Every finding on record at Garden Park Care Center

Based on interview and medical record review, the facility failed to provide the necessary care and services to ensure one of three sampled residents (Resident 1) attained and maintained the highest practicable well-being. * The facility failed to administer Resident 1's clonidine (antihypertensive) medication and notify the physician when Resident 1's SBP was more than 160 mmHg as per the physician's orders. This failure posed the risk of not providing appropriate and consistent care to Resident 1.Findings: On 7/30/26 at 0831 hours, an interview was conducted with Resident 1. Resident 1 stated he was being discharged from the facility, but he feared about his health condition. Resident 1 stated he had heart surgery and high blood pressure. Resident 1 stated he was able to leave the facility out on pass. Medical record review for Resident 1 was initiated on 7/30/26. Resident 1 was readmitted to the facility on [DATE]. Review of Resident 1's Order Summary Report showed the following physician's orders:- dated 5/4/26, to administer clonidine 0.1 mg by mouth every six hours as needed for hypertension, SBP more than 160 mmHg;- dated 5/19/26, may go out on pass for therapeutic and psychosocial purposes;- dated 5/22/26, to monitor the blood pressure every six hours. Call the physician for SBP greater than 160 mmHg; and- dated 6/23/26, to monitor the blood pressure related to clonidine use. Review of Resident 1's MDS assessment dated [DATE], showed Resident 1 was cognitively intact and independent in his ADLs. Review of Resident 1's MAR for July 2026 showed the following:- dated 7/18/26 at 1800 hours, Resident 1's BP was 164/87 mmHg;- dated 7/20/26 at 1800 hours, Resident 1's BP was 170/79 mmHg;- dated 7/21/26 at 0000 hours, Resident 1's BP was 168/74 mmHg;- dated 7/26/26 at 1800 hours, Resident 1's BP was 170/90 mmHg; and- dated 7/30/26 at 1200 hours, Resident 1's BP was 161/91 mmHg. Further review of Resident 1's MAR for July 2026 showed Resident 1's physician was not notified when the resident's SBP was greater than 160 mmHg. Furthermore, Resident 1 was not administered the clonidine medication on 7/20/26 at 1800 hours and on 7/30/26 at 1200 hours, when the resident's SBP was greater than 160 mmHg. Review of Resident 1' Progress Notes did not show Resident 1's physician was notified when the resident's SBP was greater than 160 mmHg. On 7/31/26 at 1425 hours, an interview and concurrent medical record review for Resident 1 was conducted with the DON. The DON stated the nurses have been monitoring Resident 1's blood pressure. The DON verified the physician was not notified and the clonidine medication was not administered when the Resident 1's SBP was greater than 160 mmHg.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure the medical record was accurate for two of three sampled residents (Residents 1 and 2). * The facility failed to ensure Resident 1 and 2's Fall Risk assessment were accurate. These failures posed the risk for the residents to not receive the necessary care and interventions.Findings: Review of the facility's P&P titled Fall Prevention Program revised 4/20/26, showed each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Review of the facility's P&P titled Documentation in Medical Record revised 12/19/22, showed each resident's medical record shall contain a representation of the experiences of the resident and include enough information to provide a picture of the resident's progress. Under the Policy Explanation and Compliance Guidelines showed documentation shall be factual, objective, and resident centered. 1. Medical record review for Resident 1 was initiated on 7/21/26. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 1's eINTERACT Change in Condition Evaluation - V 5.1C dated 6/22/26, showed Resident 1 had a fall. However, review of Resident 1's Fall Risk - V4 dated 6/22/26, showed Resident 1 had no falls in the past three months. Review of Resident 1's MDS assessment dated [DATE], showed Resident 1's cognition was moderately impaired. On 7/22/26 at 1123 hours, an interview and concurrent medical record review was conducted with RN 2. RN 2 verified Resident 1 fell on 6/22/26, and the Fall Risk - V4 assessment dated [DATE], showed Resident 1 had no falls in the past three months. RN 2 stated the licensed nurse should have updated Resident 1's history of falls because the resident fell that day. 2. Medical record review for Resident 2 was initiated on 7/21/26. Resident 2 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident 2's MDS assessment dated [DATE], showed Resident 2 was cognitively intact. Review of Resident 2's eINTERACT Change in Condition Evaluation - V 5.1C dated 6/26/26, showed Resident 2 had a fall. However, review of Resident 2's Fall Risk - V4 dated 6/26/26, showed Resident 2 had no falls in the past three months. On 7/22/26 at 1613 hours, an interview and concurrent medical record review was conducted with RN 2. RN 2 verified Resident 2 fell on 6/26/26, and the Fall Risk - V4 assessment dated [DATE] showed Resident 2 had no falls in the past three months. RN 2 stated the licensed nurse should put one fall if the resident fell that day. On 7/22/26 at 1647 hours, an interview and concurrent medical record review was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of three sampled residents (Resident 2) was free from misappropriation of property. * The SSD failed to follow up with Resident 2 and conduct an investigation after being informed Resident 2 was missing three pairs of earrings. This failure had the potential to negatively impact the resident's well-being.Findings: Review of the facility's P&P titled Theft and Loss Program dated 12/19/22, showed when a personal property item is reported missing, staff should immediately begin a search for this missing property. If the property is not found, a Theft and Loss report is to be completed, and at that time, Social Services will continue the search and investigate the loss. Medical record review for Resident 2 was initiated on 5/29/26. Resident 2 was initially admitted to the facility on [DATE], and was readmitted on [DATE]. Review of Resident 2's H&P examination dated 6/4/26, showed the resident had fluctuating capacity. On 5/29/26 at 1042 hours, an interview was conducted with Resident 2. Resident 2 was asked if she was missing any personal items. Resident 2 stated she was missing three pairs of earrings. Resident 2 stated the earrings went missing about eight to nine months ago. Resident 2 stated she talked to someone at the facility about it, but could not recall who she spoke to. On 5/29/26 at 1515 hours, an interview was conducted with SSD. The SSD was asked to explain the process for when a resident's personal belongings go missing. The SSD stated once it was reported to her, she would call the staff, go into the resident's room and let the resident know they would search the room to look for the missing item. The SSD further stated she would also reach out to laundry to search for the item as well. The SSD stated if the items could not be found, a report would be started. The SSD was asked if Resident 2 reported to her the missing three pairs of earrings. The SSD stated it had not been reported to her. On 6/10/26 at 0930 hours, an interview was conducted with the SSD. The SSD stated she did not follow up with the resident on her missing earrings. The SSD stated the resident went out to the acute care hospital for three days and returned to the facility afterwards. The SSD stated the facility just had a care meeting and she did not discuss the missing jewelry with the resident. The SSD stated she would follow up with Resident 2. On 6/10/26 at 1023 hours, an interview was conducted with Resident 2. Resident 2 stated no one from the facility spoke with her about her missing earrings since 5/29/26. On 6/10/26 at 1300 hours, an interview was conducted with the DON. The DON acknowledged and verified the above findings.

Based on interview, medical record review, and facility P&P review, the facility failed to notify the resident's physician of a change in condition for one of three sampled residents (Resident 1). * The facility failed to notify Resident 1's physician regarding the resident's episode of verbal aggression towards the staff. This failure had the potential for Resident 1 not to receive appropriate and timely care and services.Findings: Review of the facility's P&P titled Notification of Changes dated 1219/22, showed it is the facility's policy to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. Medical record review for Resident 1 was initiated on 5/13/26. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 1's H&P examination dated 12/16/25, showed Resident 1 had the capacity to understand and make decisions. Review of Resident 1's nursing progress note dated 4/28/26, showed documentation Resident 1 had an episode of verbal aggression toward the staff and refused to allow the staff to keep the door open for close monitoring of his confused roommate. who was at risk for falls. The police were called to the facility as a result of the incident. However, further review of Resident 1's medical record failed to show a change of condition report was completed for the above incident and there was no documentation to show the resident's physician was notified. On 5/14/26 at 1622 hours, a telephone interview was conducted with LVN 2. LVN 2 stated Resident 1 was verbally aggressive toward her and the resident's behavior was documented in the nursing progress note. LVN 2 stated she could not recall whether the physician had been notified of the incident. On 5/15/26 at 0951 hours, a telephone interview was conducted with RN 1. RN 1 stated a change of condition report should have been completed for the resident's verbal aggression and verified the physician had not been notified but should have been. On 5/15/26 at 1232 hours, an interview was conducted with the DON. The DON was informed and verified the findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to prevent or minimize injuries from a fall for three of six sampled residents (Residents 2, 3, and 6) reviewed for falls. * Resident 2 had a history of a fall, however, the care plan for the floor mats were not resident centered for Resident 2's fall. * Resident 3 had a history of falls, however, the facility failed to ensure the 72-hour neurological assessments (assessment of the brain, and nervous system used to detect, manage, and track neurological changes or damage) were conducted completely. In addition, the facility failed to ensure the bilateral floor mats were provided, and the 24-hour orthostatic blood pressures (sudden drop in blood pressure that occurs when standing up) were conducted. * Resident 6 had a history of a fall, however, the facility failed to ensure the 72-hour neurological assessments were conducted completely, and the 72-hour orthostatic blood pressures were conducted as per physician's orders. These failures had the potential to place the residents at risk for injuries.Findings: Review of the facility's P&P titled Documentation in Medical Record revised 12/2022 showed the licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the residence medical record in accordance with state law and facility policy. Review of the facility's P&P titled Care Plan Revisions Upon Status Change dated 12/2022 showed the comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change. Review of the facility's P&P titled Fall Prevention Program revised 12/2023 showed the nurse and/or the interdisciplinary team will initiate inter4ventiosn on the resident's care plan, in accordance with the resident's level of fall risk. Fall interventions include but not limited to:a. Implement universal environmental interventions that decrease the risk of resident falling, including, but not limited to:a clear pathway to the bathroom and bedroom doors;bed is locked and lowered to a level that allows the resident's feet to be flat on the floor when the resident is sitting on the edge of the bed;call light and frequently used items are within reach;adequate lighting; andwheelchairs and assistive devices are in good repair;b. Monitor for changes in residence cognition, gait, ability to rise/sit, and balance; andc. Monitor vital signs in accordance with facility policy. 1. Medical record review for Resident 2 was initiated on 4/22/26. Resident 2 was readmitted to the facility on [DATE], transferred to an acute care facility on 4/15/26, and returned on the same day. Review of Resident 2's Nurses Progress Notes dated 4/15/26, showed resident was found with body horizonal to the left side of the bed. Review of Resident 2's Interdisciplinary Care Conference dated 4/15/26, showed Resident 2 had an unwitnessed fall on 4/15/26 at 1230 hours. Further review of the note showed recommendations for a big boy bed, and falling star program. Review of Resident 2's Rehab Screen Progress Notes dated 4/16/26, showed bed lowered to lowest setting recommended. Bedside mats and additional mattress on right side of bed in place. Review of Resident 2's Care Plan Report dated 4/16/26, showed a care plan problem for Resident 2's fall with bump on the left forehead . Further review of the care plan did not show any interventions addressing the bilateral floor mats. On 4/22/26 at 0818 hours, an observation of Resident 2 was conducted. Resident 2 was lying in bed with a fall mattress on the right side of the bed, and floor mat on the left side of the bed. On 4/22/26 at 1105 hours, an observation of Resident 2 was conducted. Resident 2 was lying in bed with a fall mattress on the right side of the bed, and floor mat on the left side of the bed. On 4/28/26 at 1351 hours, an interview and concurrent medical record review for Resident 2 was conducted with the DON. The DON verified Resident 2 did not have physician's order for floor mats, and there were no care plan interventions addressing the floor mats. The DON stated Resident 2 was not supposed to have the floor mats as a big boy bed was implemented instead. 2. Medical record review for Resident 3 was initiated on 4/22/26. Resident 3 was admitted to the facility on [DATE]. Review of Resident 3's Order Summary Report dated 4/23/26, showed a physician's order dated 8/14/25, for Clopidogrel Bisulfate (antiplatelet medication, acts as a blood thinner) oral tablet one time a day for cerebral vascular accident (stroke) prophylaxis (measures taken to prevent diseases before they occur). a. Review of Resident 3's SBAR Communication Form dated 3/11/26, showed around 0000 hours, the resident was on the floor on the right side of the bed. Resident was noted with a skin tear on the right side of the eye with swelling, resident is on a blood thinner. Review of Resident 3's Care Plan Report dated 3/11/26, showed a care plan problem addressing resident's fall with minor injury. The care plan interventions included obtaining vital signs every shift, take blood pressure lying, sitting, standing times one in the first 24 hours. Review of Resident 3's Neurological Flowsheet dated 3/11/26, showed the following:- at 0000 hours, blood pressure 140/60 mmHg, position: lying;- at 0015 hours, blood pressure 145/72 mmHg, position: lying; - at 0030 hours, blood pressure 136/54 mmHg, position: lying;- at 0045 hours, blood pressure 138/66 mmHg, position: lying;- at 0100 hours, blood pressure 140/66 mmHg, position: lying;- at 0130 hours, blood pressure 139/74 mmHg, position: lying;Further review of the Neurological Flow Sheet showed Resident 3 was transferred to an acute care facility, and vital signs were resumed on 3/11/26 at 1649 hours.- at 1649 hours, blood pressure 123/26 mmHg, position: lying;- at 2000 hours, blood pressure 127/74 mmHg, position: lying; and- at 0000 hours, blood pressure 118/74 mmHg, position: lying b. Review of Resident 3's Change in Condition Progress Note dated 4/11/26, showed the resident was noted lying on the floor on the left side of the bed in supine position. Review of Resident 3's medical record dated 4/11/26, did not show Resident 3's orthostatic blood pressure readings were obtained as care plan interventions. Review of Resident 3's Neurological Flowsheet dated 4/11/26, showed the following blank entries for vital signs, pupil response, motor response, consciousness, speech, and patient response:- 4/11/26 at 1430 hours;- 4/11/26 at 1630 hours;- 4/11/26 at 2030 hours; and- 4/12/26 at 0330 hours c. Review of Resident 3's Order Summary Report dated 4/12/26, showed a physicians order to apply bilateral floor mats to prevent further injury. Review of Resident 3's Interdisciplinary Care Conference dated 4/12/26, showed a fall incident care conference recommendations for low bed with bilateral floor mats. On 4/22/26 at 0827 hours, an observation was made of Resident 3 lying in bed, with one floor mat on the right side of the bed. On 4/23/26 at 0741 hours, an observation was made of Resident 3 lying in bed, with one floor mat on the right side of the bed. On 4/23/26 at 1308 hours, an observation and concurrent interview for Resident 3 was conducted with LVN 4. LVN 4 verified Resident 3 had one floor mat on the right side of the bed, and stated the resident's physician's orders showed bilateral floor mats. On 4/28/26 at 1351 hours, an interview and concurrent medical record review for Resident 3 was conducted with the DON. The DON stated Resident 3 was transferred to an acute care facility on 3/11/26 at 0148 hours, and returned on 3/11/26 at 1324 hours (approximately 11 and half hours later). The DON verified Resident 3's care plan for orthostatic blood pressures should have been continued upon return since it was still within the 24-hour time frame, or revised to reflect residents current condition. The DON verified Resident 3 had one floor mat, and stated the resident needed the bilateral floor mats, and verified the neurologic assessments were incomplete. 3. Medical record review for Resident 6 was initiated on 4/23/26. Resident 6 was admitted to the facility on [DATE]. Review of Resident 6's eINTERACT Change in Condition Evaluation dated 4/9/26 at 2315 hours, showed a change in condition for a fall and skin wound. Further review showed the provider notifications recommendations were to keep ice on the forehead, monitor blood pressures for 72 hours, and notify the physician. Review of Resident 6's Nurses Progress Notes dated 4/9/26 at 2315 hours, showed CNA went to answer residents call light but resident already noted sitting on the floor with bump and laceration to the left side of the forehead. Review of Resident 6's MAR dated 4/10/26, showed a physician's order for Orthostatic Hypotension - monitor blood pressure every week: lying, sitting, standing, every shift for three days. Further review of the MAR showed a check mark indicating the task was completed, however, the MAR did not show the orthostatic blood pressure results. Review of Resident 6's Interdisciplinary Care Conference dated 4/10/26, showed a fall incident care conference. The recommendations showed to monitor orthostatic hypotension for 72 hours. Review of Resident 6's Care Plan Report dated 4/10/26, showed a care plan problem addressing Resident 6's fall with bump/laceration to left side of the forehead. The interventions included neurocheck per facility protocol, and to monitor orthostatic blood pressure as ordered. Review of Resident 6's Neurological Flowsheet Dated 4/10/26 showed the following blank entries for vital signs, pupil response, motor response, consciousness, speech, and patient response:- 4/10/26 at 1555 hours;- 4/10/26 at 1955 hours;- 4/10/26 at 2355 hours;- 4/11/26 at 0755 hours; and- 4/11/26 at 2355 hours On 4/23/26 at 1345 hours, interview and concurrent medical record review for Resident 6 was conducted with RN 2. When asked what the check mark indicated in the MAR, RN 2 stated the task was completed. When asked how the facility would monitor the orthostatic blood pressure readings if there were no data for monitoring, RN 2 stated she could not see it. RN 2 verified Resident 6's neurological assessments had blanks and incomplete data, and the orthostatic blood pressure readings were not obtained per order. On 4/28/26 at 1351 hours, the DON verified the above findings. On 4/28/26 at 1533 hours, an interview was conducted with the Administrator and DON. The Administrator and DON acknowledged the above findings.

Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the appropriate use of restraints including consent, physician's order, skin assessment, removal of restraint, and ROM exercises were provided for one of six sampled residents (Resident 2) reviewed for restraints. * Resident 2 did not have a physician's order, informed consent, assessment, or monitoring for the use of the bilateral soft mittens. In addition, there was no documentation of the mittens removal, and if the hands were assessed and exercised every two hours. These failures had the potential for the increased risk of resident's skin and soft tissue injury as well as the decrease in the ROM functions related to the restraint use.Findings: Review of the facility's P&P titled Restraint Free Environment dated 12/2022 showed the following: The resident has the right to be treated with respect and dignity, including the right to be free from any physical or chemical restraint imposed for the purpose of discipline or staff convenience, and not required to treat the residents medical symptoms.Physical restraints may be used in emergency care situations for brief periods to permit medically necessary treatment that has been ordered by a practitioner, unless the resident has previously made a valid refusal of the treatment question. Falls do not constitute self-injurious behavior or a medical symptom that warrants the use of a physical restraintBehavioral interventions should be used and exhausted prior to the application of a physical restraintA physician's order alone is not sufficient to warrant the use of a physical restraint. The facility is responsible for the appropriateness of the determination to use a restraint.Before a resident is restrained, the facility will determine the presence of a specific medical symptom that would require the use of restraints, and determine:How the use of restraints would treat the medical symptom;The length of time the restraint is anticipated to be used to treat the medical symptom, who may apply the restraint, and the time and frequency that the restraint will be released;The type of direct monitoring and supervision that will be provided during the use of restraint;How the resident will request staff assistance and how his/ her needs will be met while the restraint is in place;How to assist the resident in attaining or maintaining his or her highest practical level of physical and psychosocial well-being. Review of the facilities P&P titled Informed Consent dated 3/2024 showed the following:Prior to initiating the administration of a psychotherapeutic medication or physical restraint or a device, licensed nursing staff shall verify with the resident or surrogate decision maker that he/she has given informed consent for the proposed psychotherapeutic medication or physical restraint or device to the prescriber. Psychotherapeutic medications may not be administered until the informed consent has been verified.Licensed nursing staff shall document either 1) in the order for the psycho therapeutic medication or physical restraint or device, when the order is given by the physician, that the informed consent was obtained by the physician and the name/ or relationship of the individual to the resident giving informed consent, or, 2) on a separate verification form.Initiation of a psychotherapeutic medication or physical restraint without informed consent may be necessary if there is documentation in the residence health record by the license nursing staff that an emergency existed when there was an unanticipated condition in which immediate action was necessary to prevent serious bodily harm or emotional distress to the resident or others. Informed consent will be obtained within 72 hours of administration of the medication, application of the restraint or use of a device that may lead to the inability to regain use of a normal bodily function by the ordering physician. Medical record review for Resident 2 was initiated on 4/22/26. Resident 2 was readmitted to the facility on [DATE], transferred to an acute care facility on 4/15/26, and returned on the same day. Review of the facility document titled 1500-2200 hours Shift Assignment dated 4/13/26, showed LVN 1 was assigned to Resident 2. Review of Resident 2's MAR dated 4/13/26, showed LVN 1 administered medications to Resident 2 at 2100 hours. Review of Resident 2's Medication Administration Record dated 4/14/26, showed LVN 4 administered medications to Resident 2 at 0900 hours. Review of the facility document titled 0700-1500 hours Shift Assignment dated 4/14 and 4/15/16, showed LVN 4 was assigned to Resident 2. Review of Resident 2's medical record failed to show a signed informed consent, monitoring, assessment, physician's order, care plan, or any documentation addressing the use of soft mitten restraints on bilateral hands. On 4/23/26 at 1050 hours, a telephone interview was conducted with LVN 1. When asked if Resident 2 was observed with hand mittens, LVN 1 stated Resident 2 arrived to the facility with the bilateral hand mittens. When asked if Resident 2 had an informed consent signed for the hand mittens, LVN 1 stated, Not that I'm aware of. When asked if Resident 2's hands and wrists were assessed while he had the mittens on, LVN 1 stated no. On 4/28/26 at 0819 hours, an interview was conducted with LVN 4. When asked if Resident 2 was observed with hand mittens, LVN 4 stated the resident came back to the facility with mittens. LVN 4 further stated that would be considered a restraint, and there were no orders for restraints; therefore, she instructed a CNA to remove the restraints. On 4/28/26 at 0901 hours, an interview was conducted with CNA 1. When asked if he was instructed to the remove mittens from Resident 2's hands, CNA 1 stated, no. When asked if Resident 2 was seen with hand mittens on, CNA 1 stated he had seen the mittens inside Resident 2's closet last week. On 4/28/26 at 1351 hours, an interview was conducted with the DON. The DON stated she was unaware if Resident 2 was admitted with mittens and stated, Absolutely not, we don't do mittens. The DON stated if a resident was admitted with a soft mitten restraints, there should be documentation showing that there were physician's orders, consent, assessments, removal of the restraint every two hours to assess for circulation, and a care plan. On 4/28/26 at 1533 hours, the Administrator and DON acknowledged the above findings.

Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to thoroughly investigate an allegation of facility staff to resident physical abuse for one of three sampled residents (Resident 1) when * Resident 1 alleged that her caregiver (CNA) physically abused her. The facility staff tasked with conducting potential resident witness interviews, failed to provide the facility's Abuse Coordinator with an interview conducted with Resident 1's roommate (Resident 2), who was present during the time Resident 1 alleged to have been physically abused. This failure potentially inhibited the facility's ability to determine if resident abuse occurred and posed the risk for further abuse. Findings: Review of the facility's P&P titled Abuse, Neglect and Exploitation revised 12/19/22, showed it is the policy of the facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, and exploitation. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation occurs. Procedures for investigations include identifying and interviewing all involved people, including the alleged victim, alleged perpetrator, and witnesses who might have knowledge of the allegation. Medical record review for Resident 1 was initiated on 9/17/25. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 1's MDS assessment dated [DATE], showed Resident 1 had moderately impaired cognition. On 9/17/25 at 1550 hours, an observation and concurrent interview was conducted with Resident 1. Resident 1 was observed in her room lying in her bed. Resident 1 stated approximately two weeks ago, on the night shift, her caregiver slapped her on the face, choked her, and squeezed her hands, resulting in pain to her hands. Resident 1 described the caregiver as being a female with blonde hair. Resident 1 stated she reported the incident to the facility staff. Resident 1 stated her roommate (Resident 2) was present during the incident. Medical record review for Resident 2 was initiated on 9/17/25. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's MDS assessment dated [DATE], showed Resident 2 had moderately impaired cognition. On 9/17/25 at 1600 hours, an observation and concurrent interview was conducted with Resident 2. Resident 2 was observed in her room lying on her bed. Resident 2 was asked if she witnessed any person slap or choke her roommate (Resident 1) or squeeze her roommate's hands. Resident 2 stated she had poor vision and had not seen anyone slap or choke Resident 1 or squeeze Resident 1's hands. Resident 2 stated she did hear Resident 1 yelling about being hit. On 9/17/25 at 1738 hours, an interview and concurrent facility document review was conducted with the Administrator. The Administrator stated he served as the facility's Abuse Coordinator. The Administrator stated the facility conducted an investigation specific to Resident 1's allegation that a facility staff member choked, slapped, and squeezed Resident 1's feet. The Administrator stated the SSD and Social Services Assistant (SSA) conducted interviews of the facility staff and residents during the course of the facility's investigation. The Administrator stated at the conclusion of the facility's investigation, the facility was unable to substantiated Resident 1's allegation. Review of the facility's investigation was then conducted with the Administrator. The facility's investigation failed to show documentation Resident 1's roommate (Resident 2) was interviewed, or an attempt was made to interview Resident 2, specific to Resident 1's allegations. The Administrator verified the findings and stated an interview with Resident 2 should have been included as a component of the facility's investigation. The Administrator stated he had not realized (when reviewing the facility's investigation) Resident 2's interview was not included. The Administrator stated Resident 2 was a potential witness and in accordance with the facility's Abuse P&P, needed to be interviewed. The Administrator stated interviewing potential witnesses would help the facility determine whether abuse may have occurred. On 9/18/25 at 1121 hours, an interview, medical record review, and concurrent facility document review was conducted with the SSD. The SSD stated her assistant, the SSA, conducted the interviews of the Vietnamese speaking residents, specific to the facility's investigation of Resident 1's allegations. The SSD was asked if Resident 2 (Vietnamese speaking) was interviewed during the course of the facility's investigation of Resident 1's allegations. The SSD stated the SSA had interviewed Resident 2, however, the SSD did not provide Resident 2's interview to the Administrator (Abuse Coordinator). The SSD stated she had asked the MDS Coordinator if Resident 2 had the capacity to be interviewed. The SSD stated the MDS Coordinator told her Resident 2 had no capacity. The SSD stated she then placed the SSA's documentation of the interview the SSA conducted with Resident 2 in the facility's shred box. The SSD stated she did not provide Resident 2's interview to the Administrator (Abuse Coordinator). The SSD then reviewed Resident 2's MDS assessment dated [DATE], and verified Resident 2 was assessed as having moderately impaired cognition. The SSD stated the residents with moderately impaired cognition might have the capacity to provide information, specific to whether they have been the victim of an abuse or have witnessed another resident being abused. The SSD stated she should have included Resident 2's interview as a component of the facility's' investigation into Resident 1's allegation. The SSD stated all the potential witness interviews should have been provided to the facility's Abuse Coordinator, to ensure the Abuse Coordinator had all the information necessary to determine whether resident abuse occurred. On 9/18/25 at 1148 hours, an interview was conducted with the SSA. The SSA stated in accordance with the facility's investigation of Resident 1's allegation she was physically abused, the SSA conducted an interview with Resident 1's roommate (Resident 2). The SSA stated Resident 2 could verbalize her needs and had a general conversation specific to her needs. The SSA stated Resident 2 had the ability to articulate if someone were to abuse her. The SSA stated Resident 2 had impaired vision, however, if Resident 2 were to hear someone abuse her roommate (Resident 1) she could also articulate this information.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to ensure one of five final sampled residents (Resident 4) attained and maintained their highest practicable well-being. * The facility failed to continuously monitor Resident 4 after the resident had a witnessed fall. This failure had the potential for not providing the necessary care and services if the residents had a change in condition. Findings: Review of the facility's P&P titled Fall Prevention Program revised 12/28/23, showed each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. When any resident experiences a fall, the facility will assess the resident and document all assessments and actions. Medical record review for Resident 4 was initiated on 6/25/25. Resident 4 was readmitted to the facility on [DATE]. Review of Resident 4's H&P examination dated 4/10/25, showed Resident 4 had no capacity to understand and make decisions. Review of Resident 4's MDS assessment dated [DATE], showed Resident 4 had severe cognitive impairment and needed substantial/maximal assistance with mobility. Review of Resident 4's SBAR Communication Form dated 5/13/25, showed Resident 4 was being wheeled by the CNA to go to the dining area and the wheelchair got stuck in the carpet by the door to the patio which caused Resident 4 to slide off the wheelchair and fall forward. Resident 4 did not hit her head on the ground and did not sustain any injuries. The carpet was taken off the dining room right away. Review of Resident 4's plan of care initiated on 5/13/25, showed a care plan problem addressing Resident 4's fall incident on 5/13/25. The interventions included to monitor Resident 4 for pain or discomfort, vital signs, change in level of consciousness and notify the physician as needed. Further review of Resident 4's medical record failed to show documented evidence of continued monitoring/assessment for Resident 4 by the licensed nurses after the fall incident on 5/13/25. On 6/25/25 at 1108 hours, an observation and concurrent interview was conducted for Resident 4. Resident 4 was awake and sitting in the wheelchair inside the room. Resident 4 was unable to verbalize anything when asked about the fall incident happened on 5/13/25. Resident 4 was smiling and stated she was ok. On 6/25/25 at 1510 hours, a telephone interview for Resident 4 was conducted with CNA 2. CNA 2 verified the fall incident of Resident 4 on 5/13/25. CNA 2 stated Resident 4 was confused, could not follow the instructions, and was always trying to get out of the wheelchair. CNA 2 stated she was wheeling Resident 4 to the dining room and Resident 4 tried to stand up and because it was too fast, she could not grab Resident 4 right away. CNA 2 stated it was either the wheelchair or Resident 4's feet which got stuck in the door mat. CNA 2 stated everything happened so fast. CNA 2 stated Resident 4 did not hit her head on the ground and the nurse was there and came right away to assist. On 6/25/25 at 1630 hours, an interview and concurrent medical record review for Resident 4 was conducted with RN 1. RN 1 stated she witnessed Resident 4's fall incident on 5/13/25. RN 1 stated the wheelchair in which Resident 4 was seating got stuck in the door mat while being wheeled by CNA 2 in the dining area. RN 1 stated Resident 4 fell forward but did not hit her head on the ground. RN 1 stated a fall incident was considered a change in condition. RN 1 stated for a change in condition, the licensed nurse needed to monitor the resident every shift for 72 hours. RN 1 stated the licensed nurse should monitor the resident who had a fall for any changes in the resident's condition, vital signs, pain, and level of consciousness. RN 1 further stated it was important to continuously monitor the resident when there was a change in condition because based on the assessment, they could provide the proper care to the resident and would be able to notify the physician of any changes. RN 1 verified Resident 4 was not continuously monitored on 5/14 and 5/15/25 after Resident 4 fell on 5/13/25. On 6/26/25 at 1634 hours, an interview was conducted with the DON. The DON stated for any change in condition, the licensed nurses had to monitor the resident every shift for 72 hours for any changes in the mental status, vital signs, pain or discomfort, and skin. The DON further stated the importance of monitoring the resident continuously after a change in condition like fall was to assess right away if there were any changes in the resident's status, to be able to report to the physician, and to provide the necessary care to the resident. The DON was notified and acknowledged the above findings.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by: * The facility failed to ensure the kitchen utensils were clean and free of food particles or residues. * The facility failed to ensure the kitchen utensils had smooth cleanable surface and in good condition. * The facility failed to ensure the heavy-duty blender used for puree preparation, the scoops used for food portioning, and the plastic bucket containers used for the fruits and food storage were air dried prior to storing and stacking. * The facility failed to ensure the cutting boards were kept in a sanitary condition and with cleanable surface. * The facility failed to ensure the sanitary condition of the hood over the stove was maintained. * The facility failed to ensure the ice machine drainpipe had an air gap and not touching the drain. * The facility failed to ensure the ice machine utilized for residents and staff was maintained in a sanitary condition. These failures had the potential for cross contamination and foodborne illnesses for the residents consuming the food prepared in the facility's kitchen. Findings: Review of the facility's Diet Type Report dated 5/28/25, showed 96 of 110 residents consumed the food prepared in the kitchen. 1. Review of the facility's P&P titled Dish and Utensil Procedure revised 3/3/20, showed any dish, tray, or utensil with debris should not be used. Send back to the dish room to be properly washed and sanitized. According to the USDA Food Code 2022, 4-601.11 Equipment, Food - Contact Surfaces, Nonfood Contact Surface, and Utensils, the equipment food-contact surfaces and utensils shall be clean to sight and touch, the food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations; and the nonfood- contact surface of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. According to the USDA Food Code 2017, 4-602.13, Non- Contact Surfaces, nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. On 5/28/25 at 0805 hours, during the initial kitchen tour, an observation and concurrent interview was conducted with the Dietary Manager. The following was observed: - Two stainless steel knives with black handles were observed dirty and had fuzzy films. - One stainless steel peeler with black handle was observed dirty and had dry, brownish discoloration. - One stainless steel spatula with white handle was observed dirty and had dry, white crusted residue. - Two stainless steel whisk was observed dirty and had dry, crusted residue. - One stainless steel tong was observed dirty and had dry, crusted residue. - One slotted stainless steel serving spoon was observed dirty and had dry brownish residue on the handle. The Dietary Manager acknowledged the above findings and stated the dirty utensils had to be washed again to prevent food contamination. 2. Review of the facility's P&P titled Dish and Utensil Procedure date revised 3/3/20, showed the chipped or cracked dishes, trays shall be discarded. According to the USDA Food Code 2022 Section 4-502.11 Good Repair and Calibration, (A) Utensils shall be maintained in a state of repair and condition that complies with the requirements specified under Parts 4-1 and 4-2 or shall be discarded. According to the USDA Food Code 2022, Section 4-101.11, Multiuse, Characteristics, materials that are used in the construction of utensils and food contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be durable, corrosion-resistant, nonabsorbent, finished to have a smooth, easily cleanable surface, and resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition. On 5/28/25 at 0805 hours, during the initial kitchen tour, an observation and concurrent interview was conducted with the Dietary Manager. The following was observed: - One stainless steel whisk with gray rubber handle cracked and partially burnt. - One stainless steel tong with red handle was observed worn out with partially melted handle. - One rubber spatula with red handle was observed worn out, discolored, had chipped and cracked edges and handle was partially melted. - One plastic white rice paddle was observed with partially melted handle. - One stainless steel spatula with black handle was partially melted. The Dietary Manager acknowledged the above findings and stated all the worn-out utensils and dishes should have been discarded and replaced. 3. Review of the facility's P&P titled Dish and Utensil Procedure date revised 3/3/20, showed the dishes, trays, and utensils shall be air dried before storage. Do not towel dry. In addition, review of the facility's P&P titled Dry Storage- Dishes and Utensils revised 2/1/12, showed the dishes must be stored to promote air drying i.e. use dish racks or trays with plastic mesh that allow air to circulate, and air dry the dishes. According to the USDA Food Code 2022, 4-901.11, Equipment and Utensils, Air-Drying Required, that after cleaning and sanitizing, equipment, and utensils shall be air-dried or used after adequate draining before getting in contact with food. According to the USDA Food Code 2022, 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles, cleaned equipment and utensils shall be stored in a self-draining position that allows air drying. On 5/28/25 at 0805 hours, during the initial kitchen tour, an observation and concurrent interview was conducted with the Dietary Manager. The following was observed: - One heavy-duty blender stored on the counter shelf was observed still wet with visible water inside and on the lid. - Two clear plastic bucket containers used for fruits and food storage were observed wet with visible water inside and stacked on top of each other. - One stainless steel serving spoon was observed wet with visible water and had dry watermarks. - Two stainless steel serving scoop with green handles were observed wet with visible water. - One stainless steel scoop with blue handle use for food portioning was stored wet with visible water. - One stainless steel scoop with green handle use for food portioning was stored wet with visible water. - Two stainless steel scoop with gray handles use for food portioning were stored wet with visible water. - One stainless steel spatula with black handle was stored wet with visible water. The Dietary Manager verified the above findings and stated the blender and utensils should have been air dried prior to storage. 4. Review of the facility's P&P titled Dish and Utensil Procedure revised 3/3/20, showed the cutting boards need to be washed and sanitized between each use. Replace cutting boards once lined with knife marks and they are unsanitizable. Color-coded cutting boards are desirable designating boards for raw products versus cooked products. According to the USDA Food Code 2022, Section 4-501.12, Cutting Surfaces, for surfaces such as cutting boards and blocks that become scratched and scored may be difficult to clean and sanitize. As a result, pathogenic microorganisms transmissible through food may build up or accumulate. These microorganisms may be transferred to the foods that are prepared on such surfaces. On 5/28/25 at 0805 hours, during the initial kitchen tour, a concurrent observation and interview was conducted with the Dietary Manager. The green, red, brown, and yellow cutting boards were observed fuzzy, heavily marred and had deep grooves. The Dietary Manager verified the findings and stated the cutting boards were changed every three months and should have been replaced for infection control purposes because it could not be thoroughly cleaned. 5. Review of the facility's P&P titled Hoods and Filters revised 8/31/18, showed hoods must be kept free of grease and dust at all times. Because of potentially high fire hazard, it is important that hood filters be part of a strictly enforced cleaning schedule and be free of grease and dust at all times. According to the USDA Food Code 2022 Section 4-204.11 Ventilation Hood Systems, Drip Prevention. The dripping of grease or condensation onto food constitutes adulteration and may involve contamination of the food with pathogenic organisms. Equipment, utensils, linens, and single service and single use articles that are subjected to such drippage are no longer clean. On 5/28/25 at 0805 hours, during the initial kitchen tour, an observation and concurrent interview was conducted with the Dietary Manager. The kitchen hood over the stove was observed with black, greasy, dirt residue. The Dietary Manager acknowledged the finding and stated the dietary staff cleaned the hood once a week and an outside company serviced for the kitchen hood was conducted on 1/2025. 6. Review of the facility's P&P titled Backflow Prevention/Air Gap revised 8/15/17, showed an air gap is the space between the faucet and flood rim or the space between the drain and the floor drain. According to the USDA 2017 Food Code, Section 5-202.13, Backflow Prevention, Air Gap, an air gap between the water supply inlet and the flood level rim of the plumbing fixture, equipment, or nonfood equipment, shall be at least twice the diameter of the water supply inlet and may not be less than 25 mm (1 inch). On 5/28/25 at 0842 hours, during the initial kitchen tour, an inspection of the ice machine was conducted with the Dietary Manager. The drain pipe was observed resting on the ground and touching the drain. The Dietary Manager acknowledged the findings. On 5/28/25 at 0848 hours, an inspection of the ice machine was conducted with the Director of Plant Operations. The drain pipe was observed resting on the ground and touching the drain. The Director of Plant Operations acknowledged the findings and stated the drain pipe should have been fixed to prevent any backflow. 7. Review of the facility's P&P titled Ice Machine revised 10/18/18, showed the cleaning and sanitizing of internal components of the ice machine should follow EPA-registered label use instructions and is usually done by the maintenance department or by a contracted ice machine maintenance company. Per Food Code the internal components must be cleaned and sanitized per manufacturer's guidelines, county or state regulations and not less than twice per year. According to the USDA Food Code 2017, Section 4-601.11, the equipment food-contact surfaces and utensils shall be clean to sight and touch. On 5/28/25 at 0848 hours, an observation, interview, and concurrent facility record review was conducted with the Director of Plant Operations. The Director of Plant Operations stated the facility had one ice machine for the residents' use located in the resident's dining room. The Director of Plant Operations stated he was in charge of the cleaning and maintenance of the ice machine. Review of the Ice Machine Cleaning/Maintenance log showed the ice machine was last cleaned and sanitized on 5/20/25, and the filter was due to be replaced on 8/15/25. Observation of the internal panel of the ice machine was conducted with the Director of Plant Operations. The internal panel of the ice machine adjacent to the water curtain located directly above the ice bin, was observed with a brownish residue. The Director of Plant Operations verified the above findings and stated the ice machine needed to be cleaned because a contaminated ice could cause illnesses. On 6/3/25 at 1452 hours, the DON and Administrator were informed of the above findings. The DON and Administrator was asked if they would serve the ice from the dirty ice machine to the residents and they replied, no.

Based on observation, interview, and facility P&P review, the facility failed to provide the reasonable accommodation to meet the needs of one final sampled resident (Resident 75) reviewed for communication needs. * The facility failed to ensure Resident 75 was provided with the means to communicate his daily needs. This failure had the potential to negatively impact the resident's psychosocial well-being or result in delayed provision of care. Findings: Review of the facility's P&P titled Effective Communication revised 10/2022 showed the following: - During the prescreening and admission process, as much information as possible will be obtained regarding the resident's current processes for communication; - Direct care staff will be educated on effective communication that reflects the needs of the resident population and needs of the staff, corresponds with the Facility Assessment; and - Staff will communicate with the resident, using techniques identified in their plan of care, and in accordance with his/her established routine for communication, as possible. Adaptive techniques include but are not limited to using sign language and using communication boards or writing materials. Medical record review for Resident 75 was initiated on 5/29/25. Resident 75 was admitted to the facility on [DATE]. Review of Resident 75's H&P examination dated 5/1/25, showed Resident 75 had the capacity to understand and make decisions. In addition, the H&P examination showed the resident's diagnoses included CVA and aphasia. Review of Resident 75's MDS assessment dated [DATE], showed the following: - Section B0600 Speech Clarity: 2, unclear speech- slurred or mumbled words; - Section B0700 Makes Self Understood: 1, usually understood-difficulty communicating some words or finishing thoughts but is able if prompted or given time; and - Section C0500 Brief Interview for Mental Status (BIMS) score of 99 which meant Resident 75 was unable to complete the interview. However, section C 1000 for Cognitive Skills for Daily Decision-Making assessment showed code zero which meant independent. On 5/28/25 at 0839 hours, during the initial tour, Resident 75 was observed lying in bed, awake, alert and mumbled words with gestures. Greeted and communicated with Resident 75; however, Resident 75's words and gestures were incomprehensible. There was no visible sign of language interpreter information or communication board available in Resident 75's room. On 5/28/25 at 0845 hours, an observation of Resident 75 and concurrent interview was conducted with CNA 1. Resident 75 was observed mumbling words and gesturing to CNA 1. CNA 1 mentioned Resident 75 understood Vietnamese language only. CNA 1 was observed pointing at things and attempting to guess what Resident 75 was trying to tell her. CNA 1 was observed not using any communication/picture board with the resident. In addition, CNA 1 failed to inform the charge nurse to call the language interpreter line or requested another Vietnamese speaking staff to translate for Resident 75 to communicate his needs. When CNA 1 was asked how she could communicate and understand Resident 75, considering the language barrier between the two of them, CNA 1 stated she tried to understand Resident 75's wants and needs through Resident 75's gestures. When CNA 1 was asked if Resident 75 was provided with a communication board or the phone number to call the language interpreter line, CNA 1 stated Resident 75 was not provided with a communication board to use in his room and was not aware of the language interpreter line. On 5/28/25 at 0959 hours, an observation of Resident 75 and concurrent interview was conducted with LVN 1. LVN 1 verified Resident 75 did not have any communication or picture board available at bedside or in his room, and the information for the language interpreter line was not available. Review of Resident 75's Social Service assessment dated [DATE], showed the following: - Orientation was alert and oriented x 3 (indicates a patient's level of consciousness and orientation); - Communication status impaired; - Primary language was Vietnamese, communicated by shaking and nodding his head; - Adequate hearing; and - Adequate eyesight and did not wear eyeglasses. Review of Resident 75's care plan for communication problem related to language barrier and no speech due to stroke dated 5/1/25, showed the goal was for Resident 75 to be able to make his needs known by communication board daily. The care plan interventions included to anticipate and meet the resident's needs, the resident preferred to communicate in Vietnamese, and to discuss with the resident/family concerns regarding the communication difficulty. However, the care plan interventions did not include a communication means for the staff and resident to use, including communication board and language interpreter line to achieve the established goal. On 5/30/25 at 1400 hours, an interview and concurrent medical record review for Resident 75 was conducted with RN 1. RN 1 was asked about the facility's process to communicate with non-English speaking or aphasic residents. RN 1 stated the facility provided a communication board to the residents, and the staff could use a language interpreter services line. When RN 1 was asked if all the staff were informed and aware on how to use the language interpreter line, RN 1 stated she thought so; however, she stated she was not 100% sure if all staff were aware that the facility provided the language interpreter line for any of the staff to use to communicate to non-English speaking residents. Resident 75's care plan for communication problem related to language barrier and no speech due to stroke was reviewed with RN 1 and she verified the facility failed to provide Resident 75 with the communication board to achieve the goal and ensure the interventions included the necessary means of communication be provided. Furthermore, RN 1 stated the implications for failure to provide the necessary means of communication was a delay in providing Resident 75's daily needs. On 6/2/25 at 1444 hours, an interview and concurrent medical record review for Resident 75 was conducted with the MDS Coordinator. The MDS Coordinator stated Resident 75 was diagnosed with aphasia and the primary language was Vietnamese. Resident 75's MDS Section B assessment dated [DATE], was reviewed with the MDS Coordinator. The MDS Coordinator verified the MDS Section B assessments and stated without a Vietnamese staff interpreter, she was not able to understand Resident 75 through his gesturing and incomprehensible words. The MDS Coordinator did not mention about using or providing a communication board or could have called the facility's language interpreter line to communicate with Resident 75. The MDS Coordinator stated there was not a Vietnamese speaking staff working in every shift, mostly morning and evening shifts. Furthermore, the MDS Coordinator stated the nursing staff, social services, and activity department were responsible in providing the means of communication like a communication board to each of the resident who needed it. On 6/3/25 at 1400 hours, an interview was conducted with the Administrator, DON, and Nurse Consultant. The Administrator stated upon admission of each resident to the facility, the admitting nurse must assess the communication status of the resident and must provide the communication board if the resident spoke a different language other than English or aphasic. In addition, the Administrator stated the activity staff must check and follow up daily for the presence and availability of the communication board at the resident's bedside. The Administrator, DON, and Nurse Consultant were informed and acknowledged the above findings.

3. Medical record review for Resident 914 was initiated on 5/28/25. Resident 914 was admitted to the facility on [DATE]. Review of Resident 914's Order Summary Report showed a physician's order dated 4/11/25, to administer sertraline 25 mg by mouth a day for depression. Review of Resident 914's MAR for May to June 2025 showed Resident 914 was administered the sertraline medication from 5/1 to 6/2/25 at 0900 hours. Further review of Resident 914's medical record failed to show the non-pharmacological interventions were implemented prior to administering the sertraline medication. On 6/2/25 at 1059 hours, an interview and concurrent medical record review for Resident 914 was conducted with RN 2. RN 2 verified the non-pharmacological interventions were not implemented prior to administering the sertraline medication to Resident 914. RN 2 stated the non-pharmacological interventions were implemented prior to administering psychotropic medications as needed but not for routine psychotropic medications. 4. Medical record review for Resident 93 was initiated on 5/28/25. Resident 93 was readmitted to the facility on [DATE]. Review of Resident 93's Order Summary Report showed the following physician's orders: - dated 3/28/25, to administer zolpidem by mouth at bedtime every Monday, Tuesday, Wednesday, Thursday, Friday and Saturday for insomnia; and - dated 9/13/24, to monitor the hours of sleep and record the number of times the behavior was manifested every evening and night shift. Review of Resident 93's MAR for April and May 2025 showed Resident 93 was administered the zolpidem medications on 4/1 to 4/5, 4/7 to 4/12, 4/14 to 4/19, 4/21 to 4/26, 4/26 to 5/2, 5/5 to 5/10, 5/12 to 5/17, 5/19 to 5/24, and 5/26 to 5/31/25. a. Review of Resident 93's Monitor Record for April and May 2025 showed Resident 93's hours of sleep were ranged from four to ten hours. However, the record failed to show the number of times for the behavior manifested when Resident 93 had insomnia. b. Review of Resident 93's Psychopharmaceutical Summary Sheet for April 2025 related to the use of zolpidem medication showed the behavioral manifestation was hours of sleep. The summary sheet, under the column for the number of behavior episodes/shift showed one to four hours for 1500 to 2300 hours shift and three to seven hours for 2300 to 0700 hours shift. Further review of the summary sheet did not show the number of episodes of insomnia was accurately recorded. On 6/2/25 at 1622 hours, an interview and concurrent medical record review for Resident 93 was conducted with the DON. The DON verified the physician's order for the administration of the zolpidem medication did not show the behavioral manifestation of the insomnia which was inability to sleep. The DON stated the inability to sleep meant the resident's hours of sleep was less than six hours. The DON verified the licensed nurses were documenting Resident 93's hours of sleep for the evening and night shifts; however, they were not monitoring when the resident slept less than six hours. The DON further verified the monthly behavior summary was inaccurate since it did not show the number of episodes when Resident 93 slept less than six hours. 2. Review of the facility's P&P titled Use of Psychotropic Medication(s) revised 3/17/25, showed the Policy Explanation and Compliance Guidelines section with the following information: - Non-pharmacological interventions must be attempted unless clinically contraindicated to minimize the need for psychotropic medications, use the lowest possible dose, or discontinue the medication; and - The effects of psychotropic medications on a resident's physical, mental, and psychosocial well-being will be evaluated on an ongoing basis, such as upon physical evaluation (routine and as needed). Medical record review for Resident 86 was initiated on 5/29/25. Resident 86 was readmitted to the facility on [DATE]. Review of Resident 86's H&P examination dated 4/1/25, showed Resident 86 had the capacity to understand and make decisions. Review of Resident 86's Order Summary Report showed the following physician's orders: - dated 3/31/25, to administer venlafaxine hydrochloride (medication to treat depression) 37.5 mg one tablet by mouth one time a day for depression as manifested by verbalizing feeling sad; - dated 3/31/25, to administer buspirone hydrochloride (medication to treat anxiety) 10 mg one tablet by mouth three times a day for anxiety as manifested by verbalizing nervousness; - dated 4/9/25, to monitor for depression as manifested by verbalizing sadness and record the number of times the behavior was manifested every shift for venlafaxine; - dated 4/9/25, to monitor for anxiety as manifested by verbalizing feeling of nervousness, and record the number of times the behavior was manifested every shift; and - dated 4/9/25, to monitor for side effects related to use of psychotropic medications every shift for buspirone and venlafaxine in use. Review of Resident 86's plan of care showed the following: - a care plan problem revised 12/30/24, addressing Resident 86's use of antidepressant medication - venlafaxine medication related to depression as manifested by verbalized sadness; and - a care plan problem revised on 5/29/25, addressing Resident 86's use of antianxiety medication - buspirone medication related anxiety disorder. Further review of Resident 86's plan of care failed to show a care plan addressing the implementation of non-pharmacological interventions prior to administering the psychotropic medications when Resident 86 manifested the behavior of verbalizing sadness or nervousness. Review of Resident 86's MAR for 4/2025 and 5/2025 showed Resident 86's following manifested behaviors and medications received: - venlafaxine medication for feeling sad on 4/5, 4/11, 4/12, 4/14, 4/25, 4/26, 4/28, 5/2, 5/3, 5/5 and on 5/17/25 at 0900 hours; and - buspirone medication for verbalizing nervousness on 4/5, 4/11, 4/12, 4/14, 4/25, 4/26, 4/28, 5/2, 5/3, 5/5 and on 5/17/25 at 0900, 1300, and 1700 hours, and on 5/26/25 at 1700 hours. Further review of Resident 86's medical record failed to show documented evidence Resident 86 was provided with non-pharmacological interventions prior to administering the psychotropic medications when Resident 86 was observed with behavior of feeling sad or nervousness. Review of Resident 86's Monitor Record for 4/2025 and 5/2025 showed Resident 86 was not monitored for side effects related to the use of psychotropic medications on 4/12, 5/14, and 5/17/25, for the night shift, and 5/11 and 5/18/25, for the day shift. On 6/2/25 at 0900 hours, an observation and concurrent interview was conducted with Resident 86. Resident 86 was observed lying in bed and watching TV. Resident 86 stated at times, she felt sad, but it did not last long. Resident 86 stated at times, she felt very sleepy as well. Resident 86 stated she knew she was taking medications for sadness or anxiety. On 6/2/25 at 0932 hours, an interview for Resident 86 was conducted with CNA 7. CNA 7 stated she had not observed Resident 86 feeling sad or anxious. CNA 7 stated she had observed Resident 86 sleepy at times and she would report it to the nurses. On 6/2/25 at 0944 hours, an interview and concurrent medical record review for Resident 86 was conducted with LVN 6. LVN 6 stated Resident 86 could be sleepy at times, liked to just stay in the room and watch TV. LVN 6 stated she had not observed Resident 86 being sad or anxious. LVN 6 verified Resident 86 was taking the venlafaxine medication for depression and the buspirone medication for anxiety. LVN 6 stated when giving these kinds of medications, it was important to monitor if Resident 86 was having the behaviors related to the illness. LVN 6 stated if Resident 86 was manifesting the behaviors such as feeling sad or nervousness, Resident 86 should be provided first with non-pharmacological interventions such as modifying the environment to keep it quiet, let the resident get involved with other activities or massage. LVN 6 stated by providing non-pharmacological interventions first and if it helped Resident 86, the use of psychotropic medication could be avoided. LVN 6 stated the nurses should monitor the side effects of psychotropic medications to the residents. LVN 6 further stated if the side effects were present, the psychotropic medications dose might need to be decreased or discontinued. LVN 6 verified Resident 86 was not provided with non-pharmacological interventions during the times Resident 86 manifested the behavior of feeling sad or nervousness. LVN 6 also verified Resident 86 was not monitored for the side effects of psychotropic medications on April and May 2025. LVN 6 further stated if it was not documented, it was not done. On 6/2/25 at 1107 hours, an interview and concurrent medical record review for Resident 86 was conducted with RN 1. RN 1 stated if the resident was receiving the psychotropic medications, it was important to monitor the resident for manifestation of behaviors related to the illness and the side effects related to the use of psychotropic medications. RN 1 stated the monitoring was documented in the Monitor Record in the PCC. RN 1 stated if the side effects related to the use of psychotropic medications were present, the nurses needed to report it to the physician, and the physician could evaluate if the medications should be continued or not. RN 1 stated it was important to document the monitoring because it showed the nurse assessed the resident and if it was not documented then it was not done. RN 1 stated the examples of non-pharmacological interventions were redirecting the attention of the resident, 1:1 conversation with the resident, let the resident speak to the family member, providing quiet environment or playing music to calm the resident. RN 1 stated providing non-pharmacological interventions prior to administering the psychotropic medication when the resident was manifesting behaviors kike sadness or nervousness would help the staff to assess the need for the medications. RN 1 stated if the non-pharmacological interventions would help alleviate the behavior of the resident, the resident might not need the medications anymore, and they could avoid the use of too much psychotropic medications to the resident. RN 1 further stated the implementation of non-pharmacological interventions should be addressed in the plan of care as well. RN 1 verified the above findings. On 6/3/25 at 1400 hours, an interview was conducted with the DON. The DON stated all the monitoring required and ordered should be documented because if it was not documented, it was not done. The DON stated the non-pharmacological interventions should be provided whether the psychotropic medications were given routinely or as needed when the resident was manifesting the behavior related to the illness prior to administering the medication. The DON was notified and aknowledged the above findings for Resident 86. Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the freedom from unnecessary drugs for three of 23 final sampled residents (Residents 86, 93, and 914) and one nonsamples resident (Resident 15). * The facility failed to ensure an physician's order for the temazepam medication was obtained prior to administering the medication to Resident 15. * The facility failed to ensure the non-pharmacological interventions were implemented prior to administering the venlafaxine (antidepressant medication) and buspirone (antianxiety medication) medications, and to monitor the side effects of psychotropic medications to Resident 86. * The facility failed to ensure non-pharmacological interventions were implemented prior to administering the sertraline (antidepressant medication) to Resident 914. * The facility failed to ensure Resident 93 was accurately monitored for the number of episodes of insomnia related to the use of zolpidem (antidepressant medication). These failures had the potential for adverse effects from the psychotropic medications and the potential for not providing the correct data to the prescriber to adjust the dosage of psychotropic medications. Findings: Review of the facility's P&P titled Use of Psychotropic Medication(s) revised 3/17/25, showed a psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. Psychotropic drugs include, but are not limited to antipsychotics, antidepressants, antianxiety, and hypnotics. The Policy Explanation and Compliance Guidelines section of the P&P showed, the psychotropics used on a PRN basis must have a diagnosed specific condition and indication for the PRN use documented in the resident's medical record and is subject to the limitations as noted: a. PRN order for psychotropic medication, excluding antipsychotics, shall be limited to no more than 14 days unless the attending physician or prescribing practitioner believes it is appropriate to extend beyond 14 days. The medical record should include documentation from the physician or prescriber for the rationale for the extended time period and indicate a specific duration. Review of the facility's P&P titled Medication Administration revised 12/19/22, showed the medications are administered by the licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards and practices. The procedure for administering medications includes the following: - Review of the MAR to identify the medication to be administered. - Compare the medication source (bubble pack, vial, etc.) with the MAR to verify the resident name, medication name, form, dose, route, and time. 1. Medical record review for Resident 15 was initiated on 5/28/25. Resident 15 was admitted to the facility on [DATE]. Review of Resident 15's H&P examination dated 1/29/25, showed Resident 15 had no capacity to understand and make decisions. Review of Resident 15's Order Summary Report dated 4/1 to 5/28/25, showed a physician's order to administer temazepam (medication used to treat insomnia) 7.5 mg capsule by mouth every 24 hours at bedtime for 14 days for insomnia manifested by the inability to sleep. Further review of Resident 15's Order Summary Report showed the physician's order for the 7.5 mg temazepam capsule was completed on 5/9/25. There was no active order for temazepam medication. However, review of Resident 15's Antibiotic or Controlled Drug Record log (undated) showed the temazepam 7.5 mg capsule was signed out on 5/26/25 at 2100 hours. Review of Resident 15's MAR for May 2025 showed no documented evidence the temazepam 7.5 mg capsule was administered to Resident 15 on 5/26/25, as listed on the Antibiotic or Controlled Drug Record log. On 5/28/25 at 1216 hours, an in interview and concurrent medical record review for Resident 15 was conducted with LVN 1. LVN 1 verified the above findings. On 5/28/25 at 1232 hours, an interview and concurrent medical record review for Resident 15 was conducted with the DON. The DON verified the above findings and stated Resident 15 was administered the temazepam 7.5 mg capsule without an active physician's order. On 6/3/25 at 1315 hours, an interview was conducted with the Administrator, DON, and Nurse Consultant. they were were made aware and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one final sampled resident (Resident 90) reviewed for ADL care was provided with the necessary care and services to maintain their ADL capabilities. * The facility failed to ensure the care and services were provided to maintain good grooming and personal hygiene when Resident 90's left ear was observed with a large amount of brownish cerumen covering the left ear canal. This failure had the potential to negatively affect the resident's well-being. Findings: Review of the facility's P&P titled Activities of Daily Living (ADLs) revised on 12/19/22, showed the following: - The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADL care do not deteriorate unless deterioration is unavoidable; - Care and services may consist of the following daily activities like bathing, dressing, grooming, oral care, transfer and/or ambulation, toileting, eating to include meals and snacks, and using speech, language, or other functional communication systems; - A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene; and - The facility will maintain individual objectives of the care plan and periodic review and evaluation. Medical record review for Resident 90 was initiated on 5/29/25. Resident 90 was readmitted to the facility on [DATE]. Review of Resident 90's MDS assessment dated [DATE], showed Resident 90's BIMS score was six, which meant severe cognitive impairment. On 5/28/25 at 1255 hours, during the dining observation, Resident 90 was observed sitting in his wheelchair and eating his lunch. After checking Resident 90's meal ticket, Resident 90 was observed with a large amount of brownish colored cerumen in the left ear canal. Further review of Resident 90's medical record failed to show an assessment, SBAR or change of condition documentation, notification of MD, and care plan were initiated to address Resident 90's left ear impacted cerumen. On 5/29/25 at 1350 hours, an observation of Resident 90 and concurrent interview was conducted with CNA 6. Resident 90 was observed sitting in his wheelchair, awake, and alert. CNA 6 was asked for assistance in checking Resident 90's left ear. Resident 90's left ear was observed with a large amount of brownish colored cerumen impacted in the ear canal. CNA 6 verified the above findings. CNA 6 was asked when Resident 90 was provided with personal hygiene including ear care. CNA 6 stated he provided ear care to Resident 90 after every shower schedule on Monday and Wednesday. CNA 6 stated he cleaned Resident 90's bilateral outer areas of his ears yesterday after the shower. Furthermore, CNA 6 was asked if he saw Resident 90's large, impacted cerumen in his left ear canal yesterday or today and he stated he did not see the large, impacted cerumen in his left ear canal yesterday or today. On 5/29/25 at 1400 hours, an observation of Resident 90 and concurrent interview was conducted with LVN 2. Resident 90's left ear was observed with a large amount of brownish colored cerumen impacted in the ear canal. LVN 2 verified the above findings. LVN 2 was asked who was responsible to chec Resident 90's ears for cleanliness and she stated the assigned CNAs and the licensed nurses must check Resident 90's ears and provide ear care every shift as part of personal hygiene. LVN 2 stated if any change of condition, like large and impacted cerumen, the licensed nurse must check and report the condition to the physician for any orders. LVN 2 stated the licensed nurses must complete an SBAR, carry out the physician's order, formulate a care plan, and document monitoring in the progress notes every shift for 72 hours. Furthermore, LVN 2 stated implications for cerumen impacted ears may cause infection or impairment of hearing. On 5/30/25 at 1037 hours, an interview and concurrent medical record review for Resident 90 was conducted with RN 1. RN 1 stated CNAs were responsible for the residents' personal hygiene from head to toe including cleanliness and providing the necessary care every shift. In addition, RN 1 stated the CNAs must document the personal hygiene provided to each of the resident every shift. On 5/30/25 at 1054 hours, an interview and concurrent medical record review for Resident 90 was conducted with the DSD. The DSD stated the CNAs must chart the ADL tasks in the EHR for each resident every shift in 24 hours. The DSD was asked about the importance of complete and accurate documentation and she stated the documentation must be completed to show care was provided and if not documented, then care was not rendered. The DSD stated she checked for completion and audited the CNAs' documentation in the EHR daily. Resident 90's ADL-Personal Hygiene task dated 5/17-5/29/25, was reviewed with the DSD. The document failed to show documentation of the evening shift on 5/20-5/21/25, and the night shift from 5/17-5/29/25. The DSD verified the above findings. On 5/30/25 at 1125 hours, an interview was conducted with the DON. The DON was asked about the facility's expectation to document each resident's ADL care including the personal hygiene. The DON stated there were three shifts and the CNAs were expected to document each resident's ADL care including the personal hygiene every shift. On 6/3/25 at 1400 hours, an interview was conducted with the Administrator, DON, and Nurse Consultant. The Nurse Consultant stated the CNAs must document personal hygiene every shift. The Administrator, DON, and Nurse Consultant were informed and acknowledged the above findings.

2. Review of the facility's P&P titled Incidents and Accidents dated 12/19/22, showed in the event of an unwitnessed fall or a blow to the head, the nurse will initiate neurological checks as per protocol and document on the neurological flow sheet. Abnormal findings will be reported to the practitioner. Review of the facility's Neurological Flowsheet form showed the neurological assessments were to be completed every 15 minutes x 4, every 30 minutes x 2, every hour x 2, every two hours x 2, every four hours x 4, and every eight hours x 3. The neurological assessment record included checking whether the resident was transferred to the acute care hospital or not, and if not, the licensed nurses were to document the resident's vital signs (blood pressure, temperature, pulse, respiration and pain level), pupil size and response light of the right and left eyes, motor response of the hand grasps, and motor functions of the extremities, level of consciousness, speech, and response to name, pain, environment. Medical record review for Resident 21 was initiated on 5/28/25. Resident 21 was admitted to the facility on [DATE]. a. Review of Resident 21's SBAR Communication Form dated 3/27/25, showed the CNA noted resident sitting on the floor on the left side of the bed. Review of Resident 21's Neurological Flowsheet - V3 dated 3/27/25, failed to show the neurological assessments were completed on 3/27/25 at 1730 and 2130 hours, 3/28/25 at 0530 hours, and 3/29/25 at 0530 hours (for a total of four assessments). b. Review of Resident 21's SBAR Communication Form dated 4/30/25, showed the resident was observed with a small discoloration to the coccyx (tailbone) area. Review of Resident 21's Progress Notes, under the nursing note, dated 4/30/25 at 1823 hours, showed a CNA found Resident 21 on the floor in the room. Review of Resident 21's Neurological Flowsheet - V3 dated 4/30/25, failed to show the neurological assessments were completed on 5/1/25 at 1630 hours, and 5/2/25 at 0830 and 1630 hours (for a total of three assessments). c. Review of Resident 21's SBAR Communication Form dated 5/1/25, showed Resident 21 was found in the restroom, on her knees, leaning to her left side, and complaining of lower back pain. Review of Resident 21's Radiology Results Report dated 5/1/25, showed Resident 21 sustained an acute, transverse, non-displaced fracture at S4 sacral segment. Review of Resident 21's Neurological Flowsheet - V3 dated 5/1/25, failed to show the neurological assessments were completed on 5/1/25 at 1600 and 2000 hours, and 5/2/25 at 2400 and 0400 hours (for a total of four assessments). On 10/12/22 at 1219 hours, an interview and concurrent medical record review for Resident 21 was conducted with RN 1. RN 1 stated for an unwitnessed fall, the neurological assessments were to be completed in the resident's electronic health record. RN 1 verified Resident 21's neurological assessments were not completed for Resident 21's unwitnessed falls on 3/27, 4/30, and 5/1/25. Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary care and services to prevent accidents for one of two residents reviewed for smoking (final sampled resident, Resident 50). In addition, the facility failed to assess following multiple unwitnessed falls for one of one final sampled resident (Resident 21) reviewed for falls. * The facility failed to complete the neurological assessments following unwitnessed falls on 3/27, 4/25 and 5/1/25, for Resident 21. * The facility failed to ensure the safe smoking practices were followed for Residents 50 when the resident was permitted to keep the cigarettes with his possession after being assessed as requiring supervision while smoking. These failures posed the risk of injuries from fire and serious injuries to the residents who smoked and to the other residents who resided in the facility. Furthermore, these failures had the potential to delay the detection and response to changes in neurological status post-fall for the residents. Findings: Review of the facility's P&P titled Resident Smoking - Smoke Free Facility revised on 12/19/22, showed the following: - All the residents will be asked about tobacco use during the admission process, and during each quarterly or comprehensive MDS assessment; - Residents who smoke will be further assessed, using the Resident Safe Smoking Assessment, to determine whether or not supervision is required for smoking, or resident is safe to smoke at all; - All safe smoking measures will be documented on each of the resident's care plan and communicated to all the staff, visitors and volunteers who will be responsible for supervising the residents while smoking. Supervision will be provided as indicated on each of the resident's care plan; and - Smoking materials of the residents requiring supervision with smoking will be maintained by the nursing staff. Medical record review for Resident 50 was initiated on 5/29/25. Resident 50 was readmitted to the facility on [DATE]. Review of Resident 50's H&P examination dated 3/9/25, showed Resident 50 had the capacity to understand and make decisions. Review of Resident 50's MDS assessment dated [DATE], showed Resident 50's BIMS score was 13, which meant the resident was cognitively intact. Review of Resident 50's Smoking Safety initial assessment dated [DATE], showed the following: - Risk factors for safety and concerns were impaired gait and balance and receiving medications that affect alertness and function; and - Resident may smoke independently. Review of Resident 50's care plan dated 4/16/25, showed the following interventions: - The resident's smoking supplies are stored in the nursing station; and - The resident requires supervision while smoking. On 5/28/25 at 0856 hours, during the initial tour, Resident 50 was observed lying in bed awake, alert and verbally responsive. Resident 50 stated he smoked twice a day and the staff supervised him while he smoked. On 5/28/25 at 0907 hours, an observation and concurrent interview for Resident 50 was conducted with LVN 5. LVN 5 was requested to check Resident 50's bedside drawer for smoking paraphernalia. A pack of sealed Clipper Cigars in Resident 50's bedside drawer was observed. LVN 5 verified the above findings. LVN 5 stated all the smoking paraphernalia like cigarettes and lighters must be kept at the nurse's station for safekeeping due to fire hazards. In addition, LVN 5 stated the CNAs and licensed nurses must check the residents' drawers and belongings for the smoking paraphernalia. LVN 5 stated he would place Resident 50's pack of cigars at the nurse's station for safekeeping. On 5/29/25 at 1500 hours, an interview and concurrent medical record review for Resident 50 was conducted with RN 1. RN 1 verified the initial Smoking Safety assessment dated [DATE], she completed for Resident 50 showed the resident had risk factors for safety. RN 1 also verified she recommended for Resident 50 to smoke independently after being assessed as having risk factors for safety. RN 1 stated the facility's process when a resident smoked included for a staff from the activity or nursing department to supervise every time the resident would smoke for smoking safety regardless if the resident may smoke independently or not. RN 1 stated the failure to observe safety smoking measures would lead to fire or burn injuries. Resident 50's care plan dated 4/16/25, addressing the interventions to store the smoking supplies at the nurse's station was reviewed with RN 1 and she stated the facility's policy for storage of the smoking paraphernalia was to store at the nurses' station in a plastic container for safekeeping. Furthermore, RN 1 stated all the staff must be educated regarding the safekeeping of the smoking paraphernalia at the nurses' station. On 6/3/25 at 1400 hours, an interview was conducted with the Administrator, DON, and Nurse Consultant. The Administrator stated the nursing staff must check the resident's room especially if the resident smoked including the cabinets or drawers every shift for any smoking paraphernalia. The DON stated there must be a staff present each time any resident smoked, regardless if the resident was independent. In addition, the DON stated all the residents required supervision while smoking. The Administrator, DON, and Nurse Consultant were informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of one final sampled resident (Resident 75) reviewed for catheter care received the appropriate care and services for an indwelling urinary catheter. This failure had the potential for the resident to develop complications associated with the use of the indwelling urinary catheter. Findings: Review of the facility's P&P titled Urinary Catheter Use revised 12/19/22, showed the following: - If an indwelling catheter is in use, the facility will provide appropriate care for the catheter in accordance with current professional standards of practice and resident care policies and procedures that include but are not limited to ongoing monitoring for changes in condition related to potential catheter-associated urinary tract infections, recognizing, reporting and addressing such changes. Review of the facility's P&P titled Notification of Changes revised on 12/19/22, showed the facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring notification include the following: - Significant change in the resident's physical, mental, or psychological condition such as deterioration in health, mental, or psychosocial status which may include life-threatening conditions or clinical complications; - Circumstances that require a need to alter treatment may include new treatment or discontinuation of current treatment due to adverse consequences, acute condition, and exacerbation of a chronic condition; and - The facility must still contact the resident's physician and notify the resident's representative, if known. Medical record review for Resident 75 was initiated on 5/29/25. Resident 75 was admitted to the facility on [DATE]. Review of Resident 75's H&P examination dated 5/1/25, showed Resident 75 had the capacity to understand and make decisions. On 5/28/25 at 0839 hours, during the initial tour, Resident 75 was observed lying in bed awake, alert, and aphasic. Resident 75 was observed with an indwelling urinary catheter connected to a urinary drainage bag placed on the side of the bed. The urinary drainage bag tubing was observed with tea colored urine and blood clots. On 5/28/25 at 0845 hours, an observation of Resident 75 and concurrent interview was conducted with CNA 1. Resident 75 was observed with tea colored urine and blood clots in the urinary catheter tubing. CNA 1 verified the above findings. CNA 1 stated she had the same observations yesterday between 1400-1430 hours, and she informed the assigned charge nurse. In addition, CNA 1 stated her responsibilities with Resident 75's indwelling urinary catheter were to provide catheter care, empty the drainage bag, and report any abnormal changes to the charge nurse. On 5/28/25 at 0913 hours, an observation of Resident 75 and concurrent interview was conducted with LVN 5. Resident 75 was observed with tea colored urine and blood clots in the urinary catheter tubing. LVN 5 verified the above findings. LVN 5 stated the charge nurse had informed him yesterday of Resident 75's blood in urinary drainage bag, and he flushed the indwelling urinary catheter and changed the urinary drainage bag. On 5/29/25 at 1401 hours, Resident 75 was observed lying in bed, awake, and alert with aphasia. Resident 75's urine in the urinary catheter tubing remained tea colored and dark blood tinged. Resident 75 did not show any signs of pain or discomfort. Review of Resident 75's Order Summary dated 5/30/25, showed the following: - dated 5/3/25, Indwelling Catheter: Foley Catheter size 16 French, balloon size 10 cc, to change for blockage, leaking, pulled out and excessive sedimentation; and change catheter drainage bag as needed and with every change of indwelling catheter as needed for BPH with obstructive uropathy; - dated 5/3/25, to irrigate with 60 ml every 24 hours as needed for hematuria; - dated 4/30/25, apixaban (anticoagulant) 5 mg one tablet by mouth two times a day for DVT; and monitoring for the side effects or adverse reactions of apixaban. Review of Resident 75's MAR dated 5/2025, failed to show for the presence of blood in urine under the monitoring for the dates of 5/27 to 5/30/25. Review of Resident 75's TAR dated 5/2025, showed LVN 5 irrigated Resident 75's indwelling urinary catheter on 5/27/25 at 1500 hours. Review of Resident 75 medical record conducted on 5/29/25, failed to show documentation of change of condition or in SBAR, notification to the physician and responsible party, care plan, and monitoring in the nurse's progress notes for 5/2025 which addressed Resident 75's tea colored urine and blood clots in the urinary catheter tubing. On 5/30/25 at 1405 hours, an interview and concurrent medical record review for Resident 75 was conducted with RN 1. RN 1 was asked about the facility's process to follow when a change of condition about a resident was identified. RN 1 stated the charge nurse must check the resident; RN must assess the resident; and licensed nurse must complete the SBAR, inform the physician and resident's Responsible Party, carry out the orders, and document in the resident's progress notes to monitor the resident every shift for 72 hours. RN 1 verified Resident 75's medical record failed to show documentation for SBAR regarding tea colored urine with blood clots, physician and responsible party notification, care plan, and monitoring in the resident's progress notes. RN 1 was informed about Resident 75's tea colored urine with blood clots in the urinary catheter tubing observed for the past two days and was previously verified by LVN 5. RN 1 stated she was not informed of Resident 75 experiencing abnormal urine color or blood clots in urine for the current month of May. Furthermore, RN 1 stated implications of failure to report signs of infection in the urine would lead to sepsis, low hemoglobin, and urgent blood transfusion. On 6/3/25 at 1400 hours, an interview was conducted with the Administrator, DON, and Nurse Consultant. The DON stated Resident 75 had hematuria two weeks ago; however, for any change of condition like another episode of hematuria or signs and symptoms of infection, the charge nurses must assess the resident, complete SBAR, inform the physician and responsible party, formulate a care plan, and document monitoring in the resident's progress notes every shift for 72 hours. The Administrator, DON, and Nurse Consultant were informed and acknowledged the above findings.

4. On 5/28/25 at 1011 hours, 5/29/25 at 1040 hours, 5/30/25 at 1048 and 1334 hours, Resident 915 was observed in bed receiving oxygen at two liters per minute via nasal cannula. Medical record review for Resident 915 was initiated on 5/28/25. Resident 915 was admitted to the facility on [DATE]. Review of Resident 915's Order Summary Report showed a physician's order dated 5/16/25, to administer oxygen at two liters per minute via nasal cannula as needed for SOB or wheezing. Review of Resident 915's TAR for 5/2025 failed to show the administration of oxygen to Resident 21 was documented. Further review of Resident 915's medical record failed to show a documented evidence Resident 21 was monitored for shortness of breath or wheezing. On 5/30/25 at 1352 hours, an observation for Resident 915 and concurrent interview and medical record review was conducted with the DON. The DON verified Resident 915 was receiving oxygen at two liters per minute via nasal cannula. The DON further verified there was no documentation of the administration of oxygen to Resident 915 and monitored for shortness of breath or wheezing as an indication for the use of oxygen as per the physician's order. Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care and services for three of 23 final sampled residents (Residents 84, 96, and 915) and one nonsampled resident (Resident 71) reviewed for oxygen therapy. * The facility failed to follow the physician's order for Residents 84 and 96's oxygen therapy. * The facility failed to ensure the oxygen tubing for Resident 71 was labeled with the date. * The facility failed to ensure the administration of oxygen to Resident 915 was documented in the TAR. In addition, the facility failed to monitor Resident 915 for SOB or wheezing as an indication of the use of oxygen as per the physician's order. These failures had the potential for the residents to not receive the appropriate care and may negatively impact on the residents' medical conditions. Findings: Review of the facility's P&P titled Oxygen Administration date revised 5/20/24, showed oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. Oxygen is administered under orders of a physician, except in the case of an emergency. In such case, oxygen is administered and orders for oxygen are obtained as soon as practicable when the situation is under control. 1. On 5/28/25 at 1035 hours, during the initial tour of the facility, Resident 84 was observed lying in bed with the oxygen on via nasal cannula and transferred in a wheelchair, and the nasal cannula was removed from the nose but was attached to the oxygen concentrator machine and set at three and half liters per minute. During the observation, the oxygen tubing was labeled and dated; however, the resident propelled self out of the room. On 5/28/25 at 1254 hours, Resident 84 was observed lying in bed with the oxygen on via nasal cannula and was attached to the oxygen concentrator machine and set at four liters per minute. Medical record review for Resident 84 was initiated on 5/28/25. Resident 84 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 84's H&P examination dated 12/5/24, showed Resident 84 had fluctuating capacity to understand and make decisions. Review of Resident 84's Order Summary Report dated 5/31/25, showed a physician's order dated 2/14/25, to administer oxygen at two to three liters per minute via nasal cannula as needed for SOB or oxygen saturation level less than 90%. Review of Resident 84's Care Plan Report dated 1/17/25, showed a care plan focus addressing the resident's oxygen therapy. The interventions included to administer the oxygen via nasal cannula at two liters per minute for SOB or oxygen saturation level less than 90%. On 5/28/25 at 1301 hours, an observation, interview, and concurrent medical record review for Resident 84 was conducted with RN 1. RN 1 verified the above findings and stated the physician's order for the oxygen administration for Resident 84 should have been followed. 2. On 5/28/25 at 1250 hours, during the initial tour of the facility, Resident 96 was observed lying in bed with the oxygen via nasal cannula, which was attached to the oxygen concentrator machine and set at five liters per minute. During the observation, the oxygen tubing was labeled and dated. On 5/28/25 at 1304 hours, Resident 96 was observed sitting up in a wheelchair with the oxygen on via nasal cannula and was attached to the oxygen concentrator machine and set at four liters per minute. Medical record review for Resident 96 was initiated on 5/28/25. Resident 96 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 96's H&P examination dated 4/9/25, showed Resident 96 had the capacity to understand and make decisions. Review of Resident 96's Order Summary Report dated 5/30/25, showed a physician's order dated 4/7/25, to administer oxygen at two to three liters per minute via nasal cannula continuous to maintain oxygen saturation level greater than 90% every shift. Review of Resident 96's Care Plan Report dated 3/21/25, showed a care plan focus addressing the resident's use of oxygen due to altered respiratory status/difficulty breathing related to COPD, chronic respiratory failure with hypoxia, CHF, and dependence on supplemental oxygen. The interventions included to administer the oxygen via nasal cannula at two to three liters per minute continuous to maintain oxygen saturation level greater than 90%. On 5/28/25 at 1306 hours, an observation, interview, and concurrent medical record review for Resident 96 was conducted with RN 1. RN 1 verified the above findings and stated the physician's order for the oxygen administration for Resident 96 should have been followed. 3. Review of the facility's P&P titled Oxygen Administration revised 5/2024 showed oxygen is administered under the orders of a physician, except in the case of an emergency. Infection control measures include to change the oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. On 5/8/25 at 1053 hours, an observation of Resident 71 was conducted. Resident 71 was observed sitting in his manual wheelchair outside of his room, Room A. Resident 71 was observed with oxygen administered via nasal cannula at 2 l/min. Resident 71's nasal cannula tubing was undated. The portable oxygen tank was empty. On 5/8/25 at 1055 hours, an observation of Resident 71 and concurrent interview was conducted with LVN 2. LVN 2 verified Resident 71's oxygen tubing was undated and the portable oxygen tank was empty. LVN 2 stated all oxygen tubing should be labeled with the date when it was changed. Medical record review for Resident 71 was initiated on 5/28/25. Resident 71 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 71's Order Summary Report dated 6/3/25, showed a physician's order dated 2/9/25, to administer oxygen at 2 l/min via nasal cannula continuously. On 6/3/25 at 1315 hours, an interview was conducted with the Administrator, DON, and Nurse Consultant. They were made aware and acknowledged the above findings.

Based on observation, interview, and facility document review, the facility failed to ensure the competency of four of six licensed nurses (LVN 1, RN 1, DSD, and DON) observed in performing a control solution check with the glucometer. LVN 1, RN 1, the DSD, and DON were unable to demonstrate the competency in the quality control of the glucometer. This failure had the potential of not providing care to the residents in a safe and competent manner. Findings: Review of the glucometer manufacturer's information sheet titled Assure Platinum Blood Glucose Monitoring System Quality Assurance/Quality Control Reference Manual (undated) under the Quality Checks section showed the following: - To perform a control solution test, before testing with the Assure Platinum System for the first time, when a new bottle of test strips was opened, whenever meter or test strips may not be functioning properly, if the test results appear to be abnormally high or low, or are not consistent, when the test strip bottle has been left open or exposed to temperatures below 39 degrees F or above 86 degrees F, or humidity levels above 8%, to check technique, when the Assure Platinum Meter has been dropped or stored below 32 degrees F or above 122 degrees F, and each time the batteries are changed. Step one and two of the six step control solution check process were described as follows: Step 1: insert the test strip into the glucometer. The meter will turn on automatically. Step 2: Press the back and forward arrow buttons on the glucometer one at a time to enter the control solution mode. A control solution bottle icon will appear at the top right of the screen. If you do not enter the control solution mode, the control solution result will not be valid. Using the control solution mode will flag the result in the glucometer's memory. On 5/28/25 at 1033 hours, an inspection of Medication Cart 4 and concurrent facility document review was conducted with LVN 1. The Assure Platinum Blood Glucose Monitoring System: Quality Control Record dated 5/2025 showed the most recent quality check was performed during the 11 PM to 7 AM shift on 5/27/25. When asked about the process for performing the control solution check on the glucometer, LVN 1 was unable to state the steps for the control solution check process. LVN 1 was unable to state how to tell the difference between the values of a glucose check and the control solution check when displayed on the glucometer. Additionally, LVN 1 was unable to show the control solution check was performed on the glucometer on 5/27/25, as documented on the Quality Control Record. LVN 1 stated the licensed nurses on the 11 PM to 7 AM shift were responsible for performing the daily control solution checks on the glucometers. During the interview and review of the Quality Control Record dated May 2025 with RN 1, RN 1 was asked about the process for performing the control solution check on the glucometer. RN 1 was unable to state the process for performing the control solution check on the glucometer. RN 1 was unable to state how to tell the difference between the values of a glucose check and the control solution check when displayed on the glucometer. Additionally, RN 1 was unable to show the control solution check was performed on the glucometer on 5/27/25, as documented on the Quality Control Record. On 5/28/25 at 1142 hours, an interview was conducted with the DON. The DON was asked to verbalize the process for performing the control solution check on the glucometer. The DON was unable to verbalize the process for performing the control solution check on the glucometer. The DON was unable to show the control solution check was performed on the glucometer on 5/27/25, as documented on the Quality Control Record. On 5/28/25 at 1147 hours, an interview was conducted with the DSD. The DSD stated all the licensed staff were expected to have competency to perform the control solution check on the glucometers. The DSD was unable to show the control solution check was performed on the glucometer as documented on the Quality Control Log. The DSD stated the glucometer should display an icon of the control solution bottle on the right side of the glucometer screen to show the value was a control solution check and not a blood glucose result. When asked when the most recent inservice was provided to the licensed staff regarding the control solutions check for the glucometer, the DSD stated the inservice was provided last year by the former DSD. Review of the facility document titled Record of Inservice dated 12/5/24, showed the inservice titled Blood Glucose Monitoring: Assure Platinum blood glucose monitor solution test was conducted at the facility. LVN 1 and RN 1 were listed on the Record of Inservice as attendees. On 5/29/25 at 1033 hours, the facility document review and concurrent interview was conducted with LVN 1. LVN 1 verified she attended the inservice titled Blood Glucose Monitoring: Assure Platinum blood glucose monitor solution test. LVN 1 verified her name and signature were present on the Record of Inservice dated 12/5/24. On 5/29/25 at 1038 hours, a facility document review and concurrent interview was conducted with RN 1. RN 1 verified she attended the inservice titled Blood Glucose Monitoring: Assure Platinum blood glucose monitor solution test. RN 1 verified her name and signature were present on the Record of Inservice dated 12/5/24. On 5/29/25 at 1038 hours, a follow-up interview was conducted with the DON. The DON verified all the licensed staff were expected to know the procedure for performing the control solution checks on the glucometer. The DON stated she believed the control solutions tests were performed as shown on the Quality Control Log. The DON stated the staff performing the control solution checks may not have had the glucometer in the control solution mode while performing the control solution checks. The DON verified the values of blood glucose checks cannot be differentiated from control solution checks that were performed while the glucometer was not in the control solution mode. On 6/3/25 at 1315 hours, an interview was conducted with the Administrator, DON, and Nurse Consultant. They were made aware and acknowledged the above findings.

2. Review of the facility's P&P dated [DATE], showed the following: - Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this stated, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection; and - Compare medication source (bubble pack, vial, etc.) with the MAR to verify resident name, mediation name, form, dose, route and time. On [DATE] at 0834 hours, a medication administration observation for Resident 86 was conducted with LVN 7. LVN 7 prepared and administered the following medications to Resident 86 via GT: - One tablet of vitamin C (supplement) 500 mg; - One tablet of docusate sodium (stool softener) 100 mg; - One tablet of buspirone (antianxiety) 10 mg; - One tablet of famotidine (antacid) 20 mg; - One tablet of Lasix (diuretic) 20 mg - One tablet of lactobacillus (supplement); - One tablet of levothyroxine (synthetic thyroid hormone); - One tablet of magnesium oxide (supplement) 400 mg; - One tablet of metoclopramide (gut motility stimulator) 5 mg; - One tablet of Movantik (used for the treatment of opioid-induced constipation) 25 mg; - One tablet of multivitamins with minerals (supplement); - One tablet of venlafaxine (antidepressant) 37.5 mg; and - One tablet of metoprolol (antihypertensive) 50 mg. Medical record review for Resident 86 was initiated on [DATE]. Resident 86 was readmitted to the facility on [DATE]. Review of Resident 86's Order Summary Report showed the following physician's orders: - dated [DATE], to administer ascorbic acid 500 mg one tablet orally in the morning; - dated [DATE], to administer buspirone 10 mg one tablet orally three times a day; - dated [DATE], to administer docusate sodium 100 mg one tablet orally two times a day; - dated [DATE], to administer famotidine 20 mg one tablet orally two times a day; - dated [DATE], to administer lactobacillus one tablet orally two times a day; - dated [DATE], to administer Lasix 20 mg one tablet orally one time a day; - dated [DATE], to administer levothyroxine 50 mcg one tablet orally one time a day; - dated [DATE], to administer MagOx 400 mg one tablet orally one time a day; - dated [DATE], to administer metoclopramide 5 mg one tablet orally two times a day; - dated [DATE], to administer metoprolol 50 mg one tablet orally two times a day; - dated [DATE], to administer Movantik 25 mg one tablet by mouth one time a day; - dated [DATE], to administer multi-vitamins with minerals one tablet one time a day; and - dated [DATE], to administer venlafaxine 37.5 mg one tablet orally two times a day. On [DATE] at 1312 hours, a follow-up interview and concurrent medical record review for Resident 86 was conducted with LVN 7. LVN 7 verified he gave the medications to Resident 86 via GT, and not orally as specified in the physician's order. LVN 7 stated he gave the medications via GT because Resident 86 preferred to get her medications via GT. LVN 7 further stated he used his judgement to use the GT because she was coughing a lot. On [DATE] at 1315 hours, an interview was conducted with the Administrator, DON, and Nurse Consultant. They were made aware and acknowledged the above findings. Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the pharmaceutical services were provided when: * The facility failed to ensure the complete documentation for the destruction of medications. * The facility failed to ensure LVN 7 administered the medications to Resident 86 via the correct route. LVN 7 administered the medications to Resident 86 via GT, and not orally as per the physician's order. These failures had the potential for drug diversion and to cause ineffective treatment and complications from the medications administered. Findings: Review of the facility's P&P titled Destruction of Unused Drugs revised [DATE], showed all the unused, contaminated, or expired prescription drugs shall be disposed of in accordance with the state laws and regulations. The section titled Policy Explanation and Compliance Guidelines showed the following: - The actual destruction of drugs conducted by our facility must be witnessed by the consultant pharmacist or the licensed nurse. - A destruction record must be maintained for all drugs destroyed. The actual destruction of drugs conducted by our facility must be witnessed by facility staff as per state requirements. The following information shall be included on this record: a. The name of the patient; b. The date the medication was destroyed; c. The prescription or lot number of the medication; d. The prescription name, strength, and quantity of the medication being destroyed; e. The method of destruction; f. The signature of the consultant pharmacist and registered nurse destroying the controlled medications; and g. The signature of the consultant pharmacist or licensed nurse destroying the non-controlled medications. 1.a. On [DATE] at 0954 hours, an inspection of Medication Storage room [ROOM NUMBER] and concurrent interview and facility document review was conducted with RN 1. The Medication Disposition Record/Pass Log dated 5/14 to [DATE], was reviewed with RN 1. The Medication Disposition Record/Pass Log failed to show a witness signature for the destruction of the following medications: - 30 tablets of clonidine (used to treat high blood pressure) Hcl (hydrochloride) 0.1 mg; - Six tablets of methotrexate (used to treat inflammatory conditions and cancer) 2.5 mg; and - 12 tablets of lisinopril (used to treat high blood pressure) 5 mg. RN 1 verified the above findings. On [DATE] at 1017 hours, an interview and concurrent facility document review was conducted with the DON. The DON verified the Medication Disposition Record/Pass Log dated 3/14 to [DATE], was missing the witness signature for the destruction of the medications listed above. The DON verified the log must show the signature of the licensed staff destroying the medications and the signature of the person who witnessed the destruction of the medications. b. On [DATE] at 1023 hours, an inspection of Medication Storage room [ROOM NUMBER] and concurrent interview and facility document review was conducted with RN 1. The Medication Disposition Record/Pass Log dated [DATE], was reviewed with RN 1. The Medication Disposition Record/Pass Log failed to show a witness signature for the destruction of the following medications: - Six capsules of gabapentin (prevents seizures and treats pain for conditions in the nervous system) 100 mg; - 16 capsules of gabapentin 100 mg; - 30 tablets of metformin hcl (used to treat high blood sugar levels for type 2 diabetes) 500 mg; - 25 tablets of metoprolol (used to treat high blood pressure) 25 mg; - 30 tablets of hydralazine (used to treat high blood pressure) 25 mg; - 25 tablets of metoprolol 50 mg; - 22 tablets of amlodipine (used to treat high blood pressure) 5 mg; - 21 tablets of metoprolol 25 mg; - 24 tablets of atenolol (used to treat high blood pressure) 50 mg; - 26 tablets of losartan (used to treat high blood pressure) 25 mg; - 12 tablets of atorvastatin (used to treat high cholesterol) 10 mg; and - 20 tablets of metoprolol 25 mg. RN 1 verified the above findings. Further review of the Medication Disposition Record/Pass Log showed two undated pages of the log which failed to show documentation of the method of disposition, date of disposition, signature of the licensed staff who disposed of the medications, and witness signature for the destruction for the following medications: - Seven tablets of diltiazem (used to treat high blood pressure) 30 mg; - 14 tablets of furosemide (used to help treat fluid retention and swelling that is caused by liver disease, kidney disease, or other medical conditions) 20 mg; - 28 tablets of divalproex (used to treat seizures) sodium ER 500 mg; - 28 tablets of Entresto (used to treat heart failure which occurs when the heart can't pump enough blood to meet the body's needs) 24 mg-26 mg; - 28 tablets of lithium (used to treat bipolar disorder) 300 mg; - Six tablets of Eliquis (blood thinner) 2.5 mg; - Eight capsules of gabapentin 100 mg; - 10 tablets of topiramate (used to treat and prevent seizures) 100 mg; - 28 tablets of topiramate 100 mg; - 18 tablets of trihexyphenidyl (used to treat muscle spasms and poor muscle control) 2 mg; and - 18 tablets of trihexyphenidyl 2 mg. RN 1 verified the above findings. On [DATE] at 1038 hours, an interview and concurrent facility document review was conducted with the DON. The DON verified the Medication Disposition Record/Pass Log dated [DATE], did not show the witness signature for the destruction of the medications listed above. The DON verified the log must have the signature of the licensed staff destroying the medication and the signature of the person who witnessed the destruction of the medication. The DON verified the two undated pages of the Medication Disposition Record/Pass Log did not show the method of disposition, the date of disposition, the signature of the licensed staff who disposed of the medications, and the witness signature for the destruction of the medications listed above. The DON verified all columns and rows on the Medication Disposition Record/Pass log require complete documentation for the destruction of medications. On [DATE] at 1315 hours, an interview was conducted with the Administrator, DON, and Nurse Consultant. They were made aware and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure two final sampled residents (Residents 86 and 914) and two nonsampled residents (Residents 41 and 916) were free from the unnecessary medications. * The facility failed to ensure Resident 41 was not administered the metoprolol (antihypertensive) and amiodarone (antiarrythmic) medications without parameters when to hold or administer the medications. * The facility failed to ensure Resident 914 was not administered the carvedilol (antihypertensive medication) without monitoring the resident's blood pressure and heart rate as per the physician's order. * The facility failed to ensure Resident 916 was not administered the hydralazine (antihypertensive medication) when the SBP less than 160 mmHg as per the physician's order. * The facility failed to ensure the monitoring for signs and symptoms of bleeding was completed related to use of enoxaparin sodium medication (anticoagulant medication, use to prevent blood clots) to Resident 86. These failures had the potential for the residents to receive unnecessary medications and develop significant side effects. Findings: 1. On 5/30/25 at 0813 hours, a medication administration observation for Resident 41 was conducted with LVN 7. LVN 7 was observed administering one tablet of metoprolol 25 mg to Resident 41, without checking the blood pressure nor the heart rate. Medical record review for Resident 41 was initiated on 5/28/25. Resident 41 was readmitted to the facility on [DATE]. Review Resident 41's Order Summary Report showed a physician's orders dated 5/29/25: - To administer amiodarone 200 mg by mouth one time a day; and - To administer metoprolol medication 25 mg one tablet by mouth one time a day. There were no parameters of blood pressure or heart rate for when to give or hold the amiodarone and metoprolol medications. Review of Resident 41's MAR for 5/2025 showed Resident 41 was administered the metoprolol medication on 5/30/25, by LVN 7. The MAR did not show LVN 7 administered the amiodarone medication. On 5/30/25 at 1312 hours, an interview and concurrent medical record review for Resident 41 was conducted with LVN 7. LVN 7 verified he administered the amiodarone medication to Resident 41 without monitoring the resident's blood pressure and heart rate. When asked about the amiodarone medication, LVN 7 stated he administered the amiodarone medication at 1250 hours, but was not able to document in the MAR. LVN 7 verified there were no parameters of blood pressure or heart rate when to give or hold the amiodarone and metoprolol medications. 2. Medical record review for Resident 914 was initiated on 5/28/25. Resident 914 was admitted to the facility on [DATE]. Review Resident 914's Order Summary Report showed a physician's order dated 5/28/25, to administer carvedilol 3.125 mg by mouth two times a day, and to hold the medication if SBP below 100 mmHg, or heart rate below 60 beats per minute. Review of Resident 914's MAR for May and June 2025 showed Resident 914 was administered the carvedilol medication on 5/29/25 at 1800 hours, 5/30 and 5/31/25 at 0800 and 1800 hours, and 6/1/25 at 0800 hours. Further review of the MAR did not show Resident 914's blood pressure and heart rate were checked when the resident was administered the carvedilol medication. On 6/2/25 at 1059 hours, an interview and concurrent medical record review for Resident 914 was conducted with RN 2. RN 2 verified Resident 914's blood pressure and heart rate were not checked when the resident was administered the carvedilol medication. RN 2 stated she clarified with the physician about the timing of the medication administration, and she had to re-enter the physician's order in the electronic health record; however, she did not include the required section for the licensed nurses were to document Resident 914's blood pressure and heart rate prior to administering the medication. 3. Medical record review for Resident 916 was initiated on 5/28/25. Resident 916 was admitted to the facility on [DATE]. Review Resident 916's Order Summary Report showed a physician's order dated 5/24/25, to administer hydralazine 25 mg by mouth two times a day, and to give if the SBP above 160 mmHg. Review of Resident 916's MAR for May and June 2025 showed Resident 916 was administered the hydralazine medication when the resident's SBP was below 160 mmHg as follows: - On 5/25/25 at 0900 hours, a blood pressure of 147/62 mmHg; - On 5/28/25 at 0900 hours, a blood pressure of 131/74 mmHg; - On 5/28/25 at 1800 hours, a blood pressure of 121/65 mmHg; - On 5/29/25 at 1800 hours, a blood pressure of 133/69 mmHg; - On 5/31/25 at 0900 hours, a blood pressure of 149/80 mmHg; and - On 6/1/25 at 0900 hours, a blood pressure of 119/52 mm Hg. On 6/2/25 at 1107 hours, an interview and concurrent medical record review for Resident 916 was conducted with RN 2. RN 2 verified Resident 916 was administered the hydralazine medication when the resident's SBP was below 160 mmHg. 4. According to DailyMed, the most common clinically adverse effect of the enoxaparin sodium injection medication was the risk of serious and potentially fatal bleeding. Local reactions at the injection site may occur such as swelling, redness, rounded lump, oozing of blood and skin necrosis occurring at either the injection site or distant from the injection site. Review of the facility's P&P titled High Risk Medication - Anticoagulants revised 12/19/22, showed the facility recognizes that some medications, including anticoagulants, are associated with greater risks of adverse consequences than other medications. The Policy Explanation and Compliance Guidelines section showed the resident's plan of care shall alert staff to monitor for adverse consequences. Risks associated with the anticoagulants include bleeding and hemorrhage (bleeding gums, nosebleed, unusual bruising, blood in urine or stool), fall in the hematocrit (volume of red blood cells which carries oxygen in the blood) or blood pressure, and thromboembolism (blood clots that causes obstruction of blood flow in the veins). Medical record review for Resident 86 was initiated on 5/29/25. Resident 86 was readmitted to the facility on [DATE]. Review of Resident 86's H&P examination dated 4/1/25, showed Resident 86 had the capacity to understand and make decisions. Review of Resident 86's Order Summary Report showed the following physician's order: - dated 3/31/25, to inject enoxaparin sodium prefilled syringe 30 mg/0.3 ml subcutaneously one time a day for DVT prophylaxis; and - dated 4/9/25, monitor resident for any of the following: blood in the urine, blood in the stool, unusual bleeding after shaving, bleeding from the gums, bleeding from the nose, excessive bleeding from the wounds, large hemorrhagic area, petechiae every shift. If my initial N is noted, it means I've observed signs and symptoms, hold anticoagulants/antiplatelet dose and notify MD. If my initial Y is noted, it signifies the absence of the listed signs and symptoms Review of Resident 86's Care Plan revised 1/26/25, showed a care plan focus problem addressing Resident 86's on anticoagulant therapy. The interventions included to monitor/document/report as needed the adverse reactions of anticoagulant therapy: blood tinged or red blood in the urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, shortness of breath, loss of appetite, sudden changes in mental status, significant or sudden changes in the vital signs. Review of Resident 86's MAR for 4/2025 and 5/2025 showed Resident 86 received enoxaparin sodium injection solution on the following dates and times: - from 4/1 to 4/30/25, at 0900 hours; and - from 5/1 to 5/31/25, at 0900 hours. Review of Resident 86's Monitor Record for April and May 2025 showed Resident 86 was not monitored for signs and symptoms of bleeding related to anticoagulant therapy on 4/12, 5/14, and 5/17/25, for the night shift, 5/11 and 5/18/25, for the day shift. Further review of the Monitor Record failed to show the shifts where the licensed nurses had their initial the Y or N. On 6/2/25 at 0944 hours, an interview and concurrent medical record review for Resident 86 was conducted with LVN 6. LVN 6 verified Resident 86 was still receiving the enoxaparin sodium injection medication daily. LVN 6 stated she had not observed Resident 86 experienced any signs and symptoms of bleeding. LVN 6 stated the nurses had to monitor any resident on blood thinner medication for signs and symptoms of bleeding such as bruising, blood in urine and stool, nosebleed and bleeding gums every shift and report to the physician. LVN 6 stated it was very important to monitor the resident for signs and symptoms of bleeding related to the blood thinner medication use to assess if the resident was tolerating the medication and for the nurses to be able to hold the medication and report to the physician if there were signs and symptoms of bleeding observed. LVN 6 stated they documented in the Monitor Record in the PCC for their monitoring. LVN 6 verified the nurses should note either Y' for no signs and symptoms of bleeding and N for with signs and symptoms of bleeding, the medication was held, and the physician was notified. LVN 6 further stated it was very important to document their assessment to show they did it because if it was not documented then it was not done. LVN 6 verified the above findings for Resident 86. On 6/3/25 at 1400 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings for Resident 86.

Based on observation, interview, medical record review, facility documentation review, and facility P&P review, the facility failed to ensure the removal of the discontinued medications from one of six medication carts (Medication Cart 4) inspected. This failure had the potential to result in drug diversion of controlled medications and the administration of medication without a physician's order. Findings: Review of the facility's P&P titled Disposal of Medications and Medication-Related Supplies IE3: Discontinued Medications revised 1/2025 showed when the medications are expired, discontinued by a prescriber .the medications are marked as discontinued or stored in a separate location and later destroyed. The procedure for discontinued medications was described as follows: A. If a medication expires, or a prescriber discontinues a medication, the discontinued drug container shall be marked or otherwise identified and shall be stored in a separate location designed solely for this purpose. B. Medications are removed from the medication cart or storage area prior to expiration, and immediately upon receipt for an order to discontinue. On [DATE] at 1206 hours, an inspection of Medication Cart 4 and concurrent narcotic count was conducted with LVN 1. The Antibiotic or Controlled Drug Record log (undated) for Resident 15 showed 14 capsules of temazepam (used to treat insomnia) 7.5 mg medication were delivered to the facility on [DATE]. The log showed to give one 7.5 mg capsule of temazepam by mouth every 24 hours as needed for insomnia for 14 days at bedtime. The bubble pack for Resident 15's temazepam medication was observed in the controlled medications drawer in Medication Cart 4. During the narcotic count, an interview and concurrent medical record review for Resident 15 was conducted with LVN 1. LVN 1 verified Resident 15's temazepam 7.5 mg capsule medication remained in Medication Cart 4 without an active order, and the medication should have been removed. Medical record review for Resident 15 was initiated on [DATE]. Resident 15 was admitted to the facility on [DATE]. Review of Resident 15's H&P examination dated [DATE], showed Resident 15 had no capacity to understand and make decisions. Review of Resident 15's Order Summary Report dated 4/1 to [DATE], showed a physician's order to administer temazepam 7.5 mg capsule by mouth every 24 hours at bedtime for 14 days for insomnia manifested by the inability to sleep. Further review of Resident 15's Order Summary Report showed the physician's order for the temazepam 7.5 mg capsule was completed on [DATE], and not an active order. Review of Resident 15's Order Summary Report dated [DATE], failed to show an active physician's order for the use of the temazepam medication. On [DATE] at 1225 hours, an interview was conducted with the DON at Medication Cart 4. The DON verified the above findings. On [DATE] at 1232 hours, a follow-up interview and concurrent medical record review for Resident 15 was conducted with the DON. The DON verified the above findings. The DON verified the bubble pack for Resident 15's temazepam medication should have been removed from Medication Cart 4 on [DATE], when the order was no longer active. On [DATE] at 1315 hours, an interview was conducted with the Administrator, DON, and Nurse Consultant. They were made aware and acknowledged the above findings.

Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 54.29%. Two of the two licensed nurses (LVNs 7 and 8) who were observed during medication administration were found to have errors. * LVN 7 failed to administer the Eliquis (anticoagulant medication) medication to Resident 41. * LVN 7 failed to ensure the medications were not administered together when administering medications via the GT to Resident 86, and to flush the GT in between the medications and after the administration of the medications. * LVN 7 failed to administer the artificial tears to Resident 86. * LVN 8 failed to ensure Resident 6 received the correct amount of prescribed eye medication. * LVN 8 failed to ensure the GT was properly flushed in between the medication administration for Resident 99. These failures created the risk for the residents to have potential side effects or complications related to the medications. Findings: 1. On 5/30/25 at 0813 hours, a medication administration observation for Resident 41 was conducted with LVN 7. LVN 7 prepared and administered the following medications to Resident 41: - One tablet of iron (supplement) 325 mg; - One tablet of famotidine (antacid) 20 mg; - One tablet of gabapentin (nerve pain medication ) 300 mg; - One tablet of metoprolol (antihypertensive) 25 mg; - One tablet of Geri-kot (stool softener) 8.6 mg; and - One tablet of sodium chloride (supplement) one gram. LVN 7 stated the Lidocaine (local anesthetic) patch and Eliquis (anticoagulant) medications were missing for Resident 41. LVN 7 stated the two medications had been ordered from the pharmacy and should be delivered today. Medical record review for Resident 41 was initiated on 5/28/25. Resident 41 was readmitted to the facility on [DATE]. Review Resident 41's Order Summary Report showed the following physician's orders dated 5/29/25: - To administer amiodarone 200 mg by mouth one time a day; - To administer Eliquis 5 mg by mouth every twelve hours; - To administer famotidine 20 mg by mouth one time a day; - To administer ferrous sulfate 325 mg by mouth one time a day; - To administer gabapentin 300 mg by mouth three times a day; - To apply Lidocaine external patch 4% mg to the right hip topically one time a day; - To administer metoprolol 25 mg by mouth one time a day; - To administer Senna 8.6 mg by mouth one time a day; and - To administer sodium chloride 1 gram by mouth one time a day; On 5/30/25 at 1312 hours, an interview was conducted with LVN 7. LVN 7 verified the above findings. When asked about the medications that were not given during the medication administration observation for Resident 41, LVN 7 stated he already applied the Lidocaine patch to Resident 41 an hour after the initial medication administration observation. LVN 7 further stated he also administered the amiodarone medication at 1250 hours. When asked if he checked Resident 41's heart rate prior to administering the amiodarone medication, LVN 7 stated the CNA checked the resident's heart rate which was 82 bpm at 1130 hours. When asked about the Eliquis medication, LVN 7 stated he did not administer and missed the Eliquis medication. LVN 7 stated he had to find the Eliquis medication for Resident 41. 2. Review of the National Institute of Health's peer-reviewed journal titled Preventing Errors When Drugs Are Given via Enteral Feeding Tubes dated 10/2013 showed incompatibility between drugs being given together can be a problem. Mixing two or more drugs together, whether in solid or liquid forms, creates a brand-new, unknown entity with an unpredictable mechanism of release and bioavailability. Proper flushing of the GT before, during, and after each drug administration can help prevent problems. Review of the facility's P&P titled Medication Administration via Enteral Tube dated 12/19/22, showed the following: - Flush the enteral tube with at least 15 ml of water prior to administering medications unless otherwise ordered by prescriber; - Dilute the solid or liquid medication as appropriate and administer using a clean oral syringe; - Flush tube again with at least 15 ml water taking into account the resident's volume status; - Repeat with the next medication (if appropriate); and - Flush the tube with a final flush of at least 15 ml of water to ensure drug delivery and clear the tube. Review of the facility's document titled Lesson Plan for Enteral Feeding Medication dated 2/19/25, showed the following: - Crush tablet or capsule separately, dissolving each medication in at least 10 ml of water; - Dilute liquid medication in 10-30 ml of warm water or enteral formula; - Dilute gastric irritants in water for highly concentrated solutions - Remove plunger from the syringe and connect the syringe to the tubing; - Flush the tube with at least 15 ml of water prior to medication administration; - Allow medication to flow down the tube via gravity; - Give gentle boosts with the plunger (approximately one inch down) if the medication will not flow by gravity. Repeat if necessary; - Administer each medication separately and flush with at least 15 ml of water or other appropriate liquid between each medication; - Flush the tube with at least 15 ml of water; -Leave head of the bed elevated to prevent aspiration of stomach contents. On 5/30/25 at 0834 hours, a medication administration observation for Resident 86 was conducted with LVN 7. LVN prepared the following medications for Resident 86: -One tablet of vitamin C (supplement) 500 mg; -One tablet of docusate sodium (stool softener) 100 mg; -One tablet of buspirone (antianxiety) 10 mg; -One tablet of famotidine (antacid) 20 mg; -One tablet of Lasix (diuretic) 20 mg -One tablet of lactobacillus (supplement); -One tablet of levothyroxine (synthetic thyroid hormone); -One tablet of magnesium oxide (supplement) 400 mg; -One tablet of metoclopramide (gut motility stimulator) 5 mg; -One tablet of Movantik (used for the treatment of opioid-induced constipation) 25 mg; -One tablet of multivitamins (supplement); -One tablet of venlafaxine (antidepressant) 37.5 mg; and -One tablet of metoprolol (antihypertensive) 50 mg. During the medication administration, the following was observed: - LVN 7 poured 10 ml of water to each medication cup to dissolve the crushed medications. - LVN 7 connected the syringe to the tubing, and flushed the GT with 30 ml water, then clamped the tubing. - LVN 7 poured the metoprolol medication, and added the multivitamins with minerals medication into the syringe, unclamped the tubing, flushed with 30 ml water and clamped the tubing. - LVN 7 poured the vitamin C medication, added the famotidine, Lasix, and the docusate sodium, unclamped the tubing, flushed with 15 ml water and clamped the tubing. - LVN 7 verified he was mixing the medications into the syringe connected to the tubing. LVN 7 stated if it is vitamin C in liquid form, that we do not mix. We do not mix the liquids. Also, based on my experience, there were no adverse effects when the medications were mixed together. There were no warning labels to not mix the medications together. - LVN 7 was observed scraping the multivitamin with minerals residue in the medication cup and added 5 ml of water, and also observed scraping the metoprolol residue in the medication cup and added 5 ml of water. - LVN 7 was observed mixing the venlafaxine medication, then added it to medication cup with the docusate sodium residue. - LVN 7 poured the buspirone medication, added the venlafaxine, levothyroxine, and reglan, lactobacillus, and magnesium medications, unclamped the tubing, flushed with 15 ml of water, and clamped the tubing. -LVN 7 poured the Movantik medication, then added medication residues of the multivitamin with minerals, docusate sodium and metoprolol medications, unclamped the tubing, flushed with 15 ml of water, and clamped the tubing. -LVN 7 poured the lactobacillus medication residue, flushed with 15 ml of water, clamped the tubing, and turned off the GT valve port. - LVN 7 started stacking the medication cups and stated she was done. A significant amount of medication residue was observed in the medication cups. LVN 7 verified there were medication residues in the medication cups. LVN 7 stated the residues were the magnesium oxide and docusate sodium medications. -LVN 7 was observed scraping the magnesium oxide residue in the medication cup and added 10 ml of water, and also observed scraping the docusate sodium residue in the medication cup and added 10 ml of water. Then, LVN 7 observed adding these two medications together in a bigger cup. -LVN 7 turned the GT valve port on, unclamped the tubing and the magnesium oxide and docusate sodium were administered via syringe push, then turned off the GT valve port. -LVN 7 was not observed flushing the tubing after the medication administration. -LVN 7 verified he was done with the medication administration, and there were no missing medications for Resident 86. Medical record review for Resident 86 was initiated on 5/28/25. Resident 86 was readmitted to the facility on [DATE]. Review of Resident 86's Order Summary Report showed the following physician's orders: - dated 3/31/25, may crush all crushable medications; - dated 3/31/25, to administer ascorbic acid 500 mg one tablet orally in the morning; - dated 3/31/25, to administer buspirone 10 mg one tablet orally three times a day; - dated 3/31/25, to administer docusate sodium 100 mg one tablet orally two times a day; - dated 3/31/25, to administer famotidine 20 mg one tablet orally two times a day; - dated 3/31/25, to administer lactobacillus one tablet orally two times a day; - dated 3/31/25, to administer Lasix 20 mg one tablet orally one time a day; - dated 3/31/25, to administer levothyroxine 50 mcg one tablet orally one time a day; - dated 3/31/25, to administer MagOx 400 mg one tablet orally one time a day; - dated 3/31/25, to administer metoclopramide 5 mg one tablet orally two times a day; - dated 3/31/25, to administer metoprolol 50 mg one tablet orally two times a day; - dated 4/5/25, to administer Movantik 25 mg one tablet by mouth one time a day; - dated 3/31/25, to administer multi-vitamins with minerals one tablet one time a day; - dated 3/31/25, to administer venlafaxine 37.5 mg one tablet orally two times a day; - dated 3/31/25, to administer artificial tears 1.4% one drop in both eyes two times a day; and - dated 3/31/25, to inject enoxaparin sodium 30 mg subcutaneously one time a day. On 5/30/25 at 1312 hours, an interview and concurrent medical record review for Resident 86 was conducted with LVN 7. LVN 7 verified the above findings. When asked if he had given any other medication to Resident 86 after the initial medication administration observation, LVN 7 stated he administered the enoxaparin medication just after the initial medication administration observation. LVN 7 was informed he missed giving the artificial tears to Resident 86. LVN 7 verified the findings. LVN 7stated he did not administer the artificial tears because the resident usually refused it. 3. Review of the facility's P&P titled Administration of Eye Drops or Ointments revised 12/19/22, showed under the Policy Explanation and Compliance Guidelines section, the nurse should verify the orders and labeling prior to administration and to compare the label with the order to verify correct medication, dose, route, and time of administration. On 5/30/25 at 0900 hours, a medication administration observation for Resident 6 was conducted with LVN 8. LVN 8 was observed instilling two drops of the Artificial Tears eye drops (medication use to lubricate the eyes) in both eyes of Resident 6. Medical record review of Resident 6 was initiated on 5/30/25. Resident 6 was readmitted to the facility on [DATE]. Review of Resident 6's Order Summary Report showed a physician's order dated 3/27/16, to instill artificial tears solution in both eyes one drop two times a day for dry eyes. Review of Resident 6's H&P examination dated 5/14/24, showed Resident 6 had the capacity to make medical decisions. On 5/30/25 at 1100 hours, an interview and concurrent medical record review for Resident 6 was conducted with LVN 8. LVN 8 stated prior to administering any medication, the nurses should recheck for the correct medication, dose and route. LVN 8 further stated overdosing of any medication could give adverse reaction to the resident. LVN 8 acknowledged Resident 6 received two drops in both eyes of the artificial tears eye drops medication. On 5/30/25 at 1135 hours, an interview was conducted with RN 1. RN 1 stated the nurse should double check the right dosage of the medication to be administered to prevent medication error. RN 1 further stated overdosing of the medication might give adverse effects to the resident. RN 1 was notified and acknowledged the above findings for Resident 6. On 6/3/25 at 1400 hours, an interview was conducted with the DON. The DON was notified and acknowledged the above findings for Resident 6. 4. On 5/30/25 at 0814 hours, a medication administration observation for Resident 99 was conducted with LVN 8. LVN 8 was observed administered the diluted plavix (medication use to prevent heart attack and other heart problems) medication followed by the multi-vite liquid (multivitamins supplement) via GT without flushing with water in between the medication administration. Medical record review of Resident 99 was initiated on 5/30/25. Resident 99 was readmitted to the facility on [DATE]. Review of Resident 99's H&P examination dated 4/18/24, showed Resident 99 did not have the capacity to understand and make decisions. Review of Resident 99's Order Summary Report, showed a physician's order dated 5/4/24, to flush the enteral tube with 15-30 ml of water before and after medication administration and 5 ml of water between each medication. On 5/30/25 at 1100 hours, an interview and concurrent medical record review for Resident 99 was conducted with LVN 8. LVN 8 stated when giving medication via GT, the medication should be given one at a time, then flush with 10 cc of water after each medication. LVN 8 stated flushing with water in between the medication administration would ensure the medication was properly delivered and to prevent interactions between the medications. LVN 8 verified there was no water flushing done in between administration of the plavix and multivitamins. On 5/30/25 at 1135 hours, an interview was conducted with RN 1. RN 1 stated it was the facility's protocol to flush the GT with a certain amount of water between medication administration to prevent blockages of the GT, ensure the medication was properly administered, and prevent adverse reactions between each medication. RN 1 was informed and acknowledged the above findings for Resident 99. On 6/3/25 at 1400 hours, an interview was conducted with the DON. The DON was notified and acknowledged the above findings for Resident 99.

Based on observation, clinical record review and interview, the facility failed to maintain acceptable parameters of nutrition when four of 22 sampled residents (Resident 2, 14, 17 and 10) showed severe weight loss and failed to provide sufficient calories, protein and fluids. The RD failed to accurately calculate the nutritional requirements for the residents based on the residents' clinical conditions. Resident 14 had a significant weight loss of 8% in one month. Resident 14 had a Stage III (full thickness tissue loss; subcutaneous fat may be visible, but bone, tendon or muscle are not exposed) pressure ulcer and required additional protein for wound healing. The RD failed to recommend the needed protein and calorie intake for Resident 14 to help promote wound healing and prevent weight loss. Resident 2 had a Stage IV pressure ulcer and a significant weight loss of 5.5% during a hospitalization . Upon return to the facility, no assessment or care planning was done to address the weight loss or the ongoing nutritional needs to promote wound healing. Resident 17 weighed 137 pounds on 8/12/11. Resident 17 a weight loss of 14.5% in six months. The facility failed to evaluate the weight loss and calorie intake. Resident 10 had a significant weight loss and low blood protein levels (an indicator of malnutrition). After the weight loss, the facility did not notify the physician, and the RD did not implement any new interventions to stop further weight loss or reassess the resident's protein level, in view of the fact the resident was being treated for [REDACTED]. Failure of the facility to provide nutritional treatment and interventions when the residents began losing weight led to significant weight loss, failure to promote wound healing and adequate nutrition for a resident with infections. Findings: 1. Clinical record review for Resident 14 was initiated on 3/20/12. Resident 14 was readmitted to the facility on [DATE]. Review of the Record of Admission shows [DIAGNOSES REDACTED]. A 2009 National Pressure Ulcer Advisory Panel white paper entitled The Role of Nutrition in Pressure Ulcer Prevention and Treatment shows ...all stages of healing require adequate protein. Caloric (energy) needs must be met first in order to spare protein from being utilized as an energy source. The recommended range of protein associated with healing currently is between 1.2 to 1.5 gm per kilogram of body weight per day. Review of the admission height and weight obtained on 2/9/12, shows Resident 14 is 64 inches tall and weighs 113 pounds. The initial documentation of Resident 14's enteral feeding, water, diagnosis, wounds, medications and laboratory data was dated 2/13/12, as completed by the DSS. Review of the DSS' documentation shows Resident 14's weight was 122 pounds. This document was faxed to the RD for review and recommendations. The RD completed the Enteral Feeding Assessment and faxed this document back to the facility on [DATE]. The RD calculated the BMI (Body Mass Index - a standardized estimate of an individual's relative body fat calculated from his or her height and weight) as 21 (a BMI of less than 22 is considered underweight). The RD's calculation of Resident 14's daily nutritional needs shows calories 1200 to 1400, protein 55 to 67 gm and fluid at 1300 to 1600 ml. The RD noted the current formula did not meet Resident 14's calorie or hydration needs and recommended an increase in the rate of the Glucerna (a liquid nutritional supplement used for diabetics) from 40 ml per hour to 45 ml per hour for 20 hours per day. This increase in the amount of Glucerna would supply 1080 calories and 53.25 gm of protein per day to Resident 14. The liquid nutrition and the addition of water flushes would give Resident 14 approximately 1200 ml of fluid per day. Resident 14's assessed nutritional needs are not being met with this amount of Glucerna. Review of Resident 14's weekly weights shows on 2/12/12, the weight was 114 pounds; on 2/23/12, the weight was 109 pounds; on 2/24/12, the weight was 109 pounds; on 3/1/12, the weight was 105 pounds. An RD note dated 3/1/12, shows fluctuations in Resident 14's potassium level. The RD recommended changing the tube feeding to Nepro (a liquid nutritional supplement used in [MEDICAL CONDITION]) at 30 ml per hour for 20 hours per day. This would supply Resident 14 with 1080 calories and 49 gm of protein and water, totaling 1038 ml per day. Resident 14's weight was 104 pounds on 3/8/12. This represents a significant weight loss of 7.96% in one month. The RD's recommendations did not address Resident 14's low BMI, the weight loss or the need for wound healing. During an interview with the RD on 3/21/12 at 0840 hours, the RD stated she is at the facility once per week for less than eight hours due to teaching a class; initial assessments are handled by faxed information from the DSS; the RD does not receive a copy of the Record of Admission or the physician's history and physical. The RD stated she receives additional information from the facility staff on residents with weight loss or changes in wounds. The RD stated she does reassessments quarterly, unless the nursing staff alerts her to a change in a resident's condition. When asked about Resident 14's weight loss of 9 pounds in one month, the RD replied the information she had received from the DSS showed Resident 14 had generalized body [MEDICAL CONDITION], so she had expected Resident 14 to lose weight. When asked why her nutritional recommendations for Resident 14 were below the assessed nutritional needs and did not take into consideration Resident 14's pressure ulcer, the RD asked if the [DIAGNOSES REDACTED]. After reviewing the Record of Admission, the RD stated she was unaware of Resident 14's pressure ulcer. The RD stated she would redo the nutritional calculations for Resident 14 to include the nutrition necessary for wound healing. 2. Clinical record review for Resident 2 was initiated on 3/19/12. Resident 2 was readmitted to the facility on [DATE]. Review of the Record of Admission shows [DIAGNOSES REDACTED]. Review of Resident 2's clinical record prior to the hospitalization on [DATE], shows Resident 2 is 70 inches tall and weighed 146 pounds. Review of the Enteral Feeding Assessment completed by the RD dated 10/28/11, shows Resident 2 was receiving a GT feeding [MEDICATION NAME] at 90 ml per hour for 20 hours per day, and a water flush of 250 ml every 6 hours. This feeding provided Resident 2 with 2,340 calories, 67 gm of protein and 2,422 ml of fluid per 24 hours. Review of the admission height and weight obtained on 3/2/12, shows Resident 2 is 70 inches tall and weighs 138 pounds. This represents a significant weight loss of 5.5% in one month. The initial documentation of Resident 2's enteral feeding, water, diagnosis, wounds, medications and laboratory data was dated 3/5/12 as completed by the DSS. This documentation was faxed to the RD for review and recommendations. The RD completed the Enteral Feeding Assessment and faxed this document back to the facility on [DATE]. The RD calculated the BMI as 19.9. The RD's calculation of Resident 2's daily nutritional needs shows 1700 to 2100 calories, 90 to 125 gm of protein, and fluid at 1600 to 1900 ml per 24 hours. The RD noted the current formula provides 1680 calories, 78 gm of protein and 1334 ml of fluid. The RD documented the current formula of [MEDICATION NAME] at 70 ml per hour will meet Resident 2's calorie and hydration needs. The RD recommended adding Promod (a high protein supplement) 30 ml twice per day for 30 days. The addition of the Promod would add 200 calories and 20 gm of protein to Resident 2's nutritional intake. The addition of Promod to the [MEDICATION NAME] will meet the low end of Resident 2's nutritional needs, but does not address the BMI of 19.9 or any needed weight gain. During an interview and clinical record review with the RD on 3/21/12 at 0840 hours, the RD was asked about Resident 2's height and weight. The RD agreed the weight seemed low for a man of this height. The RD was asked about the calories and protein being provided by the [MEDICATION NAME] and the Promod. The RD stated Resident 2's minimum needs were being met, and she felt it was important for Resident 2 not to gain weight, as this might cause worsening of his respiratory problems. Review of the weight prior to the hospitalization shows Resident 2's weight was 146 pounds, and now is 138 pounds. The RD stated she was unaware of the prior weight. When asked why the current enteral feeding was supplying fewer calories and protein then the feeding Resident 2 received prior to the hospitalization , the RD stated she could not remember what formula each resident was on prior to a hospitalization , and she did not have the time to go to medical records and look at everyone's old chart. When asked if she had reviewed the documentation of Resident 2's hospital [DIAGNOSES REDACTED]. When asked if she was aware of Resident 2's [DIAGNOSES REDACTED]. When antidiuretic hormone regulation fails, the body retains fluid and loses sodium), the RD replied she was unaware of this diagnosis, she relies on the information the DSS faxes to her, and she does not have time to review each clinical record in detail. The RD further stated she relies on the nursing staff to alert her to changes in [DIAGNOSES REDACTED]. The RD stated she covers nine skilled nursing facilities,and she has a difficult time reviewing every resident's clinical record. After her initial recommendations, usually done by fax, she tries to review any new admits or readmits when she comes to the facility on ce per week. The RD stated, if she is not alerted to problems, she reviews residents on a quarterly basis only. 3. Review of the facility's P&P titled Weight Policy and Procedure revised 5/07, showed the physician will be notified if a resident gains or loses five pounds in one month, or there is a 3% change in one week, a 5% change in one month, a 7.5% change in three months, or a 10% change in six months. Review of the facility's P&P titled Nutrition Committee Guidelines revised 5/07, showed residents considered at nutritional risk because of a significant unplanned weight gain or loss are presented to the committee. Review of Resident 17's clinical record was initiated on 3/20/12. The resident was readmitted to the facility on [DATE]. He has a history dysphagia (difficulty swallowing) with a GT (a tube inserted through the wall of the abdomen into the stomach, used to provide nutrition) feeding. Review of the Vital Signs and Weight Record showed Resident 17's weight was 137 pounds on 8/12/11. Review of the Enteral Feeding Assessment showed an entry dated 8/16/11, showing his UBW (usual body weight) was 133 pounds. Review of the Physician's Admission Enteral Orders/Medication Record dated 8/12/11, showed to provide Glucerna 1.0 (nutritional formula) at 50 ml per hour for 20 hours via pump; weekly weights for four weeks; and nothing by mouth. Review of the Vital Signs and Weight Record showed Resident 17's weight was 132 pounds on 8/15, 8/18, and 8/25/11. He lost five pounds, a 3.6 % weight loss in two weeks. Review of the Vital Signs and Weight Record showed the RD calculated his nutritional needs were 1600 to 1900 calories per day, and 75 to 93 gm of protein a day. His Body Mass Index (BMI) was 21.5 (A BMI less then 22 is defined as under weight) The RD's recommendation was to change the formula to Glucerna 1.5 to run at 50 ml per hour for 20 hours to provide 1000 ml, or 1500 calories (less then the calculated nutritional needs). Review of the physician's orders [REDACTED]. Review of the Dietary Progress Notes showed an entry dated 8/18/11, documented by the RD, showing Resident 17 was receiving Glucerna 1.5 at 50 ml per hour for 20 hours, or 1500 calories and 83 gm of protein. The RD documented the TF meets the resident's needs. Review of the Vital Signs and Weight Record showed on 9/1/11, Resident 17's weight was 130 pounds, a seven pounds loss. On 9/8/11, his weight was 129 pounds, an eight pounds weight loss. On 9/15/11, his weight was 128 pounds. He lost nine pounds, a 6.5% weight loss in 34 days. There was no documentation to show the nutritional committee evaluated the resident for this significant weight loss. Review of the physician's orders [REDACTED]. Review of the Vital Signs and Weight Record showed Resident 17's weight was 126 pounds on 10/6/11. Review of the physician's orders [REDACTED]. Review of the Dietary Progress Notes showed an entry dated 10/20/11, showing the RD was consulted to evaluate the risk for weight loss, and decreased oral intake. The RD notes reflect the resident's weight was 126 pounds on 10/6/11; he lost four pounds in one month, and six pounds in two months. The RD's recommendation was to increase the TF to Glucerna 1.5 to run at 65 ml per hour for 20 hours, providing 1950 calories and 107 gm of protein; She expected the resident's weight to be stable. There was no documentation to show the physician was notified of the RD's recommendation. There was no documentation to show the physician ordered to increase the TF to 65 ml per hour for 20 hours as the RD recommended. There was no documentation to show Resident 17 received Glucerna 1.5 at 65 ml per hour. Review of the Dietary Progress Notes showed an entry dated 11/19/11, showing a quarterly assessment of Resident 17's nutritional status. The RD identified the TF of Glucerna 1.5 to run at 50 ml per hour for 20 hours to provide 1500 calories and 83 gm of protein. The RD acknowledged resident weight was 127 pounds on 11/3/11, a one pound weight gain in one month and a three pounds weight loss in three months. The RD documented the resident's weight change was not significant. Review of the Vital Signs and Weight Record showed Resident 17's weight was 124 pounds on 12/5/11, a 9.4% weight loss in four months. Review of the physician's orders [REDACTED]. Review of the Enteral Feeding Assessment showed an entry dated 12/13/11, showing Resident 17 was receiving Glucerna 1.5 at 50 ml per hour for 20 hours and receiving a puree diet with thin liquid; his current weight was 124 pounds; his UBW was not applicable. The resident's BMI was 19.5. The resident lost three pounds in one month, six pounds in three months, and 13 pounds in six months since admission. The RD calculated the resident's nutritional needs were 1600 to 1900 calories, and 75 to 95 gm of protein per day. The RD assessed the resident as having weight loss in six months. The RD expected the resident's weight to be improved with the TF and oral intake, or the resident will improve his oral intake in addition to the TF. The plan was, the TF may be decreased as the resident gains weight; the RD will follow up. The RD documented there was no change needed at that time. Review of the Clinical Recommendations faxed to the facility on [DATE], from the RD showed the RD's recommendation was, FYI (for your information) to continue the current TF and diet as ordered; as oral intake increases to an average of 70%, may discontinue the TF, conduct a calorie count. Review of the Vital Signs and Weight Record showed Resident 17's weight was 117 pounds on 12/12/11, 115 pounds on 12/19/11, and 120 pounds on 12/27/11. He lost 12.4% of his weight in four and a half months. Review of the physician's orders [REDACTED]. There was no documented evidence to show a calorie count was conducted for Resident 17. There was no documentation to show the resident's nutritional status or weight loss was evaluated by the nutritional committee. Review of the physician's orders [REDACTED]. Review of the Dietary Progress Notes showed an entry dated 12/28/11, showing the RD was consulted for eating well per the ST. The RD acknowledged the decrease of Glucerna 1.5 to run at 30 ml per hour for 20 hours on 12/27/11, providing 900 calories or 49.5 gm protein. She documented the resident's oral intake was 100% per staff. He had good oral intake per the ST. The RD documented the resident's weight was 120 pounds on 12/27/11; he gained five pounds in one week, his weight was fluctuating, and was within normal limits of his UBW. The RD suggested to hold the TF; if his oral intake was less than 50%, 120 ml of Glucerna 1.2 will be offered to the resident; if he refused, Glucerna to be given to him via GT. Review of the Clinical Recommendations faxed to the facility on [DATE] by the RD showed Resident 17 was eating well; TF decreased to nocturnal (night time) lower rate; [MEDICATION NAME] level was within normal limits. She suggested to hold the TF; encourage oral intake; if the oral intake is less than 50%, offer house nourishment 120 ml by mouth; if refused, may consider a bolus of 120 ml of house formula. Review of the physician's orders [REDACTED]. Review of the physician's orders [REDACTED]. Review of the Vital Signs and Weight Record showed on 1/9/12, Resident 17's weight was 117 pounds, a 14.5% weight loss in 5 months. There was no documented evidence to show the physician was notified of Resident 17's weight loss. There was no documented evidence to show Resident 17 was evaluated by the nutritional committee for his weight loss, or his nutritional status when he had significant weight loss on 1/9/12. There was no documented evidence to show Resident 17's weight loss, his calorie intake, or his nutritional status was evaluated before holding the TF. Review of the physician's orders [REDACTED]. Review of the Nutritional Support assessment dated [DATE], showed Resident 17's weight was 137 pounds on admission. His current weight was 115 pounds. He lost 5.7% of his weight in one month; 9.4% of his weight in three months; and 12.9% of his weight in six months. His current diet was a puree diet in addition to Glucerna 1.5 to run at 50 ml per hour for 12 hours from 1800 hours to 0800 hours to provide 900 calories. The committee recommended to consult with the RD. Review of the Dietary Progress Notes showed an entry dated 2/9/12, showing the RD reviewed Resident 17's weight. His weight was 115 pounds on 2/3/12, a 5.7% weight loss in one month, a 9.4% weight loss in three months, and a 12.9% weight loss in six months. He had significant weight loss. The RD acknowledged the TF was changed to Glucerna 1.5 to run at 50 ml per hour for 12 hours to provide 900 calories on 2/3/12. He was on a puree diet. His oral intake was 50% to 80%. The TF was discontinued on 1/4/12, per the family's request, when the resident gained weight and his oral intake improved. The TF was restarted when the resident's weight decreased. Review of the Nutrition Support Committee Meeting dated 2/12, 2/20, 2/27, and 3/5/12, showed Resident 17's admission weight was 137 pounds. His weight was 115 pounds on 2/12/12, and 114 pounds on 2/20, 2/27, and 3/5/12. The resident's weight was assessed as being stable. The plan was to continue the weekly weights, and to consult with the RD as needed. The reason for the weight loss was left blank. Review of the physician's orders [REDACTED]. Review of the Dietary Progress Notes showed an entry dated 3/8/12, showing Resident 17 was receiving Glucerna 1.5 at 50 ml per hour for 12 hours. His oral intake was 50% - 100%. He was receiving a puree diet; Glucerna 120 ml was offered if his oral intake is less than 50%. The RD acknowledged the resident's weight was 114 pounds on 3/7/12; his weight did not change in one week; he lost two pounds in one month, 10 pounds in three months, and 16 pounds in six months. His weight changed, but was not significant. Further review showed to continue the current plan. During an observation on 3/20/12 at 1813 hours, Resident 17 was observed eating his dinner meal with assistance from a staff member. A container of fat free milk was on the dinner tray. On 3/20/12 at 0810 hours, CNA 8 was observed assisting Resident 17 with breakfast. A 118 ml container of fat free milk was observed on the tray. The resident was observed drinking milk from a cup. On 3/21/12 at 0840 hours, the RD was asked how she evaluates a resident's weight. She stated she evaluates the residents quarterly unless there is an issue with the weight. She stated she does the weight report if the resident has a significant weight loss in one month, three months, and six months. She was asked how she follows up with a resident's weekly weights. She stated she relies a lot on verbal communication from the staff; the staff will let her know when a resident has weight loss. She was asked how she communicates with the staff about her recommendations. She stated she makes notes and recommendations in the resident's clinical record; then she generates her recommendations in her computer; then she faxes or emails her recommendations to the DSS, the DON, or the Administrator. She also stated her recommendations generated from the computer will be exactly as her recommendations written in the resident's clinical record. She was asked how she identifies a resident who is at high risk for weight loss. She stated a resident who is on weekly weights, or has skin issues is identified as a high risk for weight loss. On 3/21/12 at 1000 hours, a follow up interview and review of Resident 17's clinical record was conducted with the RD. The RD was asked why the resident did not receive Glucerna 1.5 at 65 ml per hour for 20 hours as she recommended on 10/20/11, and why she did not make further recommendations when she evaluated the resident again on 11/19/11. She stated she looked at the nurses' notes to determine why her recommendations were not followed; it was possible the physician did not agree with her recommendations; that is the reason she did not give further recommendations. She was asked for, but was unable to find documentation to show the reason why her recommendations were not implemented. The RD was asked the reason why she suggested the resident's TF be held on 12/28/11. She stated the ST asked to hold the TF because the resident was eating by mouth. The RD was observed looking on her computer, and she stated the resident's family member urged to hold the resident's TF. She was asked if the resident's oral intake met his nutritional needs. She stated three puree meals will provide 2000 calories for the resident. She was asked if she calculated the resident's calorie intake. She stated she did not calculate his calorie intake in her notes. She was asked if she reassessed the resident when the TF was held on 1/4/12, and when the resident had a significant weight loss on 1/9/12. She stated she did not reassess the resident in January, 2012. She was asked if it was appropriate to hold the TF when the resident had weight loss since admission. She reviewed the resident's weights and stated she should have recommended to give 120 ml of Glucerna three times a day to provide 500 more calories a day for the resident instead of giving Glucerna 120 ml if his oral intake is less than 50%. The RD was asked if she recommended to decrease the Glucerna to 30 ml per hour from 50 ml per hour on 12/27/11. She stated she did not recommend to decrease the Glucerna to 30 ml per hour. She also stated that was a significant decrease in calorie intake for Resident 17. She was asked how Resident 17 received adequate calories, or nutrients when the resident had a weight loss since admission. She stated she should not suggest to hold the TF, and should recommend alternating feedings by providing the TF during the night time for the resident. She stated that will be more beneficial for the resident since the resident had a significant weight loss. She also stated she wants his weight to be stable, not decrease based on his weight on admission and his IBW. On 3/21/12 at 1030 hours, an interview and clinical record review was conducted with the DON. The DON was asked when the nutritional committee should evaluate a resident for weight loss. She stated when the resident has a significant weight loss. She was asked for, but was unable to find documentation to show Resident 17 was evaluated for weight loss by the nutritional committee before 2/5/12. On 3/21/12 at 1045 hours, an interview and review of Resident 17's clinical record was conducted with the Subacute Director. She was asked for, but was unable to find documentation to show the physician was notified of the RD's recommendations on 10/20/11. She was observed looking for the information in the dietary recommendation binder. She stated she was unable to find the RD's recommendations made for Resident 17 on 10/20/11. On 3/21/11 at 1100 hours, an interview and clinical record review was conducted with the DON. She was asked who recommended to decrease the Glucerna to 30 ml per hour on 12/27/11. She stated the RD recommended to decrease the Glucerna to 30 ml per hour. She was asked for, but was unable to find documentation to show the RD's recommendation to decrease the Glucerna to 30 ml per hour. She was asked how Resident 17 was evaluated for his nutritional intake prior to holding the TF. She reviewed the resident's clinical record and stated a calorie count was possibly conducted for the resident. She was asked for, but was unable to find documentation to show a calorie count was conducted for Resident 17. 4. Clinical record review for Resident 10 was initiated on 3/19/12. Review of the Vital Signs and Weight Record dated 1/28/12, showed Resident 10 was 63 inches tall and had an admission weight of 147 pounds. Resident 10 had a [DIAGNOSES REDACTED]. Review of the Enteral Feeding assessment dated [DATE], showed the RD assessed Resident 10 as needing 1700 - 2100 calories daily and 65 - 78 gm of protein daily. Resident 10 was started on [MEDICATION NAME] 1.5 at 55 ml an hour for 20 hours a day, via his GT. According to the RD's calculations, the formula would provide 1650 calories a day and 70 gm of protein. Review of the laboratory report dated 2/6/12, showed Resident 10 had a low pre-[MEDICATION NAME] of 9 (protein level in the blood used as an indicator of malnutrition, normal range 17 to 34). Further review of the report showed a note the resident was started on Promod, a protein supplement, 60 ml twice a day, and to reorder the pre-[MEDICATION NAME] in one week. Further review of the Vital Signs and Weight Record showed on 2/9/12, Resident 10's weight dropped to 145 pounds. On 2/14/12, the laboratory report showed the pre-[MEDICATION NAME] remained unchanged at 9, and on 2/16/12, Resident 10's weight dropped to 141 pounds. Resident 10 was readmitted to the hospital on [DATE] with an infection. Review of the acute hospital's dietary consultation dated 2/20/12, showed the RD documented Resident 10's weight in January, 2012, was 151 pounds, and the resident may have lost 5% of his body weight in six weeks. The RD at the hospital showed Resident 10 is 68 inches tall. The resident was placed on [MEDICATION NAME] 55 ml an hour for 20 hours a day. Resident 10 was discharged from the hospital and readmitted to the facility on [DATE]. Review of the Nurses' Admission Record dated 2/21/12, showed Resident 10 has +2 [MEDICAL CONDITION] (swelling) of both feet. There is no other mention of [MEDICAL CONDITION] found documented in the record. The new Vital Signs and Weight Record dated 2/22/12, showed Resident 10's readmission weight was 141 pounds. Review of the new Enteral Feeding assessment dated [DATE], showed the new GT feeding ordered for Resident 10 was decreased to [MEDICATION NAME] 1.5 at 50 ml hour for 20 hours a day. The calculated needs for the resident are 1700 - 2100 calories a day and 96 - 128 gm of protein needed. Resident 10 is being provided 1800 calories and 94 gm of protein. According to the injury factors documented in the assessment, if a resident has an infection the estimated calories needed should be multiplied by 1.3 to 1.55. Using this factor, Resident 10's estimated caloric needs would be 1847 - 2202 daily. On 3/8/12, Resident 10's weight dropped to 133 pounds (a significant weight loss of 5% or greater in one month or less). Review of the Dietary Progress Notes dated 3/8/12, showed the RD documented Resident 10's weight loss is due to [MEDICAL CONDITION]. There are no new orders and no documentation to show the physician was notified of the weight loss. An observation of Resident 10 on 3/20/12 at 0745 hours, showed the resident had no swelling of the feet or legs. A CNA was asked to measure Resident 10 to verify his height, Resident 10 measured 64 inches tall. An interview with the RD was initiated on 3/21/12 at 1030 hours. The RD stated, when a resident goes into the hospital and returns to the facility, she would continue the resident on the same diet the hospital had them on until she had the opportunity to reassess them. She was asked if Resident 10's weight was decreasing (151 pounds in January, 2012, to 133 pounds in March, 2012), why was he started on a lower calorie diet on the second admission. The RD stated she did not remember what diet Resident 10 was on when he was previously at the facility. The RD was asked why the pre-[MEDICATION NAME] level had not been rechecked since the resident's readmission. The RD stated she overlooked it.

Based on observation, interview and clinical record review, the facility failed to administer the amount of formula via the GT as ordered for one of 13 sampled residents (Resident 25). Resident 25 received about 300 ml less than the prescribed volume of 1500 ml per day for the 24 hour cycle from 5/6/12 at 1300 hours to 5/7/12 at 1338 hours. This poses the potential for [MEDICAL CONDITION] and a delay in wound healing. Findings: On 5/7/12 at 0814 hours, during the initial tour observation with LVN 3, observation showed Resident 25's tube feeding was on at 75 ml per hour with about 500 ml of formula left in the 1500 ml container (1000 ml infused). Observation of the label showed the container was hung on 5/6/12 at 1300 hours. On 5/7/12, clinical record review showed Resident 25 was readmitted to the facility on [DATE], with two wounds, including a Stage III pressure ulcer (full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Some dead tissue may be present) to the left heel and a vascular ulcer to the right first metatarsal (toe) head. On 5/7/12 at 1528 hours, an interview with clinical record review was conducted with LVN 4. The LVN stated the Stage III pressure ulcer to the left heel remained the same, 5 cm x 6 cm, unable to determine the depth with 60% necrotic (dead) tissue and 40% slough (white or yellow tissue in the process of separating from the viable tissue of the body) for the last two weeks. LVN 4 showed the vascular wound to the right metatarsal heel was opened on 4/30/12, and remained the same in the last two weeks, 2 cm x 2 cm, unable to determine the depth with 40% granulation tissue and 60% slough. Review of the Dietary Progress Note dated 4/23/12, showed a weight loss of one pound, a 0.9% weight loss in one week. The RD documented the resident was noted with weight loss and a low [MEDICATION NAME] of 2.9 (normal range 3.1 - 5.1) and a low pre-[MEDICATION NAME] of 11 (normal range 17-34). The RD recommended to increase the rate from 60 ml to 75 ml per hour for 20 hours to provide an additional 360 Kcal (Kcal is the measuring unit of the amount of energy given from a type of food) per day and 18 grams of protein per day. A physician's orders [REDACTED]. On 5/7/12 at 0950 hours, the tube feeding alarm was sounding. LVN 3 came in and turned the tube feeding off. Observation showed 450 ml of formula was left in the 1500 ml container that was hung on 5/6/12 at 1300 hours (about 1050 ml infused for 20 hours and 50 minutes hanging time). On 5/7/12 at 1215 hours, observation showed the tube feeding was off. On 5/7/12 at 1338 hours, observation showed the tube feeding was on at 75 ml per hour. About 350 to 400 ml was formula was left in the container. Per calculation, on 5/7/12 at 1338 hours, Resident 25 had received about 1100 to 1150 ml of formula in 24 and a half hours since 5/6/12 at 1300 hours, or 350 to 400 ml less formula in 24 hours than the prescribed volume of 1500 ml per day. On 5/7/12 at 1400 hours, LVN 7 was asked to check the tube feeding. The LVN stated the bag was hung on 5/6/12 at 1300 hours, and between 300 and 400 ml of formula was left in the 1500 ml container. Per calculation, Resident 25 had received 1100 to 1200 ml of formula in the last 25 hours; 300 to 400 ml less formula than the prescribed order for a 24 hour period.