealed the resident was prescribed the following antidepressant psychotropic medications:-Venlafaxine, 100 mg twice a day, prescribed for depression on 4/13/21;-Trazodone 100 mg once a day, prescribed for insomnia on 4/10/23.-The resident was on two antidepressant medications, with Trazadone being used for insomnia. The resident's care plan dated 4/12/23 revealed the resident had depression at risk for adverse reactions to antidepressant medication. The focus area for psychotropic medications was to include interventions to monitor, document, and report as needed adverse reactions to antidepressant medications, and to monitor and document side effects and effectiveness of the antidepressant therapy every shift. The care plan documented the staff should document, report signs and symptoms of depression, including hopelessness, anxiety and sadness. -The resident's CPO failed to include orders to monitor the resident for adverse reactions to antidepressant therapy or side effects and effectiveness of the antidepressant medications.-A review of the resident's May 2023 medication and treatment records revealed there was no documented monitoring for adverse reactions, side effects or effectiveness of the antidepressant medications. In addition, the resident's hours of sleep were documented and the resident self-reported and did not include hours of sleep observed by facility staff. The NHA located a psychiatrist note signed on 4/27/23. The psychiatrist noted the resident had residual depression and recommended an increase with the Venlafaxine dosage. -There was no documentation in the medical record that indicated the psychiatrist recommendation was forwarded to the resident's physician for consideration. On 5/16/23 the NHA provided an email document sent to her from the resident's counselor on 5/16/23 at 3:52 p.m. The counselor documented on 5/9/23 the resident had returned from a doctor appointment, was sleepy and declined her appointment. The counselor documented the resident was sleeping at the table. On 5/11/23, the counselor documented the resident spoke with monosyllabic (using brief words) speech, was observed very sleepy, and the resident reported she was depressed and in a lot of pain. -There was no documentation in the medical record that indicated the counselor updated the facility staff with the resident's status.-The resident was sleepy per documentation and observations (see above), there was no review of her antidepressant medications. V. Staff interviews Licensed registered nurse (LPN) #1 was interviewed 5/16/23 at 10:30 a.m. LPN #1 said when the staff track specific behaviors for residents the information was recorded on the individual resident's medication administration record. She said staff could track, monitor and document medication side effects or adverse reactions when ordered by the physician. LPN #1 said when a resident has depression staff should monitor the resident for changes in mood. LPN #1 said she was familiar with the resident and she felt the resident was sleeping more frequently. The LPN said she was aware the resident had depression and took antidepressant medication but was unable to recall the resident's specific causes of depression but felt it might be chronic pain. The LPN said when the nurse documented hours of sleep, the number of hours was provided from the resident and recorded on the resident's medication administration record. The LPN said she thought the resident slept more hours than the resident thought, but the resident's time was self reported (not recorded by staff). The LPN said a side effect of Venlafaxine was sleepiness. The NHA and director of nursing (DON) were interviewed together on 5/17/23 at 11:45 a.m. The NHA said tracking for antidepressant medication was recorded on the resident's medication administration record. The NHA was unable to locate documentation on behavior or mood tracking for the resident or documentation the facility monitored the resident for medication effectiveness or for adverse reactions in regards to the antidepressant therapy. The NHA and DON stated they had observed the resident to have increased sleepiness. The DON stated the facility tracks hours of sleep and the documented information would be available for the physician to review during the psychotropic medication review committee.