Every finding on record at Arbor Trail Rehab and Skilled Nursing Center

Based on observation, interview, and record review, the facility failed to ensure food items were stored, labeled, and discarded according to professional standard of practice. Findings include: During an observation while conducting an initial tour of the kitchen on 4/27/2025 at 9:07 AM, there were three ready-to-eat chicken sandwiches wrapped in a bag with a date label reading 4/21, eight pieces of unpackaged meat wrapped together with no identifier label or date, two plates of salad containing lettuce, tomato, eggs and ham with a label dated 4/23 in the refrigerator. There were brown-stained bananas and one opened bag of pasta in the dry storage, and there was poultry stored in the freezer with no identifier label or date. During an observation while conducting the second tour of the kitchen on 4/28/2025 at 10:52 AM, there was a three-tiered kitchen cart obstructing the handwashing sink and eyewash station. The kitchen cart contained soiled oven mitts, an unlabeled and uncovered empty drinking cup, and a green bucket containing liquid and a rag. The green bucket was on the second tier of the cart, next to three bags of hamburger buns. During an interview on 4/28/2025 at 10:54 AM, Staff F, CDM, stated that the items were not permitted on the cart next to the hamburger buns, nor were they permitted to obstruct the handwashing sink. During an interview on 4/28/2025 at 2:00 PM, Staff F, Certified Dietary Manager (CDM), stated that the sandwiches dated 4/21 should have been discarded, the deteriorated salad and browned bananas should have been disposed of, and the open pasta bag and unlabeled/undated poultry were improperly stored. He also stated that the unpackaged meat in the refrigerator should have been labeled and kept in its original packaging. Review of the facility policy and procedure titled Food Storage Principles with the last review date of 4/16/2025 read, Purpose: To preserve food quality before and after food is prepared. Fundamental Information: Proper food storage is essential for preserving food quality. This applies to foods stored prior to preparation, and also to prepared foods (leftovers) that are placed in storage. Storage factors that impact the preservation of quality include holding period, temperature, and humidity. Procedure . 3. Label each package, box, can, etc. with date of receipt, and when the item was stored after preparation. a. Discard foods that have exceeded their expiration date. b. Discard leftover foods that have not been used withing 72 hours of preparation . 5. Keep food storages areas clean and free of spills and leaks.

Based on record review and interview, the facility failed to ensure the physician/prescriber documented the rationale for declining the pharmacist's recommendations for 2 of 5 residents reviewed for unnecessary medications, Residents #21, and #27. Findings include: Review of Resident #21's physician order dated 10/8/2024 read, Nitrofurantoin Macrocrystal Capsule 50 mg [milligram], Give 1 capsule by mouth in the morning for prophylactic ABT [Antibiotic] therapy . Status: Active. Review of Resident #21's medication regimen review showed the consultant pharmacist's recommendation dated 4/1/2025 that read, Comment: [Resident #21's name] has received nitrofurantoin for UTI [Urinary Tract Infection] prophylaxis since 10/2024. Recommendation: Please reevaluate and perhaps discontinue nitrofurantoin while monitoring for signs and symptoms of recurrent UTI. Rationale for Recommendation: The potential for developing pulmonary fibrosis, hepatotoxicity, C difficile infection, and peripheral neuropathy increases with duration of use . Physician's Response . I decline the recommendation(s) above and do not wish to implement any changes due to the reasons below. The form was signed by the physician on 4/4/2025 with no rationale documented. Review of Resident #27's physician order dated 11/13/2024 read, Megestrol Acetate Oral Suspension 40 MG/ML [milligram per milliliter] (Megestrol Acetate), Give 20 ml by mouth one time a day for appetite. Review of Resident #27's medication regimen review showed the consultant pharmacist's recommendation dated 11/15/2024 that read, Comment: (Issued on 11/15/2024) [Resident #27's name] receives megestrol for unintentional weight loss and does not have a diagnosis of AIDS. Recommendation: Please discontinue megestrol. Rationale for Recommendation: Megestrol is approved for anorexia, cachexia, or unexplained, significant weight loos in AIDS. In other populations, the risk may outweigh the benefit as it produces small increases in weight, and is associated with adverse consequences (e.g. thromboembolism). The physician's response read, MD [Medical Doctor] declined at this time. 11/15/24. The form did not include the physician's signature or rationale documented. Review of Resident #27's physician order dated 11/13/2024 read, Pantoprazole Sodium Oral Tablet Delayed Release 20 MG (Pantoprazole Sodium), Give 1 tablet by mouth one time a day for gerd [Gastro-esophageal Reflux Disease]. Review of Resident #27's physician order dated 3/7/2025 read, Sucralfate Oral Tablet 1 MG (Sucralfate), Give 1 tablet by mouth two times a day for ulcer prevention. Review of Resident #27's medication regimen review showed the consultant pharmacist's recommendation dated 3/3/2025 that read, Comment: [Resident #27's name] receives sucralfate in addition to another gastroprotective therapy, Pantoprazole Sodium for GERD. Sucralfate may reduce the effectiveness of other medications and require adjustments to the administration schedule. Recommendation: Please discontinue sucralfate . Physician's Response . I decline the recommendation(s) above and do not wish to implement any changes now due to the reasons below. The form was signed by Staff G, Nurse Practitioner (NP) on 3/7/2025 with no rationale documented. Review of Resident #27's physician order dated 2/24/2025 read, Propranolol HCl Oral tablet 10 MG (Propranolol HCl), Give 1 tablet by mouth every 12 hours for migraines notify MD if sbp [systolic blood pressure] below 110. Review of Resident #27's physician order dated 1/13/2025 read, Carvedilol Oral Tablet 25 MG (Carvedilol), Give 2 tablets by mouth two times a day for HTN [hypertension- high blood pressure] hold if SBP less than 100 or HR [heart rate] less than 60. Review of Resident #27's medication regimen review showed the consultant pharmacist's recommendation dated 4/1/2025 that read, Comment: [Resident #27's name] has orders for duplicate therapy: Propranolol Hydrochloride and Carvedilol- both contain beta-nonselective properties . Recommendation: Please reevaluated [Sic.] and discontinue where appropriate . Physician's Response . I decline the above recommendation(s) above and do not wish to implement any changes due to the reasons below. The form was signed by Staff G, Nurse Practitioner (NP) on 3/7/2025 with no rationale documented. During an interview on 4/29/2025 at approximately 2:30 PM, the Director of Nursing (DON) stated that physicians/prescribers should provide a rationale for not accepting the pharmacist's recommendations, but that they did not do so. Review of the facility policy and procedure titled Medication Regimen Review with the last review date of 4/16/2025 read, Procedure: 1. The consultant pharmacist will conduct MRRs [Medication Regimen Reviews] if required under a Pharmacy Consultant Agreement and will make recommendations based on the information made available in the residents' health record. 2. The facility and consultant pharmacist will follow guidance outlined in the CMS [Centers for Medicare and Medicaid Services] State Operations Manual Appendix PP and current practice guidelines, for the appropriate provision of pharmaceutical care . 9. Facility should encourage physician/prescriber or other responsible parties receiving the MRR and the director of nursing to act upon the recommendations contained in the MRR. 9.1 For those issues that require physician/prescriber intervention, facility should encourage physician/prescriber to either accept and act upon the recommendations contained within the MRR or reject all or some of the recommendations contained in the MRR and provide an explanation as to why the recommendation was rejected, as outlined in the State Operations Manual Appendix PP. 9.2 The attending physician should document in the residents' health record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. 9.2.1 If the attending physician/prescriber has decided to make no change in the medication, the attending physician should document the rationale in the residents' health record.

Based on interview and record review, the facility failed to ensure Minimum Data Set (MDS) assessments were accurate for 2 of 8 residents reviewed, Resident #16, and #21. Findings include: 1) During an interview on 4/27/2025 at 9:32 AM, Resident #16 stated she had never had pneumonia in the facility. Review of Resident #16's MDS assessment dated [DATE] showed the resident had pneumonia under Infections under Section I. Active Diagnoses. During an interview on 4/29/2025 at 10:00 AM, the Infection Preventionist confirmed that Resident #16 did not have pneumonia while in the facility. During an interview on 4/29/2025 at 11:02 AM, the MDS Registered Nurse stated, There is a discrepancy on [Resident #16's Name]'s most recent MDS dated on 3/25/2025 because [Resident #16's Name] didn't have pneumonia. I need to revise it. When asked for the facility policy, the MDS Registered Nurse stated, We do not have a policy. We follow the RAI [Resident Assessment Instrument). 50695 2) Review of Resident #21's physician order dated 10/8/2024 read, Nitrofurantoin Macrocrystal Capsule 50 mg [milligram], Give 1 capsule by mouth in the morning for prophylactic ABT [Antibiotic] therapy . Status: Active. Review of Resident #21's care plan read, Focus: [Resident #21's name] has an infection/ Colonization of MRSA of the urine [Sic.]. Date Initiated: 10/16/2024; Created on: 10/16/2024 . Revision on: 01/25/2025 . Interventions . Prophylactic medications as ordered. Review of Resident #21's MDS assessment dated [DATE] showed the resident was not taking antibiotics under Section N. Medications, N0415. High-Risk Drug Classes: Use and Indication. During an interview on 4/30/2025 at 9:40 AM, MDS RN stated, I know she takes a prophylactic antibiotic. She has since I've been here. The MDS is wrong. During an interview on 4/30/2025 at 9:50 AM, the DON stated that she expected the information entered on Resident #21's MDS assessment regarding antibiotic use to be accurate.

Based on observation, record review, and interview, the facility failed to ensure residents received intravenous (IV) therapy in accordance with professional standards of practice for 1 of 3 residents reviewed for IV medication administration, Resident #156. Findings include: During an observation on 4/28/2025 at 12:38 PM, Staff A, Licensed Practical Nurse (LPN), was preparing Resident #156's Peripherally Inserted Central Catheter (PICC) line on her upper right arm for administration of Meropenem Intravenous Solution Reconstituted 1 gram (Meropenem). Staff A sanitized and flushed the PICC line with 10 ml (milliliters) of normal saline and initiated Meropenem 1 gram antibiotic via infusion pump. Staff A did not check the patency of the line by aspiration for blood return to determine patency prior to flushing or administering medication. During an interview on 4/28/2025 at 12:38 PM, Staff A, LPN, stated, We do not have to aspirate prior to flushing unless there is a physician order to do so. We just flush with saline first and then give the medications as ordered. During an interview on 4/28/2025 at 12:43 PM, the Assistant Director of Nursing stated, The PICC line must be checked for patency by aspiration of blood prior to flushing with normal saline and before administering medication via the line. During an interview on 4/28/2025 at 1:52 PM, the Director of Nursing stated, We should be aspirating prior to flushing to make sure the line is patent. We follow the SASH [Saline flush, Administer medication, Saline flush, and Heparin flush] method. Review of the facility policy and procedure titled Administration of an Intermittent Infusion with the last review date of 4/16/2025 read, Procedure . 16. Maintaining asepsis, attach flush syringes to needleless connector. Aspirate the catheter to obtain positive blood return to verify vascular access device patency. Flush with prescribed flushing agent. Remove syringe.

Based on observation and interview, the facility failed to ensure the nurse staffing information was posted on a daily basis (Photographic evidence obtained). Findings include: During an observation on Sunday, 4/27/2025 at 9:02 AM, the facility's nurse staffing information was posted on the receptionist desk with a date of Friday, 4/25/2025 on it. During an interview on 4/27/2025 at 10:10 AM, the Administrator stated that the nurse staffing report needed to be updated daily.

Based on observation, interview, and record review, the facility failed to ensure that drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principles in 3 of 4 medication carts. Findings include: During an observation of 400 Hall Medication Cart on [DATE] at 9:18 AM with Staff B, Licensed Practical Nurse (LPN), there were one opened bottle of Timolol Maleate Ophthalmic Solution 0.5% eye drops for Resident #77 with no opened or expiration dates and one opened bottle of Latanoprost 0.005% eye drops for Resident #47 with no opened or expiration dates. During an interview on [DATE] at 9:23 AM, Staff B, LPN, stated, There is no open date or expiration date written on the eye drops. When the eye drops are opened, the date opened and the expiration date are written on the bottle. The eye drops expire in 28 days. During an observation of 300 Hall Medication Cart on [DATE] at 9:29 AM with Staff C, LPN, there was one opened Insulin Lispro 100 unit/ml (milliliter) Pen for Resident #65 with an expiration date of [DATE]. During an interview on [DATE] at 9:30 AM, Staff C, LPN, stated, The insulin is expired and should have been thrown away and replaced. During an observation of 100 Hall Medication Cart on [DATE] at 9:41 AM with Staff D, LPN, there were one bottle of Latanoprost 0.005% eye drops for Resident#16 opened on [DATE] and expired on [DATE], one bottle of Latanoprost 0.005% eye drops for Resident #14 with opened date of [DATE] and expiration date of [DATE], and one Novolog 100 unit/ml Flex pen for Resident #68 opened on [DATE] and expired on [DATE]. During an interview on [DATE] at 9:44 AM, Staff D, LPN, confirmed that the eye drops for Resident #16 and Resident #14 and insulin pen for Resident #68 were expired. During an interview on [DATE] at 9:58 AM, Staff E, LPN, Unit Manager, stated, Eye drops expire 30 days after they are opened, and insulin expires 28 days after it is removed from the refrigerator and opened. The Medications are to be removed from the cart returned to the pharmacy for destruction when they are expired. During an interview on [DATE] at 7:18 AM, the Director of Nursing stated, All medications are to have an open date and expiration date written on the medication and they are to be removed from the cart and disposed of properly when expired. Review of the facility policy and procedures titled 5.3 Storage and Expiration Dating of Medications, Biologicals with the last revision date of [DATE] read, Applicability: This Policy 5.3 sets forth the procedures relating to the storage and expiration dates of medications, biologicals, syringes and needles Procedure . 4. Facility should ensure that medications and biologicals that: (1) have an expired date on the label; (2) have been retained longer than recommended by manufacturer or supplier guidelines; or (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the pharmacy or supplier. 5. Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the primary medication container (vial, bottle, inhaler) when the medication has a shortened expiration date once opened or opened 5.4. When an ophthalmic solution or suspension has a manufacturers shortened beyond use date once opened, facility staff should record the date opened and the date to expire on the container.

Based on observation, record review, and interview, the facility failed to ensure staff followed practice standard for infection prevention and control during medication administration to prevent the possible spread of infection and communicable diseases for 2 of 6 residents reviewed for medication administration, Residents #243 and #7. Finding include: During an observation on 2/6/2024 at 6:48 AM, Staff G, Licensed Practical Nurse (LPN), completed blood sugar monitoring using glucose meter for Resident #73. Staff G did not sanitize the glucose meter before or after use and returned the glucose meter back into the medication cart. During an interview on 2/6/2024 at 6:48 AM, Staff G, LPN, stated, It's my first day on the floor by myself and the glucose meter should be cleaned before and after each patient with the bleach wipe. During an observation on 2/6/2024 at 8:30 AM, Staff H, LPN, popped Carvedilol tablet 6.25 mg (milligram) and Furosemide tablet 20 mg for Resident #243 into her bare non-gloved hand and placed the medication in the medication cup. Staff H proceeded to administer the medication to Resident #243. Then, Staff H injected Humalog solution 100 unit/ml (milliliter) into Resident #243's right upper arm subcutaneously. Staff H did not sanitize the skin with an alcohol pad prior to injection. Staff H proceeded to prepare medications for Resident #7 and popped one Morphine Sulfate oral tablet 30 mg into her bare non-gloved hand and placed the pill into the medication cup. Staff H administered the medication to Resident #7. During an interview on 2/6/2024 at 8:42 AM, Staff H, LPN, stated, I know I shouldn't touch them, but my nails get in the way. I was taught in school that I was supposed to clean the site before any injection of medications. During an interview on 2/6/2024 at 11:35 AM, the Director of Nursing stated, The expectation is for the pills to be popped directly into the medication cup to prevent contamination and prior to administering injection medication the site is to be cleaned with alcohol pad to prevent infection. Blood glucose meters must be cleaned before and after each resident use with germicidal wipes. Review of the guideline provided by the facility titled Guidelines for Cleaning and Disinfecting Blood Glucose Meter read, Procedure Steps 1-5 . 5. Disinfecting the Blood Glucose Meter (Before & after each use). Disinfect the meter with a germicidal wipe (Wrap in Wipe for 3 full minutes). Review of the facility policy and procedures titled Med Pass with Medication cart revised on 12/21/2023 read, Procedure . 11. Prepare the medication . b. Pour the prescribed dosage(s) from the container and place in a souffle cup or calibrated liquid measure cup.

Based on observation, interview, and record review the facility failed to ensure residents receive respiratory care services for oxygen administration consistent with professional standards of practice for 4 of 5 residents reviewed for respiratory care, Residents #195, #61, #82, and #32 in a total sample of 33 residents. Findings include: 1) During an observation conducted on 8/22/2022 at 11:04 AM, Resident #195 was observed resting in bed with the head of his bed flat with 4 liters of oxygen being administered through a nasal cannula connected to an oxygen concentrator. The oxygen humidification bottle was empty and not dated. Review of the medical record documented Resident #195 was admitted to the facility on [DATE] with the following diagnoses, COVID-19 [CONDITION(S)] pneumonia, liver [CONDITION(S)], liver cell cancer, [CONDITION(S)] [CONDITION(S)], [CONDITION(S)], chronic kidney disease, major depressive disorder, essential (primary) hypertension, [CONDITION(S)], and status post [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation conducted on 8/23/2022 at 12:03 PM, Resident # 195 was observed resting in bed with oxygen running at 4 liters through a nasal cannula connected to an oxygen concentrator. During an observation conducted on 8/24/2022 at 7:15 AM Resident #195 was observed resting in bed with oxygen being administered at 4 liters through a nasal cannula connected to an oxygen concentrator. During an interview conducted on 8/24/2022 at 7:20 AM Staff D, Licensed Practical Nurse (LPN) stated, His oxygen is set at 4 liters and that seems kind of high. Let me see what he is supposed to be set at. He should have 2 liters of oxygen running. I will usually check what oxygen is at when I give residents their medications and I just haven't had time to do his meds yet. During an interview conducted on 8/24/2022 at 11:30 AM the Director of Nursing (DON) stated, I expect that nurses will check the amount of oxygen that is running at least when they administer their medications if not more frequently. Review of Policy and Procedure titled, Oxygen Administration via Concentrator approval date 2/28/2022 reads, Purpose: To deliver oxygen to the resident using an oxygen concentrator. A licensed nurse or respiratory care practitioner performs this procedure. Procedure: Setting up the concentrator: 2. Turn to proper flow rate as ordered by the physician. Check the concentrator to assess the maximum flow rate. 2) An observation on 08/22/22 at 10:30 AM showed resident #61 was being administered oxygen at 2 liters/min via nasal cannula. There was no date on the oxygen tubing. An observation on 8/24/2022 at 1:10 PM showed resident #61 was not being administered oxygen. The resident was seated alone in the common area at the end of the East hallway. The oxygen tubing was not dated. During an interview on 8/24/2022 at 1:11 PM Resident #61 stated the facility turned my oxygen off yesterday and told me that they could not give me oxygen until they got permission from the doctor. I need my oxygen. During an interview on 8/24/2022 at 1:51 PM Staff D, LPN stated, I was verbally told this resident's oxygen is as needed. Something happened yesterday and she needed oxygen. I see the order has the oxygen as routine at 3 liters dated 7/19/2022. The residents do not have paper charts. The oxygen tubing does not have a date because whoever changed the tubing did not put a date on the tubing. During an interview on 8/24/2022 at 2:00 PM Staff J, LPN stated, Until today the resident's oxygen order was for 2 liters per nasal cannula routine. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 3) An observation on 08/22/22 at 11:37 AM showed the oxygen concentrator was set at 4 liters/min being administered via nasal cannula for Resident #82. The oxygen tubing was dated 8/8/2022. The nebulizer mask was on the bed uncovered/not bagged and was dated 8/8/2022. Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation on 8/23/2022 at 8:18 AM showed Resident #82 was sitting in a chair eating breakfast. The resident was being administered oxygen via nasal cannula at 4 liters/minute. During an Interview with Resident #82 on 8/23/2022 at 8:20 AM she said, I use 4 liters at night and 3 liters in the daytime, that is too high for me. Resident stated she does not adjust the oxygen rate, I do not touch that, the nurses do. During an interview on 8/24/2022 at 1:38 PM Staff B, LPN stated, The oxygen gets turned up with the [CONDITION(S)] [continuous positive airway pressure] and sometimes it doesn't get turned back down to the liters as ordered by the doctor. The night shift nurses are supposed to label the oxygen tubing Review of the medical record for Resident #82 documented the resident was admitted on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Monitor oxygen saturation and temperature every shift. Notify provider if temperature > [greater than] 100.4, and O2 [oxygen] saturation of < [less than] 98%. Review of the daily temperatures and daily oxygen saturation for the period of 7/30/2022 to 8/23/2022 documented the following: Oxygen Saturation: 7/31/2022 at 22:34 [10:34 PM] of 90%. 8/1/2022 at 21:39 [9:39 PM] - 97%. 8/2/2022 at 21:28 [9:28 PM] - 97%. 8/3/2022 at 07:34 AM and 10:34 AM - 92%, at 21:19 [9:19 PM] - 94%. 8/4/2022 at 07:48 AM - 91%, and at 14:20 [2:20 PM] at 92%. 8/6/2022 at 11:32 - 95%. 8/7/2022 at 20:20 [8:20 PM] - 95%. 8/8/2022 at 22:02 [10:02 PM] - 97%. 8/9/2022 at 07:20 AM and at 07:35 AM - 96%. 8/10/2022 at 10:45 AM - 95%, and at 22:02 [10:02 PM] - 92%. 8/11/2022 at 12:17 PM - 96%, and at 21:08 [9:08 PM] - 95%. 8/12/2022 at 07:23 - 92%, 22:46 [10:46 PM] and 23:55 [11:55 PM] - 97%. 8/14/2022 at 01:00 AM, 07:30 AM and 13:12 [1:12 PM] - 97%. 8/15/2022 at 21:32 [9:32 PM] - 92%. 8/16/2022 at 07:52 AM - 97%, and 22:29 [10:29 PM] - 96%. 8/17/2022 at 19:47 [7:47 PM] - 94%. 8/20/2022 at 11:29 AM - 92%. 8/22/2022 at 07:11 AM - 95%, and at 21:07 [9:07 PM] - 97%. 8/23/2022 at 07:11 AM - 97%. Review of Resident #82's medical record did not contain documentation of the physician having been notified of the oxygen saturations per the physician order. 4) Review of Resident #32's medical record documented the resident was admitted on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 8/22/2022 at 9:32 AM of Resident #32's room it showed the resident's nebulizer mask was on top of the bedside dresser, uncovered and dated 7/25/2022. At the bedside is a concentrator with a nasal canula tubing hanging in the drawer of the bedside dresser, uncovered and dated 7/25/2022. During an interview with Resident #32 and Resident #32's spouse on 8/22/2022 at 9:33 AM he stated, I use the oxygen at night. During an observation on 8/23/2022 at 8:35 AM it showed Resident #32's oxygen and nebulizer tubing continue to be uncovered and dated 7/25/2022. During an interview on 8/23/2022 at 9:26 AM the East Wing Unit Manager confirmed Resident #32's oxygen tubing and nebulizer mask are dated 7/25/2022 and uncovered. The Unit Manager stated, The tubing is supposed to be changed every Sunday by the night nurses, the tubing must be dated and covered. During an observation on 8/23/2022 at 1:30 PM it showed Resident #32's oxygen tubing and nebulizer mask are dated 7/25/2022. During an interview on 8/23/2022 at 1:30 PM Resident #32's spouse stated, I wished they would put the mask and nasal cannula in a bag because he uses them to put on his face. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Change oxygen tubing every Sunday (11PM - 7 AM). Order dated 8/3/2022 reads, [MEDICATION(S)]-[MEDICATION(S)] solution 0.5 - 2.5 3mg/3 ml [3 milligrams/3 milliliters], 3 ml. inhale orally every 6 hours as needed for oxygen saturation < 88% via Nebulizer. Review of Resident #32's treatment administration record (TAR) from July 1 through July 31, 2022, revealed respiratory oxygen tubing and nebulizer mask were not changed throughout the month of July 2022. Review of Resident #32's treatment administration record from August 1 through August 24, 2022, revealed respiratory oxygen tubing and nebulizer mask were marked X all throughout August indicating the tubing and mask were not changed. During an interview with the Director of Nursing on 8/24/2022 at 3:00 PM stated, We do not have a policy specific to changing of respiratory tubing, we based it on doctors' orders.

Based on observation, interview and record review the facility failed to provide care for central venous access devices in accordance with professional standards of practice for 1of 1 resident with a central venous access device, in a total of 36 residents, Resident #194. Findings include: During an observation of Resident #194 conducted on 8/22/2022 at 10:30 AM Resident #194 was observed sitting in a wheelchair, there was a left upper arm midline catheter with a 2 x 2 gauze that covered the insertion site of the catheter, under a transparent dressing that was dated 8/16/2022. During an interview conducted on 8/22/2022 at 10:30 AM Resident #194 stated, I got that [right midline catheter] put in, in the hospital, they have not changed the dressing on that since I was in the hospital. During an interview conducted on 8/22/2022 at 10:30 AM Staff C, Licensed Practical Nurse (LPN) stated, [Resident #194's name] has one more dose of IV [intravenous] antibiotics, she has a midline, the dressing is within date and doesn't need to get changed. I see the gauze under the dressing. During an observation of Resident #194 conducted on 8/22/2022 at 1:45 PM Resident #194 was observed sitting in bed with a left upper arm midline catheter with 2x2 gauze under a transparent dressing dated 8/16/2022. Review of the medical record documented that Resident #194 was admitted to the facility on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Change catheter dressing, change securement device q [every] week every day shift every Wednesday. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation of medication administration conducted on 8/23/2022 at 12:15 PM Staff C, LPN was observed administering 10 milliliters of 0.9% normal saline flush to Resident #194's midline catheter. Staff C, LPN cleaned the needleless connector with alcohol and immediately administered the normal saline. Staff C did not let the needleless connector dry or verify line placement (by checking for blood return) prior to administering the medication. During an interview conducted on 8/23/2022 at 12:25 PM Staff C, LPN stated, I did clean the connector, but should have verified placement. I did not let the needleless connector dry before administering the saline. During an observation of medication administration conducted on 8/24/2022 at 8:20 AM Staff B, LPN, cleaned Resident #194's needleless connector for three seconds and administered 10 milliliters of normal saline intravenously. Staff B did not let the needleless connector dry or verify line placement before administering the medication. During an interview conducted on 8/24/2022 at 8:25 AM Staff B stated, I should have cleaned the hub (needleless connector) longer, I should have let it dry, and checked for blood before administering the normal saline. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the treatment administration record documented no midline catheter dressing changes and no measurements for the external catheter length. Review of the nursing admission assessment documented no midline catheter and no measurements for the external catheter length. During an interview conducted on 8/24/2022 at 11:30 AM the Director of Nursing (DON) stated, There is no documentation of the midline catheter or measurements on the nursing admission assessment and there should be. There are no measurements documented according to the orders. The dressing was changed on 8/22/2022, but should have been changed on admission if it had gauze under the dressing. Review of the policy and procedure titled, Midline Catheter Dressing Change with an approval date of 2/28/2022 reads, Considerations: 1. The catheter insertion site is a potential entry site for bacteria that may cause a catheter- related infection. Guidance: 1. Sterile dressing change using transparent dressings is performed: 1:1 Upon admission. 2. When a transparent dressing is applied over a sterile gauze dressing it is considered a gauze dressing and is changed: 2:1 upon admission, 2.2 every 2 days. 6. Assessment of the vascular access site is performed: 6.1 upon admission and during dressing changes. 8. Length of the external catheter is obtained: 8.1 upon admission. 8.2 During dressing changes. 9. Arm circumference (10 cm above the antecubital fossa) is obtained: Upon admission, then weekly. 9.4 Compare to baseline measurement to detect possible catheter - associated venous thrombus: a 3 cm increase in arm circumference and [CONDITION(S)] were associated with upper arm [CONDITION(S)]. Reivew of the policy and procedure titled, Midline Catheter Flushing and Locking with an approval date of 2/28/2022 reads, Considerations: 4. Needless connectors require vigorous cleansing with alcohol prior to accessing to reduce the risk of catheter-related bloodstream infection. Guidance: 6. catheter patency must be verified prior to each medication administration. To assess patency, aspirate the catheter to obtain positive blood return. The aspirated blood should be the color and consistency of whole blood.

Based on record review and interview the facility failed to complete a discharge summary to include a recapitulation of the resident's stay for 1 of 3 residents, Resident #90, sampled for closed record reviewed. Findings include: Review of Resident #90's record revealed documentation the facility had stopped billing for Resident #90 on 8/1/2022. Review of Resident #90's progress note, dated 8/1/2022, revealed Resident #90 was discharged to an assisted living facility with an effective date of 8/1/2022 at 5:57 PM. Review of Resident #90's discharge records failed to reveal documentation the facility completed a discharge summary to include a recapitulation of stay for Resident #90. During an interview on 8/24/22 at 7:55 AM, the Director of Nursing reported the facility was unable to locate a discharge summary for Resident #90. During an interview on 8/24/22 at 9:04 AM, the Administrator confirmed the facility was unable to find a discharge summary related to Resident #90's discharge that contained a recapitulation of stay. Review of the facility policy titled Transfer and Discharge, last reviewed 2/28/2022, showed the policy read Discharge summary: When the facility anticipates discharge a resident must have a discharge summary that includes, but is not limited to, the following: a. A recapitulation of the resident's stay that includes, but is not limited to: diagnosis, course of illness, treatment &/or [and/or] therapy, and pertinent lab, radiology, and consultation results.

Based on observation and interview the facility failed to ensure appropriate treatment and services to prevent the possibility of urinary tract infection for 1 of 3 residents observed for indwelling foley catheters, Resident #77. Findings include: Review of the medical record documented Resident #77 was admitted to the facility on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Nursing Care plan reads, Ensure proper positioning of drainage tube at all times, keep drainage bag below the level of the bladder. During an observation conducted on 8/24/2022 at 7:35 AM Resident #77 was resting in bed, there was an indwelling urinary catheter bag observed on the left side of the bed lying on the floor. During an interview conducted on 8/24/2022 at 7:35 AM Resident #77 stated, My catheter hurts. During an interview conducted on 8/24/2022 at 7:53 AM Staff E, Certified Nursing Assistant (CNA) stated, I have not been in her room yet. I will check residents when I am doing rounds. Catheter bags should not be on the floor.

Based on interview and record review, the facility failed to ensure the medical record for 1 of 3 residents, Resident #55, reviewed for nutrition was complete. Findings include: Record review of Resident #55's care plan, date Initiated 02/01/21, documented Resident #55 was at risk for decreased nutritional status and dehydration related to a history of COVID-19, dysuria, cough, and difficulties with swallowing. Resident #55's care plan documented nutritional interventions to include Monitor PO [by mouth] intakes. Record review of Resident #55's Point of Care Response History for Eating Meal Percentage dated 7/26/22 - 8/23/22, failed to reveal completed documentation of the intake amounts Resident #55 consumed at each meal. Resident #55's meal intake was not recorded on 2 of 28 days, was recorded for 1 of 3 meals for 15 of 28 days and was recorded for 2 of 3 meals for 10 of 28 days. During an interview on 8/24/2022 at 8:32 AM, Staff A, Licensed Practical Nurse/West Unit Manager confirmed staff should be recording Resident #55's meal intake percentages for three meals a day. During an interview on 8/24/2022 at 10:28 AM, the Director of Nursing stated Resident #55's meal intake data had not been recorded for each meal. During an interview on 8/24/2022 at 11:40 AM, the Director of Nursing reported the facility did not have a policy specific to documentation.

Based on observation, interview and record review the facility failed to ensure posted staffing information was accurate and current on 2 of 4 residential halls and in the lobby. Findings include: During the initial tour conducted on 8/22/2022 at 9:05 AM upon arrival into the building the staffing posted in the front lobby receptionist desk was dated 8/19/2022. During a tour conducted on 8/22/2022 at 9:15 AM of the west wing the posted staffing on the large white dry erase board was dated 8/20/2022. During an observation on 8/22/2022 at 10:45 AM, the staffing posted in the lobby at the receptionist's desk was dated 8/19/2022. During an interview conducted on 8/21/2022 at 10:50 AM the Administrator stated, The posted staffing is not correct. It was last posted three days ago and should be updated. Review of the policy and procedure titled, Nursing Scheduling/Staffing/Posting with an approval date of 2/28/2022 reads, 5. Posted staffing information & Retention a. Data requirements: The facility must post the following information on a daily basis: 1) Facility name, 2) the current date, 3) The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: b. Posting requirements: The facility must post the nurses staffing data specified above on a daily basis at the beginning of each shift. Data must be posted as follows: Clear and readable format. In a prominent place readily accessible to residents and visitors.

Based on observation, record review, and interview, the facility failed to ensure the facility stored food in accordance with professional standards for food service safety. The facility also failed to ensure proper sanitation measures, by following their policies, were maintained in the kitchen regarding cleanliness of large equipment. Findings: A tour of the kitchen with the Certified Dietary Manager (CDM) on 3/1/2021 beginning at 9:00 AM showed a large box of tomatoes, approximately 50, were observed in the walk-in cooler. The tomatoes had dark black spots on them. Some of the tomatoes with dark black spots had a white furry substance growing on them. The box was completely open on the top with no covering. There was no marking or other notification the tomatoes were not edible, waiting to be destroyed, or to be removed. Further observation of the kitchen showed a deep fryer vat with dark brown oil and debris. It was cool to the touch. The oil was so dark. It did not allow visualization to determine what food substance chucks were in the oil. The front of the fryer had oil and grease with debris covering the outside (Photographic Evidence Obtained). During an interview on 3/1/2021 at 9:15 AM, the Certified Dietary Manager confirmed a large number of the tomatoes stored in the walk-in cooler had black spots with a white furry substance growing on them, and the oil fryer was filled with dark brown oil containing debris, and food substance chunks. She stated they were not sure when the fryer was last used but it needed to be cleaned on the basis of use and need. The tomatoes should be thrown out. She confirmed there was no direction or notification on the box for the staff to know the condition of the tomatoes and the plan for them. She stated, the tomatoes just came in last Thursday. Review of the facility policy number 0303.002 titled Disposal of Spoiled Foods, approved on 12/19/2019, read, Procedure: 1. Fresh produce that has an unpleasant odor or signs of insect infestation, has cuts, mushiness, discoloration, or is wilting will be discarded immediately. Review of the facility policy number 04.037 titled Fryers, approved on 12/13/2019, read, Policy: The facility will maintain deep fryers in a clean and sanitary condition.

Based on observation, interview, and record review, the facility failed to ensure respiratory care, specific to oxygen therapy, was provided consistent with professional standards of practice and the comprehensive person-centered care plan for 2 of 6 sampled residents, Residents #11 and #21, in a total sample of 37 residents. Findings: 1. Review of Resident #11's medical records revealed a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #11's physician's order dated 4/30/2020 revealed an order for [REDACTED]. On 3/1/2021 at 10: 02 AM, Resident #11 was observed being administered oxygen via nasal cannula attached to a concentrator at 0.5 liters per minute (LPM). On 3/1/2021 at 1:20 PM, Resident #11 was observed being administered oxygen at 0.5 LPM via nasal cannula attached to an oxygen concentrator. On 3/2/2021 at 8:18 AM, Resident #11 was observed up in a wheelchair being administered oxygen via nasal cannula. The oxygen concentrator was set at 0.5 LPM. On 3/2/2021 at 12:32 PM, Resident #11 was observed up in a wheelchair being administered oxygen via nasal cannula attached to a portable oxygen cylinder behind the wheelchair. The portable oxygen cylinder was in the off position. During an interview on 3/2/2021 at 12:32 PM, Resident #11 stated, I get short of breath sometimes. I get easily short of breath when I am up. On 3/2/2021 at 12:38 PM, during observation of the setting on the oxygen concentrator with Staff B, Licensed practical Nurse (LPN), Unit Manager, she confirmed the oxygen concentrator was set at 0.5 LPM and confirmed the physician's order read for oxygen to be administered at 2 LPM. Staff B obtained Resident #11's oxygen saturation and it showed 93 - 94% while the resident was being administered oxygen at 0.5 LPM. During an interview on 3/2/2021 at 12:39 PM, Staff B, LPN, Unit Manager, stated, The primary nurse is responsible for checking the concentrator setting on a daily basis. Review of Resident #11's care plan read, Resident is on oxygen related to impaired gas exchange. Interventions include: Monitor for S/S (sign and symptoms) of respiratory distress, respiration, pulse oximetry, increased heart rate, restlessness, diaphoresis, headaches, lethargy, confusion, atelectasis, hemoptysis, cough, pleuritic pain, accessory muscle usage, skin color. Oxygen as ordered. Position resident to facilitate ventilation/perfusion matching. 2. Review of Resident #21's medical records revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #21's physician's orders read, Oxygen via nasal cannula 2 liters per minute PRN (as needed) for shortness of breath. On 3/1/2021 at 11:02 AM, Resident #21 was observed in bed, with the head of bed being elevated, and the resident was being administered oxygen at 3.5 LPM via nasal cannula. During an interview on 3/4/2021 at 9:00 AM, Staff F, Registered Nurse (RN), confirmed Resident #21 had been administered oxygen via nasal cannula at 3.5 LPM and was ordered for 2 LPM as needed. Review of the facility policy number SHCRC .02 titled Oxygen Administration, revised on 5/22/2018, read, Purpose: A resident will need oxygen therapy when hypoxemia (low oxygen in blood) occurs . Procedure: 1. Check physician's order . 11. Turn the unit to the desired flow rate and assess equipment for proper functioning. Review of the facility policy number SHCO .04 titled Physician Orders, revised on 10/24/2017, read, Purpose: Physician orders are obtained to provide a clear direction in the care of the resident.

Based on observation, record review, and interview, the facility failed to maintain an infection prevention and control program to provide a safe and sanitary environment and to help prevent the possible development and transmission of communicable diseases and infections. The facility failed to ensure the staff performed hand hygiene and prevented the contamination of a clean wound dressing field while performing wound care for 2 of 3 residents, Residents #43 and #21, in a total sample of 37 residents. The facility stored a urine specimen in the active use medication storage room refrigerator. Findings: 1. Review of Resident #43's medical records revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. On 3/3/2021 beginning at 11:17 AM, Staff F, Registered Nurse (RN), was observed entering Resident #43's room with Staff G, Certified Nursing Assistant (CNA). Staff F placed a towel on the bedside table and placed the clean dressing supplies on the towel barrier. Staff F doffed her gloves, performed hand hygiene, donned gloves and removed the soiled dressing from the resident's sacral area. Staff F performed hand hygiene, donned gloves, cleansed the open wound area with pre-soaked normal saline gauze three times, patted the area dry, and placed the contaminated/soiled gauze on the clean field next to the clean wound dressings. Staff F applied skin prep around the peri-wound, using two skin prep pads. Staff F placed the used skin prep pads on the clean wound dressing field. During an interview on 3/3/2021 at 11:35 AM, Staff F, RN, confirmed she placed the contaminated gauze and used skin prep pads on the clean dressing field next to the clean dressing items. Staff F stated, I should have put them in the trash can. 2. Review of Resident #21's medical records revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The physician order read, Cleanse open area to sacrum with normal saline, apply [MEDICATION NAME] calcium alginate and cover with foam dressing. During an observation of wound care conducted with Staff F, Registered Nurse (RN), on 3/3/2021 at 1:15 PM, Staff F assembled the supplies to perform the sacral wound dressing change. Staff F did not perform hand hygiene, donned gloves, entered the resident's room, placed the supplies on a barrier on the bedside table and assisted the resident to reposition for the wound care to be done. The resident had a bowel movement. Staff F doffed her gloves, did not perform hand hygiene, donned a new pair of gloves and cleaned the resident. Staff F doffed her gloves, did not perform hand hygiene, donned a new pair of gloves, and removed the resident's soiled wound dressing. Staff F doffed her gloves, performed hand hygiene, donned new gloves, and cleansed the wound bed with gauze, using the same gauze. Staff F cleansed the wound bed again. Staff F got another gauze and cleansed the wound bed twice with that gauze. Staff F doffed her gloves, did not perform hand hygiene, donned a new pair of gloves, and applied [MEDICATION NAME] (used to promote a moist wound environment that aids and supports the body's enzymes and natural fluids to soften bad tissue to swell and separate from the wound) to two Q tip swabs and applied the [MEDICATION NAME] to the wound bed. Staff F applied more [MEDICATION NAME] to the same Q tip swabs and applied it to the wound bed. Staff F applied the foam dressing to the wound, doffed her gloves and performed hand hygiene. During an interview on 3/3/2021 at 1:35 PM, Staff F, RN, stated, I don't know why I didn't wash my hands after each time I removed my gloves. I thought that when I got the [MEDICATION NAME] a second time that I turned the swabs around, but I didn't. I should not have used the swabs twice. I should have used a whole new one. During an interview on 3/4/2021 at 07:30 AM, the Director of Nursing stated, All staff should perform hand hygiene per our wound care policies and procedures. Review of the facility policy #SHCRC .07 titled Clean Dressing Change, revised on 11/28/2017, read, Procedure: . 10. Clean bedside table with germicidal wipe to ensure clean field . 14. Set up supplies on barrier . 15. Position resident for comfort and that allows access to wound. 16. Perform hand hygiene. 17. Don gloves . 19. Remove used dressing and place in resident's trash can. 20. Remove gloves. 21. Perform hand hygiene 22. Don gloves. 23. Cleanse wound as ordered with single outward [MEDICAL CONDITION] and using separate gauze for each cleansing wipe. 24. Use dry gauze or other ordered supply to pat the wound dry. 25. Discard any used gauze for cleaning/drying in resident's trash can as needed. 26. Remove gloves. 27. Perform hand hygiene. 28. Don gloves. 29. Apply clean dressing as ordered. Review of the facility policy #SHCO .04 titled Hand Washing/Hygiene, revised on 6/5/2019 read, Policy: The facility considers hand hygiene the primary means to prevent the spread of infections and provides guidance to perform hand hygiene. This policy is in accordance with national standards from the Centers of Disease Control and Prevention and the World Health Organization . Proceudre: 1. Soap and water is required for hand hygiene when: . b. after potential exposure to body fluid . 2. Alcohol-based hand rub may be used for all other hand hygiene (e.g. when soap and water is not aindicated per #1 above). According to the World Health Organization, hand hygiene is to be performed: . c. When moving from a contaminated body site to a clean body site, such as when changing a brief or wound dressing. d. After caring for a resident including after removing gloves . 3. The Centers for Medicare and Medicaid State Operations Manual indicates that hand hygiene should be performed: . e. Before and after assisting resident with personal care . h. Before and after changing a dressing . o. After removing gloves or aprons . 4. Hand hygiene is the final step after removing and disposing of personal protective equipment. 5. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is the recognized as the best practice of preventing health care associated infections. 3. On 3/1/2021 at 1:45 PM, a resident's urine sample was observed in the clean medication storage room in the medication refrigerator in the West Wing medication storage room. During an interview on 3/1/2021 at 1:45 PM, the West Wing Unit Manager stated, The urine samples are supposed to be in the dirty utility room refrigerator and not in the medication storage room refrigerator. Review of the facility policy #5.3 titled Medication Storage and Expiration, Dating of Medications, Biologicals, Syringes, and Needles, effective 12/1/2007, last revised on 10/28/2019, read, 9. Facility should ensure that resident medication and biological storage areas are locked and do not contain non-medication/biological items.

Based on observation, interview, and record review, the facility failed to implement a comprehensive care plan for 1 of 3 residents reviewed for wound care, Resident #21, in a total sample of 37 residents. Findings: Review of Resident #21's facility medical records revealed the resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident #21's physician's orders [REDACTED]. An order dated 10/5/2019, read, TED ([MEDICAL CONDITION]-[MEDICAL CONDITION] Deterrent; used to help prevent blood clots and swelling in the legs) hose bilateral lower extremities on in the AM (morning) off at HS (hour of sleep) [MEDICAL CONDITION] control. Review of Resident #21's care plan read, Impairment to skin integrity related to pressure wound to coccyx, open area to right heel, wound to upper right, TED hose on in AM and off at HS (Hours of Sleep). At risk for impaired skin integrity related to immobility off load pressure areas. On 3/2/2021 at 12:14 PM, Resident #21 was observed resting quietly on his back in bed. The resident did not have heel protectors or TED hose on the resident. On 3/3/2021 at 7:51 AM, Resident #21 was observed resting quietly on his back in bed. No heel protectors or TED hose was observed on the resident. On 3/3/2021 at 9:32 AM, Resident #21 was observed sitting up in a wheelchair. No TED hose was observed on the resident. On 3/3/2021 at 11:32 AM, Resident #21 was observed sitting in a wheelchair. He did not have TED hose on. During an interview on 3/2/2021 at 3:20 PM, Staff E, Certified Nursing Assistant (CNA), stated, I don't think he has heel protectors ordered to be on him. I will check. During an interview on 3/3/2021 at 1:35 PM, Staff F, Registered Nurse (RN), stated, I see the order for TED hose, but he has not had them on. He should have them on according to the doctor's orders. During an interview on 3/4/2021 at 07:30 AM, the Director of Nursing stated, I expect that if TED hose or heel protectors are ordered by a physician that the staff place them on according to the orders.

Based on observation, interview, and record review, the facility failed to perform hand hygiene and follow appropriate infection prevention and control practices for 1 (#231) of 7 residents observed for medication administration out of a total of 27 medication opportunities. Findings: During the medication observation on 7/29/2019 at 10:00AM, Staff A, Licensed Practical Nurse (LPN) was observed disconnecting Intravenous (IV) antibiotic medication to Resident # 231 Peripherally Inserted Central Catheter (PICC) line. The nurse was observed donning gloves and dropped the empty IV bag in the trash and pressed it down with her gloved hand. Without changing gloves or washing hands the nurse proceeded to flush the PICC line. The nurse was then observed inserting the flush syringe into the PICC line connector before cleaning the connector with alcohol. In an interview on 7/29/2019 at 10:00AM, Staff A, confirmed she should have changed gloves and washed her hands prior to flushing the PICC line. She also confirmed that she should have cleaned the resident's PICC line connector with alcohol prior to flushing the line. Record review of the Facility's Central Vascular Access Device Flushing and Locking Policy, last Revision dated, (MONTH) 1, (YEAR), Number 5 under Considerations states, Needleless connectors require vigorous cleansing with alcohol prior to accessing to reduce the risk of catheter related bloodstream infection. Number 7 under Procedure states, Vigorously cleanse needleless connector with alcohol. Allow to air dry. Record review of Facility's Handwashing Policy, Revised 6/5/2019, Number 3 states, The Centers for Medicare and Medicaid State Operations Manual indicates that hand hygiene should be performed Before and after handling peripheral vascular catheters and other invasive devices.

Based on observation, record review and interview the facility failed to ensure the proper infusion rate for enteral feedings for 1 of 3 residents out of 32 total sampled residents. (Resident # 75) Photographic Evidence Findings: Observation of Resident # 75's room on 7/29/19 at approximately 9:30 AM, revealed an enteral feeding pump which was turned to the off position. The 1.5 [MEDICATION NAME] bottle hanging from the pole listed the Resident's name, room number, date of 7/28/19, rate of 80 milliliters (mls) per hour and the time of 2 PM at which this bottle began infusing. The manufacturer's measurements on the side of the bottle noted there was still 350 milliliters in the 1000 milliliter bottle. The infusion rate for 7/28/19 is a start time of 2:00 PM until 7/29/19 at 10:00 AM, the stop time, was 32 mls per hour instead of the physician ordered 80 mls per hour. Further observation of the enteral feeding bottle and infusion pump, on 7/30/19 at 8:10 AM revealed a new bottle of [MEDICATION NAME] 1.5 which contained 800 mls of formula. The label notes it was started at 04:20 AM on 7/30/19 at 80 mls per hour. The infusion rate was approximately 50 mls per hour. An interview with Resident #75 on 7/30/19 at 7:55 AM revealed he was awake, laying in bed. He stated he was hungry. He had no further information. An interview and observation of Resident #75's infusion pump with Staff B/Registered Nurse on 7/30/19 at 8:10 AM and Staff D/the Unit Manager at 8:20 AM, revealed there was no documentation of any times when the pump was stopped for Resident care or Resident choice. They stated they do not monitor the pump infusion rate, only that the pump is on or off. They stated they look at the digital display screen to determine if the pump is infusing. They confirmed the 1000 ml bottle contained 800 mls during this observation. They confirmed the label noted the start time was 04:20 AM on 7/30/19. They confirmed that was not an infusion rate of 80 mls per hour as ordered. They confirmed there was no further process or actions taken to ensure the Resident received the proper nutritional intake when the pump infusion rate was not commensurate with the order. They confirmed the 310 amount of formula infused which was the number listed on the digital screen, did not match the amount of liquid noted to be in the bottle. They stated they thought the amount of infusion on the digital screen should be closer to 320. Staff D/The Unit Manager stated the Nurse on duty is the responsible party for ensuring the infusion rate of the pump. She stated if the pump is already infusing then the Nurse should be checking the pump rate when the Nurse begins the shift. Staff B stated he started the shift at 7:00 AM. Staff B and D stated no Certified Nursing Assistants stop or start the infusion pumps, only nurses. They confirmed there was no procedure or process for checking the infusion rates or documenting when the pump was stopped during the ordered time. They had no further information. Review of Resident #75's record revealed no documentation for the start and stop times for the pump for enteral feedings, when stopping the pump to provide Resident care or the Resident's attendance in Activities. There was no documentation of Nursing staff which accommodated or adjusted the nutritional intake when the Resident was not infusing during the ordered times. Further review of the record revealed a July, 2019, Medication Administration Record [REDACTED]@ 80 cc/hour via pump by GT x 20 hours off at 10 AM on at 2 00 PM every shift for total nutritional source encourage weight gain with a start date of 6/11/19. Enteral Feed Order in the afternoon, change feeding bag daily at 1400 date tubing /bag (q 24 hrs) with a start date of 6/30/19 and Enteral formula via pump every evening and night shift started on 5/29/19. Review of the Care Plan for Enteral Feeding listed the following interventions, auscultate lung sounds, check for tube placement, discuss with family /resident any concerns, Keep HOB elevated during and after tube feeds, Labs/Diagnostic work, Site Care . The Resident has a Care Plan for [MEDICAL CONDITION] started 4/16/19. It directs Review diet and make recommendations as required. Review of the Weekly Weights for the Resident beginning 5/8/19 revealed he weighed 150 pounds. He dropped to 140 pounds by 6/4/19. It dropped again on 6/16/19 and 7/14/19 back down to 140 pounds after a slight increase. He fluctuated between 140 and 145 pounds through the most recent weight on 7/28/19. Review of the Registered Dietician notes on 7/18/19 revealed weight note: cbw 140-3 % 1 week noted. Resident is NPO and tube fed. RD to assess this month. Will follow as needed. After the infusion rate issue was discussed, with the facility, the following note was added to the record by the Registered Dietician on 7/30/19, TF/weight review: Weight noted in past month (July up/down from 144/140/143 and cbw 145) which was addressed on 7/18, can be r/t if wheelchair or Hoyer used to weigh resident. Will start to use wheelchair to weigh resident to get accurate weight. Most recent labs from 7/15 indicate slightly depleted Hgb+HCt @12.3/37.6; BUN elevated @ 25, and [MEDICATION NAME] depleted @ 3. 1 L, but improved from last lab. TF via PEG tube of [MEDICATION NAME] 1.5 @ 80 ml/hr x 20 hr (off 10 AM on 2 PM)=1600 ml formula, 2400 kca, 102 gm protein, 1216 ml fluid. Review of the Minimum (MDS) data set [DATE] revealed Cognition score of 12, for Resident #75, which is somewhat strong, but can be confused. Review of the Facility policy for Enteral Feeding: Pump Method listed the procedure for hanging the feeding bottles but no process for monitoring the infusion rates. No further policy was provided. During a tour of the facility on 7/31/19 at 7:26 AM, Staff C/Licensed Practical Nurse advised the staff in general at the Nursing Station on the 100/200 hall there was a new protocol for monitoring Resident # 75's enteral feeding container for the amount of formula used. She reminded the staff he likes to go to Activities like Bingo for 2 hours and the pump is not infusing at that time which causes the rate of infusion to be low. During an interview with the Clinical Director of Services on 7/31/19 at approximately 8:30 AM she stated the facility staff was given additional training to document the times when the infusion pumps are turned off during the infusion periods on 7/30/19. She stated the Medical Director and their Quality Assurance Team convened yesterday and discussed a change in the process for monitoring the infusion rates. An interview conducted with the facility's Registered Dietician on 7/31/19 at 2:00 PM revealed Resident # 75's feeding schedule of off at 10 AM and on at 2 PM was designed to allow him to engage in Activities or other tasks and still get his needed nutritional feeding. She stated the 80 mls per hour for 20 hours per day, does not include the loss of nutrition when the pump is turned off at times not documented. She stated the amount of time when the Resident is not receiving the infusion is important to document, to ensure the proper nutritional intake. She confirmed the Resident lost weight during 05/19 and his formula was increased in 06/19. While the weight drop stopped in 06/19- 07/19 , there has not been a stable weight increase. She confirmed there is a loss of nutritional intake when the bottle finishes on the night shift and the new bottle is not started. She noted the bottle with the start time on 7/28/19 of 2 PM and the same bottle hanging at approximately 9:30 AM on 7/29/19 with 300 mls still in it, when the survey commenced. She stated a new bottle should have been started at approximately 2:30 AM. Further, she confirmed a new bottle started at 4:20 AM on 7/30/19 indicates there were 2 hours when the Resident was not receiving nutritional intake. She had no information as to why the bottle started at 4:20 AM on 7/30/19 still had 800 mls at 8:10 AM on 7/30/19 if it was actually infusing at 80 mls per hour.

Based on observation, interview, and record review, the facility failed to treat a resident with respect and dignity for 1 (#75) of 7 residents observed for medication observation out of 27 medication opportunities. Findings: During a medication observation on 7/29/2019 at 2:30 PM, Staff member B, a Registered Nurse, failed to close Resident #75's room door and pull the privacy curtain before exposing the resident's abdomen to flush the [DEVICE]. The resident was exposed to a roommate in the room and staff and family members in the hallway. In an interview on 7/29/2019 at 2:30 PM, the Staff B, said he was supposed to close the door and curtain for privacy but forgot. Record review of the facility's Resident Dignity & Personal Privacy Policy, revised 4/4/2019, number 2a states, Examine and treat residents in a manner that maintains their privacy. Use a closed door, a drawn curtain, or both, to shield the resident during all personal care and treatment procedures. Number 3, states, Drape and dress residents appropriately at all times to avoid exposure and embarrassment.