Every finding on record at Canyon Transitional Rehabilitation Center, LLC

Based on record review and interviews, the facility failed to ensure a safe environment and provide adequate supervision to prevent accidents for 1 (R #1) of 1 (R #1) resident, when staff failed to:Verify R #1's transfer assistance needs to provide the supervision and assistance necessary to safely assist R #1 with a transfer from the bed to a wheelchair, which resulted in R #1 experiencing a fall to the floor with injury.This deficient practice is likely to result in residents experiencing avoidable accidents and increases the risk of serious injury and harm. The findings are: A. Record review of the facility's safe resident handling/transfer equipment policy, revised on 01/15/26, revealed the following:Staff assessed residents upon admission and on an ongoing basis to determine their ability to transfer and reposition and to identify the need for safe resident handling equipment.Two trained persons were required to operate a total lift (device supports the entire body, reducing the caregiver's physical effort and risk of injury. It can be used when the patient cannot safely bear weight or needs full support) or a sit to stand lift (a medical device that assists individuals with partial mobility to safely rise from a seated position to a standing position and transfer to another surface).Staff used a total lift as the primary intervention for dependent resident lifting and transferring. B. Record review of R #1's Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), revealed an admission date of 02/20/24 and a Brief Interview of Mental Status (BIMS; a screening for cognitive impairment) score of 03, indicating severe cognitive impairment. R #1's MDS also indicated R #1 required partial or moderate assistance (the helper providing less than half of the effort and lifting, holding, or supporting the resident's trunk or limbs) with lying to sitting on the side of the bed (moving from lying on the back to sitting on the side of the bed with no back support). R #1 required substantial or maximal assistance (the helper providing more than half of the effort and lifting or holding the resident's trunk or limbs) with chair and bed-to-chair transfers. C. Record review of R #1's lift transfer evaluation, dated 02/20/26, revealed R #1 required a total mechanical lift (a device designed to help staff move a resident from one place to another within a room or from one position to another) with a divided-leg sling (separate leg sections that wrap around the thighs and legs, providing individualized support for each leg) for all transfers. D. Record review of R #1's bed safety evaluation, dated 04/24/26, revealed R #1 had a balance deficit, pain, weakness, and an inability to support her trunk when in an upright position (standing or sitting vertically rather than lying down, leaning, or slouching). The evaluation also indicated R #1 was unable to pull herself from a lying to a sitting position, balance herself while transferring to and from the bed, support herself, enter or exit the bed safely, or transfer safely to and from the bed. E. Record review of R #1's provider progress notes, dated 06/28/26, revealed a nurse called to report R #1 had a fall from her bed at 12:25 PM. R #1 reportedly slid sideways off the bed and landed on her left hip and left knee. F. Record review of R #1's Change in Condition (CIC; any new, unexpected, or unusual change in a resident's health status that may indicate a developing problem, worsening illness, or the need for a care plan adjustment) evaluation, dated 06/28/26, revealed the following:R #1 sustained a fall while positioned on the side of the bed in preparation for transfer to a wheelchair. R #1 reported falling sideways and hitting her hip and knee on the floor.R #1's pain assessment was positive, indicating she was experiencing pain. Nursing staff documented there was no bruising, bleeding, scratches, or other apparent injuries present. Staff initiated neuro evaluations, (neurocheck; a brief neurological assessment performed by staff repeatedly to monitor a resident's neurological status).The primary care clinician was notified on 06/28/26 at 12:50 PM. The provider ordered continued neuro evaluations and monitoring of R #1's left hip and knee for inflammation, pain, and bruising. Staff were instructed to notify the provider of significant changes, at which time an x ray would be ordered. G. Record review of R #1's electronic health record (EHR), dated 06/29/26, revealed an x ray showed R #1 sustained a left femur (long bone that connects the hip to the knee) fracture with mild displacement. Staff documented R #1's left knee was warm to the touch, with pain upon movement. The provider ordered R #1 to be transferred to the hospital. H. On 08/10/26 at 3:37 PM, during an interview, R #1 stated she fell while she was left alone on 06/28/26. She stated she landed on her buttocks and experienced a lot of pain. I. On 08/10/26 at 5:20 PM, during an interview, R #1's representative stated she visited R #1 on 06/28/26 at approximately 3:00 PM. R #1's representative stated R #1 told her the Certified Nursing Assistant (CNA) left R #1 sitting on the side of the mattress, turned to retrieve the wheelchair, and R #1 then fell to the floor. R #1's representative stated R #1 was experiencing significant pain during the visit. She stated she discussed R #1's fall with a nurse, who told her the CNA should have called for assistance and should not have left R #1 sitting alone on the side of the mattress. J. On 08/11/26 at 3:13 PM, during an interview, CNA #1 stated she assisted R #1 to sit on the edge of the bed in preparation for transferring her to the wheelchair. CNA #1 stated she turned away to retrieve the wheelchair and R #1 then fell to the floor. CNA #1 stated she believed R #1 was a one person transfer assist based on a verbal report from the previous shift and R #1's statement she could scoot herself into her wheelchair. CNA #1 stated the Kardex (a quick-reference tool that summarizes essential patient information to help nurses provide efficient and safe care) was used to identify residents' required assistance levels, but she did not review R #1's Kardex prior to providing care and later learned R #1 was a two person transfer assist. K. On 08/13/26 at 12:30 PM, during an interview, Registered Nurse (RN) #1 stated CNA #1 told her she was attempting to transfer R #1 into the wheelchair, turned away to reach for the wheelchair, and then felt R #1 fall from the bed to the floor. RN #1 stated R #1 required two person assistance for transfers and used a Hoyer lift (equipment used to move residents who have limited mobility) at the time of the fall. RN #1 stated R #1's transfer status was documented in the EHR, and CNA #1 should have waited for another staff member before attempting to transfer R #1 alone. RN #1 stated CNAs were expected to review a resident's EHR and check with nursing to verify a resident's transfer status. RN #1 also stated CNAs were expected to notify nursing when a resident requested assistance with a transfer so the nurse could supervise the transfer. L. On 08/13/26 at 2:50 PM, during an interview, the Corporate Director of Nursing (CDON) stated R #1 required a total mechanical lift with two person assistance for transfers at the time of the fall. The CDON stated CNAs had access to the Kardex to identify residents' transfer status and were expected to clarify resident transfer information with the nurse or nurse manager.

Based on record review and interviews, the facility failed to immediately notify a resident representative following an accident involving the resident that resulted in injury or had the potential to require physician intervention for 1 (R #1) of 1 (R #1) resident reviewed, when staff failed to:Immediately notify R #1's representative after R #1 sustained a fall with pain requiring provider notification and additional monitoring, which resulted in a leg fracture.This deficient practice is likely to result in the resident's representative not being able to advocate for the resident and the resident being at further risk of injury. The findings are: A. Record review of the facility's change in condition policy, revised on 07/01/24, revealed the following:The facility was required to immediately inform the resident, consult with the resident's physician, and notify the resident's representative when an accident involving the resident resulted in injury and had the potential to require physician intervention.The purpose of the policy was to provide appropriate and timely information regarding changes relevant to the resident's condition. B. Record review of R #1's Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), revealed an admission date of 02/20/24 and a Brief Interview of Mental Status (BIMS; a screening for cognitive impairment) score of 03, indicating severe cognitive impairment. C. Record review of R #1's face sheet identified R #1's daughter as the resident representative and emergency contact for R #1. D. Record review of R #1's provider progress notes, dated 06/28/26, revealed a nurse called to report R #1 had a fall from her bed at 12:25 PM. R #1 reportedly slid sideways off the bed and landed on her left hip and left knee. E. Record review of R #1's Change in Condition (CIC; any new, unexpected, or unusual change in a resident's health status that may indicate a developing problem, worsening illness, or the need for a care plan adjustment) evaluation, dated 06/28/26, revealed the following:R #1 sustained a fall while positioned on the side of the bed in preparation for transfer to a wheelchair. R #1 reported falling sideways and hitting her hip and knee on the floor.R #1's pain assessment was positive, indicating she was experiencing pain. Nursing staff documented there was no bruising, bleeding, scratches, or other apparent injuries present. Staff initiated neuro evaluations, (neurocheck; a brief neurological assessment performed by staff repeatedly to monitor a resident's neurological status).The primary care clinician was notified on 06/28/26 at 12:50 PM. The provider ordered continued neuro evaluations and monitoring of R #1's left hip and knee for inflammation, pain, and bruising. Staff were instructed to notify the provider of significant changes, at which time an x ray would be ordered.R #1's representative was documented as being notified of R #1's fall on 06/28/26 at 3:00 PM. F. Record review of R #1's electronic health record (EHR), dated 06/29/26, revealed an x ray showed R #1 sustained a left femur (long bone that connects the hip to the knee) fracture with mild displacement. The provider ordered R #1 to be transferred to the hospital. G. On 08/10/26 at 5:20 PM, during an interview, R #1's representative stated she arrived at the facility on 06/28/26 at approximately 3:00 PM and learned of the fall from R #1, and not the facility staff. R #1's representative stated the facility staff had not notified her of the fall prior to her arrival and stated she believed she should have been immediately notified so she could participate in the medical decision making process for R #1. H. On 08/13/26 at 12:30 PM, during an interview, Register Nurse (RN) #1 stated she attempted to notify R #1's representative following the fall but could not recall the time of the notification attempt. RN #1 stated she believed she documented the attempt in the progress notes or CIC and would normally document whether the representative answered or a message was left. RN #1 stated the facility's expectation was for the resident representative to be notified as soon as possible following a fall. I. On 08/13/26 at 2:50 PM, during an interview, the Corporate Director of Nursing (CDON) reviewed R #1's notification documentation and the facility's change in condition policy. The CDON stated the CIC documented the provider was notified at approximately 12:50 PM, and R #1's representative was not notified until 3:00 PM.

Based on observation, record review, and interviews, the facility failed to ensure staff properly stored and secured medications for all residents on the 300 hall when the hall medication cart (a mobile storage unit equipped with drawers and locking mechanisms to hold medications) was not secured and was left unattended. If the facility fails to secure medication carts, residents are likely to experience unauthorized access to medications, potentially resulting in injury or illness.The findings are: A. Record review of the facility's medication storage policy, revised January 2026, revealed the medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. The policy states medication rooms, cabinets, and medication supplies must remain locked when not in use or when not attended by authorized personnel. B. On 07/01/26 at 1:15 pm, during an observation of the 300 Hall, an unlocked medication cart was positioned in the hallway without staff present, and the cart remained unattended and accessible to anyone walking through the area. C. On 07/01/26 at 1:25 pm, during an interview, Registered Nurse (RN) #1 stated he left the medication cart unlocked. RN #1 stated the cart contained narcotic (opioid) medications stored inside a locked box, and the remaining drawers contained other resident medications. RN #1 stated if the medication cart is left unlocked, a resident could take and misuse medications not prescribed to them. D. On 07/01/26 at 1:30 pm, during an interview, the Unit Manager (UM) #1 stated his expectation is for all medication carts to be locked and secured. UM #1 stated all clinical staff are responsible for ensuring medication carts remain locked and secured. UM #1 stated if medication carts are left unlocked, residents are at risk of taking medications not prescribed to them and becoming ill. E. On 07/01/26 at 3:34 pm, during an interview, the Corporate Director of Nursing (CDON) stated the facility's expectation is for all medication carts to remain locked, and the nurse assigned to the cart is responsible for ensuring it is secured. She stated residents are at risk of taking medication that is not theirs if the medication carts are left unlocked and unattended.

Based on observation, record review, and interviews, the facility failed to safeguard protected health information (PHI) for 4 (R #10, R #11, R #12, and R #13) of 4 (R #10, R #11, R #12, and R #13) residents. If the resident's clinical information is not sufficiently safe guarded, resident's PHI is likely to be viewed by unauthorized residents, visitors, and staff. The findings are: A. Record review of the facility's protecting patient/resident privacy policy, provided on 07/01/26, revealed all staff have a responsibility to protect the privacy of patients and residents. The policy states confidential or protected health information on desks or other publicly accessible areas must be secured by using designated work areas or locked storage containers, cabinets, or desks. The policy also states staff must lock the computer screen when stepping away to prevent unauthorized individuals from viewing patient or resident information. B. On 07/01/26 at 1:10 pm, during an observation of the 300 hall, a laptop computer left on an unattended medication cart was open and displaying R #10's electronic health record (EHR). C. On 07/01/26 at 1:15 pm, during an observation of the 300 hall, an unattended medication cart had multiple documents containing residents' PHI exposed on top of the cart, including:A diet order communication form for R #10 containing the resident's room number.A medication list for R #10.An appointment information form for R #11.Appointment information and a physician appointment summary containing physician notes for R #12.An inventory of personal effects form for R #13. D. On 07/07/26 at 1:30 pm, during an interview, the Unit Manager (UM) #1 stated his expectation is for facility computer screens to be locked and patient information not to be left out or visible. UM #1 stated visible patient information is a violation, and all staff are responsible for ensuring patient information is secured. E. On 07/07/26 at 3:34 pm, during an interview, the Corporate Director of Nursing (CDON) stated the facility's expectation is for all resident information to be secured. She stated all staff are responsible for securing resident information, and potential risks include sensitive information being accessible to unauthorized individuals. F. On 07/07/26 at 3:45 pm, during an interview, the Administrator (ADM) stated her expectation is for all resident information to be secured by the person handling the information. The ADM stated if resident information is left visible and unattended, unauthorized individuals may gain access to information they should not have.

Based on record review and interviews, the facility failed to ensure Certified Nurse Aides (CNAs) received the required in-service training of at least 12 hours per year for 4 (CNAs #12, #13, #16 and #17) of 7 (CNAs #11, #12, #13, #14, #15, #16, and #17) CNAs randomly reviewed for required in-service training. This deficient practice is likely to result in CNA's not receiving the necessary training to meet the care needs of the residents. The findings are: A. Record review of the facility Certified Nursing Assistants (CNA) staffing and training log indicated the following: CNA #12 was hired on 03/24/25. CNA #12 only completed 7 hours 52 minutes of in-service training and did not complete at least 12 hours of required in-service training.CNA #13 was hired on 09/30/24. CNA #13 only completed 4 hours 11 minutes of in-service training and did not complete at least 12 hours of required in-service training.CNA #16 was hired on 04/22/15. CNA #16 only completed 4 hours 44 minutes of in-service training and did not complete at least 12 hours of required in-service training.CNA #17 was hired on 05/30/24. CNA #13 only completed 5 hours of in-service training and did not complete at least 12 hours of required in-service training. B. On 02/26/26 at 2:58 pm, during an interview, the Director of Nursing (DON) stated this facility has never had a nurse educator, but the facility hired one and she will start soon. The DON stated she and the Unit Manager have been managing the education for each CNA. The DON confirmed CNAs #12, #13, #16, and #17 did not complete at least 12 hours of required in-service training and should have.

Based on observation, record review, and interview, the facility failed to ensure food was prepared, served, handled, and monitored under sanitary conditions when staff failed to: Complete required daily logs of the sanitizer bucket, three compartment sink, and the dish machine in the kitchen.Complete daily refrigerator and freezer temperature logs in the nourishment room. Properly seal and protect open food items to prevent air exposure inside the large refrigerator located in the kitchen. Properly store raw meat inside the large refrigerator located in the kitchen. Wear gloves and avoid bare hand contact with ready-to-eat food while obtaining food temperaturesThese deficient practices are likely to affect all 68 residents listed on the resident census list provided by the Administrator on 02/23/26 and is likely lead to foodborne illnesses in residents if food is not being stored properly and safe food handling practices are not adhered to. The findings are: Incomplete Logs: A. Record review of the facility's Sanitizer Bucket Log (used to document that sanitizing solutions in wiping-cloth buckets are tested to ensure the proper concentration for disinfecting food preparation surfaces) dated February 2026, revealed the log was not documented as completed on 02/01/26, 02/07/26, and 02/08/26. B. Record review of the facility's Three-Compartment Sink Log (used to document how the wash, rinse, and sanitizing sink compartments are maintained at appropriate temperatures and sanitizer concentrations, to ensure proper manual dishwashing and sanitization of food-contact equipment and utensils) dated February 2026, revealed the log was documented as completed for only one day (02/18/26) during the time frame of 02/07/26 through 02/22/26. C. Record review of the facility's Dish Machine Log (used to document the mechanical dishwashing machine is operating at the appropriate wash and rinse temperatures and/or sanitizer levels to ensure proper cleaning and sanitization of dishes and food-contact equipment) dated February 2026, revealed the log was not documented as completed on 02/07/26, 02/08/26, and 02/16/26. D. Record review of the facility's refrigerator and freezer temperature logs (used to ensure cold food storage equipment is maintained at safe temperatures to prevent food spoilage and bacterial growth), dated February 2026 in the nourishment room, revealed the logs had not been documented as completed from 02/14/26 through 02/26/26. E. On 02/26/25 at 11:55 am, during an interview, the District Dietary Manager (DDM) stated kitchen staff were responsible for completing all logs. She acknowledged the sanitizer bucket, three compartment sink, the dish machine, the nourishment room refrigerator, and nourishment freezer logs were not completed and stated they should be. Improper Food Storage and Protection from Contamination: F. On 02/23/25 at 8:32 am, observation of the kitchen revealed the following: One small box of crab cakes was open and exposed to the air inside of the large freezer. One medium package of raw meat was stored above a tray of prepared pudding cups on a speed rack (a tall, open-frame metal cart designed to vertically store, cool, or transport multiple sheet pans) inside the large refrigerator. G. On 02/26/25 at 11:30 am, observation of the kitchen revealed one medium box of corn was open and exposed to the air inside the large freezer. H. On 02/26/25 at 11:55am, during an interview, the DDM stated it was her expectation all food would be properly stored and not be exposed to air. She stated all meats should not be stored above any prepared foods. The DDM further stated it was her expectation all kitchen staff would adhere to these standards as they had all been trained in safe food handling and identified E.coli (bacteria spread by consuming contaminated food) as a possible risk to residents as a result. I. On 02/27/26 at 12:54 PM, during a lunch test tray observation, the lunch test tray consisted of a chicken sandwich, mixed vegetables (broccoli, cauliflower, and carrots), and pineapple. The Dietary Manager (DM) was observed obtaining the temperature of the chicken sandwich with a digital thermometer while not wearing gloves and touched the bun of the sandwich with her bare hands. J. On 02/27/26 at 1:16 PM, during an interview, the DDM stated it is her expectation gloves are to be worn while obtaining any temperature of food, and food should not be touched with bare hands. The DDM stated this could lead to transmission of bacteria to food, which could make residents ill.

Based on record reviews and interviews, the facility failed to prevent a significant medication error for 1 (R #84) of 1 (R #84) resident reviewed, when:The facility administered Tylenol (acetaminophen; pain medication) without a manufacturer's expiration date or date of opening on bottle. This deficient practice is likely to result in residents not receiving full benefit from medications, possible prolonged treatment period, or unwanted effects. The findings are: A. On [DATE] at 8:39 AM, during an observation of R #84's medication administration, Certified Medication Aide (CMA) #1 prepared R #84's Tylenol for administration. There was no observed expiration or opening date printed on the Tylenol bottle or label. CMA #1 administered Tylenol to R #84. B. On [DATE] at 8:40 AM, during an interview, CMA #1 stated over the counter medications (OTC; medications sold to individuals without a prescription) like Tylenol, can be used for 30 days after opening. CMA #1 stated all bottles should have a manufacturers expiration date present with a date the bottle was opened by staff. CMA #1 verified no manufacturer expiration date or date of opening was placed on the bottle, and stated if used residents could get sick, or have stomach related issues. CMA #1 stated he should have obtained a new bottle and not used the bottle which did not have a manufacturer expiration date or date of opening present. C. On [DATE] at 1:27 PM during an interview with the Director of Nursing (DON), she stated during medication administration of OTC medications it is her expectation the staff check the expiration date on the bottles of medication. The DON further stated it is her expectation, if an OTC medication does not have an expiration date, it should not be used, and a new bottle should be obtained. The DON stated if a medication without an expiration date is used, it could be expired, and result in medication being less effective or possibility of residents becoming ill.

Based on observation, record review, and interviews, the facility failed to maintain a safe and sanitary environment to prevent the transmission of infectious agents and communicable diseases for 2 (R #4, and R #43) of 2 (R #4, and R #43) residents, when the facility: Failed to prevent a urinary catheter (a thin, flexible tube which drains urine from the bladder) bag and tubing from touching the floor for R #4. Placed an oxygen humidification container (device used to add moisture to dry oxygen gas before it is delivered to a patient) on the floor of R #43's room. These deficient practices have the potential to expose staff and other residents to infectious diseases. The findings are: R #4: A. Record review of the facility's Catheter Care Procedure (steps to maintain the catheter and drainage system), last revised on 01/15/26, revealed staff were required to secure catheter tubing to keep the drainage bag below the level of the patient's bladder and off the floor. B. Record review of R #4's face sheet revealed R #4 was originally admitted into the facility on [DATE] with a diagnosis of chronic kidney disease (CKD; impaired kidney function). C. Record review of R #4's physician orders revealed an active order, dated 02/17/26, for an indwelling catheter (a thin, flexible tube which drains urine from the bladder). D. On 02/25/26 at 11:57 am, during a dining room observation, R #4 was seated in a wheelchair eating lunch. The observation revealed R #4's urinary catheter drainage bag and attached tubing was hanging from the wheelchair and was in contact with the floor. E. On 02/27/26 at 9:35 am, during an interview, the Director of Nursing (DON) stated catheter bags should be positioned under the resident's wheelchair and not touching the floor. The DON also stated staff are expected to ensure proper positioning and identified infection as a potential hazard if a catheter bag touches the floor. R #43: F. On 02/23/26 at 10:50 am during an observation of oxygen use for R #43, an oxygen humidification container (refillable container attached to oxygen concentrators to add moisture to the oxygen) connected to a nasal cannula (a small, flexible tube that delivers oxygen to the nose through soft prongs), was on the floor of R #43's room. G. Record review of R #43's physician orders dated 02/12/26, revealed for oxygen use of 1 to 6 liters per minute via nasal cannula, continuously every day and night for Chronic Obstructive Pulmonary Disease (COPD; lung disease). H. On 02/23/26 at 3:30 pm during a repeat observation of R #43's oxygen equipment, R #43's oxygen humidification container remained on the floor of R #43's room. I. On 02/23/26 at 3:34 pm during an interview, Licensed Practical Nurse (LPN) #1 stated oxygen humidification should not be placed on the floor as it is an infection control issue, which could lead to residents becoming ill. J. On 02/27/26 at 10:11 am, during an interview, the Director of Nursing (DON) stated it is her expectation R #43's oxygen equipment should not be placed on the floor. The DON also stated if a resident's oxygen humidification container is placed on the floor, it poses a risk of infection for the resident.

Based on record review and interview, the facility failed to revise a care plan for 1 (R #70) of 1 (R #70) resident reviewed for feeding tube (medical device to provide nutrition to people who cannot obtain nutrition by mouth) use. If the facility is not updating the care plan to reflect the residents' current care areas and treatment, then the facility may not be providing the appropriate care and treatment to meet the residents' needs. The findings are: A. Record review of R #70's face sheet revealed R #70 was admitted into the facility on [DATE] with the following diagnoses: Dysphagia (difficulty with swallowing food or liquid),Aphasia (disorder that results from damage, usually from a stroke or traumatic brain injury to areas of the brain that are responsible for language),Malnutrition (imbalance between the nutrients your body needs to function and the nutrients your body gets). B. Record review of R #70's nursing progress notes dated 02/04/26 revealed the following: R #70 was sent to the hospital due to poor nutritional status from resident having dysphagia. R #70's poor intake was causing his wounds to not heal properly. R #70 had a Fiberoptic Evaluation of Swallowing (FEES test helps detect aspiration, swallowing difficulties, and other dysphagia-related issues) indicating a risk of silent aspiration (hidden risk of fluid entering the lungs without a cough). Facility was asking the hospital for an assessment for possible feeding tube placement for R #70 to receive proper nutrition. C. Record review of R #70's nursing progress notes dated 02/12/26 revealed R #70 was readmitted into the facility on [DATE] with a feeding tube. D. Record review of R #70's physician orders dated 02/13/26 revealed the following: Enteral (tube) feed every day and night shift, flush tube with 30 milliliters (ml) of water prior to feeding, 45 ml per hour during continuous feeding, and a 30 ml flush of water at the end of each feeding. Nothing by mouth (NPO). E. Record review of R #70's care plan dated revealed the following: Dated 01/01/26: Focus: Impaired swallowing related to stroke. Interventions: Provide assistance during meals, resident will be at 90 degrees upright position when swallowing food or drink, encourage small sips and bites and cue as needed, encourage resident to chew and swallow each bite, and encourage resident to alternate liquids and solids. This care plan focus was current as of 02/27/26. Dated 02/23/26: Focus: Enteral feeding tube to meet nutritional needs. Interventions: Check patency and placement of the tube daily, formula per medical doctor protocol, feeding tube changes per order, head of bed elevated 30 to 45 degrees during feeding, and monitor for nausea, vomiting, diarrhea, cramping fatigue, weakness, and vital signs. R #70's care plan was not updated to remove the impaired swallowing with dining assistance interventions. F. On 02/27/26 at 12:08 pm, during an interview, the Director of Nursing (DON) stated if the impaired swallowing care plan focus was no longer relevant for R #70, then it should show as resolved and no longer be active on R #70's care plan. The DON stated since R #70 used a feeding tube, there should not be a care plan present for feeding assistance.

Based on observation, interviews, and record review, the facility failed to develop an accurate comprehensive, person-centered care plan for 1 (R #30) of 2 (R #1 and #30) residents reviewed for care planning, when facility staff failed to initiate a care plan to reflect R #30's behavioral health needs, including Suicidal Ideation (SI; thoughts, preoccupations, or plans about ending one's own life, ranging from fleeting considerations to detailed planning). This deficient practice is likely to result in residents being at risk for unmet needs, a decreased quality of life, and avoidable decline in physical and psychosocial well-being. The findings are: A. Record review of R #30's face sheet revealed an admission date of 01/18/26. B. Record review of R #30's nursing progress notes revealed the following: Dated 01/19/26 at 11:25 am: R #30 made a comment about hurting herself to staff. Nurse and supervisor followed up with resident and R #30 denied active suicidal ideation, stating she was frustrated when she said that she would hurt herself. R #30 further stated she previously lived alone and had not acted on these impulses and that she didn't think she would be able to follow through with hurting herself. Dated 01/20/26 at 12:34 pm: Interdisciplinary team (IDT; a group of professionals from various fields working together to achieve a shared goal) review of orders including a new order for psychiatric services, as soon as possible (ASAP) related to R #30's Suicidal Ideation. Dated 01/21/26 at 10:16 am: Mood and behavior note: R #30 anxious this morning, verbalized she is supposed to be in a different place not at facility and wants to go home. Dated 01/21/26 at 5:15 pm: Since the last evaluation, behavior symptoms have increased; R #30 is not sleeping good at night due to insomnia (difficulty falling asleep or staying asleep). C. Record review of R #30's Brief Cognitive Assessment Tool (BCAT; a structured instrument developed to evaluate cognitive function, cognitive skills, and cognitive impairments) dated 01/20/26, revealed R #30 has a Total BCAT Score of 20 (a BCAT score of 44 or higher is considered normal, while scores below 44 may indicate mild cognitive impairment or dementia). R #30's BCAT score indicates R #30 has cognitive impairment and/or dementia. D. Record review of R #30's admission Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) dated 01/22/26 revealed the following: R #30 has a diagnosis for Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment).R #30 reported little interest or pleasure in doing things 2 to 6 days over the past two weeks. R #30 reported feeling down, depressed, or hopeless 7 to 11 days over the past two weeks. R #30 reported feeling bad about herself or that she is a failure or has let her family down 12 to 14 days over the past two weeks. R #30 reported having trouble concentrating on things, such as reading the newspaper or watching television. R #30 reported moving or speaking so slowly that other people have noticed or has been so fidgety or restless that she has been moving around a lot more than usual. R #30 sometimes feels lonely or isolated from others. R #30's Patient Health Questionnaire 2 to 9 (PHQ2-9; tools used for screening and diagnosing depression) Total Severity Score of 10 (1 to 4 equals minimal depression; 5 to 9 equals mild depression; 10 to 14 equals moderate depression; 15 to 19 equals moderately severe depression; and 20 to 27 equals severe depression), indicating R #30 was experiencing moderate depression. E. Record review of R #30's Care Plans dated 01/25/26, revealed a care plan was not developed for R #30's dementia related behaviors or psychiatric service needs. F. On 02/25/26 at 11:23 am during an observation of R #30, she was observed sitting in her room alone. R #30 declined to be interviewed, but signs of emotional withdrawal (act of distancing oneself from emotional engagement) was present. G. On 02/27/2026 at 2:17 pm during an interview, the Director of Nursing (DON) stated R #30's care plan should have been developed to address R #30's behavioral concerns and Suicidal Ideation (SI). The DON confirmed R #30's care plan was not developed to address behaviors, including SI.

Based on observation, interview, and record review, the facility failed to maintain the kitchen in a sanitary manner when staff failed to: - Store opened food with labels and dates to prevent cross contamination and outdated usage, - Store meat in a manner to prevent leakage and contamination of other food items, These failures had the potential to result in cross contamination and foodborne illness which could affect all residents who ate food from the kitchen. The findings are: A. On 11/25/24 at 7:53 am, observation during a walk-through of the kitchen refrigerator revealed the following: that multiple items were either not dated or were past the date to be served and should have been thrown out. - Unidentified sandwiches did not have a label on them. - Mashed potatoes with a date of 11/19/24 and use by 11/24/24. - Egg salad with unclear dates written on the label. - Sliced cheese was partially wrapped and was hard and discolored. - Container of deli ham not sealed. - A large container of leftovers was not labeled and dated. - Ham stored in a cardboard box sat on a shelf above a large container of unidentified, undated leftovers. Juice from the ham leaked onto the foil which covered the leftovers. B. On 11/25/24 at 8:00 am, during an interview with Kitchen Assistant #2, he stated he removed a tray of unlabeled food, and there was more food in the refrigerator that was not labeled properly. He stated the juice on top of the leftovers was from the ham sitting on the shelf above it. He stated the ham was not stored properly and leaked through the box. C. On 12/02/24 at 11:32 am, the Kitchen Manager said all of his staff knew better than to leave the kitchen the way the staff found it after the weekend. He said they must have been in a rush to leave. D. On 12/02/24 at 11:40 am, during an interview with the Interim Registered Dietician, she stated she did a sanitary audit of the kitchen on 11/19/24. She stated she found unlabeled food in the refrigerator.

Based on record review, observation, and interview, the facility failed to keep a resident free from significant medication errors for 1 (R #132) of 1 (R #132) residents when they failed to administer R #132's vancomycin (an antibiotic medication) intravenous (IV; a tube that is inserted into a blood vessel and used to administer medications, fluids, or nutrition into the bloodstream) medication in a timely manner as per the physician's order. This deficient practice is likely to cause R #132 to have adverse drug effects including but not limited to lowering the effectiveness of the antibiotic treatment and potentially contributes to antimicrobial resistance (when microorganisms, like bacteria, viruses, fungi, and parasites, change and are no longer affected by the drugs used to treat them). The findings are: A. Record review of R #132's face sheet, dated 11/12/24, revealed he was admitted to the facility on [DATE] with multiple diagnoses including but not limited to: - Osteomyelitis of vertebra, lumber region (a rare bone infection of the spine that can occur when bacteria or fungi spread to the bones.) - Discitis, unspecified, lumber region (a serious condition that causes inflammation of the discs in the spine.) - Bacteremia (the presence of bacteria in the blood.) B. Record review of R #132's provider's orders revealed the following: - Dated 11/12/24, administer vancomycin intravenous solution, 750 milligrams (mg)/150 milliliter (ml) for discitis/osteomyelitis every eight hours. - Dated 11/13/24, use 10 ml of normal saline (a solution of water and salt that's 0.9% sodium chloride commonly used in the clinical setting) flush solution to flush the PICC line intravenously every shift prior to medication administration. C. On 11/25/24 at 9:53 am, during observation of Nurse #1 administering medications to R #132, the resident had a peripherally inserted central catheter (PICC; a thin, flexible tube that is inserted into a vein in the upper arm and threaded into a large vein near the heart, is used for long-term IV antibiotics, nutrition or medications, and for blood draws) in the right upper arm. D. On 11/25/24 at 9:53 am and 2:31 pm, during an interview with Nurse #1, she stated the vancomycin was not available to administer to R #132 since the pharmacy did not deliver it. Nurse #1 stated she called the pharmacy on 11/24/24 and the morning of 11/25/24 to request a vancomycin delivery. E. Record review of R132's Medication Administartion Record (MAR), dated November 2024, revealed R #132 missed vancomycin doses as follows: - On 11/25/24 at 6:00 am, 2:00 pm, and 10:00 pm due to medication was not received from the pharmacy. - On 11/26/24 at 2:00 pm and 10:00 pm due to PICC line was clogged and not usable for medications or fluids administration. - On 11/27/24: 6:00 am due to PICC line was clogged and not usable for medications or fluids administration. F. On 11/26/2024 at 8:30 am, during an interview with Nurse #2, she stated R #132's PICC line was clogged, and she was not able to administer the vancomycin dose on time. She stated a specialized nurse from an outside agency attempted to unclogg R #132's PICC line but did not succeed. G. Record review of R #132's progress notes ,dated 11/27/24, revealed the specialized nurse attempted to unclog the PICC line at 2:33 am with no success. He then advised that another specialized nurse needed to insert a new PICC line in the morning of 11/27/24. H. On 11/27/2024 at 8:55 am, during an interview with the Director of Nursing (DON), she stated she was not aware of R #132's PICC line situation. She stated the Nurse Manager would handle similar situations. She stated if staff had notified her of the incident, then she would have called the pharmacy and the specialized team who were supposed to come over and unclog the PICC line. She also stated the medication room might have vancomycin in stock, and the facility nurses were expected to check if vancomycin was available in the medication room stock I. On 11/27/24 at 9:03 am, during an interview with Nurse #2, she stated that vancomycin, 750 mg, was not available in stock. She stated she called the pharmacy three times on three different occasions on 11/26/24. She stated she inquired regarding when the pharmacy would send the alteplase (a medication that dissolves blood clots, and was ordered to be used in an attempt to unclog the PICC line by a specialized nurse from outside the facility.) She added the alteplase arrived on 11/26/24 around 4:00 pm, and she called the specialized nurse to come and attempt to unclog the PICC line. She stated that attempt was unsuccessful. J. On 11/27/24 9:16 am and 9:25 am, during an interview with the Nurse Practitioner (NP), he stated he was not aware R #132 missed doses of the vancomycin, because the nursing staff did not notify him. He stated he became aware when he saw the on-call provider's report in his email on the morning of 11/27/24. The NP stated he was on the floor during the time when R #132 missed his vancomycin doses, and a communication book was available by his office door. He stated the communication book did not contain any mention of the situation. The NP stated he reviewed the on-call report (a medical report where the on-call providers write their notes and send them to the NP on daily basis) dated 11/26/24 and he found out the floor nurse called the on-call provider to report the clogged PICC line. He stated he expected nurses and other healthcare staff at the facility to notify him of any missed medications doses for R #132. He added he would contact the Infectious Disease Team (a medical clinic that R #132 follows up with regarding his infection) if staff made him aware. He stated if the staff had notified him, then he would also call the pharmacy to order a vancomycin trough blood level test (a test that meausures the concentration of vancomycin in the blood) in order to see if the pharmacy staff needed to make an adjustment on the vancomycin's course of treatment.

Based on observation, interview and record review, the facility failed to notify the physician or the nurse practitioner for 2 (R #29 and #132) of 2 (R #29 and #132) residents for: 1. R #29 who had significant amount of pain. 2. R #132 who did not receive several doses of his intravenous (IV; a tube inserted into a blood vessel and used to administer medications, fluids, or nutrition into the bloodstream) antibiotic. If the facility is not notifying the physician or nurse practitioner of changes in a residents medical condition then the resident will not receive prompt medical care and could cause a delay in treatment, unnecessary pain, and could create more serious health complications. The findings are: Resident #29 A. On 11/25/24 at 11:14 am, during an observation and interview of R #29, she rubbed her hand and cried. R #29 stated she was in a lot of pain. She stated staff gave her Tylenol (pain medication) a little bit ago, but it did not help. She stated her pain level was an 11 (the pain scale indicates pain based on 1 being the lowest and 10 being highest.) B. Record review of R #29's medical record indicated staff documented the resident's pain level was a 10 on 11/25/24 at 10:52 am, and staff administered Tylenol. C. Record review of R #29's medication administration note revealed that staff gave R #29 two Tylenol 500 mg on 11/25/24 at 10:50 am and at 12:18 pm, and staff noted the medication was ineffective. Staff did not document anything else in the progress notes after the medication was found to be ineffective. D. On 11/25/24 at 11:45 am, during an interview with Nurse #1, she stated she was aware R #29 asked for another medication for her pain, but R #29 did not have an order for another pain medication. She stated R #29 only had an order for Tylenol for pain, and she gave the resident some Tylenol a little bit ago. She stated R #29 was not due to receive another dose of Tylenol at this time. She stated R #29 did not have an order for an as needed (PRN) pain medication. Nurse #1 stated she did not notify the provider. E. Record review on 11/26/24 of R #29's medical record physician progress notes, nursing progress notes, and physician orders revealed staff did not notify the physician or nurse practitioner of R #29's pain level. F. On 12/02/24 at 2:32 pm, during an interview with the Unit Manager, he stated he expected staff to document a progress note regarding notification of the physician of R #29's pain. He stated staff should have documented a change in condition (CIC; when there is a change from what is a person's normal baseline) due to pain of an 11 and notified the physician. He stated if the nurse found the Tylenol was not effective then the nurse should have notified the physician. 51919 Resident #132 F. Record review of R #132's provider's orders, dated 11/12/24, revealed an order to administer vancomycin (an antibiotic medication) IV solution, 750 milligrams (mg)/150 milliliter (ml) for discitis/osteomyelitis (a serious condition that causes inflammation of the discs in the spine) every eight hours. G. Record review of R #132's medication administration record (MAR), dated November 2024, revealed staff did not administer R #132 the vancomycin on 11/25/24 at 6:00 am, 2:00 pm, and 10:00 pm due to medication was not received. H. On 11/25/24 at 9:53 am and 11/25/24 at 2:31 pm, during an interview with Nurse #1, she stated vancomycin was not available to administer to R #132, because the pharmacy did not deliver it. Nurse #1 stated she called the pharmacy on 11/24/24 and the morning of 11/25/24 to request a vancomycin delivery. I. On 11/27/24 9:16 am and 9:25 am, during an interview with the Nurse Practitioner (NP), he stated he was not aware R #132 missed doses of the vancomycin, because the nursing staff did not notify him. He stated he became aware when he saw the on-call provider's report in his email on the morning of 11/27/24. The NP stated he was on the floor during the time when R #132 missed his vancomycin doses, and a communication book was available by his office door. He stated the communication book did not contain any mention of the situation. He stated he expected nurses and other healthcare staff at the facility to notify him of any missed medications doses for R #132. He added he would contact the Infectious Disease Team (a medical clinic that R #132 follows up with regarding his infection) if staff made him aware. He stated if the staff had notified him, then he would also call the pharmacy to order a vancomycin trough blood level test (a test that measures the concentration of vancomycin in the blood) in order to see if the pharmacy staff needed to make an adjustment on the vancomycin's course of treatment. J. On 11/27/24 at 9:38 am during an interview with Nurse #2, she stated she was expected to notify the floor NP regarding any missed medications doses for R #132.

Based on interviews and observations, the facility failed to provide a clean, homelike environment for all 21 residents who lived on the 400 hall. This deficient practice is likely to result in residents not feeling comfortable, which could affect their psychological well-being. The findings are: A. On 11/25/24 at 8:00 a.m., observation during the initial tour of the building revealed the 400 hall had a strong odor of urine and feces throughout. B. On 11/27/24 at 11:06 a.m., during an interview, R #266 stated she had a bedside commode. She stated she did not always put the lid down, because she frequently needed to use the bathroom. She stated she missed the bedside commode in the past while she tried to open the lid. C. On 11/237/24 at 11:06 a.m., it was observed that R#266 bedside commode sat next to the resident's bed, the lid was up, and urine was in the commode. D. On 11/27/24 at 11:15 a.m., during an interview with Certified Nursing Assistant (CNA) #1, she stated R #266 did not keep the lid on her bedside commode down after she used it, which made the 400-hallway smell of urine. E. On 11/27/24 at 2:00 p.m., during an interview, R #20 stated he could smell the odors in the hallway, and it bothered him.

Based on record review and interview, the facility failed to provide care that met professional standards for 1 (R #60) of 3 (R #23, #60 and #16) residents when the facility failed to maintain and care for R #60's gastrostomy tube (g-tube; a tube surgically inserted through the abdomen into the stomach and used to provide fluids, nourishment and medications.) This deficient practice is likely to result in residents not receiving proper nutritional needs and also places residents at risk for complications and infections that may affect their quality of life. The findings are: A. Record review of the facility's policy, Enteral Management, dated 03/01/22, revealed staff to provide safe and effective management of enteral tubes. B. Record review of the facility's policy, Enteral Tubes Medication Administration, dated 03/01/22, revealed guidelines for managing complications. Staff directed to do the following: 1. Check first to see the tube was not kinked. 2. If the feeding tube became clogged, then interventions should occur immediately. Warm water should be tried first. 3. Clogged tube - Clogging can occur from internal blockage. a. If the clog was still present, then gently milk the tube from top to bottom to release any clog that may be in that part of the tube. b. Do not force-flush the tube or use a rigid object in an attempt to clear the tube. If the clog was persistent, then contact the medical doctor (MD) if the above techniques fail. Resident #60 C. Record review of the face sheet for R #60, dated 11/23/24, revealed an initial admitted [DATE] and included the following diagnoses: - Severe protein-calorie malnutrition, - Aphasia (disorder that impairs the ability to process language), - Dysphasia (difficulty swallowing), - Dysarthria (when the muscles used for speech are weak or hard to control) and anarthria (severe form of dysarthria), - Aphasia (language disorder that affects the ability to speak and understand what others say), - Gastrostomy status (surgical procedure for inserting a tube through the abdomen into the stomach for administration of food, fluids and medications), - Ileus (condition where your intestines can't push food and waste out of the body). D. Record review of physician's orders for R #60, various dates, revealed orders for staff to administer R #60's medications via g-tube. E. Record review of Change in Condition for R #60, dated 11/10/24 at 9:14 pm, revealed the resident's percutaneous endoscopic gastrostomy (PEG; a type of g-tube) was clogged. Staff unable to unclog the PEG and notified the on-call provider. Provider ordered medication to aid unclogging PEG. Will attempt as soon as the medication becomes available. F. Record review of the physician's progress notes, dated 11/10/24 at 11:00 pm, revealed the resident's PEG was clogged. Previously had medication ordered to unclog PEG tube, but it was unavailable from pharmacy. Order given to go ahead with Creon (medication that contains a combination of enzymes that help digest fats, proteins, and sugars) medication to assist with unclogging PEG tube. G. Record review of progress notes for R #60 revealed the following: - Dated 11/11/24 at 12:45 pm, Nurse Management note: Review of change in condition, dated 11/10/24. Clogged g-tube noted. Attempted multiple ways to unclog g-tube, to include declogger soda and pressure unsuccessfully. Resident sent to emergency room for possible new tube. - Dated 11/11/24 at 3:35 pm, Patient was transferred to hospital 2:23 pm on this day due to his g-tube became clogged. This nurse, as well as other nurses, tried to unclog the g-tube. Using pressure, carbonated beverages, warm water, and wand to unclog tube. H. Record review of hospital discharge documentation for R #60, dated 11/11/24, revealed the resident had a past medical history of stroke, status post (after) g-tube placement, and was brought in by emergency medical services (EMS) from the nursing facility for an evaluation of a g-tube issue. Patient's g-tube got clogged last night. Today the nursing facility staff attempted to unclog this with five cleaners and Dr. Pepper; however, they were unsuccessful. Patient did not report abdominal pain and did not have any complaints today. He acknowledged there was a clog in his g-tube. On chart review, patient had a gastrostomy tube placed on 10/22/2024. Initial vital signs revealed tachycardia, and that resolved without intervention. Physical exam revealed a soft, non-tender abdomen. Attempted to flush the catheter without success. Then placed an endotracheal stylette (small, unbreakable, plastic coated metal rod) also without success. Contacted interventional radiology (offers patients an image guided minimally invasive procedure to alleviate a condition that could be otherwise be potentially life-threatening) for assistance. They used a [NAME] syringe (a disposable syringe used for irrigating wounds and catheters) with pressure and dislodged the clot. Patient was stable for discharge back to his facility. Recommend he follow-up with his primary care provider and return to the hospital with any concerns. I. On 12/02/24 1:48 pm during an interview, the Director of Nursing (DON) stated the staff used declogger wands to unclog the resident's PEG, and the Nurse Practitioner (NP) #1 advised them to use the soda method. The DON stated using soda or carbonated beverages to unclog a g-tube was probably not considered best practice.

Based on observation, record review, and interview, the facility failed to ensure the medication error rate did not exceed 5 percent (%) for 7 residents (R #25, #32, #52, #130, #131, #132, and #317) of 11 residents (R #3, #16, #25, #31, #32, #45, #52, #130, #131, #132, and #317) reviewed during medication administration. Staff administered 80 medications with 39 errors, which resulted in a medication error rate of 48.75 %. If medications are administered in error, residents are likely to experience less than optimal results from their medication regimen. The findings are: R #25 A. Record review of R #25's physician orders, dated 12/2/24, revealed the following: - Potassium oral tablet (treats hypokalemia; a condition where the level of potassium in blood is lower than normal), 20 milliequivalents (meq). Give one tablet by mouth for hypokalemia at 8:00 am. - Sotalol oral tablet (manages blood pressure), 80 milligrams (mg). Give one tablet by mouth for high blood pressure at 8:00 am. - Sertraline oral tablet (treats depression; a mood disorder that causes a persistent feeling of sadness and loss of interest), 50 mg. Give one tablet by mouth for depression at 8:00 am. - Furosemide oral tablet (treats congestive heart failure; impaired heart function), 40 mg. Give one tablet by mouth for congestive heart failure at 8:00 am. - Flovent inhaler (treats shortness of breath). One puff inhaled orally for shortness of breath at 8:00 am. - Lidocaine patch (relieves nerve pain). Apply one patch to right hip topically for pain at 8:00 am. B. On 11/25/24 at 09:15 am during observation of Nurse #1, she administered the following morning medications to R #25: - Potassium oral tablet, 20 meq. - Sotalol oral tablet, 80 mg. - Sertraline oral tablet, 50 mg. - Furosemide oral tablet, 40 mg. - Flovent inhaler, one puff. - Lidocaine patch. C. On 11/25/24 at 9:15 am during an interview with Nurse #1, she stated she passed the morning medications for the 100 hall late, because the Certified Medication Aide (CMA) assigned to the hall did not come to work. D. On 11/25/24 at 9:15 am during observation, Nurse #1 attempted to administer medication to R #23, but the resident asked if she could postpone her medications. Nurse #1 took R #25's medications and put them in the medication cart. Nurse #1 then went to ask the Nurse Manager to talk to the resident. The resident decided to take her medications without delaying them. Nurse #1 did not inform R #25 about the medications being administered. R #32 E. Record review of R #32's physician orders, dated 12/2/24, revealed the following: - Lidocaine patch (relieves nerve pain). Apply one patch to affected area topically for pain at 8:00 am. -Apixaban oral tablet (treats vascular accident (CVA; a condition when an area of the brain becomes damaged from lack of blood supply to the brain) 5 mg. Give one tablet by mouth for CVA at 8:00 am. -Benzonatate oral capsule (treats cough), 100 mg. Give one capsule by mouth for cough at 8:00 am. -Guaifenesin oral tablet (treats cough), 600 mg. Give one tablet by mouth for cough at 8:00 am. -Sulfasalazine oral tablet (treats rheumatoid arthritis; a chronic disease where body's immune system mistakenly attacks the lining of joints), 500 mg. Give one tablet by mouth for rheumatoid arthritis at 8:00 am. -Furosemide oral tablet, 40 mg. Give one tablet by mouth as a diuretic at 8:00 am. -Nebulization treatment solution (treats cough and shortness of breath), 3 milliliter (ml) inhale orally via nebulizer for cough and shortness of breath at 8:00 am. F. On 11/25/24 at 9:27 am during observation of Nurse #1, she administered the following morning medications to R #32: - Lidocaine patch. -Apixaban oral tablet, 5 mg. -Benzonatate oral capsule, 100 mg. -Guaifenesin oral tablet, 600 mg. -Sulfasalazine oral tablet, 500 mg. -Furosemide oral tablet, 40 mg. -Nebulization treatment solution. G. On 11/25/24 at 9:27 am during observation of Nurse #1, she did not inform R #32 about the medications being administered. R #317 H. Record review of R #317's physician orders, dated 12/2/24, revealed the following: -Losartan oral tablet (manages high blood pressure), 50 mg. Give one tablet by mouth for high blood pressure at 8:00 am. -Carvedilol oral tablet (manages high blood pressure), 12.5 mg. Give one tablet by mouth for high blood pressure at 8:00 am. -Ticagrelor oral tablet (prevents blood clots), 90 mg. Give one tablet by mouth to prevent blood clots at 8:00 am. I. On 11/25/24 at 9:32 am during observation of Nurse #1, she administered the following morning medications to R #317: -Losartan oral tablet, 50 mg. -Carvedilol oral tablet, 12.5 mg. -Ticagrelor oral tablet, 90 mg. R #130 J. Record review of R #130's physician orders, dated 12/2/24, revealed the following: -Venlafaxine oral tablet (treats depression), 75 mg. Give one tablet by mouth for depression at 8:00 am. -Baclofen oral tablet (relieves muscle spasms), 10 mg. Give one tablet by mouth for muscle spasm at 8:00 am. K. On 11/25/24 at 9:40 am during observation of Nurse #1, she administered the following morning medications to R #130: -Venlafaxine oral tablet, 75 mg. -Baclofen oral tablet, 10 mg. R #131 L. Record review of R #131's physician orders, dated 12/2/24, revealed the following: -Protonix oral tablet (treats gastroesophageal reflux disease (GERD; a condition in which the stomach contents move up into the esophagus), 40 mg. Give one tablet by mouth for GERD at 8:00 am. -Wellbutrin oral tablet (treats depression), 150 mg. Give one tablet by mouth for depression at 8:00 am. M. On 11/25/24 at 9:40 am during observation of Nurse #1, she administered the following morning medications to R #131: -Protonix oral tablet, 40 mg. -Wellbutrin oral tablet, 150 mg. R #132 N. Record review of R #132's physician orders, dated 12/2/24, revealed the following: -Oxcarbazepine oral (treats seizures; a disorder in which nerve cell activity in the brain is disturbed, causing seizures), 300 mg. Give one tablet for seizures at 8:00 am. -Tylenol oral tablet (relieves pain), 325 mg. Give two tablets for pain at 8:00 am. -Gabapentin oral capsule (relieves pain), 300 mg. Give one capsule for pain at 7:00 am. -Paroxetine oral tablet (treats mood disorder; a mental health condition that affects a person's emotional state, causing long periods of extreme sadness, happiness, or both), 40 mg. Give one tablet for mood disorder at 8:00 am. -Amantadine oral tablet (treats intellectual disability; a chronic condition that limits a person's ability to learn, think, and perform daily activities) and traumatic brain injury (TBI; a brain injury caused by an outside force, such as a blow or jolt to the head, or an object piercing the skull), 100 mg. Give one tablet for intellectual disability and TBI at 8:00 am. -Metoprolol oral tablet (manages high blood pressure), 25 mg. Give one tablet for high blood pressure at 8:00 am. - Vancomycin intravenous (IV; into a vein), (treats discitis/osteomyelitis; infection of the spine), 750 mg/150 ml. Infuse 150 ml intravenously for discitis/osteomyelitis at 6:00 am. O. On 11/25/24 at 9:53 am during observation of Nurse #1, she administered the following morning medications to R #132: -Oxcarbazepine oral tablet, 300 mg. -Tylenol oral tablet, 650 mg. -Gabapentin oral capsule, 300 mg. -Paroxetine oral tablet, 40 mg. -Amantadine oral tablet, 100 mg. -Metoprolol oral tablet, 25 mg. -Vancomycin intravenous, 750 mg/150 ml. P. On 11/25/24 at 9:53 am, during an interview with Nurse #1, she stated she contacted the pharmacy to deliver vancomycin on 11/24/24 and again on 11/25/24. She stated the vancomycin was not delivered yet. She stated R #132 missed his 6:00 am dose of vancomycin. Nurse #1 stated we will be lucky if we receive it by the end of this week. R #52 Q. Record review of R #52's physician orders, dated 12/2/24, revealed the following: -Amoxicillin-pot clavulanate oral tablet (treats gangrene on medial right ankle; means that the inner side of the right ankle is affected by gangrene; a serious condition that occurs when body tissue dies), 875-125 mg. Give one tablet by mouth for gangrene on medial right ankle at 8:00 am. -Cilostazol oral tablet (treats symptoms of intermittent claudication; is a muscle pain during activity that stops when the person rests), 100 mg. Give one tablet by mouth for symptoms of intermittent claudication at 8:00 am. -Escitalopram oral tablet (treats depression), 20 mg. Give one tablet by mouth for depression at 8:00 am. -Gabapentin oral capsule (relieves pain), 300 mg. Give three capsules by mouth for pain at 8:00 am. -Isosorbide oral tablet (treats coronary artery disease; a heart disease that occurs when the arteries supplying blood to the heart narrow due to plaque buildup), 30 mg. Give one tablet by mouth for coronary artery disease at 8:00 am. -Losartan oral tablet (manages high blood pressure), 50 mg. Give one tablet by mouth for high blood pressure at 8:00 am. -Metoprolol oral tablet (manages high blood pressure), 100 mg. Give one tablet by mouth for high blood pressure at 8:00 am. -Tapazole oral tablet (treats hyperparathyroidism; a disorder in which 1 or more of the parathyroid glands in the neck produce too much parathyroid hormone) , 10 mg. Give one tablet by mouth for hyperparathyroidism at 8:00 am. R. On 11/26/24 at 8:10 am during observation of Certified medication Aid (CMA) #1, she administered the following morning medications to R #52: -Amoxicillin-pot clavulanate oral tablet, 875-125 mg. -Cilostazol oral tablet, 100 mg. -Escitalopram oral tablet, 20 mg. -Gabapentin oral capsule, 900 mg. -Isosorbide oral tablet, 30 mg. -Losartan oral tablet, 50 mg. -Metoprolol oral tablet, 100 mg. -Tapazole oral tablet, 10 mg. S. On 11/26/24 at 8:10 am during observation of CMA #1, she did not inform R #52 about the medications being administered. CMA #1 stated she would inform R #52 about her medications if she asked. T. On 12/02/24 at 2:52 pm during interview with Nurse #4, she stated staff should administer resident medications within a two hour period, one hour before to one hour after the time stated on the resident's orders.

Based on observations, interviews and record review, the facility failed to: 1. Ensure medication refrigerators did not contain medications that belonged to discharged residents. 2. Ensure nurses and CMAs dated opened insulin (a medication prescribed to help the body turn food into energy and manages blood sugar levels) vials and discarded them within 28 days of opening. 3. Ensure medication carts did not contain medications that belonged to discharged residents. These deficient practices are likely to result in residents receiving medications that are less effective or expired for all 70 residents who reside in the facility, as identified on the census list provided by the facility Administrator on [DATE]. The findings for the medication refrigerator: A. On [DATE] at 10:50 am, during observation of medication refrigerator located inside the medication room, revealed the following: 1. Lispro 10 milliliter multiple-dose vial insulin (a short-acting insulin) vial was open and did not have an opening date. The insulin vial belonged to R #8. 2. Vancomycin (an antibiotic medication) syrup bottle was open and did not have an opening date. The medication belonged to R #316. B. Record review of the manufacturer's instructions for Lispro multiple dose vial insulin revealed staff to throw away all opened vials after 28 days of use, even if there is insulin left in the vial. C. Record review of R #8's physician orders, dated [DATE], revealed R #8 was actively receiving lispro insulin. D. Record review of R #316's face sheet, dated [DATE], revealed R #316 was discharged from the facility on [DATE]. E. On [DATE] at 10:55 am, during an interview with the Nurse Manager, he stated staff must date the opened Lispro insulin vial and discard it within 28 days from the opening date. He stated staff must discard medications that belonged to discharged residents, and staff should not leave them in the medication fridge. The findings for the medication cart. F. On [DATE] at 1:30 pm, during observation of medication cart in the 100 hall, a multivitamin bottle was open and not dated. The bottle belonged to R #43. G. Record review of R #43's face sheet, dated [DATE], revealed R #43 was discharged from the facility on [DATE]. H. On [DATE] at 1:30 pm, during an interview with CMA #2, he stated the multivitamin bottle belonged to R #43 who was discharged on [DATE]. He stated he should have removed R #43's medications from the medication cart.

Based on record review and interview the facility failed to ensure advance directives (a document which provides an individual's wishes for emergency and life saving care) were complete for 1 (R #45) of 1 (R #45) resident reviewed for advance directives when staff failed to ensure the resident signed the advance directive. This deficient practice is likely to result in residents receiving unwanted or unplanned treatment during a medical emergency. The findings are: A. Record review of R #45 electronic medical record (EMR) revealed R #45 elected a code status of do not resuscitate [DNR; a medical order that instructs healthcare providers not to perform cardiopulmonary resuscitation (CPR) if a patient's heart stops beating or breathing stops.] B. Record review of R #45's Medical Orders for Scope of Treatment (MOST; an advance directive) form, dated [DATE], revealed the resident did not sign it. C. On [DATE] at 3:48 PM during an interview, the Director of Nursing (DON) stated R #45's MOST form should be signed by the resident, but it was not.

Based on interview and record review, the facility failed to ensure staff completed the comprehensive care plans for 2 (R #23 and R #166) of 2 (R #23 and R #166) residents reviewed for care plans, when staff failed to: 1. Complete care plans for R #23 for the following areas: Activities of daily living (ADL; basic self-care tasks) care, psychotropic medications (medications that affect behavior, mood, thoughts and perception), and respiratory complications; and2. Complete care plans for R #166 for the following areas: ADL care, cardiovascular (heart) symptoms or complications, oral health, diabetes (high blood sugar levels), anemia (not having enough healthy red blood cells), and anticoagulant (medication that thins the blood) medication use. This failure has the potential to adversely affect staff's ability to implement preventative measures for the residents' health and well-being. The findings are: Resident #23 A. Record review of face sheet for R #23 revealed an admitted [DATE] and included the following diagnoses: - Muscle weakness; - Lack of coordination; - Unsteadiness on feet; - Reduced mobility; - Conduct disorder (a behavioral and emotional disorder that presents as repetitive, disruptive and violent behavior); - Fatigue (a feeling of tiredness or lack of energy); - Mental disorders due to known physiological condition (a broad group of severe mental and behavioral disorders); - Respiratory failure with hypoxia (when you don't have enough oxygen in your blood); and - Need for assistance with personal care. B. Record review of Physicians Orders for R #23 revealed the following:- Sertraline (medication used to treat anxiety) oral tablet, 25 milligrams (mg). Give one tablet by mouth in the morning for anxiety. Start date: 11/14/24. End date: 11/22/24.- Sertraline oral tablet 50 mg. Start date: 11/23/24.- Trazodone (medication used to treat depression) oral tablet, 50 mg. Start date: 11/21/24.- Buspirone (medication used to treat anxiety). Start date 11/13/24.- Olanzapine (medication used to treat mental disorders and depression) oral tablet, 2.5 mg. C. Record review of Care Plan dated 10/15/23 for R #23 revealed that R #23 required assistance with ADL care. Staff did not complete any additional information to include ADSs, goals and interventions. - Dated 09/23/24, Focus: Resident was at risk for complications related to the use of psychotropic drugs. Staff did not complete the Goal Section. - Dated 10/15/24, Focus: Resident exhibited or was at risk for respiratory complications related to recent hospitalization . Staff did not complete the Goal Section to include the number of days the resident would not have signs or symptoms of respiratory distress. Resident #166 D. Record review of face sheet for R #166 revealed an admitted [DATE] and included the following diagnoses: - Type 2 diabetes mellitus with the following complications: 1) diabetic retinopathy (eye disease caused by diabetes) with macular edema (swelling in the eye), 2) diabetic nephropathy (kidney disease caused by diabetes), and 3) hyperglycemia (high blood sugar); - Cerebrovascular disease (conditions that affect blood flow to the brain); - Hyperlipidemia (high levels of fat in the blood); - Hypertension (high blood pressure); - History of venous thrombosis (formation of blood clots in the veins) and embolism (blood clot that blocks the flow of blood). E. Record review of the care plan for R #166 revealed the following: - Dated 11/25/24, R #166 required assistance with ADL care. Staff did not complete any additional information to include ADLs, goals, and interventions. - Dated 11/25/24, Focus: Resident exhibited or was at risk for cardiovascular symptoms or complications related to diagnosis of hypertension, hyperlipidemia, and history of stroke. Staff did not complete the Goal Section to include the number of times a day the resident would participate in skilled physical therapy/occupational therapy without any signs or symptoms of activity intolerance. - Dated 11/25/24, Focus: The resident had a diagnosis of diabetes and was insulin dependent. Staff did not complete the Goal Section to include the number of days the resident would not have signs or symptoms of hypo/hyperglycemia (low/high blood sugar). - Dated 11/25/24, Focus: Resident was at risk for injury or complications related to the use of anticoagulation therapy medication, Apixaban (brand name.) Staff did not complete the Goal Section to include the number of days the resident would not have signs or symptoms of bleeding. E. On 12/02/24 at 1:43 pm during an interview, the Director of Nursing (DON) stated the care plans were incomplete for R #23 and #166, and staff should have completed the care plans.

Based on observation, record review, and interview the facility failed to provide adequate and timely pain relief for 1 (R #29) of 2 (R #29 and #132) residents reviewed for pain. This deficient practice likely resulted in R #29 to be in significant pain. The findings are: Resident #29 A. On 11/25/24 at 11:14 am, during an observation and interview of R #29, she rubbed her hand and cried. R #29 stated she was in a lot of pain. She stated staff gave her Tylenol a little bit ago, but it did not help. She asked the Certified Nursing Assistant (CNA) #6 to ask the nurse to bring her the medication for her nerve pain, and the CNA stated he would tell the nurse. R #29 stated that sometimes the Tylenol worked and sometimes it did not. She stated her pain level was an 11. B. Record review of the physicians orders for R #29 indicated an order for Tylenol extra strength, oral tablet 500 milligrams (mg). Give two tablets by mouth every eight hours as needed for generalized pain. C. Record review of the medical record for R #29 indicated staff documented the resident's pain level to be a 10 (the pain scale indicates pain based on 1 being the lowest and 10 being highest) on 11/25/24 at 10:52 am. D. Record review of the Medication Administration Record (MAR) for R #29 revealed the following: - Dated 11/25/24 at 10:50 am, staff administered two Tylenol 500 mg to R #29 for pain. - Dated 11/25/24 at 12:18 pm, staff noted the Tylenol was ineffective for the resident's pain. - Staff did not document anything else after the medication was determined to be ineffective. E On 11/25/24 at 11:35 am, during an interview with CNA #6, he stated he informed the nurse of R #29's pain and requested her pain medication. F. On 11/25/24 at 11:45 am, during an interview with Nurse #1, she stated she was aware R #29 asked for another medication for her pain, but R #29 did not have another pain medication on order. She stated R #29 only had Tylenol for pain, and she gave the resident some Tylenol a little bit ago. She stated R #29 was not due to receive another dose of Tylenol at this time. She stated R #29 did not have anything else ordered for pain, like another as needed (PRN) pain medication. She stated R #29 did not have an order for an as needed (PRN) pain medication. Nurse #1 stated she did not notifythe provider. G. On 12/02/24 at 2:32 pm, during an interview with the Unit Manager, he stated he expected staff to document a progress note regarding notification of the physician of R #29's pain. He stated staff should have documented a change in condition (CIC; a change in what is baseline or normal for a person) due to pain of an 11 and notified the physician. He stated if the nurse found the Tylenol was not effective then the nurse should have notified the physician.

Based on observation, interview, record review, and facility policy review, the facility failed to notify the physician of the need to alter treatment for one of one resident (Resident (R) 47) reviewed for [CONDITION(S)] [swelling] in a total sample of 23 residents. The failure to notify the physician of ongoing bilateral [CONDITION(S)] of the feet resulted in the physician not having the opportunity to assess and change the treatment which resulted in actual harm when R 47 developed extensive blood clots in both legs. Findings include: Review of the facility policy titled, Physician/Advanced Practice Provider (APP) Notification, revised 12/01/21, indicated, Upon identification of a patient who has a change in condition, abnormal laboratory values, or abnormal diagnostics, a licensed nurse will: Report to physician/advanced practice provider (APP). If unable to contact attending physician/APD the Medical Director will be contacted. Review of R 47's Admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed an admitted [DATE] with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R 47's admission Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 03/29/22, revealed a Brief Interview for Mental Status (BIMS) score was zero out of 15, indicating R 47 was severely cognitively impaired. During an interview on 04/25/22 at 4:15 PM, R 47's Responsible Party (RP) 1 stated R 47 had swelling in both feet. RP 1 stated she did not feel the facility had adequately addressed the issue. RP 1 stated the nursing staff donned soft, pink boots on R 47 on two occasions but was unaware of any additional interventions. During an observation at this time, R 47 was noted to have bilateral [CONDITION(S)] in her lower extremities, mainly her feet. During additional observations on 04/26/22 at 9:00 AM, 04/27/22 at 8:52 AM, and 04/27/22 at 1:36 PM, R 47 was observed seated upright in her wheelchair with her feet resting on the wheelchair pedals. Review of R 47's Medical Progress Notes, dated 03/23/22 and located in the EMR under the Misc tab, indicated, Resident arrived to the facility via stretcher .Skin is intact with [CONDITION(S)] [swelling] noted to ankles and feet. Review of R 47's physician's Encounter Note, dated on 03/24/22 and located in the EMR under the Notes tab, revealed the following: No peripheral [CONDITION(S)], cyanosis [blue discoloration of skin], or clubbing [swelling of tips of fingers and/or toes affecting the nails]. Review of R 47's Nursing Documentation Note, dated on 03/24/22, located in the EMR under the Notes tab, revealed the following: Lower pitting [skin indentation after pressure applied] [CONDITION(S)] present. Continued review of R 47's Nursing Documentation Notes, dated 03/24/22 through 03/31/22, revealed Cardiovascular system reviewed. skin is cool. Lower extremity pitting [CONDITION(S)] present. Description and location of pitting [CONDITION(S)]: 1+ BLE [bilateral lower extremity]. Review of R 47's General Note, dated on 04/02/22 and located in the EMR under the Notes tab, revealed Resident bilateral feet observed [CONDITION(S)]. Doctor .informed, order BMP [basic metabolic panel-blood test] one time only and start [MEDICATION(S)] [diuretic] 20 mg[milligrams] once daily for 7 days after the blood work. Review of R 47's physician's Encounter Note, dated on 04/02/22 and located in the EMR under the Notes tab, revealed Patient was being seen today due to worsening lower extremity swelling. Staff has no other concerns at this time. Patient states her legs feel like they are swollen. Nursing staff was instructed to add [MEDICATION(S)] [[MEDICATION(S)]] 20 mg daily for 7 days with repeat blood work prior to starting and repeat blood work at 7 days. Review of R 47's April 2022 Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R 47's Nursing Documentation Notes, dated 04/05/22 through 04/16/22 revealed, Lower extremity pitting [CONDITION(S)] present. Description and location of pitting [CONDITION(S)]: 1+ bilateral lower extremities. Review of R 47's Nursing Documentation Note, dated 04/17/22 revealed, Pressure reducing boots applied to feet bilaterally. Cardiovascular system reviewed. skin is cool. Lower extremity pitting [CONDITION(S)] present. Description and location of pitting [CONDITION(S)]: 1+ BLE. An additional note dated 04/18/22 revealed, Pressure reducing boots applied to feet bilaterally. Cardiovascular system reviewed. skin is cool. Lower extremity pitting [CONDITION(S)] present. Description and location of pitting [CONDITION(S)]: 1+ BLE. Review of R 47's General Note, dated on 04/19/22 and located in the EMR under the Notes tab, revealed Foot assessment: Feet edematous and pitting ++ bilaterally. Pedal [foot] pulse not palpable due to swelling. Resident is able to feel sensations on both feet. Capillary refill less than 3 sec [seconds]. No injuries noted, dry flakes noted in-between toes. Nails short and thick. Resident sitting on a wheelchair and resting both feet on footrest. Review of R 47's medical record revealed no notification to the physician regarding the continued bilateral [CONDITION(S)] after the [MEDICATION(S)] was completed on 04/10/22 and when on 04/19/22 the [CONDITION(S)] increased to 2+ and the pedal pulse could not be felt. Review of R 47's Nursing Documentation Notes, dated 04/20/22 through 04/25/22 revealed, Lower extremity pitting [CONDITION(S)] present. Description and location of pitting [CONDITION(S)]: 1+ bilateral lower extremities. Further review of these nursing notes revealed no physician notification of continued pitting [CONDITION(S)]. Review of R 47's nursing Interact, note dated 04/26/22 and located in the EMR under the Assessments tab, revealed: Received report that pt [patient] this evening that pt continues with persistent bilateral [CONDITION(S)], POA [power of attorney] called and notified, POA stated that she was worried about her mother having blood clots, all questions and concerns were addressed and answered. MD in building this evening notified of pt's persistent [CONDITION(S)], new orders received for 20 mg [MEDICATION(S)] PO [Per oral] once a day x [times] 7 days, a BMP lab draw on 5/4 after [MEDICATION(S)] order complete, and new order for BLE venous ultrasound to rule out blood clots. Orders entered in system; Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: New orders: [MEDICATION(S)] 20 mg PO once a day for 7 days, BMP lab draw on 5/4 following completion of [MEDICATION(S)] order, and BLE venous doppler/ultrasound to rule out bloot [sic] clots r/t swelling; B. New Testing Orders:- Blood Tests Venous Doppler. This was the first physician notification of the continued pitting [CONDITION(S)] since the physician saw R 47 on 04/02/22 (24 days earlier). During an interview on 04/27/22 at 3:00 PM, RP 1 informed the survey team that she was concerned with R 47's bilateral swelling in her feet. RP 1 informed the survey team that the facility was sending R 47 to the emergency room due to [CONDITION(S)] [blood clot]. Review of R 47's Diagnostic Ultrasound, dated 04/27/22 and provided by the facility to the survey team revealed: Acute [CONDITION(S)] in the right external iliac [artery], common femoral, femoral, popliteal, posterior tibial, peroneal, and gastrocnemius veins. Acute [CONDITION(S)] in the left external iliac, common femoral, femoral, popliteal, posterior tibial, peroneal [outer side of the calf of the leg], and gastrocnemius veins. Bilaterally fully occlusive from EIV [external iliac vein] to lower calf veins. During an interview on 04/27/22 at 9:14 AM, Registered Nurse (RN) 1 stated she observed R 47's bilateral [CONDITION(S)] and reported it to the doctor. RN 1 stated the day she reported the bilateral [CONDITION(S)] was the one and only time that she cared for R 47. During an interview on 04/27/22 at 3:53 PM, the Unit Manager (UM) stated he was never notified of R 47's bilateral swelling until today [04/27/22]. The UM stated it would be his expectation for the staff to assess the resident and immediately notify the physician of the concerns. The UM stated after R 47's completed her [MEDICATION(S)] on 04/10/22, there were no follow-up notifications to the physician regarding R 47's continued bilateral swelling until R 47's RP brought the concern to nursing staff on 04/26/22. During an interview on 04/28/22 at 9:40 AM, the Center Nurse Executive (CNE) stated he expected any change of condition to be reported to the doctor. The CNE stated he reviewed R 47's medical record and did not see any reports to the physician regarding the bilateral [CONDITION(S)] after the [MEDICATION(S)] was completed on 04/10/22. During an interview on 04/28/22 at 5:00 PM, the Center Executive Director (CED) stated a change of condition should be reported to the physician. During an interview on 04/28/22 at 10:07 AM, the Medical Doctor (MD) stated the facility did not report continued bilateral [CONDITION(S)] after the [MEDICATION(S)] was completed. The MD stated he continued to monitor R 47's labs and ordered a doppler on 04/27/22 after speaking with R 47's RP. The MD stated that R 47 was transferred to theER on [DATE] and had been started on [MEDICATION(S)] (a daily injection to treat/prevent blood clots). The MD stated that a consult with a vascular surgeon was ordered since the blood clots were so extensive throughout multiple veins in both legs.

Based on record review, and interview, the facility failed to ensure that resident's nutritional status (nutrition and hydration) was being appropriately monitored by weighing new residents once every week for the first four weeks to obtain a baseline weight, and by notifying appropriate facility staff when weight loss or a change in meal and fluid intakes had occurred for 5 (R #45, #110, #299, #356 and #358) of 5 (R #45, #110, #299, #356 and #358) residents reviewed for nutrition. This deficient practice likely resulted in weight loss in residents who were already vulnerable to losing weight due to COVID-19 (a contagious disease caused by severe acute respiratory syndrome), and caused one resident to be admitted to the hospital severely dehydrated (excessive loss of fluid from the body) and needing to be placed on life support; causing a physical and mental decline in the residents' well being. The findings are: Findings for R #356 A. Record review of the face sheet indicated that R #356 was admitted on [DATE]. He was admitted from the hospital due to being positive for COVID. He had been residing in a home for individuals with intellectual disabilities. He had a [DIAGNOSES REDACTED]. This is not an all inclusive list. B. Record review of R #356's weight on admit reveled that R #356 did not have a weight on file. C. Record review of the care plan dated 11/11/20 indicated the following: Monitor for changes in nutritional/hydration status (change in intake, ability to feed self, unplanned weight loss/gain, abnormal labs) and report to Dietary Manager, Registered Dietician, and physician as indicated. Further review of the care plan did not reveal whether R #356 required assistance or supervision with eating or drinking. D. Record review of the Task sheets for meal intake indicated the following: -On 11/11/20 breakfast indicated that R #356 ate independently, during lunch time it appears he did not eat and/or accept a drink. There was no documentation for dinner. -On 11/12/20 there was no documentation for breakfast, lunch and dinner. -On 11/13/20 there was no documentation for breakfast or lunch. For dinner it indicated that he ate and accepted a drink. -On 11/14/20 the documentation indicated that he ate breakfast. Nothing is documented for lunch and dinner. -On 11/15/20, 11/16/20 and 11/17/20, there was no documentation. -On 11/18/20 he did not eat breakfast. Lunch he did not eat, and dinner there was no documentation. Resident discharged to the hospital on [DATE]. E. On 02/10/21 at 1:03 pm, during an interview with Registered Dietician (RD) #3 was not familiar with R #356. She stated that he was not here long enough at the facility to do an initial nutrition assessment for him. F. On 02/10/21 at 3:41 pm, during an interview with RD #2, was not familiar with R #356. She stated that he was not here long enough at the facility to do an initial nutrition assessment for him. G. On 02/11/21 at 9:05 am, during an interview with Licensed Practical Nurse (LPN), LPN #6 stated that he needed to eat with assistance because he would eat too fast. She stated that he would not know, on a cognitive level (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses), to reach for the water, he would be dependent on staff for that. She stated that she had gone on leave over a weekend and when she came back she heard that he hadn't been eating and was sent out to the hospital. H. On 02/12/21 at 10:24 am, during an interview with LPN #7, he stated that he had noticed that R #356 was declining and had told one of the day nurses (didn't recall which one). He stated that he talked to the Certified Family Nurse Practitioner) CFNP. Then CFNP called him and asked him to go get R #356's pulse. He did that, and R #356's pulse was above 110 beats per minute. He remembers the conversation because the CFNP was wondering if his pulse was high because he was dehydrated or anxious. LPN #7 also remembered that R #356 would not open his mouth, so he was pretty sure that he was dehydrated. It was difficult to give him water. He stated that to get R #356 to take 1/2 a cup of water, it would take thirty minutes. So he was pretty sure that he was dehydrated because it was impossible to get food or fluids in him. He stated that he had asked the day shift about his intake and they stated that they didn't have any issues. LPN #7 stated that R #356 was difficult to assess because of his cognitive delay. He stated that during that night of 11/17/20 his pulse had gone up which was different for him. So, he called the on call physician and he was told to send him to the hospital non emergent. When he called the ambulance they said they would be there in two hours. He stated that two hours passed and he called again and they told him that they would be there in thirty minutes, they didn't show up again. They finally showed up around two hours after that. I. On 02/15/21 at 11:01 am, during an interview with CFNP, she stated she does remember this case. She remembered that there were concerns about his intake level. She remembers she had gone into see R #356 because they were talking about sending him back to his home. She stated that she saw in his chart that he was [MEDICAL CONDITION] (a heart rhythm disorder with heartbeats faster than usual, greater than 100 beats per minute) which was not something he was noted as having previously. She stated that she wasn't sure if this was an anxiety response or if there was something else going on like an infection or dehydration. Later that evening she called to get another set of vitals and she had asked the nurse about R #356 having anxiety around being in unfamiliar place, or something else. She stated that the nurse told her that he thought it was likely dehydration because of poor oral intake. She stated that poor oral intake had not been reported to her. She also stated that she had not been getting notifications (in general about any residents) of weight loss. She stated that with COVID residents they do see a lot of weight loss and that it can be expected. She stated that the Registered Dieticians should be monitoring for that. She stated that she has not had any contact with the Registered Dieticians and previously there have been issues with getting a hold of them. J. Record review of the five day follow up that was submitted to the state licensing agency for R #356, indicated the following findings: -CFNP assessed R #356 for possible discharge home. Upon record review discovered Tachycarida. The etiology of the [MEDICAL CONDITION] unclear so monitoring and STAT (immediate) labs in the morning were ordered and to push fluids. -Nurse contacted physician on call due to ongoing concerns and physician indicated send to hospital non-urgent transport. Nurse continues to call ambulance to get an update on when they will come by to pick up R #356. -After the facility did their investigation they identified opportunities for improvement regarding documentation and report of change in status with meal intakes . -Agency Certified Nursing Assistant (CNA) do not have access to point of care (where the CNA's document resident's activities of daily living (ADL). - CNA's are not using the SBAR (Situation, Background, Assessment, Recommendation) or stop and watch form) to notify their charge nurse when a resident meal consumption had changed. K. Record review of the medical records from (name of hospital) dated 11/18/20 indicated the following: -On arrival to ED patient was [MEDICAL CONDITION] ([MEDICAL CONDITION] a common type of heart rhythm disorder (arrhythmia) in which the heart beats faster than normal while at rest), tachypenic (a lack of oxygen or too much carbon [MEDICATION NAME] in the body is a common cause), and hypotensive (relating to or suffering from abnormally low blood pressure). They are unable to obtain pulse oxygen. Due to depressed mental state, patient was intubated (intubation is a medical procedure involving the insertion of a tube into the body) shortly after arrival . -Systemic [MEDICAL CONDITION] Response Syndrome (SIRS): (is a serious condition related to systemic inflammation, organ dysfunction, and organ failure). Patient met SIRS criteria on arrival. Empirically (verifiable or provable by means of observation or experiment) covered with [MEDICATION NAME] (antibiotic that treats infections) and [MEDICATION NAME] (is used to treat a wide variety of bacterial infections) However, now that work-up is completed, SIRS criteria were likely met because of severe dehydration /[MEDICAL CONDITION] (elevated blood sodium caused by a deficit of total body water relative to total body sodium caused by water intake being less than water losses). The only evidence of infection is resolving basilar infiltrates (means the trunk or bottom of the lung(s). An infiltrate is the filling of airspaces) related to recent Covid. No evidence of severe bacterial infection. May be reasonable to discontinue further antibiotics. -[MEDICAL CONDITION] (a sodium and water imbalance in the body)/Secondary to dehydration (excessive loss of fluid from the body). Patient initially received [MEDICATION NAME] Ringer's bolus ([MEDICATION NAME] Ringer's solution, or LR, is an intravenous (IV) fluid you may receive if you are dehydrated, having surgery, or receiving IV medications.) Will switch to half normal saline for ongoing resuscitation (restoration to life or consciousness of one apparently dead, or whose respirations had ceased). Dehydrated/acute [MEDICAL CONDITION]: (excessive loss of fluid causing kidney failure, which occurs when your kidneys lose the ability to filter waste from your blood sufficiently). Continue IV fluids. -Critical care was necessary to treat or prevent imminent or life-threatening deterioration (the process of becoming progressively worse) of the following conditions: Circulatory failure (the circulatory system fails to maintain the supply of oxygen and other nutrients to the tissues and to remove the carbon [MEDICATION NAME] and other metabolites from them), CNS failure (Central Nervous System, the brain is command central. It orders your lungs to breathe and your heart to beat. It rules virtually every other part of your body and mind), or compromise and [MEDICAL CONDITION]. -Clinical Impressions as of 11/18/20: Dehydration, Acute [MEDICAL CONDITION] (kidney failure occurs when your kidneys lose the ability to filter waste from your blood sufficiently), Acute metabolic [MEDICAL CONDITION] (Metabolic [MEDICAL CONDITION] is a transient or permanent impairment of brain function). Findings for R #45 L. On 02/08/21 at 10:38 am, during an interview with R #45, she stated that she has lost a lot of weight since she has been here. The food is not good, so she won't eat it. She is on a puree diet. M. Record review weights of R #45 indicated that R #45 had a 12.69% weight lost from 01/17/21 to 02/07/21: 01/17/2021 134.4 Lbs 01/24/2021 131.0 Lbs 01/31/2021 129.2 Lbs 02/07/2021 117.2 Lbs N. Record review of the Initial Nutrition Assessment on 01/21/21 indicated that PO (by mouth) intake is 100% based on 1 meal recorded. Unable to assess adequacy of PO (by mouth) intake w/ (with) limited meal information. R #45 was admitted on [DATE]. O. Record review of the care plan 01/21/21, indicated the following: -R #45 is at nutritional risk due to protein deficiency (a protein deficiency means someone is not getting enough protein to meet their needs) and suboptimal intake (less than optimal, not sufficient) due to therapeutic diet with texture alteration (change in food texture). Resident #45 is not eating enough of balanced diet to meet her needs due to her puree diet. -R #45 will tolerate the safest and least restrictive diet without complications through next review, will consume 75-100% of meals 3 meals per day and will maintain her weight. Interventions in the care plan are as follows: -Provide liquid protein supplement ( a medical food that provides a concentrated source of protein for people with increased protein needs) as ordered -Honor food preferences within meal plan -Encourage 100% consumption of all fluids provided -Offer/encourage fluids of choice -Weigh per protocol and alert dietitian and physician to any significant loss or gain -Monitor for changes in nutritional status (changes in intake, ability to feed self, unplanned weight loss/gain, abnormal labs) and report to food and nutrition/physician as indicated -Monitor intake at all meals, offer alternate choices as needed, alert dietitian and physician to any decline in intake -Provide diet as ordered -Shows on Kardex (medical information system used by nursing staff as a way to communicate important information on their patients) -Offer snacks -Supervise/cue/assist as needed with meals -Place call light within reach at all times P. On 02/10/21 at 1:03 pm, during an interview with Registered Dietician RD #3, she stated that she did R #45's initial assessment and that her assessment included only one meal that was documented at 100%. She stated that it is hard to do assessments when there isn't documentation to go off of. She stated that their primary focus was on the initial assessments for new residents coming into the facility. She stated that they just started pulling weight reports again recently. There is a report that they pull that would show any weight loss and that this report is pulled once per month, but she can pull whenever she wants to. RD #1 stated that she looked at weight loss last week for residents. She stated that R #45 was not on her list for weight loss. No one has contacted her about R #45. Findings for R #299 Q. On 02/08/21 at 9:32 am, during an interview with R #299, he stated that the food sucks. It's horrible, and they never serve me enough of it. He stated that he had lost weight and is always hungry. R #299 was admitted on [DATE]. R. Record review of R #299's weight revealed the following: 01/29/2021 164.4 Lbs 01/31/2021 165.6 Lbs 02/07/2021 144.0 Lbs S. On 02/10/21 at 2:35 pm, during an interview with the Dietary Manager, he stated that R #299 had just been weighed because he saw his weight loss in his chart. He stated that he weighed 141 pounds on 02/10/21. He stated that they just started a new tracking program this week and he saw that R #299 was ordering sandwiches five times this week. So he looked at his meal intake and they were all 100%. So he asked the CNA on that hall to re-weigh him. He stated no one had made him aware of the weight loss and that the Registered Dietician (RD) needed to re-assess him. T. On 02/10/21 at 3:21 pm, during an interview with Certified Nursing Assistant #6, she stated that they weigh residents on Sundays and on admission. The process if there is any weight loss is that they report it to the charge nurse. Please have findings in Chronological order by dates and times. U. On 02/10/21 at 3:30 pm, during an interview with LPN #4, he stated that the RD's do get notifications in the electronic medical system and they can look up weights at any time for any residents. He stated that the weights are done on Sundays and that the CNA's will enter the weights into the system. Please have findings in Chronological order by dates and times V. On 02/10/21 at 3:37 pm, during an interview with Center Nurse Executive (CNE). She stated that the process for weighing residents is that they are weighed every week on Sunday. The Unit Manager # 2 looks at the weights on the weekends and makes sure that they are getting done. The Dietician goes in and reviews the weights weekly. Dietician will step in if they see anything or if there is a weight loss. W. On 02/10/21 at 3:41 pm, during an interview with RD #2, she stated that no they have not been getting notified from the facility staff about weight loss. They have been focused on the Initial Assessments for Nutrition and not weight loss. She was not familiar with R #299 weight loss until yesterday. He has been re-assessed. X. Record review of a nutrition progress note dated 02/11/21 indicated the following: R #299 had a significant weight loss of 21.6# (pounds) (-13%) x 7 days compared to 1/31/21 wt of 165.6# (pounds) . It is unlikely that he lost that significant amount of wt (weight) in that short period of time. However, he was reweigh on 2/10 and his weight was confirmed to be 144# (pounds), per Dining Services Director. Unsure of cause of significant discrepancy. Intake is usually 100% w/ an average of 96% over the last 14 days, per meal intake records. Per Dining Services Director, he has an ongoing request for midday snacks. He is meeting 84-100% of his estimated nutritional needs. However, he reports feeling hungry even after completing meals. Recommend offering large portions of entrée x3 meals/day and snacks BID (twice per day). Y. On 02/15/21 at 9:51 am, during an interview with UM #2, she stated that she does oversee that the weights are getting done on Sunday. She will go through Monday and check the weights. She will make sure that everyone is weighed. UM #2 stated that she has been overseeing this about one month to 6 weeks now. UM #2 stated that she will go over weight loss with the Dietary Manager and the CNE and it is discussed in clinical's in the morning. UM #2 stated that she does not know who the Registered Dieticians are and she has not had any contact with them. She stated that she was not aware of R #299's weight loss and was aware of R #45's weight loss. Z. On 02/15/21 at 11:53 am, during an interview with ICF Care Giver, he stated that he has been working with R #356 for [AGE] years. He stated that R #356 got sick with COVID and he went to the hospital and after that, went to a transitional facility. He stated that before R #356 became sick with COVID he was able to feed himself, but would need to be watched so he didn't eat too fast. They could tell him to slow down and to take a drink and he would do that. The care giver also stated that R #356 did need some prompting to drink fluids. AA. On 02/16/21 at 2:21 pm, during an interview with CNE (Center Nurse Executive), she stated that the last few weeks 3 or 4 weeks they (registered dietician's) started attending clinical's. Not sure why they weren't showing up. Could have been that she had not invited them before. She is aware that she could get a hold of them though. Not sure if they get involved with the physician or call them with concerns. She stated that they have access to the system so they can check in on anyone here in the facility. She stated that some training needs to be happening around this. BB. Record Review of the Weights and Heights Policy and Procedure last reviewed on 12/20/19 indicated the following: 1. Obtaining and documenting weights: 1.1.1 Admissions and re-admissions will be weighed within 24 hours of admission. 1.1.4 If the body weight is not as expected, re-weigh the patient. 2. Significant Weight Change Management: 2.1 Significant weight changes will be reviewed by the licensed nurse for assessment: 2.2 The licensed nurse will: 2.2.1 Notify the physician/APP and Dietician of significant weight changes. Findings for R #358: CC. Record review of the admission record for R #358 revealed she was admitted on [DATE] with a primary [DIAGNOSES REDACTED]. She had additional [DIAGNOSES REDACTED]. DD. Record review of dietary evaluation dated 05/18/20 revealed the resident weighed 103 pounds on 05/15/20, had a percutaneous endogastric tube (PEG) (tube placed in the stomach and exiting to the abdomen for administration of food and liquids that cannot be obtained orally). and that the resident also took food per mouth, that she was at, high nutritional risk, due to her medical diagnosis' and difficulty self-feeding requiring full assistance. EE. Record review of residents documented weights revealed: 1. On 05/15/20 weight was 103 pounds. 2. On 05/24/20 weight had decreased to 93 pounds. 3. On 05/31/20 weight was 93 pounds. 4. On 06/07/20 weight had increased to 97.4 pounds. 5. On 06/14/20 weight was 88 pounds. FF. On 02/10/21 at 10:00 am, during telephone interview with the Program Director of the group home where the resident was transferred back to by the facility on 06/16/20, she revealed, a registered nurse (RN) at her house assessed R #358 when she returned to the facility and sent her to the local acute care emergency room for evaluation and treatment. There the resident was noted to be dehydrated and given intravenous (through a vein) fluids. GG. 02/15/21 8:30 am, during interview with the Social Services Director she revealed she did most of the care plan meetings on her own since COVID-19 pandemic in progress as other disciplines, nursing, activities and dieticians, while invited had been too busy to attend. She revealed that, in fact she had eventually quit inviting dietary as they never responded to her. She revealed that nursing did begin sending a representative approximately three weeks ago She had never invited nursing technicians. HH. On 02/15/21 at 1:28 pm during telephone interview with Registered Dietician she revealed, regarding weight loss noted above she revealed, no arrangements, had been made since COVID-19 for her to participate in morning meetings and care conferences and that is where she often found out about residents weight loss. II. Record review of communication notes obtained from the group home dated 06/16/20 at 3:55 pm, revealed the RN made a referral for the resident to go to the local acute care at that time. JJ. Record review of communication notes from the group home dated 06/16/20 at 7:25 pm, revealed, (first name of R #358) was being treated for [REDACTED]. Findings for R #110: KK. On 02/08/21 at 11:48 am, during an interview with R #110, when asked if he is satisfied with the food, he stated the quality of the food is fine. I do have some issues, I asked the kitchen to give me more carbs (carbohydrates). I'm losing weight, I don't get a lot of food. The kitchen said they need approval to get what I want. She said I could get different things like snacks and a 4 oz (ounce) shake. I'm still losing weight. I've lost 5 pounds. I asked about getting double portions but that never happened. So, I have my friend bring me snacks. When I ask for a snack from here, yes, they will bring me 1 but I should not be losing weight. LL. On 02/08/21 at approximately 12:45 pm, an observation of the meal ticket for R #110 was made. The meal ticket did not indicate that the resident should receive double portions. MM. Record review of the resident's face sheet reveals that the resident was admitted to the facility on [DATE] with the following pertinent Diagnosis: [REDACTED]. NN. Record review of physician orders [REDACTED]. 01/13/2021: Regular/Liberalized diet, Dysphagia Advanced texture Diet (nearly regular textures that requires moistening and should be in bite-size pieces) 01/17/21: Weight x 4 while on skilled stay every day shift every Sun for 4 Weeks 01/20/21: ST (Speech Therapy)- clarification order- ST (Speech Theraoy) eval (evaluation) and treat- QD1-5 x wk x 30 days (every day, 1-5 times a week for 30 days) . 02/12/21: House Supplement - three times a day 02/12/21: Nourishment - three times a day diet appropriate snack OO. Record review of weights for R #110 reveals the following weights: 01/12/21: 151.2 pounds 01/24/21: 146.8 pounds 02/07/21: 155.4 pounds 02/14/21: 152.4 pounds PP. Record review of care plan reveals the following (Name of R #110) is at nutritional risk for sub optimal meal intake r/t (related to) acute and chronic illness and need for an altered textured diet Date Initiated: 01/19/2021 QQ. Record review of the dietary assessment, dated 1/19/21, reveals the following: (R #110 is meeting his est. (estimated) needs as he consumes 75-100% of his meals. He is assessed with [REDACTED]. His diet is appropriate at this time. He has no nutritional concerns at this time. Goals: consume 75% of his meals, have no significant weight changes through the next review. Plan: Continue current nutritional plan, weigh per protocol. Dietitian available as needed. RR. On 02/10/21 at 11:13 am, during an interview with the Speech Therapist, when asked to explain how therapy was for R #110, she stated he was doing really well when he came in, he has had therapy in the past for swallowing and they taught him to do a throat clear after swallowing but he was having more coughing. So, he was doing more coughing and throat clearing, with food and thin liquid. We started doing regular trials and working on a diet upgrade however; it was inconsistent. One day he would make progress and then not the next. He was cut form therapy by his insurance. I was getting close to upgrading his diet, I was looking for more consistency. His diet is appropriate for him right now. If we had more time we may have been able to upgrade him. When asked if he mentioned weight loss or if he was wanting more food, she stated he asked for more, he said that he was very hungry, and he was very concerned about his weight loss. I talked to the dietary manager about getting him snacks and double portions. He consulted with the dietician. SS. On 02/10/21 at 3:22 pm, during an interview with RD #3, when asked to review R #110, she stated his assessment was completed by (name of other dietician). According to her assessment, she said that he was consuming about 75-100 of meals. When asked if she has received notification that he would like an increase in portions, she stated I have never spoken to anybody from (name of facility), I don't see any portion adjustments forms for him. So, that's when it gets a little bit tricky, I don't know if (name of another dietician) was notified or not. She maybe saw that he was meeting his nutritional needs and didn't see a need for an increase. When asked how weights are monitored, she stated We have a chart that we keep track of and it would show who we track. When asked what occurs when weights seem incorrect, she stated, There is no way of knowing if the weight was incorrect upon admission, if his weight has dropped after my assessment, there was no way for me to know if his weight was accurate. I would have to ask my supervisor to see if we could get a redo on weights. I typically only get a monthly report of someone who triggers for weight loss. At that time, we evaluate everything. TT. On 02/11/21 at 11:15 am, during an interview with R #110, he stated I was weighed at (Name of hospital) on 12/23/20 and I weighed 163. I told the speech therapist I wanted more food. I am used to being between 165-170 pounds. I don't feel comfortable seeing my ribs and being this skinny. It's hard being in my room all the time and I am already on anti-depressant medications. I don't like losing weight like that. To me, it doesn't make any sense. I'm not doing anything but sitting around in a wheel chair. Most of the time, when I open my meal tray, I say, 'whoa, you got to be kidding me', because I know this is not going to fill me up. I'm really not big on snacks, normally I don't eat snacks, but I have to, to compensate for my small meals. UU. On 02/11/21 at 3:47 pm, during an interview with the Dietary Director, when asked to explain what happens if a resident wants more food, he stated we automatically put more food on their plate and tell the dietician and she will reassess. For (name of R #110), we changed it to double portions. The other communication I have for him was from the speech therapist and she requested snacks. Snacks have been on there since 1/27. The resident stated that he wanted snacks. VV. On 02/15/21 at 10:08 am, during an interview with UM #2, when asked if she is familiar with the weight of R #110, she stated yes, we are reviewing his weights. He had an assessment on Friday. We are re-weighing him today. Double portions started last Friday, and we gave him the alternate meal and the full menu. WW. On 02/17/21 at 10:43 am, during an interview with the CNE, when asked what is expected when monitoring resident weights, she stated they are supposed to get weighed on a weekly basis. If they are up or down 3 pounds, they are supposed to get a re-weigh. We recently did an in-service on that. I started the in-service last week. Every resident will be weighed weekly and if there is an up or down of 3 pounds the nurse should verify by re-weighing. This will be done on Sundays. The unit manager oversees that on Sundays. The next step is to let the dietician and DM know. It is up to the dietician to see if there is anything that needs to be added to their nutritional regimen.

Based on record review and interview the facility failed to ensure quality care for 2 (R #2 and #3) of 2 (R #2 and #3) residents looked at for abuse and/or neglect by: 1. Not following physician's orders [REDACTED]. 2. Not taking action on R #3's lab work when it indicated that he had an infection, This deficient practice caused R #3 to have an infection that went without treatment before being sent out to the hospital; and R #2 not having her heel and her two amputated toes treated, monitored and booted consistently, causing an unstageable pressure ulcer on her right heel. The findings are: R #2 [NAME] Record review of the medical chart indicated that resident was admitted on [DATE] R #2 did have two toes amputated at the hospital, but did not have any pressure wounds at the time of admission to the facility. B. Record review of the physician orders [REDACTED]. C. Record review of the physician orders [REDACTED]. D. Record review of the physician orders [REDACTED]. Elevate L (left) heel off the bed. E. Record review of the physician orders [REDACTED]. F. Record review of the TAR (treatment administration record) dated Septemeber 2019 indicated that none of the above four physician orders [REDACTED]. The above orders were not being completed. [NAME] Record review of Skin Integrity Reports (SIRS) indicated that the first SIR was dated 09/27/19. H. Record review of the progress note for wound care dated 09/27/19, indicated the following: Wound Care completed to R heel. UN (unstageable) (full thickness skin or tissue loss with unknown depth, the actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) PU (pressure ulcer) (Injury to the skin and its underlying tissue due to prolonged pressure on it) measures 7 cm x 3.3 cm. Cleansed with NS, painted with [MEDICATION NAME] (help prevent infections before they start). Nonstick pad applied and secured with Kerlix. Pt (patient) s/p (after)( R (right) great and 2nd toe amputation. 11 stitches removed per treatment order (T/O) by (name of physician). Stitches removed intact and patient showed no s/s (signs and symptoms) pain or discomfort and tolerated well. SX (symptoms) incision appears to be healing well with no s/s of infection. Patient wearing Prevalon (can help prevent heel pressure ulcers by lifting the heel off of the mattress, minimizing pressure) boot to R foot I. Record review of the TAR indicated the following order: Wound Care: UN PU to R heel. Cleanse with NS (normal saline), pat dry. Paint with [MEDICATION NAME]. Cover with nonstick pad and secure with Kerlix. Every day shift every Mon, Wed, Fri for UN PU R heel -Start Date- 09/30/19. [NAME] Record review of the progress notes dated 10/04/19 indicated the following: Wound care completed. Patient has open MASD (moisture associated skin damage) to buttocks. Zinc oxide (topical (for the skin) is used to treat diaper rash, minor burns, severely chapped skin, or other minor skin irritations)applied. Patient shows no signs of distress or pain. R heel measures 7 cm x 3.5 cm. Eschar to wound bed. Tolerated treatment well. K. On 01/21/20 8:50 am, during an interview with Unit Manager she stated that she did not know about the wound on #2's heel. She stated she does not see another SIRS report, only the one on 09/26/19. She also does not see notes for the skin checks. L. On 01/22/20 at 9:50 am, during an interview with the CNE (Center Nurse Executive) CNE, she stated that they are implementing a whole new system for wounds and for training. She stated prior to the new system and it was the two Unit Managers and herself who were monitoring the wound care program. M. On 01/23/20 at 8:57 am, during an interview with the Medical Director, she stated that she saw (R #2) on 09/26/19, she did an H (history) and P (physical). She agreed that she wrote the orders for the measurements, the wound care, and the boot. She was not aware that they are not on the TAR and were not being done. She stated that yes, they were having problems with wounds. She stated that the agency nurses are lacking competence or lacking caring and concern. She stated that sometimes she can't even get the nurses to report issues to her. R #3 N. Record review of a wound care progress note dated 08/16/19, indicated the following: St 4 (stage 4) to L (left) hip measures 7.8 cm (centimeter) x 8 cm x 1.4 cm, Tunneling (tunneling wounds snake through the layers of tissue, creating horizontal S-shaped curves) at 1 o'clock 4 cm, tunneling at 11 o'clock is 2.5 cm and undermining (are wounds that extend in all directions into the subcutaneous tissue under the skin) from 3 o'clock to 5 o'clock is 1.5 cm. 100% granulation tissue (is new connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process) moderate SS drainage (serosanguineous drainage is a sign of healing, and it is not usually a cause for concern when it appears in normal amounts), no odor. St 4 to L buttock measures 1.5 cm x 1.5 cm x 3 cm with tunneling at 9 o'clock measuring 2.8 cm and tunneling at 3 o'clock measuring 3.6 cm. 100% granulation tissue, moderate SS drainage and no odor. St 4 R buttock measures 3 cm x 1.5 cm x 2 cm, moderate SS drainage and no odor. St 3 to coccyx measures 2 cm x 1.5 cm x <0.1 cm. 50% [MEDICATION NAME] and 50% granulation tissue. Moderate SS drainage and no odor . Patient states no pain during treatment, tolerated well. O. Record review of a nutrition progress note dated 08/20/19, indicated the following: Report of new Stage III pressure ulcer (full thickness skin loss involving damage or necrosis of subcutaneous tissue) on coccyx. Wound on left hip . and sacrum (triangular bone at the base of the spine) have not improved . P. Record review of a wound care progress note dated 09/27/19, indicated the following: Wound Vac (device to assist in wound healing) dated 9/23 removed from patient buttocks and hip. All wounds have copious (a lot) amount of serosanguinous (contains or relates to both blood and the liquid part of blood (serum)) discharge and are malodorous (have odor). St 4 to L hip measures 9 cm x 8.5 cm x 1 cm. Undermining at 5 o'clock to 7 o'clock 0.9 cm, undermining 1 o'clock to 3 o'clock 2 cm, undermining 11 o'clock to 12 o'clock measures 3.8 cm. Wound bed 50 % granulation. Edges slough and eschar (is composed of necrotic granulation tissue, muscle, fat, tendon or skin). St 4 to L buttock measures 3 cm x 3.5 cm x 2.3 cm with tunnel at 11 o'clock measuring 3.7 cm. 90% granulation tissue, 10% slough (can range in color from white (scant bacterial colonization) to yellow or green (larger bacterial counts) to brown (hemoglobin is present)) around edges. [NAME] foam found deep in tunnel. Was removed after approx. 30 minutes, saturating with NS (normal saline) using cotton swab and hemostats (a surgical tool used in many surgical procedures to control bleeding) . Foam appeared intact. Tunnel inspected with pen light and no residual foam visualized. St 4 to R (right) buttock measures 2.3 cm x 1 cm x 2.8 cm, tunnel 3 o'clock 3.3 cm, tunnel 7 o'clock 2.4 cm. Granulation tissue to wound bed. St 3 to coccyx measures 2 cm x 1.7 cm x <0.1 cm. Slough to wound bed . Q. Record review of the Skin Integrity Report (SIRS) indicated that there were no wound measurements done between 08/21/19 to 09/27/19 for the pressure ulcer on the left hip, left buttock, right buttock and the coccyx. R. Record review of the history and physical dated 10/01/19 indicated in the Chief Complaint/Nature of Presenting problem: Worsening wounds. In the plan section it indicated that on 10/01/19: Multiple stage 4 pressure ulcers . the vac can no longer be used on the pressure ulcers due to slough. He is received (sic) dressing changes. A CBC (complete blood count) CMP (comphrensive metabolic panel), EST (erythrocyte sedimentation rate test ) and CRP (detect inflammation and could detect the start of an infection) will be drawn tonight. He completed IV Ceftaiaxone (antibiotic) and [MEDICATION NAME] (antibiotic) for pelvic osteo[DIAGNOSES REDACTED] (bone infection) on 07/29/2019. S. Record review of the Lab Results Report indicated that the lab was collected on 10/03/19 and was reported on 10/04/19. The results of the lab indicated that the WBC (white blood count) was 18.2 and the reference range is 3.8-10.1. A high white blood count could indicate an infection. The CRP (C-reactive protein) and the erythrocyte sedimentation rate (ESR or sed rate) can indicate that there is inflammation (is a process by which the body's white blood cells and substances they produce protect us from infection with foreign organisms, such as bacteria [MEDICAL CONDITION].) The CRP result was 188.2 and the reference range was 0.0-10.0. The ESR Sed Rate was 107 and reference range was 0-20. Both tests indicated that R #2 had a lot of inflammation. T. Record review of a wound care progress note dated 10/04/19, indicated the following: Wound care completed to St 4 PUs to L hip and bilat buttocks. L hip measures 9 cm x 10.4 cm x 1 cm with undermining the entirety of wound of 3 cm. Wound bed consists of granulation (pink or beefy red tissue with a shiny, moist, granular appearance), slough and eschar. Wound is malodorous. Heavy serosanguinous discharge. Wound edges and surrounding tissue are healthy. L buttock measures 3 cm x 4.2 cm x 4 cm with granulation and slough to wound bed Heavy serosanguinous discharge. Wound edges and surrounding tissues healthy but wound malodorous. R buttock measures 2 cm x 0.6 cm x 2.3 cm with granulation tissue to wound bed. Heavy serosanguinous discharge. Unable to resume wound vac d/t (due to) unhealthy wound bed tissue. Patient tolerated treatment well. U. Record review of Daily Nursing note dated 10/09/19: Resident is alert and oriented to time, place and person. He had a stable shift. The CNA (Certifed Nursing Assistant) brought to my attention that his briefs were soiled with blood from his wound. On observation, the blood was old blood and no active bleeding was noted. I cleaned, re-dressed and packed with wound on his left hip and buttocks. His briefs were changed thereafter and was made comfortable in bed without any further complaints. He also had [MEDICAL CONDITION] (a surgical operation in which a piece of the colon is diverted to an artificial opening in the abdominal wall so as to bypass a damaged part of the colon) care done. His call light was placed within his reach and was asked to request for help as needed. He tolerated his medications without complaints. V. Record review of the progress notes indicated that on 10/9/19 at 22:58 (10:58 pm), Change in Condition Note was made: A change in condition has been noted. The symptoms include: Abnormal vital signs (low/high BP, heart rate, respiratory rate, weight change) 10/09/2019 in the afternoon Vitals: BP (blood pressure) 70/54 - 10/9/2019 20:33 (10:33 pm), Position: Lying r/arm (right arm) P (pulse) 119 - 10/9/2019 20:33 (10:33 pm), Pulse Type: Irregular - new onset R (respirations) 20.0 - 10/9/2019 20:33 (10:33 pm) T (temperature)100.6 - 10/9/2019 20:30 (10:30 pm), Route: Oral O2 (oxygen saturation) 68.0 % - 10/9/2019 20:30 (10:30 pm), Method: Room Air BS (blood sugar) 219.0 - 10/9/2019 20:30 (10:30 pm) W. Record review of the nursing progress note indicated the following, on 10/10/19, On taking over night shift from the evening shift nurse, it was reported that resident has had low blood pressure since afternoon and fluids are being pushed in to increase blood pressure. I took the vitals myself and noted the following: (blood pressure) B/P 70/54, pulse 119, Temp 100.6, (oxygen saturation) O2 sat 68%, (blood glucose) BG 219 and (respirations) resp 20. Urine output was also low at 200 mls all day. Resident also verbalized extreme discomfort and general weakness. The Dr. on call (name of physician) was immediately notified and she advised I send to the E.R immediately . X. On 01/22/20 at 10:06 am, during an interview with the Unit Manger, she stated that his (R #3) wounds were doing well and then started to decline. The last time 09/27/19 she helped (wound care nurse) change the wound vac, there was an extreme amount of drainage and odor on the wounds. Because of the drainage the wounds were no longer appropriate for the wound vac. Yes, she stated there were concerns of infection in the wound because it was so odorous. Y. On 01/22/20 at 3:40 pm, during an interview with the wound care nurse, she stated that she left the facility to go work else where. This was mid to late August, after some changes had been made at the facility they asked her to come back every Friday to due wound care because they were struggling a bit. So she agreed to do that and probably came back in on the Friday of (MONTH) 27th. She stated that for R #3, his wounds did not look as good as they had previously. She stated that the odor coming from R #3's wound was, she stated that she couldn't even describe it. She stated that she had concerns that it was infected but without a wound culture, you can't be sure, but an odor can indicate that a wound is infected. She stated that she did remember pulling out the foam that was stuck down into the wound, she stated there is no way to know if that foam was stuck in there from a previous wound vac change or not. Z. On 01/23/20 at 8:40 am during an interview with the CED (Center Executive Director), she stated that there was a period of time when the wound care SIRS (skin integrity report) sheets were not getting done. A[NAME] On 01/23/20 at 8:57 am, during an interview with the Medical Director, she stated that she did have concerns about R #3 wounds and that they were infected. That is why she ordered the lab work to get done when she saw R #3 on 10/01/19. She stated that she doesn't ever remember viewing the lab results. She asked for two results during the interview, she asked for the SED rate which was 107 and reference range was 0-20. The CRP result was 188.2 and the reference range was 0.0-10.0. She agreed this would likely indicate an infection. She stated that nursing (wound care nurse) had said that the wounds were worsening. That there was slough in the wounds, the MD stated that she was concerned that the [DIAGNOSES REDACTED] had returned.

Based on record review and interview the facility failed to ensure the pressure ulcers/sores/wounds did not decline or develop for 2 (R #2 and R #3) of 2 (R #2 and R #3) residents. This deficient practice caused three pressure sores to decline, and two to develop due to a lack of having a consistent wound care program with consistent wound care. The findings are: R #2 [NAME] Record review of the medical chart indicated that resident was admitted on [DATE]. R #2 did have two toes amputated at the hospital, but did not have any pressure wounds at the time of admission to the facility. B. Record review of the physician orders [REDACTED]. C. Record review of the physician orders [REDACTED]. D. Record review of the physician orders [REDACTED]. Elevate L (left) heel off the bed. E. Record review of the physician orders [REDACTED]. F. Record review of the TAR (treatment administration record) indicated that none of the above four physician orders [REDACTED]. The above orders were not being completed. [NAME] Record review of Skin Integrity Reports (SIRS) indicated that the first SIR was dated 09/27/19. H. Record review of the progress note for wound care dated 09/27/19, indicated the following: Wound Care completed to R heel. UN PU measures 7 cm x 3.3 cm. Cleansed with NS, painted with [MEDICATION NAME]. Nonstick pad applied and secured with Kerlix. Pt s/p R great and 2nd toe amputation. 11 stitches removed per treatment order T/O by (name of physician). Stitches removed intact and patient showed no s/s pain or discomfort and tolerated well. SX incision appears to be healing well with no s/s (signs and symptoms) of infection. Patient wearing Prevalon boot to R foot I. Record review of the TAR indicated the following order: Wound Care: UN (unstageable) PU (pressure ulcer) to R heel. Cleanse with NS (normal saline), pat dry. Paint with [MEDICATION NAME]. Cover with nonstick pad and secure with Kerlix. Every day shift every Mon, Wed, Fri for UN PU R heel -Start Date- 09/30/2019 0600 (6:00 am). [NAME] Record review of the progress notes dated 10/04/19 indicated the following: Wound care completed . Patient shows no signs of distress or pain. R heel measures 7 cm x 3.5 cm. Eschar to wound bed. Tolerated treatment well. K. On 01/21/20 8:50 am, during an interview with Unit Manager she stated that she did not know about the wound on #2's heel. She stated she does not see another SIRS report, only the one on 09/26/19. She also does not see notes for the skin checks. L. On 01/23/20 at 8:57 am, during an interview with the Medical Director, she stated that she saw her on 09/26/19 and she did an H (history) and P (physical). She agreed that she wrote the orders for the measurements, the wound care and the boot. She was not aware that they are not on the TAR and were not being done. She stated that yes, they were having problems with wounds. She stated that the agency nurses are lacking competence or lacking caring and concern. She stated that sometimes she can't even get the nurses to report issues to her. R #3 M. Record review of the Skin Integrity Report (SIRS) indicated that upon admission 07/03/19 to the facility, R #3 had three pressure ulcer wounds. The right and left buttock and the left hip all were documented as a stage IV (4). N. Record review of a wound care progress note dated 08/16/19, indicated the following: 1. St 4 (stage 4) to L (left) hip measures 7.8 cm (centimeter) x 8 cm x 1.4 cm, Tunneling (tunneling wounds snake through the layers of tissue, creating horizontal S-shaped curves) at 1 o'clock 4 cm, tunneling at 11 o'clock is 2.5 cm and undermining (are wounds that extend in all directions into the subcutaneous tissue (under the skin) from 3 o'clock to 5 o'clock is 1.5 cm. 100% granulation tissue (is new connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process) moderate SS drainage (serosanguineous drainage is a sign of healing, and it is not usually a cause for concern when it appears in normal amounts), no odor. 2. St 4 to L buttock measures 1.5 cm x 1.5 cm x 3 cm with tunneling at 9 o'clock measuring 2.8 cm and tunneling at 3 o'clock measuring 3.6 cm. 100% granulation tissue, moderate SS drainage and no odor. 3. St 4 R buttock measures 3 cm x 1.5 cm x 2 cm, moderate SS drainage and no odor. 4. St 3 to coccyx measures 2 cm x 1.5 cm x <0.1 cm. 50% [MEDICATION NAME] and 50% granulation tissue. Moderate SS drainage and no odor. O. Record review of a nutrition progress note dated 08/20/19, indicated the following Report of new Stage III pressure ulcer (full thickness skin loss involving damage or necrosis of subcutaneous tissue)on coccyx (commonly referred to as the tailbone, is the final segment of the vertebral column). Wound on left hip, and sacrum have not improved . P. Record review of the Skin Integrity Report (SIRS) indicated that there were no wound measurements done between 08/21/19 to 09/27/19 for the pressure ulcer on the left hip, left buttock, right buttock and the coccyx. Q. Record review of a wound care progress note dated 09/27/19, indicated the following: Wound Vac (device to assist in wound healing) dated 9/23/19 removed from patient buttocks and hip. All wounds have copious (a lot) amount of serosanguinous (contains or relates to both blood and the liquid part of blood (serum)) discharge and are malodorous (have odor). 1. St 4 to L hip measures 9 cm x 8.5 cm x 1 cm. Undermining at 5 o'clock to 7 o'clock 0.9 cm, undermining 1 o'clock to 3 o'clock 2 cm, undermining 11 o'clock to 12 o'clock measures 3.8 cm. Wound bed 50% granulation (pink or beefy red tissue with a shiny, moist, granular appearance) edges, slough (can range in color from white (scant bacterial colonization) to yellow or green (larger bacterial counts) to brown (hemoglobin is present)) and eschar Eschar (a dry, dark scab or falling away of dead skin). 2. St 4 to L buttock measures 3 cm x 3.5 cm x 2.3 cm with tunnel at 11 o'clock measuring 3.7 cm. 90% granulation tissue, 10% slough around edges. [NAME] foam found deep in tunnel. Was removed after approx. 30 minutes, saturating with NS (normal saline) using cotton swab and hemostats (a surgical tool used in many surgical procedures to control bleeding) . Foam appeared intact. Tunnel inspected with pen light and no residual foam visualized. 3. St 4 to R (right) buttock measures 2.3 cm x 1 cm x 2.8 cm, tunnel 3 o'clock 3.3 cm, tunnel 7 o'clock 2.4 cm. Granulation tissue to wound bed. 4. St 3 to coccyx measures 2 cm x 1.7 cm x <0.1 cm. Slough to wound bed . R. Record review of the history and physical dated 10/01/19 indicated in the Chief Complaint/Nature of Presenting problem: Worsening wounds. In the plan section it indicated that 10/01/19: Multiple stage 4 pressure ulcers . the vac can no longer be used on the pressure ulcers due to slough. He is receiveing dressing changes. A CBC (complete blood count) CMP (comphrensive metabolic panel), EST (erythrocyte sedimentation rate test ) and CRP (detect inflammation and could detect the start of an infection) will be drawn tonight. He completed IV Ceftaiaxone (antibiotic) and [MEDICATION NAME] (antibiotic) for pelvic (between the abdomen and the thighs) osteo[DIAGNOSES REDACTED] (bone infection) on 07/29/2019. S. Record review of the Lab Results Report indicated that the lab was collected on 10/03/19 and was reported on 10/04/19 to the (name of physician) at 16:19 (4:19 pm). The results of the lab indicated that the WBC (white blood count) was 18.2 and the reference range is 3.8-10.1. A high white blood count could indicate an infection. The CRP (C-reactive protein) and the (ESR or sed rate) erythrocyte sedimentation rate can indicate that there is inflammation (is a process by which the body's white blood cells and substances they produce protect us from infection with foreign organisms, such as bacteria [MEDICAL CONDITION]) in the body. The CRP result was 188.2 and the reference range was 0.0-10.0. The ESR Sed Rate was 107 and reference range was 0-20. Both tests indicated that R #2 had a lot of inflammation. T. Record review of a wound care progress note dated 10/04/19, indicated the following: Wound care completed: 1. St 4 PUs to L hip and bilat buttocks. L hip measures 9 cm x 10.4 cm x 1 cm with undermining the entirety of wound of 3 cm. Wound bed consists of granulation, slough and eschar. Wound is malodorous (smelling very unpleasant). Heavy serosanguinous discharge. Wound edges and surrounding tissue are healthy. 2. L buttock measures 3 cm x 4.2 cm x 4 cm with granulation and slough to wound bed Heavy serosanguinous discharge. Wound edges and surrounding tissues healthy but wound malodorous. 3. R buttock measures 2 cm x 0.6 cm x 2.3 cm with granulation tissue to wound bed. Heavy serosanguinous discharge. Unable to resume wound vac d/t (due to) unhealthy wound bed tissue. Patient tolerated treatment well. U. Record review of the progress notes indicated that on 10/09/19 at 22:58 (10:58 pm), an eInteract Change in Condition Note was made: A change in condition has been noted. The symptoms include: Abnormal vital signs (low/high BP, heart rate, respiratory rate, weight change) 10/09/2019 in the afternoon Vitals: BP (blood pressure) 70/54 - 10/9/2019 20:33 Position: Lying r/arm P (pulse) 119 - 10/9/2019 20:33 Pulse Type: Irregular - new onset R (respirations) 20.0 - 10/9/2019 20:33 T (temperature)100.6 - 10/9/2019 20:30 Route: Oral O2 (oxygen saturation) 68.0 % - 10/9/2019 20:30 Method: Room Air BS (blood sugar) 219.0 - 10/9/2019 20:30 V. Record review of the nursing progress note indicated the following, on 10/10/19, On taking over night shift from the evening shift nurse, it was reported that resident has had low blood pressure since (sic) afternoon and fluids are being pushed in to increase blood pressure. I took the vitals myself and noted the following: (blood pressure) B/P 70/54, pulse 119, Temp 100.6, (oxygen saturation) O2 sat 68%, (blood glucose) BG 219 and (respirations) resp 20. Urine output was also low at 200mls all day. Resident also verbalized extreme discomfort and general weakness. The Dr. on call (name of physician) was immediately notified and she advised I send to the E.R immediately . W. On 01/22/20 at 10:06 am, during an interview with the Unit Manger, she stated that his wounds were doing well and then started to decline. The last time she helped (wound care nurse) change the wound vac 09/27/19 there was an extreme amount of drainage and odor on the wounds. Because of the drainage the wounds were no longer appropriate for the wound vac. Yes, she stated that there were concerns of infection in the wound because it was so odorous. X. On 01/23/20 at 8:57 am, during an interview with the Medical Director, she stated that she did have concerns about R #3 wounds and that they were infected. That is why she ordered the lab work to get done when she saw R #3 on 10/01/19. She stated that she doesn't ever remember viewing the lab results. She asked for two results during the interview, she asked for the SED rate which was 107 and reference range was 0-20. The CRP result was 188.2 and the reference range was 0.0-10.0. She agreed this would likely indicate an infection. She stated that nursing (wound care nurse) had said that the wounds were worsening. That there was slough in the wounds, the MD stated that she was concerned that the [DIAGNOSES REDACTED] (infection of the bone) had returned.

The facility failed to ensure there was a system in place for all clinical staff to immediately determine the code status (level of medical interventions a patient wishes to have if their heart or breathing stops) for 1 (R #1) of 1 (R #1) resident identified as suffering a delay in initiation of cardio [MEDICAL CONDITION] resuscitation (CPR: techniques to manually provide for blood circulation and oxygenation in an emergency). The resident was found unresponsive, staff removed him from the dining room via wheelchair to his room while the nurse went to the desk to access his chart to confirm his code status. This resulted in a 5 minute delay before starting CPR. This resulted in an immediate jeopardy (IJ) at a scope and severity of J (isolated jeopardy to resident health and safety) being identified on [DATE]. The facility took corrective action by providing an acceptable Plan of Removal on [DATE] at 5:05 pm. Based on the Plan of Removal, the interventions included: 1. Audit of all residents' code status 2. Staff to have a list of residents' code status provided to them from Point Click Care (name of electronic health care record system) regarding the code status of each resident in the facility that is updated daily. 3. Educate staff on code status response. 4. Random shift/staff education on code status five (5) days a week for thirty (30) days. 5. The daily code status check audits will be taken to Quality Assurance and Performance Improvement for the next ninety (90) days. Based on the Plan of Removal, the Scope and Severity was reduced from the level J to a level G. Based on record review and interview, the facility failed to initiate CPR immediately for 1 (R #1) of 1 (R #1) resident reviewed for prompt provision of CPR when required. This deficient practice increases the risk that CPR resuscitation (return of pulse and respirations adequate to support life) will be unsuccessful. The findings are: A. Record review of facility policy titled, Cardiac (heart) and/or Respiratory Arrest (stopping/cessation), dated as revised [DATE], revealed, 1. Upon discovery of a patient in cardiopulmonary arrest (e.g., no apparent pulse, blood pressure, or respiration (breathing)), staff will immediately: 1.1 Call for assistance 1.2 Alert the licensed nurse and CPR/automated external defibrillator (AED) certified staff; 1.3 Prepare the patient for CPR/AED while determining the presence of a Do Not Resuscitate order (DNR) . B. On [DATE] at 10:15 am, the CQS (Clinical Quality Specialist) revealed, They (staff) are following the (name of corporation who manages facility) policy by checking the chart (for residents' code status) .medical chart is (usually the most updated). C. Record review of R #1's medical record revealed the resident was initially admitted to the facility on [DATE], and most recently readmitted to the facility on [DATE] after a hospitalization . D. Record review of R #1's New Mexico Medical Orders For Scope of Treatment (MOST) form dated [DATE] code status revealed he was a Full Code (he had chosen to have CPR attempted if his heart stopped beating effectively or his breathing stopped). E. On [DATE] at 10:04 am, during a phone interview, Licensed Practical Nurse (LPN) #1 revealed, I was told he slumped over (in dining room) .it was right around dinner time . I went out for about a seven minute break .I noticed him when I went out .he had his back to me, sitting at a table .I noticed him because he hadn't been feeling well so I was glad to see him at dinner .sometimes he ate in his room . he was at a table close to the feeder (informal term for resident that requires assistance to eat) table .they would have been able to see him (aides at the resident assist table) they were right by him . I came back in (from break) and the day nurse, (first name of Registered Nurse (RN) #2), said that, he went unresponsive. (RN#2) was coming down the hall to check R #1's chart (for code status) . (RN #2) already had him in his room (from the dining area). (RN #2) mentioned he was DNR (Do Not Resuscitate, an order to not attempt CPR in the event that a person's breathing or heart stops). I remembered his niece had told me he was changed to a full code a week or so before .so I called a code (alerted care givers to start CPR) and called 911 (Emergency Medical Services). F. On [DATE] at 2:40 pm, during phone interview, with R #1's neice, she revealed, He (R #1) was always a full code .he had expressed to me that is what he wanted so I kept it that way. G. Record review of Certified Nursing Assistant (CNA) #2's, witness statement, dated [DATE] revealed A few minutes after (first name of R #1) had received his tray is when the male CNA (first name of CNA #3), pointed at him and my first thought was he needed to be pulled up in the chair and sleeping. He (CNA #3) told me to look closer at (first name of R #1) and (CNA #3) knew what was going on (R #1 was not conscious) so I checked his pulse and immediately took him towards the nursing station to notify a nurse. They (nurse) asked me to take him to his room as they gathered the supplies to perform CPR. H. Record review of R #1's nursing progress note, dated [DATE] at 5:57 pm revealed, Patient found unresponsive in the dining hall at 17:15 (5:15 pm), checked for breathing, air entries and pulses. CPR immediately started at 17:20 (5:20 pm) .patient pronounced dead at 18:02 (6:02 pm). I. [DATE] at 7:45 am, during interview, CNA #1 who was in dining area assisting residents to eat, confirmed that his responsibility was to ensure that residents don't choke. When asked if the resident he was assiting's heart stopped, would he start CPR, he responded I would not be sure for CPR, I don't know. (I would) tell the nurse. Usually they (nurse) are there in the hall (outside the dining area). J. On [DATE] at 7:55 am, during interview with CNA #4, when asked if she nknew the code status for the resident she was assisting, she stated No. I would get the nurse and the nurse would check the record (the electronic record?). K. On [DATE] at 8:10 am, during interview, LPN #2 (who is at medication cart, in the hall, by the dining area door) when asked if he knew the code status of the residents he was assisting, he stated If they were my residents, I would have a general idea (pointed at his head/brain) .If not, I can check the record (the electronic record). L. On [DATE] at 11:00 am, during interview, the Director of Nursing (DON) revealed that the facility has changed their policy of removing residents from the dining room prior to providing CPR. We have advised them (staff) if a resident collapses there (in dining area) don't move them.

Based on record review and interview, the facility failed to ensure 1 (R #1) of 1 (R #1) resident was provided the needed care and services when the facility failed to obtain a speech evaluation for R #1 who had recent changes in dietary consistency and was at risk for swallowing impairment after a hospitalization . This deficient practice likely contributed to the resident's aspiration of food. The facility did not have a process to ensure that residents who previously needed dietary texture modifications and/or supervision while eating were reassessed for those needs when readmitted to the facility. The findings are: A. Record review of R #1's facility and hospice medical records revealed: 1. He was initially admitted to the facility on [DATE]. 2. On [DATE], was admitted to hospice (a type of care that focuses on control and relief of discomforts a terminally ill or seriously ill patient's pain and attending to their emotional and spiritual needs) services and remained in the facility. 3. On [DATE], he revoked (ended) hospice services. 4. On [DATE], he was hospitalized , for an elevated potassium level in blood (Potassium in the appropriate amount is essential in the body. Potassium is involved in the proper functioning of nerve and muscle cells, digestion, metabolism and maintaining the balance of both electrical and chemical processes in the body. Potassium is especially important in heart function. A high level of potassium in the blood is often indicative of an underlying kidney dysfunction). 5. On [DATE], he was readmitted to the facility, no longer receiving hospice care. 6. On [DATE], at 5:57 pm, Patient found unresponsive in the dining hall at 17:15 (5:15 pm). B. Record review of R #1's physician's orders [REDACTED]. 1. On [DATE], Consistent Carbohydrate diet, Dysphagia (dysfunctional swallowing) Puree texture. Thick Liquids-Nectar Like consistency .Directions .Full Assist (depending on individual resident needs, may involve observing and verbal cueing for swallowing or positioning of head or , physically assisted by cutting food or activities such as lifting cups, spoons to mouth) With All Meals .End Date [DATE]. 2. On [DATE], Dysphagia (difficulty swallowing) Puree texture, Thick liquids-Nectar Like consistency . Directions . Full Assist With All Meals .End Date [DATE]. 3. On [DATE], Consistent Carbohydrate diet, Chopped Meat texture, Directions . Full Assist With All Meals .End Date [DATE]. 4. On [DATE], Liberalized Renal Diet, Chopped meat texture .Directions . Full Assist With All Meals .End Date: [DATE]. 5. On [DATE], Consistent Carbohydrate diet .Directions . for DM (Diabetes Mellitus) .End Date XXX[DATE]. 6. On [DATE], Liberalized Renal (kidney) diet, chopped meat texture. End Date, [DATE]. 7. On [DATE], Other(specify) diet .Directions .low potassium .End Date [DATE]. 8. On [DATE], Liberalized Renal Diet .Directions .low potassium diet .End Date XXX[DATE]. C. Record review of R #1's Speech Therapist (ST) (a health professional with expertise in assessment and treatment of [REDACTED].= severe impairment .Recommended Diet Level = Pureed foods (blended into pudding -like texture), Nectar-thick liquid (adding starch or gum thickeners to thin liquids .to make less liquid, specific to the individual with a swallowing problem). D. Record review of hospice nursing notes dated [DATE], revealed the hospice nurse asked for the resident's diet to be changed from pureed and chopped meat as he was not eating well. E. Record review of R #1's physician's orders [REDACTED]. F. Record review of the medical record revealed that no speech evaluation had been completed following the order on [DATE]. G. On [DATE] at 11:56 am, during an interview, with the ST she revealed, (At that time (on [DATE])) I would check (she took responsibility to check) all the new and readmitted residents orders for an order (for ST evaluation) .I thought he (R #1) was still on hospice so I did not look for an order (for ST to evaluate) when he came back from the hospital. H. On [DATE] at 11:32 am during phone interview with Provider # 1 (regarding how quickly she expected ST evaluations to be done after ordered) she revealed, I expect that they would get to it within 24 hours, at the most 72 hours. I. Record review of R #1's active care plan on [DATE] revealed, (name of R #1) will eat and drink to his level of comfort .Date initiated [DATE], Interventions (included) Assist with Meals initiated [DATE]. J. Record review of R #1's Documentation Survey Report for (MONTH) (YEAR) revealed the following input from the Certified Nursing Assistants (CNAs) working with R #1 at meal times. There were 11 meals documented and he was coded by the CNAs as 1. Independent eating for 9 of 11 meals 2. Set up help (help to open containers take off lids) only, for 10 of 11. K. On [DATE] at 10:04 am, during a phone interview, with Licensed Practical Nurse (LPN) #1, regarding the death of R #1, I was told he slumped over .it was right around dinner time .I went out for about a seven minute break .I noticed him when I went out .he had his back to me, sitting at a table .I noticed him because he hadn't been feeling well so I was glad to see him at dinner .sometimes he ate in his room .he was at a table close to the feeder (slang word for resident that requires assistance to eat) table .no, he didn't (have a nursing assistant present) .he wouldn't have let them help him anyway .they would have been able to see him (aides at the resident assist table) they were right by him .when EMS got there they removed food (from his mouth). L. Record review of a narrative note from the Emergency Medical Services (EMS) report for R #1 on [DATE] between 5:44 pm and 5:45 pm revealed, Staff said he was eating dinner, EMS looked in airway and found food. M. On [DATE] at 10:30 am, during telephone interview, with CNA #3 he revealed, a couple days before (before [DATE]) and he was eating in the dining room, and he was coughing, I told the nurse and she came and she said he was fine .I don't remember her name (the nurse) .I asked him did he want some water and he said okay. When asked about R #1's risk for choking on his food, CNA #3 responded He didn't eat fast, he drank fast. N. Record review of an autopsy report titled Summary and Opinion (dated [DATE]) revealed (name of R #1), died of choking (on [DATE]).

Based on record review and interviews, the facility failed to ensure that the nursing staff followed their professional scope of practice by assessing a change of condition for 1 (R #1) of 5 (R #s 1, 2, 3, 4 and 5) residents reviewed for pain and change in mental status. The practice of not assessing the resident on 01/11/18 and 01/12/18, when it was brought to the attention of nursing staff by the Speech Therapist (ST) who had recognized that R #1 was agitated, had increased confusion and fatigue, which was not observed the previous days. On 01/14/18, R #1 was yelling out in pain, unable to swallow and was sent to the hospital [MEDICAL CONDITION] (an infection in his blood stream). This deficient practice resulted in the nursing staff not recognizing a serious illness or even impending mortality (death). The findings are: A. Record review of the History and Physical dated 01/03/18, revealed the following: (Name of R #1) is an 86 yo (year-old) male with a hx (history) of TIA (transient ischemic accident or mini stroke, a temporary lack of adequate blood and oxygen to the brain) and dementia (a group of thinking and social symptoms that interferes with daily functioning) who was brought into the ED (emergency department) for a fall he sustained while in the bathroom. He got dressed and put his pants on backwards and tripped falling onto his left hip .He underwent a left hemiarthroplasty (hip repair) on 12/23/17 .He was stabilized and transferred to (name of facility) for continued medical management and rehabiliation. B. Record review of the Speech Therapy (ST) notes revealed the following: 1. The note dated 01/11/18 at 10:26 am, indicated, .During session, pt (patient) was agitated and had increased confusion and fatigue. Nursing notified immediately of pt (patient) status . 2. The note dated 01/12/18 at 9:55 am, indicated, .During session, pt had decreased alertness, increased fatigue, and decreased ability to follow directions. Nursing notified immediately of change in pt status . C. On 02/08/18 at 9:00 am, during interview, the Speech Language Pathologist (SLP) confirmed that she had been working with R #1 the entire week starting on 01/08/18 through 01/12/18, on a daily basis. She stated that R #1 was having decreased alertness and not following directions starting on Wednesday, 01/10/18. The SLP stated that during that time, there were no liquid trials or food trials. She stated that R #1 had an increased risk of aspiration (accidentally having food or fluids go into the lungs instead of the stomach). She also stated that R #1 did have some food pocketing (to store food in his cheeks or under his tongue as he forgets the need to swallow his food) in his cheeks and found food residue on the roof of his mouth. She explained that the food was sitting above his epiglottis (a flap of cartilage at the root of the tongue, which is depressed during swallowing to cover the opening of the windpipe), and that R #1 had a weakness in the throat. She stated that when R #1 was admitted to the facility he was on a nectar consistency (a thick liquid, like an apricot nectar or thick cream soups) with pureed food. She stated that at the beginning of the week, R #1 was alert and cooperative, but that towards the end of the week, he was having increase in fatigue. She said that on 01/10/18, R #1 was trialed on a mechanical soft (includes foods such as yogurt, cottage cheese and ground cooked meat) diet, but that he was pocketing on the left side of his cheek. She stated that he would just keep chewing and chewing and not swallowing his food. She stated that when she was working with R #1 at his breakfast meals on 01/09/18 and 01/10/18, she had to consistently tell R #1 to chew his food or swallow his food, depending on what was happening during the meal. During that time, R #1 would only be able to follow her instructions less than half of the time, due to his inability to understand the chewing and swallowing process of either the food or fluids. On 01/11/18, she was having to give R #1 consistent reminders of chewing or swallowing his food, with R #1 having no understanding on how to do this. On 01/08/18, she said for example, R #1 was more alert and able to chew his food, or swallow the liquids, and clear his mouth, with just a few instructions. He was never coughing or choking, no watery eyes, running nose or a wet voice quality, that would have indicated that he was having signs and symptoms of aspirating his food. When asked if it was possible that R #1 was silently aspirating? She replied, There is always that risk. It could happen silently without signs of choking or coughing. D. Record review of R #1's Skilled Nursing notes: 1. On 01/09/18 at 8:34 am, revealed the following: 0admitted (sic) for skilled services after fall at home, s/p (status [REDACTED]. Observations: Pt (patient) stable, no distress, no pain noted, pt able to make needs known, pt willing to have assistance with care. pt skin and mood assessed for distress. Action/nursing interventions: Pt stable, no distress, pain addressed as directed. pt medicated as directed, pt mood assessed as directed. Resident's response: Pt stable pt able to make need known. Author: (name of Registered Nurse (RN) #1) 2. On 01/10/18 at 10:33 am, revealed the following: 0admitted (sic) for skilled services after fall at home, s/p left femur fracture, hx dementia, TIA. Observations: Pt stable, no distress, no pain noted, pt able to make needs known, pt willing to have assistance with care. pt skin and mood assessed for distress. Action/nursing interventions: Pt stable, no distress, pain addressed as directed. pt medicated as directed, pt mood assessed as directed. Resident's response: Pt stable pt able to make need known. Author: (name of RN) #1 3. On 01/11/18 at 13:18 (1:18 pm), revealed the following: 0admitted (sic) for skilled services after fall at home, s/p left femur fracture, hx dementia, TIA. Observations: Pt stable, no distress, no pain noted, pt able to make needs known, pt willing to have assistance with care. pt skin and mood assessed for distress. Action/nursing interventions: Pt stable, no distress, pain addressed as directed. pt medicated as directed, pt mood assessed as directed. pt pain noted as addressed, pt yelling out for attention and assistance. Author: (name of RN #1) 4. On 01/12/18 at 12:57 pm, revealed the following: 0admitted (sic) for skilled services after fall at home, s/p left femur fracture, hx dementia, TIA. Observations: Pt stable, no distress, no pain noted, pt able to make needs known, pt willing to have assistance with care. pt skin and mood assessed for distress. Action/nursing interventions: Pt stable, no distress, pain addressed as directed. pt medicated as directed, pt mood assessed as directed. Resident's response: Pt stable, pt able to make needs known. Author: (name of RN #1) Record review of R #1's Skilled Nursing note dated 01/11/18 at 13:18 (1:18 pm), revealed the following: admitted for skilled services after fall at home, s/p (status [REDACTED]. Pt (patient) stable, no distress, no pain noted, pt able to make needs known, pt willing to have assistance with care. pt skin and mood assessed for distress. Pt stable, no distress, pain addressed as directed. pt medicated as directed, pt mood assessed as directed. pt pain noted as addressed, pt yelling out for attention and assistance. E. On 02/09/18 at 11:00 am, RN (Registered Nurse) #1 confirmed that he was the nurse on duty taking care of R #1 on 01/09/18, 01/10/18, 01/11/18 and on 01/12/18. He stated that he usually works on the skilled nursing unit at the facility. He stated that the electronic health record (EHR) software auto-populates for the resident's care for each day, letting the nurse know that they need to chart on the resident. Generally, he conducts a clinical assessment on the residents. When asked to show his clinical assessments for R #1 in the EHR, he could not. When asked if he remembers the ST discussing R #1's change of condition with him on 01/11/18 and on 01/12/18, he replied, No. When asked how did he know when R #1 was in pain. He replied either by checking on him, verbally asking the resident or with using non-verbal cues. When asked if the CMA (certified medication aide) has the ability to give resident's pain medication? He replied, Yes, the CMA's can give the pain medication but that the nurse on duty, returns to the resident's room, to assess if the pain medication was effective or not. RN #1 stated that here at the facility, charting is by exception on the long-term care residents and that for the skilled nursing patients, there should be daily charting. F. On 02/08/18 at 4:30 pm, during interview, Certified Nursing Assistant (CNA) #2, stated when asked what did she remember about taking care of R #1? She stated that she usually helped other CNAs take care of him. She stated that he was a 2-person transfer, he was unable to stand-up for very long. He was always in a lot of pain. She stated that you could barely touch him, he would yell out in pain all the time while he was being turned from side to side in bed. He was incontinent of urine and bowel. This interview should be in tag 658 G. On 02/09/18 at 3:10 pm, during interview, CNA #3 stated that he worked days at the facility. He stated that he remembered that R #1 was normally in bed and was always in pain. This interview should be in tag 658 H. On 02/09/18 at 3:30 pm, during interview, Certified Nursing Assistant (CNA) #4, stated that she works 16-hour shifts every Friday and Saturday on the 100 hall, she also remembered taking care of R #1 on 01/05/18, 01/06/18, 01/12/18 and on 01/13/18. She stated, When I went to change him during the shifts on 01/12/18 and on 01/13/18, he was in a lot of pain .moaning loudly barely when I was touching him. She stated that when she was feeding him in the dining room, at first there were no problems with him swallowing, but that later on there were problems. She stated that he wasn't eating, he would close his mouth, he would not swallow. She stated, I was scared to feed him .When I saw him, he was in pain, you could tell he was uncomfortable. She stated that when she was changing his brief on 01/12/18 and on 01/13/18, he did not have any redness. She stated that everybody knew he was moaning loudly, that you could hear him at the nurses station. She said that when he was being turned or when he was being changed, R #1 moaned even louder. After being turned or changed, then he still moaned but that it wasn't as loud. She said that the only time when he was quiet was when he was asleep. I. Record review of the Skilled Nursing Progress Notes dated 01/14/18 at 22:56 (10:56 pm) revealed the following: Resident awake lying in bed supine yelling out in pain vitals taken B/P (blood pressure) 98/56 P (pulse) 113 R (respirations) 34 Temp (temperature) 98.5. Resident po (oral) intake poor MD called notified orders given to transfer resident out to eval (evaluate) and treat responsible party notified .EMT (emergency medical transport) here to transfer resident to ER (emergency room ).

Based on record review and interview, the facility failed to develop a comprehensive plan of care with measurable goals and interventions to address resident's skin breakdown for 1 (R #2) of 3 (R #s 1, 2, and 3) residents reviewed for pressure ulcers. Without a care plan to identify specific resident needs, staff members are likely to implement care that is inconsistent with the resident's problem areas. The findings are: A. Record review of Physician order [REDACTED]. B. Record review of Minimum Data Set ((MDS) dated [DATE], revealed R #2 had two unstageable pressure ulcers. C. Record review of Care Plan (no date) revealed Resident is at risk for skin breakdown related to impaired sensation, recent surgery, limited mobility .The resident's wound will heal as evidenced by decrease in size, absence of [DIAGNOSES REDACTED] (reddening of the skin) and drainage and presence of granulation X ____days (OVERDUE). There were no goals or interventions in place to prevent R #2 from further skin breakdown. D. On 10/02/15 at 12:04 pm, during interview with the Assistant Director of Nursing (ADON), she confirmed that R #2 was not care planned for actual skin breakdown. The ADON confirmed that she initiated the focus area for actual skin breakdown on 10/02/15, stating There is one (care plan) initiated by me, but it was not in there (the electronic health record) for the breakdown of her heels. It said risk for skin breakdown, but not that she actually has skin breakdown. E. On 10/02/15 at 1:37 pm, during interview the Director of Nursing (DON) confirmed R #2 had no interventions for actual skin breakdown, she stated They (the interventions) were in place, but not care planned. F. Record review of Pressure Ulcer Prevention and Management revised on 08/31/15, revealed If pressure ulcers are identified, licensed nurse will: Update care plans.

Based on record review and interview, the facility failed to prevent the development of pressure ulcers for 1 (R #2) of 3 (R #s 1, 2, and 3) residents reviewed for pressure ulcers. This deficient practice likely resulted in R #2 developing bilateral (both) unstageable pressure ulcers to her heels. The findings are: A. Record review of the [DIAGNOSES REDACTED].#2 revealed a medical [DIAGNOSES REDACTED]. B. Record review of the Minimum Data Set (MDS) for R#2 revealed the following: 1. Admission assessment dated [DATE], indicated that R#2 did not have any pressure ulcers. The assessment indicated that R #2 was at risk for pressure ulcers. 2. 14-day assessment dated [DATE], revealed R #2 has a stage 1 or greater pressure ulcer and that she had two unstageable pressure ulcers, (location is not listed on the MDS). C. Record review of Care Plan (not dated), indicated Resident is at risk for skin breakdown related to impaired sensation, recent surgery, limited mobility. The care plan had no goals and interventions to address the issue of pressure ulcers. D. Record review of Physician order [REDACTED]. E. Record Review of Nurses Progress Notes dated 09/02/15 to 10/02/15, revealed no documentation that R #2 has bilateral unstageable pressure ulcers to heels. F. Record review of the Braden Scale for Predicting Pressure Sore Risk dated 09/23/15, revealed a score of 14, which indicates R #2 was at a moderate risk to develop pressure ulcers. G. On 10/02/15 at 11:49 am, during interview with Registered Nurse (RN) #1, she confirmed that R #2 acquired unstageable pressure ulcers to both heels while in the facility, she stated We do a skin check when they come back from hospital. They (pressure ulcers) weren't on the skin assessment when she came from the hospital. H. On 10/02/15 at 1:48 pm, during interview with the Director of Nursing (DON), she confirmed that R #2 acquired unstageable pressure ulcers while in the facility. The DON further confirmed both pressure ulcers could have been preventable. I. On 10/02/15 at 2:11 pm, during interview Certified Nursing Assistant (CNA) #1, confirmed she does not document when R #2's heels are elevated.

Based on record review and interview, the facility failed to ensure that 1 (#205) of 17 (#'s 2, 11, 22, 29, 50, 54, 84, 100, 130, 189, 192, 205, 209, 216, 219, 221 and 225) residents received the necessary care and services to attain or maintain the highest practicable physical well being by failing to administer insulin [MEDICATION NAME] (long acting insulin) and administering regular insulin without a physicians order. This deficient practice likely caused Resident #205 to have unstable capillary blood sugars (CBG's) by not giving the resident the insulin [MEDICATION NAME] at bedtime. Administering a medication without a physicians order presents a risk that the resident would receive a medication unneccessarily and could experience side effects from the medication. The findings are: A. Review of Resident #205's medical record revealed the following: 1. Admission Physicians orders, dated 05/18/12, indicated insulin [MEDICATION NAME] 10 units to be given subcutaneous (SQ) at bedtime and insulin [MEDICATION NAME] 5 units SQ, three times a day before meals. There was no order for any regular insulin. 2. The May 2012, Routine Treatment Administration Record (TAR) indicated the resident did not receive the bedtime insulin 05/18/12 through 05/24/12 and 05/28/12. It had not been transcribed from the physicians orders to the TAR. 3. Physicians Telephone order, dated 05/24/12, indicated "increase" [MEDICATION NAME] to 15 units each bedtime. The resident had not had the original ordered bedtime insulin for 7 days. 4. Diabetic Monitoring Flow Sheets indicated the resident received regular insulin as coverage for CBG's indicating a blood glucose level as high as 294 mg/dl (milligram per deciliter) without a physicians order on the following days; 5/15, 5/20, 5/21 two times, 5/22, 5/23, 5/24, 5/25, 5/26 two times, 5/27, 5/28 two times, 5/29 and 05/30/12. 5. Physicians telephone order, dated 05/31/12, indicated "Pt (patient) is not (underlined) on sliding scale" 6. Patient Care Plan: Diabetes, dated 05/18/12, indicated as an approach "Administer medicatins (sic) as ordered." 7. Physicians telephone order,dated 06/18/12, ordered a lab test called HbA1c, glycated hemoglobin test, or glycohemoglobin -- an important blood test used to determine how well diabetes is being controlled. Out-of-control diabetes results in complications from the disease, the resident's results after a month of the facility medicating and monitoring the resident was 7.70%, the laboratory sheet indicated a range of 4.20-5.80% was within normal limits. B. The facility's Administration of Medication policy, revised 01/03, indicated: 1. STANDARD - "All medications are administered safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms, and help in diagnosis. 2. POLICY - "A physician and/or nurse practitioner order that includes dosage, route, frequency, duration and other required considerations is required for administration of medication." C. On 06/29/12 at 7:50 am, during interview, the Director of Nursing (DON) verified that the documentation indicated the bedtime insulin was not given as ordered and the regular insulin was given without an order. She stated that she was uncertain how something like this could happen and had no explanation. It would be her expectation that the orders should be clarified and checked for correct transcription and that medications require a physicians order to be administered.

Based on record review and interview, the facility failed to follow the physicians orders regarding administration of [MEDICATION NAME]for 1 (#205) of 17 (#'s 2, 11, 22, 29, 50, 54, 84, 100, 130, 189, 192, 205, 209, 216, 219, 221 and 225) residents whose physician orders [REDACTED]. The findings are: A. Review of Resident #205's medical record revealed the following: 1. Admission Physicians orders, dated 05/18/12, indicated insulin [MEDICATION NAME] 10 units to be given subcutaneous (SQ) at bedtime and insulin [MEDICATION NAME] 5 units SQ, three times a day before meals. 2. The May 2012, Routine Treatment Administration Record (TAR) indicated the resident did not receive the bedtime insulin 05/18/12 through 05/24/12 and 05/28/12. It had not been transcribed from the physicians orders to the TAR. 3. Physicians Telephone order, dated 05/24/12, indicated "increase" [MEDICATION NAME] to 15 units each bedtime. The resident had not had the original ordered bedtime insulin for 7 days. 4. Physicians telephone order, dated 05/31/12, indicated "Pt (patient) is not (underlined) on sliding scale" 5. Patient Care Plan: Diabetes, dated 05/18/12, indicated as an approach "Administer medicatins (sic) as ordered." 6. Physicians telephone order,dated 06/18/12, ordered the lab test HbA1c, glycated hemoglobin test, or glycohemoglobin -- an important blood test used to determine how well diabetes is being controlled. Out-of-control diabetes results in complications from the disease, the resident's results after a month of the facility medicating and monitoring the resident was 7.70%, the laboratory sheet indicated a range of 4.20-5.80% was within normal limits. B. The facility's Administration of Medication policy, revised 01/03, indicated: 1. STANDARD - "All medications are administered safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms, and help in diagnosis. 2. POLICY - "A physician and/or nurse practitioner order that includes dosage, route, frequency, duration and other required considerations is required for administration of medication." C. On 06/29/12 at 7:50 am, during interview, the Director of Nursing (DON) verified that the documentation indicated the bedtime insulin was not given as ordered. She stated that she was uncertain how something like this could happen and had no explanation. It would be her expectation that the orders should be clarified and checked for correct transcription.