Every finding on record at Glasgow Hills of Journey

Based on record review and staff interview, the facility failed to comply with all applicable state laws, regulations, and codes. The facility's Infections Medical Waste Program permit was expired. This was a random opportunity for discovery. Facility census: 105.Findings included:The facility's Bureau for Public Health, Office of Environmental Health Services, Infectious Medical Waste Program permit, which was posted on the wall in the facility, was issued [DATE] and expired [DATE]. On [DATE] at 10:30 AM, the administrator confirmed the Infectious Medical Waste Program permit expired. She stated she had submitted the invoice to corporate for payment, but it had not yet been paid. On [DATE] at 11:33 AM, the Administrator stated she had just paid the invoice to renew the facility's Infectious Medical Waste Program permit. She provided the receipt to show the invoice had been paid.

Based on record review, resident interview, and staff interview, the facility failed to make prompt efforts to resolve a resident grievance. The facility failed to follow through on purchasing new pajamas for a resident after they were lost in the facility. This was a random opportunity for discovery during a complaint investigation. Census: 105. Resident identifier: #40.Findings included:a) Resident #40A review of the the Resident and Family Grievances policy revealed the following, The facility will make prompt efforts to resolve grievances.A grievance filed by Resident #40 on 02/05/26 stated she was missing a pajama set. The official follow-up written on the grievance form stated the pajamas were being replaced with a date resolved written as 02/10/26.During an interview on 05/11/26, Resident #40 stated she was missing a pajama set and had filed a grievance, but the pajamas had not been replaced. During an interview, on 05/11/26 at 1:10 PM, the Social Worker confirmed the pajamas had not been replaced.

Based on record review and staff interview, the facility failed to develop a care plan for Resident #40 based on accurate diagnoses. This was a random opportunity for discovery during a complaint investigation. Resident identifier: #40. Facility census: 105.Findings included:During a review of Resident #40's electronic medical record, the following discrepancy was found:-A review Resident #40's care plan included a focus as follows: The resident has hemiplegia/hemiparesis. Date initiated: 04/07/26.-A review of the diagnosis list for Resident #40 confirmed there was no diagnosis for hemiplegia or hemiparesis.-A review of the Minimum Data Set (MDS) confirmed there were no impairments on either side.During an interview on 05/12/26 at 10:40AM, the Director of Nursing confirmed that the diagnosis on the care plan was incorrect, and Resident #40 did not have hemiplegia/hemiparesis.

Based on record review and staff interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. Physician orders were not followed for two (2) of 30 residents reviewed in the long-term care survey sample. Resident identifiers: #101 and #33. Facility census: 101. Findings included: a) Resident #101 Review of Resident #101's physician's orders showed an order written on 06/01/25 for the antibiotic Cipro 500 milligrams (mg), by mouth, two (2) times a day for seven (7) days for a urinary tract infection. This would equal 14 doses of Cipro. Resident #101's Medication Administration Record (MAR) showed a notation at bedtime on 06/01/25 that indicated a nursing note had been written regarding the medication. The nursing note stated the medication was not available yet and the physician was aware. The MAR indicated Cipro was administered in the morning and at bedtime on 06/02/25 through 06/07/25. Cipro was administered only in the morning on 06/08/25. This equaled 13 doses of Cipro. On 06/30/25 at 1:53 PM, the Director of Nursing confirmed there was no documentation the resident received 14 doses of Cipro as ordered by the physician. b) Resident #33 Review of Resident #33's order showed the following orders: - Acetaminophen (Tylenol) 325 milligrams (mg), give two (2) tablets by mouth every six (6) hours as needed for general discomfort, ordered 05/26/25. - Hydrocodone-Acetaminophen 5-325 mg, give one (1) tablet by mouth every four (4) hours as needed for pain scale six (6) to 10, ordered 05/22/25. A pain scale is a tool used to help individuals communicate the intensity of their pain. The scale ranges from 0 (no pain) to 10 (worst pain imaginable). Resident #33's MAR showed the resident received acetaminophen on three (3) occasions since the medication was ordered. These occasions were as follows: - 05/26/25 at 2:46 PM, for pain level of 3. - 06/07/25 at 2:01 AM, for pain level of 4. - o6/17/25 at 11:36 AM, for pain level of 4. Resident #33's MAR showed the resident received Hydrocodone-Acetaminophen on 54 occasions since the medication was ordered. On ten occasions, the resident's pain was documented at a lower level than required for administration according to the physician's orders. These occasions were as follows: - 05/23/25 at 11:15 AM, for pain level of 3. - 05/27/25 at 1:00 PM, for pain level of 5. - 05/28/25 at 2:05 PM, for pain level of 5. - 05/31/25 at 8:44 AM, for pain level of 3. - 05/31/25 at 12:50 PM, for pain level of 4. - 05/31/25 at 10:55 PM, for pain level of 5. - 06/01/25 at 11:05 AM, for pain level of 4. - 06/04/24 at 7:50 AM, for pain level of 0. - 06/13/54 at 8:50 AM, for pain level of 5. - 06/21/25 at 2:50 PM, for pain level of 0. On 06/30/25 at 10:32 AM, the Director of Nursing confirmed Resident #33's Hydrocodone-Acetaminophen was administered outside the pain scale parameters ordered by the physician. No further information was provided through the completion of the survey.

Based on observation and staff interview the facility failed to ensure food was stored and prepared in a safe and sanitary manner. This failed practice has the potential to effect more than an isolated number of residents. Facility Census: 101. Findings Include: a) Initial tour of the Kitchen and Pantries An initial tour of the kitchen upon entrance to the facility on [DATE] at 9:15 AM found the kitchen staff had a cyclone floor fan blowing toward the food preparation area. The fan as observed to be covered in dust and was not clean. The dietary manager (DM) stated, I am getting rid of this right now. On the dementia unit in the refrigerator was two (2) bottles of ranch dressing which were open and not dated, a small carton of vitamin D milk which was open and not dated, and a small bag fiesta shredded cheese which was open and not dated. 06/24/25 09:15 am initial tour of the kitchen with the CDM there was a dirty fan sitting on the floor blowing toward the food prep area. The CDM said she was getting it out of here. She said it was just trying to manage the heat with the fan. The DM then stated all the items should have been dated.

Based on record review and staff interview, the facility failed to ensure complete and accurate medical records. The medication diagnosis was inaccurate for two (2) of 30 sampled residents reviewed in the Long-Term Care Survey Process. Additionally, a resident's psychiatric evaluation notes referred to her as a male. This was true for one (1) of 30 sampled residents reviewed in the Long-Term Care Survey Process. Resident identifiers: #40, #101, and #102. Facility census: 101. Findings included: a) Resident #40 A record review, completed on 06/26/25 at 11:15 AM, revealed a physician order for a 5 MG Apixaban tablet noting, Give 1 tablet by mouth two times a day for Pleural Effusion. During an interview on 06/26/25 at 11:48 AM, the Director of Nursing (DON) stated the order was not accurate. The DON noted that the order should have captured PE as a pulmonary embolism. b) Resident #101 Review of Resident #101's physician's orders showed an order written on 04/26/25 for Escitalopram Oxalate (Lexapro) 10 milligrams (mg) by mouth one (1) time a day for dementia. Lexapro is an anti-depressant medication that is also used to treat anxiety disorders. Resident #101 had diagnoses of dementia and anxiety disorder. On 06/30/25 at 12:56 PM, the Director of Nursing (DON) confirmed dementia was not an appropriate diagnosis for Lexapro. The DON stated Resident #101 was receiving Lexapro due to anxiety. No further information was provided through the completion of the survey. c) Resident #102 A review of Resident #102's medical record on 06/25/25 found Resident #102 was seen by a psychiatrist on 05/20/25 and 06/11/25. A review of each evaluation note for 05/20/25 found the following, History of Present Illness: The patient is a [AGE] year-old female presenting with a hx of Dementia and Encephalopathy. The patient is currently residing at Glasgow Hills NF for long-term care. The patient was originally admitted to the facility on [DATE]. Pt denies any significant past psychiatric history, IP/OP psychiatric services, or SA. Medication changes at last visit: initial visit The patient is not able to report when the presenting problem began. Current stressors: Alleviating factors: The patient reports feeling fine and his mood is fine. Pt denies depression and anxiety. Pt denies hallucinations, delusions, and irritability. Pt denies confusion. Pt reports that his sleep is pretty good and his appetite is good. Pt denies SI/HI. BIMS score of 9. The psychiatrist referred to resident #102 as a male three times in the note. A review of the note dated 06/11/25 found the following, History of Present Illness: The patient is a [AGE] year-old female presenting with a hx of Dementia and Encephalopathy. The patient is currently residing at Glasgow Hills NF for long-term care. The patient was originally admitted to the facility on [DATE]. Pt denies any significant past psychiatric history, IP/OP psychiatric services, or SA. Medication changes at last visit: Namenda and Buspar (Checked 06/11/2025) The patient is not able to report when the presenting problem began. Current stressors: Alleviating factors: The patient reports feeling pretty good, and his mood is pretty good. Pt denies depression and anxiety. Pt denies hallucinations, delusions, and irritability. Pt denies confusion. Pt reports that his sleep is pretty good and his appetite is good. Pt denies SI/HI. Again the psychiatrist refers to the female patient as a male. An interview with the Director of Nursing (DON) on 06/25/25 at 11:30 am confirmed the psychiatry note on 05/202/25 and 06/11/25 referred to the female patient as a male. She stated, I will address that with the provider.

Based on observation, staff interview and record review the facility failed to ensure Resident #85 received the assistance he needed with eating to enable him to maintain his dignity. This was true for one (1) of five (5) residents reviewed for the care area of Activities of Daily Living (ADL) during the long-term care survey process. Resident Identifier: #85. Facility Census:101. Findings Include: a) Resident #85 An observation of the noontime meal on 06/24/25 found Resident #85 was feeding himself with his fingers. He was eating Turkey Tex Mex which contained rice and bake beans. The resident was dropping food on his clothes. An additional observation of the noon time meal on 06/25/25 found the resident again feeding himself with his fingers. He ate a piece of pineapple upside down cake with his hands. He also had on his plate mashed potatoes, chopped broccoli and ground meatballs with gravy. He attempted to eat some mashed potatoes but had difficulty. An observation of his dining area found there were cake crumbs and bits of food scattered around the floor. He then left the dining room. During the observations no staff member was observed telling the resident to use his utensils. An interview with Nurse Aide (NA) #13 and NA #78 at 12:00 PM on 06/25/25 confirmed the resident always uses his hands to feed himself. They indicated the resident can use utensils, but he requires constant supervision and queuing to use the utensils. NA # 13, stated It has to be one on one. They both agreed that once he gets started using his utensils he does very well. An interview with the speech therapist at 1:45 PM on 06/25/25 confirmed the resident does very well when you get him started with his utensils. She indicated once you show him the utensils and get him started, he will finish eating and will do very well. A review of Resident #85's care plan found the following related to eating: Eating Assist: The res requires Set-Up, w/ eating. This was added to the care on 05/11/24 and was the active intervention at the time of this review. This confirmed with the Director of Nursing (DON) on the afternoon of 06/25/25.

Based on record review and staff interview, the facility failed to provide evidence the required Notification of Medicare Non-Coverage (NOMNC) and the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) form were issued and signed in a timely fashion for one (1) of three (3) residents reviewed for beneficiary protection notification. This failure had the potential to place the resident's legal representative at risk of not being informed of the resident's rights prior to the end of Medicare Part A covered services. Resident identifier: #102. Facility census: 101. Findings included: a) Beneficiary Notice Review A record review, completed on 06/25/25 at 12:26 PM, revealed: -Resident #102 was admitted to the facility on [DATE] -Resident #102's last covered day of Part A Service was on 05/30/25 -The NOMNC and SNF ABN forms were issued on 05/28/25 and signed by Resident #102 - The End of PPS (Prospective Payment System) Part A Minimum Dated Set, dated 05/30/25, reflected a Brief Interview for Mental Status (BIMS) score of 06. A BIMS score of 06 is indicative of severe cognitive impairment. -A physician determination of capacity, dated 04/25/25, reflected resident did not have capacity. -The emergency contact number for Resident #102 was listed as a Adult Protective Services (APS) Worker and resident's health care proxy. During an interview on 06/25/25 at 1:06 PM, the facility's Social Worker reported she would defer to the legal representative to sign for any resident who was determined to not have capacity. During an interview on 06/25/25 at 1:53 PM, the Administrator stated that the NOMNC form has been considered a financial document from the business office perspective. The Administrator noted it had been an oversight that the correct individual had not signed the form.

FACILITY Environment Based on observation and staff interview the facility failed to ensure the resident environment was clean and homelike. This was a random opportunity for discovery and as true for the bathroom shared between room [ROOM NUMBER] and 311. Facility Census: 101. Findings Include: On 06/30/25 at 11:45 am a tour with the Dementia Unit Director found the toilet seat attached to the toilet shared between room [ROOM NUMBER] and 311 was in poor repair. It appeared to be dirty at first glance, but the director indicated that the plastic coating was off and why it was discolored she stated, I have told maintenance about it. Also, in the same bathroom the baseboard trim was missing along the wall toward room [ROOM NUMBER].

Based on observation, resident interview, record review, and staff interview, the facility failed to ensure complete and accurate Minimum Data Set (MDS) assessments for two (2) of 30 residents reviewed in the long-term care survey sample. Resident Identifiers: #59 and #88. Facility census: 101. Findings included: a) Resident #59 On 06/25/25 at 3:08 PM, Resident #59 was interviewed. She was noted to have a tracheostomy tube with a speaking valve. Resident #59 stated she had the tracheostomy placed at the hospital before she was admitted to the facility. Review of Resident #59's medical records confirmed she had the tracheostomy tube when she was admitted to the facility. Resident #59's Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) 05/22/25 did not indicate the resident had a tracheostomy. On 06/26/25 on 12:34 PM, the Director of Nursing confirmed Resident #59's MDS with ARD 05/22/25 was incorrect. She stated the MDS was modified to indicate the resident had a tracheostomy. No further information was provided through the completion of the survey process. b) Resident #88 A review of Resident #88's medical record found she was admitted to the facility on [DATE]. Further review of the record found a nursing admission assessment dated [DATE] which indicated Resident #88 had fallen prior to admission in the last 31- 180 days. A review of the admission Minimum Data Set (MDS) dated found section J1700 B. Indicated the resident had not fall prior to admission in the las two (2) to six (6) months. An interview with the Nursing Home Administrator (NHA) in the afternoon of 06/25/25 confirmed the MDS was inaccurate.

Based on record review and staff interview, the facility failed to complete a new Pre-admission Screening and Resident Review (PASARR) for a resident with a newly evident or a possible serious disorder. This was true for one (1) out of 30 sampled residents reviewed during the Long-Term Care Survey Process. Resident identifier: #35. Facility census: 101 Findings included: a) Resident #35 A record review, completed on 06/24/25 at 6:18 PM, record review revealed: -A physician order which read, Divalproex Sodium Oral Tablet Delayed Release 250 MG (Divalproex Sodium). Give one (1) tablet by mouth two times a day for seizures give with 500 mg tab to equal 750 mg two (2) times a day. -Question #30 Current Diagnosis (Check all that apply) on the Pre-admission Screening and Record Review (PASARR), dated 10/16/24, did not indicate an issue with seizures. During an interview on 06/25/25 at 10:45 AM, the facility Social Worker acknowledged a new PASARR had not been completed to capture the seizure disorder.

Based on record review and staff interview, the facility failed to develop a comprehensive care plan that accurately reflected resident status and need for assistance. This deficient practice had the potential to affect two (2) of 30 residents reviewed in the long-term care survey sample. Resident Identifiers: #62 and #85. Facility census: 101. Findings included: a) Resident #62 Review of Resident #62's comprehensive care plan showed the following focus: - [Resident's name] has impaired cognitive function/dementia or impaired thought processes r/t [related to] poor recall. Psychotropic drug. BIMS [Brief Interview for Mental Status] >12. Date initiated: 05/13/23. Revision on: 08/24/24. The Brief Interview for Mental Status is a standardized assessment used to evaluate cognitive function. The BIMS is scored as follows: 13-15: Cognitively intact. 8-12: Moderate cognitive impairment. 0-7: Severe cognitive impairment. Resident #62's admission Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) 05/04/23 indicated the resident's BIMS score was 3. Resident #62's most recent quarterly MDS with ARD 05/15/25 also indicated the resident's BIMS score was 3. On 06/26/25 at 11:00 AM, the Director of Nursing (DON) confirmed Resident #62's comprehensive care plan was incorrect and the resident had never had a BIMS score of 12 during his time at the facility. The DON provided documentation that when Resident #62's comprehensive care plan was initially developed on 05/15/23, the focus stated, [Resident's name] has impaired cognitive function/dementia of impaired thought process r/t BIMS less than 12. Psychotropic drug use. The DON stated when the resident's care plan was later revised, the resident's BIMS score was incorrectly documented. No further information was provided through the completion of the survey process. b) Resident #85 An observation of the noontime meal on 06/24/25 found Resident #85 was feeding himself with his fingers. He was eating Turkey Tex Mex which contained rice, and bake beans. The resident was dropping food on his clothes. An additional observation of the noon time meal on 06/25/25 found the resident again feeding himself with his fingers. He ate a piece of pineapple upside down cake with his hands. He also had on his plate mashed potatoes , chopped broccoli and ground meatballs with gravy. He attempted to eat some mashed potatoes but had difficulty. An observation of his dining area found there was cake crumbs and bits of food scattered around the floor. He then left the dining room. During the observations no staff member was observed telling the resident to use his utensils. An interview with Nurse Aide (NA) #13 and NA #78 at 12:00 PM on 06/25/25 confirmed the resident always uses his hands to feed himself. They indicated the resident can use utensils but he requires constant supervision and queuing to use the utensils. NA # 13, stated It has to be one on one. The both agreed that once he gets started using his utensils he does very well. An interview with the speech therapist at 1:45 PM on 06/25/25 confirmed the resident does very well when you get him started with his utensils. She indicated once you show him the utensils and get him started he will finish eating and will do very well. A review of Resident #85's care plan found the following related to eating: Eating Assist: The res requires Set-Up, w/ eating. This was added to the care on 05/11/24 and was the active intervention at the time of this review. This confirmed with the Director of Nursing (DON) on the afternoon of 06/25/25.

Based on observation, resident interview, record review, and staff interview, the facility failed to revise the comprehensive care plan to reflect the resident's choices and when a resident's medication dosages changed. This deficient practice had the potential to affect two (2) of 30 residents reviewed in the long-term care survey sample. Resident Identifier: #75 and Resident #101. Facility census: 101. Findings included: a) Resident #75 On 06/24/25 at 9:30 AM, Resident #75 was noted to have an indwelling urinary catheter. The urine collection bag was hanging from the resident's bed but did not have a privacy cover to prevent the urine in the bag being seen by others. On 06/24/25 at 10:02 AM, the Director of Nursing (DON) stated Resident #75 refused to have a privacy bag placed on the urine collection bag for his catheter. She stated this was reflected in the resident's comprehensive care plan. Review of Resident #75's comprehensive care plan showed the following focus, initiated on 05/16/23, [Resident's name] has a suprapubic Catheter d/t [due to] neurogenic bladder. Interventions for the focus were as follows: - [Resident's name] has a 18Fr [French] suprapubic catheter with a 10mL [milliliter] balloon. Position catheter bag and tubing below the level of the bladder and away from entrance room door. Date Initiated: 05/16/2023 Revision on: 09/17/2024 - Change catheter bag as needed. Date Initiated: 05/16/2023 Revision on: 09/17/24 - Change dressing to suprapubic cath [catheter] site Q [every] shift per order. Date Initiated: 04/09/2024 Revision on: 09/17/2024 - Change suprapubic catheter when occluded or unable to flow freely as needed. Date Initiated: 05/16/2023 Revision on: 09/17/2024 - Enhanced Barrier Precautions for suprapubic catheter. Date Initiated: 09/19/2023 Revision on: 09/17/2024 - Flush catheter as ordered. See TAR [treatment administration record]. Date Initiated: 06/22/2024 Revision on: 09/17/2024 - Monitor and document intake and output as per facility policy Promote good fluid intake. Date Initiated: 05/16/2023 Revision on: 09/17/2024 - Monitor for s/sx [signs and symptoms] of discomfort on urination and frequency. Date Initiated: 05/16/2023 Revision on: 09/17/2024 - Monitor/document for pain/discomfort due to catheter. Date Initiated: 05/16/2023 Revision on: 09/17/2024 - Monitor/record/report to MD for s/sx UTI [urinary tract infection]: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Date Initiated: 05/16/2023 Revision on: 09/17/2024 On 06/25/25 at 3:00 PM, Resident #75 confirmed he did not want a privacy bag on his urine collection bag. On 06/26/25 at 12:45 PM, the Director of Nursing was asked to identify where Resident #75's comprehensive care plan documented the resident chose not to have a privacy bag for his urine collection bag. On 06/26/25 at 1:07 PM, the Director of Nursing provided a copy of Resident #75's comprehensive care plan which had been revised as follows: - Change catheter bag as needed. Resident refuses to allow catheter cover to be placed. Date Initiated: 05/16/23 Revision on: 06/26/25 No further information was provided through the completion of the survey. b) Resident #101 Review of Resident #101's physician's orders showed the following orders: - Seroquel oral tablet 25 milligrams (mg) (Quetiapine Fumarate) two (2) times a day, ordered 04/25/25 and discontinued 05/15/25. - Seroquel oral tablet 25 mg (Quetiapine Fumarate) one (1) time a day, ordered 05/16/25 and discontinued 05/22/25. - Seroquel oral tablet 50 mg (Quetiapine Fumarate) one (1) time a day, ordered 05/16/25 and discontinued 05/22/25. - Seroquel oral tablet 25 mg (Quetiapine Fumarate) two (2) times a day, ordered 5/22/25. This was the resident's current order. - Hydroxyzine (Vistaril), 75 mg by mouth every eight (8) hours as needed, ordered 04/30/25 for 14 days, renewed 05/15/25, and discontinued 05/21/25. - Hydroxyzine (Vistaril), 75 mg by mouth three times a day, ordered 05/21/25. This was the resident's current order. Resident #101's comprehensive care plan contained the following foci: - Altered Psychosocial needs r/t [related to] Dementia. [Resident's name] is on Seroquel 50 mg q [every] hs [night] and 25 mg in the morning, hydroxyzine 75 mg q 8 hours prn [as needed]. Date Initiated: 03/26/2025 Revision on: 05/16/2025 - The resident uses anti-anxiety medications (Vistaril PRN) r/t Anxiety disorder. Date Initiated: 04/19/2025 Revision on: 04/19/2025 On 06/30/25 at 12:46 PM, the Director of Nursing confirmed Resident #101's care plan was not revised when the Seroquel (Quetiapine Fumarate) dosage change was ordered and when the Hydroxyzine (Vistaril) was ordered to be administered around-the-clock instead of as needed. No further information was provided through the completion of the survey.

Based on observation, staff interview and record review the facility failed to ensure Resident #85's care plan accurately reflected the level and type of assistance he needed for eating. This was true for one (1) of five (5) residents reviewed for the care area of Activities of Daily Living (ADL) during the long term care survey process. Resident Identifier: #85. Facility Census:101. Findings Include: a) Resident #85 An observation of the noontime meal on 06/24/25 found Resident #85 was feeding himself with his fingers. He was eating Turkey Tex Mex which contained rice, and bake beans. The resident was dropping food on his clothes. An additional observation of the noon time meal on 06/25/25 found the resident again feeding himself with his fingers. He ate a piece of pineapple upside down cake with his hands. He also had on his plate mashed potatoes , chopped broccoli and ground meatballs with gravy. He attempted to eat some mashed potatoes but had difficulty. An observation of his dining area found there was cake crumbs and bits of food scattered around the floor. He then left the dining room. During the observations no staff member was observed telling the resident to use his utensils. An interview with Nurse Aide (NA) #13 and NA #78 at 12:00 PM on 06/25/25 confirmed the resident always uses his hands to feed himself. They indicated the resident can use utensils but he requires constant supervision and queuing to use the utensils. NA # 13, stated It has to be one on one. The both agreed that once he gets started using his utensils he does very well. An interview with the speech therapist at 1:45 PM on 06/25/25 confirmed the resident does very well when you get him started with his utensils. She indicated once you show him the utensils and get him started he will finish eating and will do very well. A review of Resident #85's care plan found the following related to eating: Eating Assist: The res requires Set-Up, w/ eating. This was added to the care on 05/11/24 and was the active intervention at the time of this review. This confirmed with the Director of Nursing (DON) on the afternoon of 06/25/25.

Based on observation, record review, and staff interview, the facility failed to ensure the resident's oxygen flow rate was set according to the physician's orders. This deficient practice had the potential to affect one (1) of one (1) residents reviewed for the care area of oxygen. Resident Identifier: #62. Facility census: 101. Findings included: a) Resident #62 On 06/24/25 at 11:18 AM, Resident #62 was observed to be using supplement oxygen therapy via nasal cannula at four (4) liters per minute. Review of Resident #62's physician's orders showed an order written on 12/30/24 for oxygen at two (2) liters via nasal cannula related to: COPD [chronic obstructive pulmonary disorder], respiratory disorder, as needed for short of breath. On 06/25/25 at 11:04 AM, Resident #62 was again observed to be using supplement oxygen therapy via nasal cannula at four (4) liters per minute. On 06/26/25 at 2:03 PM, Licensed Practical Nurse (LPN) #40 confirmed Resident #62's supplemental oxygen therapy was set to four (4) liters per minute. LPN #40 asked the resident if he had adjusted his oxygen rate, and the resident stated, no. LPN #40 set the resident's oxygen flow rate to two (2) liters per minute and stated he would check the resident's oxygen saturation level. No further information was provided through the completion of the survey process.

Based on observation, record review, and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. The facility failed to follow Enhanced Barrier Precautions (EBP) for a resident with indwelling medical devices. This was a random opportunity for discovery. Resident Identifier: #59. Facility census: 101. Findings included: a) Resident #59 The facility's policy titled, Enhanced Barrier Precautions, with implementation date 03/20/25 and revision date 03/20/25, stated Enhanced Barrier Precautions (EBP) would be followed for residents with indwelling medical devices including tracheostomy/ventilator tubes and feeding tubes. The policy also stated personal protective equipment would be worn for high-contact resident care activities for residents in EBP. High-contact resident care activities included care of medical devices, including tracheostomy care and feeding tube care. The policy also stated that enhanced barrier precautions may be followed for residents colonized with a multidrug-resistant organism not targeted by the Center for Disease Control but may be considered epidemiologically important. Review of Resident #59's physician's orders showed an order written on 03/18/25 for enhanced barrier precautions for history of Extended-Spectrum Beta-Lactamase (ESBL). The resident also had orders for tracheostomy care and percutaneous endoscopic gastrostomy (PEG) tube care. Outside of Resident #59's room was a sign stating, Stop. Enhanced Barrier Precautions. Everyone must: Clean their hands, including before entering and when leaving the room. Providers and staff must also: Wear gloves and a gown for the following High-Contact Resident Care Activities. Dressing Bathing/showering Transferring Changing Linens Providing Hygiene Changing Briefs or assisting with toileting Devise care or use: central line, urinary catheter, feeding tube, tracheostomy Wound care: any skin opening requiring a dressing. On 06/26/25 at 09:20 AM, Licensed Practical Nurse (LPN) #27 was observed providing indwelling medical device care to Resident #59. LPN #27 changed the inner cannula of the resident's tracheostomy. LPN #27 also changed the dressing on the resident's PEG tube and cleaned the PEG tube site. LPN #27 wore gloves for the procedures, but did not wear a gown as was indicated by the facility's EBP policy and procedures. On 06/26/25 at 10:10 AM, the Director of Nursing confirmed gowns were required to be worn by staff performing tracheostomy care and PEG tube care. No further information was provided through the completion of the survey process.

Based on record review and staff interview, the facility failed to ensure Resident #108 was free of chemical restraints. This was true for one (1) of six (6) residents reviewed under the care area of abuse. Resident Identifier: #108. Facility Census: 107. Findings Include: a1) Resident #108 On 05/19/25 at 12:30 PM, a record review was completed for Resident #108. The review found the resident had a physician's order for Ativan 0.5mg (milligram) by mouth every 12 hours as needed (PRN) on 05/18/24. The physician's order did not have a time limit. The monthly pharmacy review was completed on 05/23/24 with the recommendation to either discontinue the PRN Ativan or reorder with a specific number of days. The review was signed by the physician on 06/12/24. However, the physician's order was not changed until 07/06/24. At the time of the change, the PRN Ativan was ordered for 60 days. The review, also, found unacceptable reasons for two (2) doses of a PRN psychotropic medication. The first dose of PRN Ativan given on 06/12/24 noted the reason as Res (resident) refuses to stay in bed repeatedly attempting to get up without assistance. When in w/c (wheel chair) Res. attempts to transfer and ambulate unassisted as well. The second dose of PRN Ativan given on 06/26/24 at 10:19 PM was noted as Res. continuously attempting to get up unassisted. On 05/20/25 at 11:15 AM, the Director of Nursing (DON) was notified regarding the PRN Ativan. The DON stated, the monthly pharmacy recommendation was reviewed by the physician on 06/12/24. I'm not sure why the physician's order was not updated until 07/06/24. The regulation regarding chemical restraints states, When a medication is indicated to treat a medical symptom, the facility must: use the least restrictive alternative for the least amount of time; provide ongoing re-evaluation of the need for the medication; and not use the medication for discipline or convenience. a2) Behaviors and Non-Pharmacologic Interventions On 05/19/24 at 12:30 PM, a record review was completed for Resident #108. The review found the resident was administered 29 doses of PRN Ativan from 05/29/24 through 07/06/24 without any type of behaviors or non-pharmacologic interventions listed. The documentation listed increased agitation (from the physician's order) as the only behavior. The dates of the administration are as follows: --05/24/24 at 8:49 AM --05/28/24 at 9:44 PM --05/29/24 at 10:19 AM --06/01/24 at 1:25 PM --06/02/24 at 1:30 AM --06/03/24 at 10:40 PM --06/04/24 at 10:22 PM --06/06/24 at at 1:47 PM --06/07/24 at 3:12 AM --06/07/24 at 9:27 PM --06/10/24 at 7:31 PM --06/11/24 at 8:13 PM --06/15/24 at 7:33 PM --06/20/24 at 9:50 AM --06/21/24 at 12:19 PM --06/22/24 at 12:00 AM --06/22/24 at 12:26 PM --06/23/24 at 10:24 AM --06/24/24 at 1:49 PM --06/25/24 at 6:19 PM --06/26/24 at 6:45 AM --06/28/24 at 9:30 PM --07/01/24 at 8:57 AM --07/01/24 at 9:00 PM --07/02/24 at 1:30 PM --07/03/24 at 2:11 AM --07/04/24 at 2:00 AM --07/05/24 at 10:09 AM --07/06/24 at 12:06 PM On 05/20/25 at 2:00 PM, the DON was notified regarding the PRN Ativan. The DON stated, it was wrong not to list the behaviors or the interventions .we have changed how we document .education was given to the nurses in January, 2025.

Based on record review and staff interview, the facility failed to develop/implement the care plan for Resident #108 regarding non pharmacological interventions, restricted limb precautions for Resident #109, #15 and #91. This was true for four (4) of 13 residents reviewed during the survey process. Resident Identifiers: #108, #109, #15, and #91. Census: 107. Findings Include: a) Resident #108 On 05/19/25 at 12:30 PM, a record review was completed for Resident #108. The review found the resident did have a physician's order for Ativan 0.5mg (milligram) by mouth every 12 hours as needed (PRN). The care plan was reviewed and an intervention under the focus area of altered psychosocial needs r/t (related to) behaviors of resisting care, physical aggression and agitation exacerbated after family visits of provide non pharmacological interventions such as redirect with activity, offer food/fluid, offer reassurance/conversation, 1:1 (one on one). However, the review, also found the resident was administered 29 doses of PRN Ativan which did not include specific behaviors or non pharmacological interventions. The dates are as follows: --05/24/24 at 8:49 AM --05/28/24 at 9:44 PM --05/29/24 at 10:19 AM --06/01/24 at 1:25 PM --06/02/24 at 1:30 AM --06/03/24 at 10:40 PM --06/04/24 at 10:22 PM --06/06/24 at at 1:47 PM --06/07/24 at 3:12 AM --06/07/24 at 9:27 PM --06/10/24 at 7:31 PM --06/11/24 at 8:13 PM --06/15/24 at 7:33 PM --06/20/24 at 9:50 AM --06/21/24 at 12:19 PM --06/22/24 at 12:00 AM --06/22/24 at 12:26 PM --06/23/24 at 10:24 AM --06/24/24 at 1:49 PM --06/25/24 at 6:19 PM --06/26/24 at 6:45 AM --06/28/24 at 9:30 PM --07/01/24 at 8:57 AM --07/01/24 at 9:00 PM --07/02/24 at 1:30 PM --07/03/24 at 2:11 AM --07/04/24 at 2:00 AM --07/05/24 at 10:09 AM --07/06/24 at 12:06 PM On 05/20/25 at 2:00 PM, the Director of Nursing (DON) was notified regarding the PRN Ativan not having any specific behaviors or non pharmacological interventions listed. The DON stated, it was wrong not to list the behaviors or the interventions .we have changed how we document .education was given to the nurses in January 2025. implement care plan regarding the invention of do not draw blood or take b/p in left arm d/t fistula. b) Resident #109 On 05/19/24 at 9:30 AM, a record review was completed for Resident #109. The review found a physician's order dated 06/22/23 of do not take B/P (blood pressure on left arm and an additional physician's order dated 06/22/23 of location of dialysis fistula: left upper arm. Upon further review, the care plan was not implemented under the focus area of (Name of Resident) receives hemodialysis r/t ESRD (end stage renal disease). The intervention of do not draw blood or take B/P in left arm d/t fistula. The following dates indicate the blood pressure was taken in the left arm: --06/22/23 at 3:03 PM --06/23/23 at 3:44 AM --06/23/23 at 8:38 PM --06/24/23 at 10:42 PM --06/26/23 at 12:30 AM --06/26/23 at 2:59 PM --06/27/23 at 3:25 PM --06/30/23 at 12:51 AM --07/01/23 at 3:48 AM --07/02/23 at 1:29 PM --07/05/23 at 1:38 AM --07/05/23 at 2:07 PM --07/06/23 at 3:13 AM --07/06/23 at 11:55 AM --07/10/23 at 11:02 PM --07/14/23 at 10:03 PM --07/18/23 at 11:25 PM --07/19/23 at 3:30 PM --07/20/23 at 1:15 AM --07/21/23 at 4:07 AM --07/23/23 at 11:04 PM --07/31/23 at 9:56 AM --08/06/23 at 2:57 AM --08/06/23 at 11:33 PM --08/10/23 at 11:31 PM --08/11/23 at 10:55 PM --08/23/23 at 1:21 PM --09/17/23 at 10:02 AM --10/23/23 at 1:54 PM --10/25/23 at 12:17 AM --10/26/23 at 9:55 AM --10/27/23 at 4:18 PM --10/27/23 at 7:38 PM --10/29/23 at 9:49 AM --11/03/23 3:18 AM --11/04/23 at 12:55 AM --11/05/23 at 8:54 AM --11/08/23 at 12:09 AM --11/09/23 at 2:55 AM --11/10/23 at 12:29 PM --11/27/23 at 10:54 AM On 05/22/24 at 10:00 AM, the DON was notified and confirmed the care plan was not implemented regarding the restricted limb. c) Resident #15 On 05/19/25 at 10:30 AM, a record review was completed for Resident #15. The review found a physician's order dated 12/31/24 Do not take B/P on right arm every shift. The care plan under the focus area of the resident has renal insufficiency r/t d/x (diagnosis) of end stage renal disease and receives dialysis 3x (three times) weekly did list the interventions of Do not take B/P on right arm every shift and location of dialysis shunt is left arm. The documentation under the vitals tab did indicate the B/P was taken on the right arm on the following dates: --01/01/25 at 1:30 AM --01/08/25 at 8:08 PM --02/10/25 at 8:11 AM --02/17/25 at 8:53 PM --02/22/25 at 9:26 PM --02/24/25 at 8:08 AM --03/03/25 at 9:11 AM --03/10/25 at 9:28 AM --03/11/25 at 9:17 AM --03/15/25 at 8:43 AM --03/18/25 at 9:35 PM --03/19/25 at 8:06 AM --03/20/25 at 9:52 AM --03/20/25 at 8:17 PM --03/24/25 at 8:05 AM --03/24/25 at 9:38 PM --03/25/25 at 8:37 AM --03/25/25 at 9:39 AM --04/07/25 at 8:03 AM --04/14/25 at 8:07 AM --04/21/25 at 8:32 AM On 05/22/24 at 10:00 AM, the DON was notified and confirmed the care plan was not implemented regarding the restricted limb. d) Resident #91 On 05/19/25 at 11:00 AM, a record review was completed for Resident #91. The review did not find a physician's order to not take the blood pressure in the restricted limb. The review, also, found the care plan had not developed an intervention of under the focus area of the resident has renal insufficiency r/t d/x of end stage renal disease and receives dialysis 3x weekly to not take B/P in the left arm d/t a dialysis shunt. On the following dates the blood pressure was taken in the restricted limb: --04/19/25 at 1:55 AM --04/20/25 at 11:56 PM --04/22/25 at 6:03 AM --04/24/25 at 1:11 AM --04/25/25 at 1:31 AM --04/25/25 at 11:11 PM --04/27/25 at 12:42 AM --05/01/25 at 2:35 AM --05/07/25 at 7:12 AM --05/08/25 at 1:14 AM --05/08/25 at 5:16 PM --05/11/25 at 1:05 AM --05/13/25 at 2:27 AM --05/14/25 at 12:42 AM --05/15/25 at 6:45 AM --05/15/25 at 11:02 PM --05/18/25 at 4:17 AM On 05/22/24 at 10:00 AM, the DON was notified and confirmed the care plan was not developed regarding the restricted limb.

Based on record review and staff interview, the facility failed to follow physician's orders regarding restricted limb precautions for Resident #109, #15 and #91. This was true for four (3) of 13 residents reviewed during the survey process. Resident Identifiers: #109, #15, and #91. Census: 107. Findings Include: a) Resident #109 On 05/19/24 at 9:30 AM, a record review was completed for Resident #109. The review found a physician's order dated 06/22/23 of do not take B/P (blood pressure on left arm and an additional physician's order dated 06/22/23 of location of dialysis fistula: left upper arm. Upon further review, the physician's order was not followed. The following dates indicate the blood pressure was taken in the left arm: --06/22/23 at 3:03 PM --06/23/23 at 3:44 AM --06/23/23 at 8:38 PM --06/24/23 at 10:42 PM --06/26/23 at 12:30 AM --06/26/23 at 2:59 PM --06/27/23 at 3:25 PM --06/30/23 at 12:51 AM --07/01/23 at 3:48 AM --07/02/23 at 1:29 PM --07/05/23 at 1:38 AM --07/05/23 at 2:07 PM --07/06/23 at 3:13 AM --07/06/23 at 11:55 AM --07/10/23 at 11:02 PM --07/14/23 at 10:03 PM --07/18/23 at 11:25 PM --07/19/23 at 3:30 PM --07/20/23 at 1:15 AM --07/21/23 at 4:07 AM --07/23/23 at 11:04 PM --07/31/23 at 9:56 AM --08/06/23 at 2:57 AM --08/06/23 at 11:33 PM --08/10/23 at 11:31 PM --08/11/23 at 10:55 PM --08/23/23 at 1:21 PM --09/17/23 at 10:02 AM --10/23/23 at 1:54 PM --10/25/23 at 12:17 AM --10/26/23 at 9:55 AM --10/27/23 at 4:18 PM --10/27/23 at 7:38 PM --10/29/23 at 9:49 AM --11/03/23 3:18 AM --11/04/23 at 12:55 AM --11/05/23 at 8:54 AM --11/08/23 at 12:09 AM --11/09/23 at 2:55 AM --11/10/23 at 12:29 PM --11/27/23 at 10:54 AM On 05/22/24 at 10:00 AM, the DON was notified and confirmed the physician's order was not followed regarding the restricted limb. b) Resident #15 On 05/19/25 at 10:30 AM, a record review was completed for Resident #15. The review found a physician's order dated 12/31/24 Do not take B/P on right arm every shift. The documentation under the vitals tab did indicate the B/P was taken on the right arm on the following dates: --01/01/25 at 1:30 AM --01/08/25 at 8:08 PM --02/10/25 at 8:11 AM --02/17/25 at 8:53 PM --02/22/25 at 9:26 PM --02/24/25 at 8:08 AM --03/03/25 at 9:11 AM --03/10/25 at 9:28 AM --03/11/25 at 9:17 AM --03/15/25 at 8:43 AM --03/18/25 at 9:35 PM --03/19/25 at 8:06 AM --03/20/25 at 9:52 AM --03/20/25 at 8:17 PM --03/24/25 at 8:05 AM --03/24/25 at 9:38 PM --03/25/25 at 8:37 AM --03/25/25 at 9:39 AM --04/07/25 at 8:03 AM --04/14/25 at 8:07 AM --04/21/25 at 8:32 AM On 05/22/24 at 10:00 AM, the DON was notified and confirmed the physician's order was not followed regarding the restricted limb. c) Resident #91 On 05/19/25 at 11:00 AM, a record review was completed for Resident #91. The review did not find a physician's order to not take the blood pressure in the restricted limb. On the following dates the blood pressure was taken in the restricted limb: --04/19/25 at 1:55 AM --04/20/25 at 11:56 PM --04/22/25 at 6:03 AM --04/24/25 at 1:11 AM --04/25/25 at 1:31 AM --04/25/25 at 11:11 PM --04/27/25 at 12:42 AM --05/01/25 at 2:35 AM --05/07/25 at 7:12 AM --05/08/25 at 1:14 AM --05/08/25 at 5:16 PM --05/11/25 at 1:05 AM --05/13/25 at 2:27 AM --05/14/25 at 12:42 AM --05/15/25 at 6:45 AM --05/15/25 at 11:02 PM --05/18/25 at 4:17 AM On 05/22/24 at 10:00 AM, the DON was notified and confirmed there was no physician's order regarding the restricted limb.

Based on Observation, staff and resident interview the facility failed to provide a homelike environment for resident # 78. Resident ' s privacy curtain had several stains. This was true for on (1) of five (5) residents reviewed for environment. Facility Census 107. Findings included: a) An observation on 05/21/25 at 10:30 AM, Resident #78 ' s privacy curtain had several large, red stains and a brown stain. Resident ' s roommate, resident #69 stated that the curtain had been stained for at least a couple of days. b) During an interview with Nurse Aide (NA) #28 acknowledged that the curtain was stained and in need of cleaning. She reported that when they notice the stains they will notify housekeeping who will change and clean the curtains.

Based on observation and staff interview the facility failed to ensure the residents environment over which it had control was free from accident hazards. There was an unlocked medication room that contained medicaitons on the dementia care unit. This was a random opportunity for discovery. The deficient practice put all 23 residents currently residing on the dementia care unit at risk for serious injury, serious harm, serious impairment, or death. Resident identifiers: #56, #88, #59, #67 #33, #87, #43, #37, #13, #66, #68, #14, #86, #70, #8, #81, #54, #78, #19, #48, #1, #52, and #6. Facility Census: 91. Findings included: a) Record review of the facility's policy titled, Storage of Medications, with revision date November 2020, showed: -Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity control. Only persons authorized to prepare and administer medications have access to locked medications. - The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. -Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended. -Medications requiring refrigeration are stored in a refrigerator located in the drug room at the nurses ' station or other secured location. An observation on 12/04/23 from 10:32 AM to 10:44AM found the Alzheimer's unit medication room unsecure and unattended and allowing access to medication by residents, unauthorized staff, or visitors. The medication room remained unlocked until the surveyor's intervention. At 10:44 am the certified nursing assistant was asked to find the unit manager. Once Unit Manager #91 arrived and realized the door to the medication room was unlocked and the door latch was loose with the screws backing out, she went and got Licensed Practical Nurse (LPN) # 46. When the LPN arrived at the medication room the following items were found in the room and were accessible to all residents currently residing on the dementia care unit: In the Refrigerator: -Trulicity -Novolog -Basaglar -Tuberculin -Prevar In an unlocked cabinet: - Cigarettes -Amiodarone hcL -ELIQUIS -Promethazine -Allopurinol -Ondansetron -Bethanechol -Methocarbamol -Warfarin -Trazodone -Escitalopram -Isosorbide Mononitrate -Carvedilol -Atorvastatin -Ezetimibe -Clorindione -Ropinirole -Furosemide -Clopidogrel Many over the counter medication was located on an open shelf. The facility was notified of the immediate jeopardy (IJ) at 1:33 PM on 12/04/23. The facility submitted their first abatement plan of correction (POC) at 3:57 PM on 12/04/23. The state agency requested changes and the second abatement POC was submitted at 4:18 PM on 12/04/23. The abatement POC was accepted by the state agency at 4:26 PM on 12/04/23. After observation of the implementation of the abatement POC, the IJ was abated at 10:30 AM on 12/05/22. The IJ started on 12/04/23 and ended on 12/05/23. The facility's approved abatement POC consisted of the following: -The door to the Life Enrichment Unit (LEU) medication room was immediately locked. -This affected all Residents in the LEU but did not affect any of the unit as the unit is not accessible to other residents. -Change door lock to a self-locking doorknob. This will be completed today by the maintenance staff. -All staff in the facility at this time will be educated related to ensuring that all required doors are always locked, by the Staff Development Nurse. All staff will be educated before working in order to ensure all doors remain locked at all times, staff will be educated by the Staff Development Nurse or designee. -All doors required to be locked will be checked twice a shift by the Charge Nurse on that Hallway. Doors will be checked twice a day for 14 days then once a day for 30 days, will reassess the need for monitoring at that time. Any doors found unlocked will be immediately locked and staff present will be educated related to locking the doors. Documentation of the door checks will be reviewed each morning in clinical meetings to ensure that checks are being completed as planned. DISCLAIMER: The preliminary findings and subsequent abatement plan are not an admission of wrongdoing, but an acknowledgement of the surveyor's preliminary findings. During an interview, on 12/04/23 10:58 AM, Unit Manager #91 and Licensed Practical Nurse (LPN) #46, verified the medication room should have been locked when unattended.

Based on record review, staff interview, and resident interview the facility failed to protect Resident #34 from sexual abuse resulting in actual psychosocial harm. The facility failed to ensure Resident #34 was safe and not exposed to continued sexual abuse from Resident #10. This was a random opportunity of discovery. Resident identifier: #34, #10. Facility Census: 91. Findings included: a) Resident #34 A review of the facility reportables on 12/04/23 at 10:30 AM revealed the following Adult Protective Services (APS) Mandatory Reporting Form dated 11/23/23. The form contained the following information: The Alleged Victim Resident #34 The Alleged Perpetrator Resident #10 The date of incident: 11/23/23 Time of Incident: 7:25 PM Where Incident occurred: Facility Lobby Describe incident: Perpetrator accused of sexual misconduct of victim. How long has the abuse existed? one episode today and previous episodes exist. A review of the following Statement/Interview Documentation Forms revealed the following information pertaining to this incident: -- Form dated 11/23/23 Nurse Aide (NA) #54 reported she was leaving the building and spotted Resident #34 sitting in her chair in front of the fireplace in the lobby. Resident #10 was standing in front of her with his penis in her mouth. His pants were down around his thighs. NA #54 redirected both residents to their rooms and notified the nurse on duty. -- Form dated 11/23/23 Resident #34 stated He was trying to get close to me and I didn't want him to. He stated that he wanted me to suck him out and another words he wants to (F***) me, and I don't want to (F***) him. He tried to put his penis in my mouth, but he couldn't do it. -- Form dated 11/23/23 Resident #10 stated, I'm not incriminating myself. -- Form dated 11/24/23 Staff # 54 stated I, (First and Last name of NA #54), was working on Thursday November 23, 2023. I had clocked out at 7:32 PM and was walking toward the front of the building. That's when I saw resident, #10, standing up in front of the fireplace with his pants down. While another Resident #34 giving him a blow job (the act of stimulating a man's penis with the mouth for sexual pleasure). I had redirected them. Then I went back to west hall to report it to (Licensed Practical Nurse LPN #4's name) A review of Resident #34's medical records on 12/04/23 at 2:13 PM found the following progress notes: Resident #34 had a diagnosis of mild intellectual disability. -11/24/23 at 2:00 PM typed as written SW (Social Worker) met with the resident, (Resident #34 name). She discussed with SW the incident that happened with a male resident. (Resident #34 name) related feeling safe and not afraid. During the course of the conversation, (Resident #34 name) started talking about her childhood and some of the abuse that she sustained at a young age. -A Comprehensive Encounter on 12/01/23 at 5:00 PM typed as written Per nursing, noticed a change in resident's behavior and does not seem to be herself. The patient states that she is feeling not good and her mood is up and down -11/27/23 at 2:00 PM typed as written Patient has experienced crime related events: Sexual Assault- rape, attempted rape, made to perform sexual acts against consent . Patient has experienced environmental events: None of the above Trauma Responses: Upsetting thoughts or memories about any of the above mentioned come into your mind against your will? Yes. A follow up interview with the Social Worker on 12/07/23 at 8:47 AM, confirmed that during her interview with Resident #34 on 11/24/23 at 2:00 pm, Resident #34 disclosed to her she had been sexually abused previously by her family at a young age. During a record review on 12/04/23 at 12:56 PM of Resident #10's medical records the following notes were found: -09/06/23 at 11:12 AM Resident to Resident encounter of verbal sexual abuse to Resident #57. -11/09/23 at 11:00 AM Resident to Resident encounter of verbal sexual abuse to Resident #34. -11/09/23 at 3:55 PM Resident to Resident encounter of verbal sexual abuse to Resident #34. -11/12/23 at 11:39 AM Resident to Resident encounter of verbal sexual abuse to Resident #34. -11/23/23 at 11:04 AM Resident to resident encounter of sexual nature with Resident #37. During the review of the facility's APS Mandatory Reporting Forms on 12/04/23 at 10:30 AM revealed a form dated 06/22/23. The Alleged Victim was Resident #72, and the Alleged Perpetrator was Resident #10. Describe incident: (First and last name of Resident #10) told (First and Last name of Resident #72) if she would suck his (d***) he would give her a cigarette. Describe action taken to prevent further abuse/neglect: (First and last name of Resident #10) has been told to not go into resident's room. Between 09/06/23 and 11/23/23 at the time of the sexual abuse of Resident #34 Resident #10 had six (6) instances of inappropriate sexual behavior. The facility failed to identify his pattern of behavior and take steps to ensure the safety of Resident #34. During an interview on 12/05/23 at 8:25 AM the Administrator stated, (Resident #10's name) has had sexual behaviors. We have tried several things, like 15-minute checks, room changes, medication changes and alternative placement. I know the medical records were void of any evidence of the placement attempts by the previous Social Worker. The situation is unfortunate. He has a lot of street smarts and knows how to answer questions to keep himself out of trouble. During an interview on 12/06/23 at 2:36 PM the Administrator stated some of the incidents involving (Resident #10's name) I was not aware of. Then we looked at everything, if it was not hands on it did not get reported. I am not saying it is ok but if it was not an actual physical situation it was not reported. The Administrator was asked when resident #10 fondled Resident #37's breast, why did you not report it? The Administrator stated it was just an attempt to fondle the breasts, he did not touch them. I felt the staff did not report an attempt because they stopped it before it happened. I am not saying that this was handled appropriately. We have a need for education on reporting. The Administrator was asked Was the incident on 11/23/23 involving Resident #34 reported to the police? The administrator stated yes but it was reported but no documentation was done because they never returned my phone calls. The Administrator was asked why was (Resident #10 name) on 1:1 prior to 11/23/23 incident to ensure the safety of Resident #34? The Administrator stated, I am not sure, I would have to look at the timeline. No evidence of documentation of a timeline was ever presented to the Survey team prior to the exit. The Administrator stated there was a misconception of what was and was not abuse. I do not read notes daily and nursing must have not caught that information. b) Facility's abuse policy A review of the facility policy titled Freedom from Abuse and Neglect Policy found the following: Training: .3. Staff members will identify and assess suspected or alleged reports of abuse and neglect. Types of abuse may include: .C. Rape or other sexual 1. Sexual harassment 2. Sexual assault 3. Sexual coercion

Based on record review, resident interview, and staff interview, the facility failed to treat pain to the extent possible in accordance with professional standards of practice. This caused harm to the resident by causing uncontrolled pain and an emergency room visit for this uncontrolled pain. This was true for one (1) of two (2) residents reviewed for the care area of pain. Resident identifier: #22. Facility census: 90. Findings included: a) Resident #22 During an initial interview on 11/14/22 at 3:33 PM, Resident #22 reported pain from a fractured pelvis. She stated she received Tramadol for pain, which lessened but did not totally eliminate her pain. Review of Resident #22's medical records showed the resident was admitted [DATE] at 7:15 PM. Resident #22's diagnoses included fibromyalgia, pain in the shoulder, pain in the knee, osteoarthritis, and fracture of the pelvis with routine healing. She also had diabetic foot ulcers to both feet. A progress note written on 11/03/22 at 10:30 PM stated, Resident arrived at 1915 by [ambulance service]. [Ambulance service] stated that the patient had already been crying about her pain level and needed pain medication. Transferred patient from the stretcher to the bed and took her V/S [vital signs] which were BP [blood pressure]163/79, hr [heart rate] 98, resp [respiratory] 20, o2 [oxygen] 93, and temp [temperature] 98.0. Resident had 2 diabetic ulcers, one on each foot. Pain level was at a 10 she stated. Started crying and yelling. I called to get a prn [as needed] Tylenol order but that wasn't good enough to help with the pain she stated and then she wanted to be sent back to the hospital. Nursing supervisor is aware, and patient has capacitated. Resident was sent to the hospital for more observation. Will continue to monitor. (Typed as written.) Resident #22 returned to the facility on [DATE] at 10:55 PM. A progress note written at that time stated, Resident was sent out to [hospital] at 2200 for uncontrollable pain. She stated that her pain level was at a 10. She has capacity. [Hospital] call at 2230 and stated that they were sending her back. I asked if they helped with her pain. They stated that, she will tell you no that they didn't, but they gave her a tramadol. I asked if I could call them back to make sure we could still take her with her pain level that high. The nurse stated, Well she is already on her way and should be coming through the doors as we speak. The resident was transferred x2 from stretcher to bed. She has been admitted to us with a fracture pelvis, history of falls, shoulder pain, knee pain, inability to walk, x2 foot ulcers due to secondary DM [diabetes mellitus], Diabetes and Hip pain-swelling. Her pain comes from her hip and feet she stated. At this time, she is in bed in the lowest position with her eyes open, with call light within reach. NP [nurse practitioner] and [doctor] has been paged and supervisors are aware. Will continue to monitor. (Typed as written.) Review of Resident #22's medical records showed a pain evaluation assessment was started upon Resident #22's admission 11/03/22 at 7:15 PM. The pain assessment was signed on 11/04/22 at 4:59 AM. The assessment stated the resident's pain level was currently rated as a 10 on a scale from 1-10, with 10 being the worst pain imaginable. The pain locations were listed as the right heel, left heel, coccyx, and right trochanter (hip). According to the assessment form, For each site listed, describe type of pain (stabbing, burning, sharp, dull, throbbing), duration, and frequency and whether it is continuous or intermittent in the description box. The descriptions of the pain were ulcer for the right heel, ulcer for the left heel, moisture for the coccyx, and pelvic fracture for the right trochanter (hip). The pain assessment recorded Resident #22 stated pain was improved by pain medication and worsened by movement. The resident also reported the pain affected sleep and rest, social activities, appetite, physical activity and mobility, emotions, and intimacy. A comment on the pain assessment stated, Resident arrived at 1915 and was crying out in pain. She was sent back out for uncontrolled pain, and they gave her a tramadol and sent her right back. Resident was still in pain at a 10 she stated. There was no indication in the medical records that Resident #22's continued pain level of 10 when she returned from the hospital was addressed. Further review of Resident #22's medical records showed on 11/04/22 an order was written for acetaminophen (Tylenol) 325 milligrams (mg), two (2) tablets every six (6) hours as needed for mild to moderate pain in the shoulder and knee. Review of Resident #22's Medication Administration Record (MAR) showed the resident did not receive any Tylenol until 11/08/22. The following order was written on 11/04/22, Non-pharmacological techniques attempted to alleviate pain. 1. Offer snack or drink. 2. Offer diversion activity- reframing guided imagery. 3. Determine if toileting would be beneficial. 4. Determine if sleep or relaxation techniques would be beneficial. 5. Reposition affected area. 6. Offer cold or heat application. 7. Massage, pressure or vibration techniques. 8. Offer exercise or task to distract thoughts of pain. Every shift for pain, document all non-pharmacological interventions listed (numerical intervention) above. The resident's MAR showed check marks to indicate the order had been completed, but the specific non-pharmacological interventions attempted were not documented on the MAR. A nursing note written on 11/4/2022 at 2:47 PM stated, Resident continues to be monitored related to new admission; resident intermittently c/o [complaints of] pain in legs and hips, turning and repositioning effective. This was the only nursing note written regarding non-pharmacological interventions for Resident #22's pain. Resident #22 also had an order written on 11/04/22 to Observe resident for signs and symptoms of pain every shift. No pain=0, mild pain 1-4, moderate pain 5-7, and severe pain 8-10. On night shift on 11/04/22, the resident's pain was reported as 0. On 11/04/22, the resident was prescribed pregabalin (Lyrica), 300 mg, twice a pain for fibromyalgia. The medication was not available from the pharmacy until 11/05/22 at 9:00 AM. Resident #22 also had an order written on 11/04/22 for aspirin, 81 milligrams (mg), one (1) capsule by mouth one time a day for moderate pain. This low dose of aspirin is usually prescribed to prevent heart attack and strokes for people with risk factors for these conditions. Resident #22 had diagnoses of atherosclerosis and hypertension. The resident also had a previous history of a heart attack. The order was discontinued on 11/07/22. The MAR showed the resident received aspirin daily from 11/04/22 through 10/07/22. The resident's pain level was recorded on the MAR before aspirin administration and was recorded as 0 for 11/04/22. The following note was written on 11/4/2022 at 11:55 PM, Resident asked to be transferred out to the hospital for uncontrolled pain. Stated she has capacity. I asked what hospital she would like to go to, and she said it's her right not to tell me because she plans on not coming back. She signed the bed hold refusal and transfer forms. Will continue to monitor. The following note was written on 11/05/22 at 1:30 AM, Resident Returned from [hospital] at 1330. Report was called in by [nurse's name]. Resident received Tramadol 50mg for pain. Resident stated she wanted to come back to Glasgow Health and Rehab. [Doctor] is aware of her going out to the hospital for uncontrolled pain and that she came back with a new order for Tramadol 50 mg every 12 hours as needed for pain. Will continue to monitor. Following her return from the hospital on 11/05/22, Resident #22 received Tramadol twice a day for reported pain levels of 4-10. The resident's MAR reported the medication was effective at relieving her pain. On 11/09/22, the Tramadol's frequency was changed to every six (6) hours as needed for pain. Resident #22 continued to receive Tramadol two (2) to four (4) times a day for reported pain levels of 4-10. The resident's MAR reported the medication was effective at relieving her pain. On 11/16/22 at 1:12 PM, Resident #22 was interviewed regarding her transfer to the hospital on 11/04/22 for pain control. The resident stated she had been having pain all day. She thought the facility was giving her Tramadol for pain before her emergency room evaluation on 11/04/22 but stated that she went to the emergency room because she wanted a stronger pain medication. During an interview on 11/16/22 at 1:43 PM, the Director of Nursing (DON) stated Resident #22 was not prescribed pain medication after her emergency room visit on 11/03/22 because the emergency room physician did not order any medication. The DON acknowledged the facility's doctor could have prescribed pain medication. The DON stated Resident #22 was prescribed Tramadol after her emergency room visit on 11/04/22 because the emergency room physician ordered the medication. The DON also stated the resident's order for aspirin for moderate pain was incorrect, and this dosage of aspirin was not used to treat pain. No further information was provided through the completion of the survey process.

Based on resident interview, resident observation, record review and staff interview the facility failed to provide the necessary behavioral health care and services to assist the resident in attaining or maintaining the highest practicable physical, mental, and psychosocial well-being for Resident #85 following the death of his son. Observations of the resident found him to be very tearful and suffering from mental anguish. The facility had provided no grief counseling or any mental health services to help Resident #85 deal with the passing of his his son. This failure resulted in actual psychosocial harm for Resident #85 who was suffering grief on his own without any assistance from facility staff to help lessen the effects of his grief. Resident Identifier: #85 Facility Census: 90 Findings included: a) Resident #85 On [DATE] at 3:04 PM during the initial interview process Resident #85 was very tearful, depressed and emotional. He was lying in the bed in the dark. He stated his son had recently died . He explained the history of the residents ex-wife passing away when his son was just nine (9) years old and he had raised the boy alone. He was all he had and they were very close. On [DATE] at 1:10 PM this surveyor went back to speak with the Resident again and he was flipping through pictures on his cell phone. When asked if he was OK, he stated he was just looking at pictures of his son on his cell phone. Again he was tearful and very emotional. I asked him if he was able to go to the funeral, he stated he was. He further explained another relative found his son dead in the bed in their trailer that the Resident and son shared before he came to the facility. I asked the Resident if he would like to speak to someone concerning his loss. He stated he really thinks he needs to, he had been in Vietnam and this was even worse than what he saw there. He indicated no one at the facility had spoken with him about the loss of his son or his feelings about it. He further stated they had not offered to set up any counseling for him. A review of the residents care plan found no interventions related to helping the resident deal with the grief of losing his son. The care plan goal stated, .his son recently passed away and (First Name of Resident # 85) is very upset. Revision date [DATE]. However the care plan was void of any interventions to help the resident with his grief. A nurses note dated [DATE] at 1:51 Pm written by the Assistant Director or Nursing (ADON) read as follows, Resident reviewed in IdT. weight loss continues. Res no eating well according to staff. Res did have a son that passed away this week and has affected him a great deal. Facility staff was aware the resident was very upset about his son's passing and noted it was, affecting him a great deal, but failed to intervene in any form or fashion to help the resident process his grief to begin the healing process. Resulting in lasting mental anguish and psychosocial harm for Resident #85. The above was confirmed with the Administrator on [DATE] at 10:00 AM and no further information was provided.

Based on observation, resident interview, staff interview and record review, the facility failed to ensure Resident #54 received the necessary dental services to ensure he was pain free and able to attain his highest practicable physical well-being. Resident #54 was to have teeth extracted the facility has failed to make the arrangements for Resident #54 to have his teeth extracted. This failure has resulted in actual harm for Resident #54 because he has continued pain from the teeth which are in poor condition. This was true for one (1) of two (2) residents reviewed for the care area of dental status. Resident identifier: #54. Facility census: 90. Findings included: a) Resident #54 On 11/14/22 at 3:00 PM an observation and Interview, found Resident #54 had missing teeth. He stated that his teeth hurt, and he needs a dental appointment. Resident #54 stated that the facility was supposed to make him an appointment, but never has. He indicated his teeth are painful and he really needs them extracted. A care plan review found: Focus: -- Resident has the potential for oral health problems d/t he is edentulous and requires staff assistance with oral care. Goal: -- Resident will comply with mouth care at least daily through review date. Interventions included: -- Coordinate arrangements for dental care, transportation as needed/as ordered. -- Observe/document/report any signs or symptoms of oral/dental problems needing attention: Pain (gums, toothache, palate), Abscess, Debris in mouth, Lips cracked or bleeding, Teeth missing, loose, broken, eroded, decayed, Tongue (black, coated, inflamed, white, smooth), Ulcers in mouth, Lesions. A medical record review for Resident #54 revealed, a 360-care dental summary report completed 05/26/21 with the doctors note: Resident #54 has three (3) teeth that need extracted. Referral left with facility. A continued medical record review revealed, Resident #54s oral health assessment completed 07/16/21, noted broken, loose or carious teeth. No other dental assessments completed. 11/16/22 9:04 AM the Director of Nursing (DON) verified Resident #54s dental assessments should have been completed but, they were missed. Subsequent Medical record review found, consent for dental surgery signed on 02/17/22. The Physician clearance for dental treatment completed and signed on 02/16/22. A second oral surgery referral from 360 Care was made again on 07/12/22 for (5) teeth. On 11/16/22 at 11:00AM the Director of Nursing (DON) confirmed Resident #54s dental extraction appointments were canceled and never rescheduled.

Based on observation, record review and staff interview the facility neglected to ensure sufficient fluid intake was provided to maintain proper hydration and electrolyte balance for Resident #3. This deficient practice caused actual harm to Resident #3 due to the facility's failure to timely identify and treat severe dehydration that resulted in the Resident being hospitalized . This failed practice had the potential to affect a limited number of Residents. Resident identifier: #3. Facility census: 75. Findings included: a) Hydration Policy Record review of the facility's policy titled, Hydration Management, dated July 2017, found the facility's general guideline for determining baseline daily fluid intake is to multiply the resident's body weight in kilograms(kg) times 30 cc. (2.2lbs = 1kg). Using this formula Resident #3 should have received approximately 2007 cc/ml of fluid daily for the weight of 147.1 lb. that was obtained on 11/22/2021. Please note cc. (cubic centimeters) are the same as ml. (milliliters). b) Laboratory (labs) Report Record review of Resident #3's laboratory report dated 11/29/21 showed abnormal results for the following values: White Blood Count (WBC) 12.1. Normal reference range - 3.4 - 11.8. Sodium (Na) 156. Normal reference range 136 - 142. Chloride 117. Normal reference range 96 - 110. (Chloride is an important electrolyte and works to ensure that your body's metabolism is working correctly due to dehydration.) c) Nurse Practitioner (NP) Progress Note Review of physician progress noted dated 11/30/21 showed documentation from the Nurse Practitioner (NP) that stated reason for the provider was to address abnormal labs nursing reported for Resident #3 on 11/29/21. The NP noted the lab values from the report, with a treatment plan to repeat the Complete Blood Count (CBC) in one week. An order was entered in the Resident's chart that stated CBC on 12/09/21. No repeat labs were obtained per the provider's order and was verified as not obtained by the Director of Nursing on 01/12/22 at 11:02 AM. d) Oral Intake Review of Resident #3's hydration intake documentation from two weeks prior to the hospitalization that occurred on 12/14/21 indicated Resident was not receiving the appropriate recommended amount of oral hydration. Resident #3 should have received at least 2007 ml of fluid daily. The Resident received the following amount of daily oral hydration: 12/01/21: 1080 ml. Resident was also documented to have consumed 75% of the 4oz 2 Cal Supplement at 9:00 AM and 100% of the 4 oz 2 Cal Supplement at 9:00 PM. 12/02/21: 840 ml. Resident was also documented to have consumed 100% of the 4oz 2 Cal Supplement at 9:00 AM and 100% of the 4 oz 2 Cal Supplement at 9:00 PM. 12/03/21: 720 ml. Resident was also documented to have consumed 100% of the 4oz 2 Cal Supplement at 9:00 AM and 100% of the 4 oz 2 Cal Supplement at 9:00 PM. 12/04/21: 760 ml. Resident was also documented to have consumed 25% of the 4oz 2 Cal Supplement at 9:00 AM and 100% of the 4 oz 2 Cal Supplement at 9:00 PM. 12/05/21: 960 ml. Resident was also documented to have consumed 50% of the 4oz 2 Cal Supplement at 9:00 AM and 100% of the 4 oz 2 Cal Supplement at 9:00 PM. 12/06/21: 960 ml. Resident was also documented to have consumed 100% of the 4oz 2 Cal Supplement at 9:00 AM and 100% of the 4 oz 2 Cal Supplement at 9:00 PM. 12/07/21: 720 ml. Resident was also documented to have consumed 100% of the 4oz 2 Cal Supplement at 9:00 AM and 100% of the 4 oz 2 Cal Supplement at 9:00 PM. 12/08/21: 720 ml. Resident was also documented to have consumed 50% of the 4oz 2 Cal Supplement at 9:00 AM and 100% of the 4 oz 2 Cal Supplement at 9:00 PM. 12/09/21: 540 ml. Resident was also documented to have consumed 100% of the 4oz 2 Cal Supplement at 9:00 AM and 100% of the 4 oz 2 Cal Supplement at 9:00 PM. 12/10/21: 600ml. Resident was also documented to have consumed 25% of the 4oz 2 Cal Supplement at 9:00 AM and 75% of the 4 oz 2 Cal Supplement at 9:00 PM. 12/11/21: 720ml. Resident was also documented to have consumed 50% of the 4oz 2 Cal Supplement at 9:00 AM and 100% of the 4 oz 2 Cal Supplement at 9:00 PM. 12/12/21: 960 ml. Resident was also documented to have consumed 50% of the 4oz 2 Cal Supplement at 9:00 AM and 50% of the 4 oz 2 Cal Supplement at 9:00 PM. 12/13/21: 60ml. Resident was also documented to have consumed none of the 4oz 2 Cal Supplement at 9:00 AM and 50% of the 4 oz 2 Cal Supplement at 9:00 PM. 12/14/21: 360ml. Resident was also documented to have consumed 50% of the 4oz 2 Cal Supplement at 9:00 AM and was out of facility at hospital during the 9:00 PM medication pass. e) Registered Dietician (RD) Interview During an interview on 01/11/22 at 2:46 PM, the Registered Dietician (RD) stated the Resident should be receiving around '1600'ish' [1600 milliliters (ml)] of oral hydration a day. The Resident's daily oral fluid intake ranged from 60 ml per day to 1080 ml per day for 12/01/21 - 12/14/21 (two weeks prior to hospitalization ). The RD was asked if she felt that was sufficient oral intake for hydration, and the RD stated, He [Resident #3] needs more than that, but he may also some hydration from metabolism. The RD agreed it was unlikely the Resident was getting the amount of hydration from metabolism that it would take to make up for the oral intake deficit. f) Progress Notes Record review showed a progress note dated 12/14/21 at 10:25 p.m. written by Registered Nurse #49 the stated [Local Emergency Department Name] called and said [Resident #3 first name] was being admitted for dehydration. g) Hospital Discharge Summary Review of discharge summary dated 12/19/21 from the hospitalization that occurred 12/14/21 - 12/19/21 revealed the following documentation: The hospital physician stated, Patient is much improved with his electrolytes and are almost normal with IV hydration and will continue to encourage oral hydration upon discharge at nursing home. His [Resident #3] sodium level is 144 today, underlying problem was dehydration. The patient was transferred from the local skilled nursing facility secondary t decreased mental status. Patent was found to be profoundly dehydrated he was started on IV fluids in the emergency room his sodium was greater than 179 [upon arrival on 12/14/21] he received IV fluids through the night and this morning electrolytes are improved at 168. We [Hospital staff] will continue the IV fluids and correct electrolyte imbalance. He progressively started improving with his hyponatremia (lower than normal level of sodium in the bloodstream) and hyperchloremia (electrolyte imbalance and is indicated by a high level of chloride in the blood). Patient was monitored for daily intake and output and vitals remain stable and today he is back to his baseline with mental status, and he is awake and alert and talking and answering a few questions within limitation dementia which he did not do yesterday. I [hospital physician] discussed with nursing staff to communicate with nursing home staff for encouraging oral hydration and monitor vitals and labs. The discharge diagnosis was dehydration. The Resident's electrolyte lab values at the time of discharge from the hospital (12/19/21) were back within normal range as follows: Sodium (Na) 144. Normal reference range - 136 - 142. Potassium (K+) 3.6. Normal reference range 3.5 - 5.3. h) Power of Attorney (POA) Interview On 01/11/22 at 11:38 AM during an interview the Resident's POA she stated, The staff at the hospital where my father was admitted said he [Resident #3] was severely dehydrated. The POA further stated that the hospital staff told her they had no problem getting Resident #3 to drink and Resident #3 would even say 'more' when offered. The POA stated that staff had to give Resident #3 a chance to get liquid throughout the day because the Resident can't drink on his own and must be assisted with thickened liquids. The POA confirmed the Resident was never on any kind of fluid restrictions, nor should he be. i) Observation of Oral Hydration On 01/11/22 at 10:56 AM after Surveyor expressed concern for the non-availability of hydration being offered to Residents, drink pass was initiated on West wing hallway. Resident #3 was observed drinking oral hydration in the form of nectar thickened orange juice provided by CNA #9. The Resident started drinking the juice at 10:57 AM and completely consumed 240 ml by 11:09 AM. The Resident did not in any way refuse the hydration. Resident #3 opened his mouth and leaned his head forward after each sip was provided by CNA indicating he wanted more. CNA #9 stated, Yea he drinks good we just have to help him. Sometimes it just takes a while. The CNA was asked how often someone takes time to offer Resident hydration and she stated, He [Resident #3] gets drinks at meals and probably at evening snack time. j) Care Plan Review of the Resident #3's care plan showed the Resident needs assistance with eating and drinking as related to Alzheimer's disease, poor vision and he keeps his eyes closed. Resident totally dependent on staff for eating and drinking. Intervention to encourage fluids every shift and at meals. k) Physician Orders for Scope of Treatment (POST) Review of Residents POST form indicated the Resident was to have Intravenous fluid (IV), long term if indicated, antibiotics, cardiac monitoring, and transfers to hospital. l) Certified Nurse Aide (CNA) Interview During an interview on 01/11/22 at 12:53 PM, CNA #8 was asked how much she had offered Resident #3 to drink during the morning? CNA #8 replied, I haven't gave him [Resident #3] any other than with meals. m) Licensed Practical Nurse (LPN) #13 Interview On 01/12/22 at 10:30 AM, Licensed Practical Nurse (LPN) #13 was asked approximately how much fluid Resident #3 received at medication pass. LPN #13 stated that she used the 8 oz. cup from cart and usually gave about 4 oz. of nectar thickened liquids to Resident #3 with meds, or if he had a supplement, they [medication nurse] just used that. n) Director of Nursing Interview During an interview on 01/12/22 at 9:39 a.m. the DON stated she thinks she remembered why the STAT CBC and BMP labs weren't drawn on 12/14/21. The agency they contract with couldn't get the labs drawn because the resident was so 'dehydrated' and LPN #63 who is always a good 'stick' couldn't either and that's when they decided to send the resident out to the hospital. o) Administrator Interview During an interview on 01/12/22 at 10:01 a.m., the Administrator stated, I guess if the paperwork [hospital discharge summary] says its dehydration, then he was dehydrated. We done everything we could, he refused to eat his meals, we couldn't get him to respond. In summary Resident #3 became dehydrated at the facility as a result of the facility neglecting to provide adequate fluid intake and proper monitoring and follow up to ensure he maintained proper hydration.

Based on observation, record review, resident interview, family interview and staff interview, the facility failed to ensure Resident #3 was provided the appropriate care and services to maintain acceptable parameters hydration status. This resulted in Resident #3 being admitted to the hospital with severe dehydration which represents actual harm to Resident #3. In addition, appropriate hydration was not available to Resident #5, #2, #21, #40, and #23 at their bedside. This failed practice was true for six (6) of nine (9) residents reviewed for hydration during a compliant survey. Resident identifiers: #3, #5, #2, #21, #40, #23. Facility census: 75. Findings included: a) Resident #3 Record review of the facility's policy titled, Hydration Management, dated July 2017, found the facility's general guideline for determining baseline daily fluid intake is to multiply the resident's body weight in kilograms(kg) times 30 cc. (2.2lbs = 1kg). Using this formula Resident #3 should have received approximately 2007 cc/ml of fluid daily for the weight of 147.1 lb. that was obtained on 11/22/2021. Please note cc. (cubic centimeters) are the same as ml. (milliliters). Record review of Resident #3's laboratory report dated 11/29/21 showed abnormal results for the following values: White Blood Count (WBC) 12.1. Normal reference range - 3.4 - 11.8. Sodium (Na) 156. Normal reference range 136 - 142. Chloride 117. Normal reference range 96 - 110. (Chloride is an important electrolyte and works to ensure that your body's metabolism is working correctly due to dehydration.) Review of physician progress noted dated 11/30/21 showed documentation from the Nurse Practitioner (NP) that stated reason for the provider was to address abnormal labs nursing reported for Resident #3 on 11/29/21. The NP noted the lab values from the report, with a treatment plan to repeat the Complete Blood Count (CBC) in one week. An order was entered in the Resident's chart that stated CBC on 12/09/21. No repeat labs were obtained per the provider's order and was verified as not obtained by the Director of Nursing on 01/12/22 at 11:02 AM. A review of Resident #3's hydration intake documentation from two weeks prior to the hospitalization that occurred on 12/14/21 indicated Resident #3 was not receiving the appropriate recommended amount of oral hydration. Resident #3 should have received at least 2007 ml of fluid daily according to the facility's hydration policy. The Resident received the following amount of daily oral hydration: --12/01/21: 1080 ml. Resident was also documented to have consumed 75% of the 4oz 2 Cal Supplement at 9:00 AM and 100% of the 4 oz 2 Cal Supplement at 9:00 PM. --12/02/21: 840 ml. Resident was also documented to have consumed 100% of the 4oz 2 Cal Supplement at 9:00 AM and 100% of the 4 oz 2 Cal Supplement at 9:00 PM. --12/03/21: 720 ml. Resident was also documented to have consumed 100% of the 4oz 2 Cal Supplement at 9:00 AM and 100% of the 4 oz 2 Cal Supplement at 9:00 PM. --12/04/21: 760 ml. Resident was also documented to have consumed 25% of the 4oz 2 Cal Supplement at 9:00 AM and 100% of the 4 oz 2 Cal Supplement at 9:00 PM. --12/05/21: 960 ml. Resident was also documented to have consumed 50% of the 4oz 2 Cal Supplement at 9:00 AM and 100% of the 4 oz 2 Cal Supplement at 9:00 PM. --12/06/21: 960 ml. Resident was also documented to have consumed 100% of the 4oz 2 Cal Supplement at 9:00 AM and 100% of the 4 oz 2 Cal Supplement at 9:00 PM. --12/07/21: 720 ml. Resident was also documented to have consumed 100% of the 4oz 2 Cal Supplement at 9:00 AM and 100% of the 4 oz 2 Cal Supplement at 9:00 PM. --12/08/21: 720 ml. Resident was also documented to have consumed 50% of the 4oz 2 Cal Supplement at 9:00 AM and 100% of the 4 oz 2 Cal Supplement at 9:00 PM. --12/09/21: 540 ml. Resident was also documented to have consumed 100% of the 4oz 2 Cal Supplement at 9:00 AM and 100% of the 4 oz 2 Cal Supplement at 9:00 PM. --12/10/21: 600ml. Resident was also documented to have consumed 25% of the 4oz 2 Cal Supplement at 9:00 AM and 75% of the 4 oz 2 Cal Supplement at 9:00 PM. --12/11/21: 720ml. Resident was also documented to have consumed 50% of the 4oz 2 Cal Supplement at 9:00 AM and 100% of the 4 oz 2 Cal Supplement at 9:00 PM. --12/12/21: 960 ml. Resident was also documented to have consumed 50% of the 4oz 2 Cal Supplement at 9:00 AM and 50% of the 4 oz 2 Cal Supplement at 9:00 PM. --12/13/21: 60ml. Resident was also documented to have consumed none of the 4oz 2 Cal Supplement at 9:00 AM and 50% of the 4 oz 2 Cal Supplement at 9:00 PM. --12/14/21: 360ml. Resident was also documented to have consumed 50% of the 4oz 2 Cal Supplement at 9:00 AM and was out of facility at hospital during the 9:00 PM medication pass. During an interview on 01/11/22 at 2:46 PM, the Registered Dietician (RD) stated the Resident should be receiving around '1600'ish' [1600 milliliters (ml)] of oral hydration a day. The Resident's daily oral fluid intake ranged from 60 ml per day to 1080 ml per day for 12/01/21 - 12/14/21 (two weeks prior to hospitalization ). The RD was asked if she felt that was sufficient oral intake for hydration, and the RD stated, He [Resident #3] needs more than that, but he may also some hydration from metabolism. The RD agreed it was unlikely the Resident was getting the amount of hydration from metabolism that it would take to make up for the oral intake deficit. A record review showed a progress note dated 12/14/21 at 10:25 p.m. written by Registered Nurse #49 the stated [Local Emergency Department Name] called and said [Resident #3 first name] was being admitted for dehydration. A review of the discharge summary dated 12/19/21 from the hospitalization that occurred 12/14/21 - 12/19/21 revealed the following documentation: The hospital physician stated, Patient is much improved with his electrolytes and are almost normal with IV hydration and will continue to encourage oral hydration upon discharge at nursing home. His [Resident #3] sodium level is 144 today, underlying problem was dehydration. The patient was transferred from the local skilled nursing facility secondary t decreased mental status. Patent was found to be profoundly dehydrated he was started on IV fluids in the emergency room his sodium was greater than 179 [upon arrival on 12/14/21] he received IV fluids through the night and this morning electrolytes are improved at 168. We [Hospital staff] will continue the IV fluids and correct electrolyte imbalance. He progressively started improving with his hyponatremia (lower than normal level of sodium in the bloodstream) and hyperchloremia (electrolyte imbalance and is indicated by a high level of chloride in the blood). Patient was monitored for daily intake and output and vitals remain stable and today he is back to his baseline with mental status, and he is awake and alert and talking and answering a few questions within limitation dementia which he did not do yesterday. I [hospital physician] discussed with nursing staff to communicate with nursing home staff for encouraging oral hydration and monitor vitals and labs. The discharge diagnosis was dehydration. The Resident's electrolyte lab values at the time of discharge from the hospital (12/19/21) were back within normal range as follows: Sodium (Na) 144. Normal reference range - 136 - 142. Potassium (K+) 3.6. Normal reference range 3.5 - 5.3. On 01/11/22 at 11:38 AM during an interview the Resident's POA she stated, The staff at the hospital where my father was admitted said he [Resident #3] was severely dehydrated. The POA further stated that the hospital staff told her they had no problem getting Resident #3 to drink and Resident #3 would even say 'more' when offered. The POA stated that staff had to give Resident #3 a chance to get liquid throughout the day because the Resident can't drink on his own and must be assisted with thickened liquids. The POA confirmed the Resident was never on any kind of fluid restrictions, nor should he be. On 01/11/22 at 10:56 AM after Surveyor expressed concern for the non-availability of hydration being offered to Residents, drink pass was initiated on West wing hallway. Resident #3 was observed drinking oral hydration in the form of nectar thickened orange juice provided by CNA #9. The Resident started drinking the juice at 10:57 AM and completely consumed 240 ml by 11:09 AM. The Resident did not in any way refuse the hydration. Resident #3 opened his mouth and leaned his head forward after each sip was provided by CNA indicating he wanted more. CNA #9 stated, Yea he drinks good we just have to help him. Sometimes it just takes a while. The CNA was asked how often someone takes time to offer Resident hydration and she stated, He [Resident #3] gets drinks at meals and probably at evening snack time. Review of the Resident #3's care plan showed the Resident needs assistance with eating and drinking as related to Alzheimer's disease, poor vision and he keeps his eyes closed. Resident totally dependent on staff for eating and drinking. Intervention to encourage fluids every shift and at meals. During an interview on 01/11/22 at 12:53 PM, CNA #8 was asked how much she had offered Resident #3 to drink during the morning? CNA #8 replied, I haven't gave him [Resident #3] any other than with meals. On 01/12/22 at 10:30 AM, Licensed Practical Nurse (LPN) #13 was asked approximately how much fluid Resident #3 received at medication pass. LPN #13 stated that she used the 8 oz. cup from cart and usually gave about 4 oz. of nectar thickened liquids to Resident #3 with meds, or if he had a supplement, they [medication nurse] just used that. During an interview on 01/12/22 at 9:39 a.m. the DON stated she thinks she remembered why the STAT CBC and BMP labs weren't drawn on 12/14/21. The agency they contract with couldn't get the labs drawn because the resident was so 'dehydrated' and LPN #63 who is always a good 'stick' couldn't either and that's when they decided to send the resident out to the hospital. During an interview on 01/12/22 at 10:01 a.m., the Administrator stated, I guess if the paperwork [hospital discharge summary] says its dehydration, then he was dehydrated. We done everything we could, he refused to eat his meals, we couldn't get him to respond. In summary Resident #3 became dehydrated at the facility as a result of the facility neglecting to provide adequate fluid intake and proper monitoring and follow up to ensure he maintained proper hydration. b) Resident #5 On 01/11/22 at 10:40 AM Resident #5 was observed to not have any type of hydration available at bedside. Resident #5 was asked if they needed something to drink and Resident #5 replied, I could use something, I only had a sip of water a bit ago with my pills. The Director of Nursing (DON) was present and stated she would get her something and verified this Resident drinks independently. c) Resident #2 On 01/11/22 at 10:41 AM Resident #2 was observed to not have any type of hydration available at bedside. Resident #2 was asked if she was thirsty or wanted something to drink and Resident stated, Yes I would love some ice chips, my mouth stays so dry. I haven't had anything to drink since this morning when ate my breakfast. The DON was present and verified Resident was without any water or other form of hydration and proceeded to get requested ice chips. d) Resident #21 On 01/11/22 at 10:35 AM Resident #21 was observed to not have any type of hydration available to drink at bedside. The Resident's lips were very dry and cracked and the corners of her mouth were crusty. The Resident had an empty drinking pitcher/cup with a straw on bed side table that was empty. Resident #21 was asked if she was thirsty and the Resident weakly stated, Yes, very. The DON was brought into the room and verified the empty drinking cup and proceeded out into the hallway and told the nurse, Lets get a drink cart out here, now. e) Resident #40 On 01/11/22 at 11:10 AM Resident #11 was observed to not have any fresh water available to drink at bedside. An 8 oz. plastic cup (that is used for medication pass) was setting on the Residents bedside table with approximately 1 oz in it. The Resident stated, That was from last night, I think the nurse left it here after I took my pills. The DON was asked to come into the room and verify the Resident did not have any fresh water to drink. The DON stated, They are coming now with some. f) Resident #23 On 01/11/22 at 11:24 AM, a stack of empty drink cups was observed on Resident #23's bed side table. Resident was asked if she had anything to drink or needed anything, and she replied, No, I am out of money and don't have anymore of my pop [soda] so I guess I will do without. They will be along shortly with lunch, and I'll have something then. At that time, the DON intervened and asked the Resident what kind of soda she preferred so she could get some from the office. The Resident further stated she had not been offered any ice water in 'forever'. g) Interview During an interview at 9:45 AM on 01/12/22, the Administrator stated, I didn't realize we had to keep water at the bedside at all times, or something for them [Residents] to drink. I thought they got enough at mealtimes and with med (medication) pass. The Administrator stated activities will sometimes go through and ask them if they want something special to, depending on what the day is and what snacks are offered. During an interview on 01/12/22 at 9:50 AM the DON stated they the usually go around and pass out drinks in the mornings but they just hadn't gotten around to it yet.

Based on Resident interview, staff interview and record review the facility failed to ensure require [MEDICAL TREATMENT] receive such services, consistent with professional standards of practice, related to the Nurse Aide removing the dressing from the [MEDICAL TREATMENT] site, resulting in this resident having a serious bleed from the site, resulting in an emergency surgery, causing actual harm. This was true for one (1) of one (1) reviewed in the care area of [MEDICAL TREATMENT]. Identified Resident # 67. Facility Censes 94. Finding included: a) Resident #67 During an interview on 02/12/19 at 10:20 AM, Resident # 67 states that she had bleeding from her [MEDICAL TREATMENT] site Arteriovenous (AV) graft on the upper right arm (this is a tube inserted into an artery in the arm to be connected to a machine that removes undesired matter from the blood). She went on to say that she has had two (2) major bleeds from the AV graft after [MEDICAL TREATMENT]. She had to go to the hospital both times. She stated that the Nurse Aides used to take the dressing off, but after the last time when it bleeds so much, and she had to have emergency surgery, the doctor told the staff that only a nurse can remove the dressing. Review of medical records revealed the following: -11/29/2018 00:07 SBAR Summary SBAR Summary: Vital Signs: BP 184/82, Pulse 92 - Respirations 20, Temperature 98.7 Route: Oral, Wt 132.8 pounds - Oxygen saturation 98 % - Method of Oxygen delivered Nasal Cannula RN Assessment/LPN Appearance of resident - What I think is going on with the resident is: Res had Nurse Aide to remove her bandage to her right upper arm and Residents shunt started squirting blood and pressure was applied and 911 was called due to the bleeding would not stop. Additional Nursing Notes as applicable: Family/Health Care Agent Notified: Resident is her own Power of Attorney and she notified her daughter at 11/29/2018 10:00 PM. Primary Care Clinician Notified: this doctor did not return phone call, so the Nurse Practitioner was notified at 11/28/2018 11:15 PM. -5/19/2018 15:07 SBAR Summary SBAR Summary: RN Assessment/LPN Appearance of resident - What I think is going on with the resident is: Called to resident's room residents arm at shunt site had a dressing on it that was saturated with blood and was dripping. Upon removal of dressing blood was squirting, pressure applied, RN supervisor notified, Resident stated that she was starting to get sick to her stomach. 911 called and resident sent to MGH. Additional Nursing Notes as applicable: Family/Health Care Agent Notified:(NAME)at 05/19/2018 2:30 PM. Primary Care Clinician at 05/19/2018 3:00 PM. During an interview on 02/12/19 at 10:38 AM, Director of Nurses to go over Resident # 67's hospitalization s she was also asked about the note that stated the Nurse Aide (NA) removing the [MEDICAL TREATMENT] dressing. She said that they had to educate the NA about letting the nurse removed the dressing. She went on to say that the NA only did it because Resident #67 asked her to. She said, that she did not know that the resident said, that the NA's always took the dressing off until she had to have emergency surgery. She was asked if it was within the scope of practice for the NAs to remove the dressing and she said well they take off band aides. She did agree that a pressure dressing on a recently used [MEDICAL TREATMENT] site was more than a band aide.

Based on observations, record review, review of facility policy and procedures, and staff interviews, the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible and failed to provide supervision for Resident #69. The facility failed to implement preventative measures for a known accident hazard for all the residents residing on the Alzheimer Care Unit (ACU) regarding possible electrical shock from a missing outlet switch cover in the bathroom located between Room #310 and Room #312. These findings resulted in a determination of immediate jeopardy due to the potential for harm to residents. The Administrator and Director of Nursing were notified of the immediate jeopardy at 5:13 p.m. on 02/06/17. An acceptable plan of correction (POC) was received at 7:34 p.m. After verifying implementation of the POC, the immediate jeopardy was abated at 7:45 p.m. No deficient practice remained for this requirement after removal of the immediate jeopardy. This had the potential to affect more than a limited number of residents. Resident identifier: #69. Facility census: 97. Findings include: a) Electrical outlet covers On 02/06/17 at 1:15 p.m., an observation of the bathroom shared by Room #310 and Room #312 on the Alzheimer Care Unit (ACU) found the cover plate for the light switch was missing, exposing electrical wiring. On 02/06/17 at 3:45 p.m., the ACU Director agreed any mobile resident residing on the unit could receive an electrical shock from the missing light switch covers. He also reported Resident #69 was capable of pulling the outlet covers off the wall. b) Resident #69 A review of the medical record on 02/06/17 revealed the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) 11/15/16 revealed the resident's [DIAGNOSES REDACTED]. Resident #69 resided on the locked ACU with twenty-six (26) other residents. Resident #69's care plan identified the behavior of pulling items from walls. This behavior was added to resident's care plan on 12/09/16. The goal was to stop these behaviors with staff interventions. The interventions included attempting interventions before behaviors began, provide medications as ordered, make sure he was in no pain or uncomfortable, offer something he liked as a diversion, let the physician know if behaviors interfered with his daily living, and antecedent behavior monitoring as ordered. On 02/06/17 at 1:15 p.m., an observation of the bathroom shared by Room #310 and Room #312 on the Alzheimer Care Unit (ACU) found a missing light switch cover with exposed electrical wiring. During an interview with the Maintenance Supervisor on 02/06/17 at 2:30 p.m., he reported Resident #69 was known to remove electrical outlet covers from the walls on the ACU. He also reported he had replaced electrical outlet covers on this unit in the past two (2) months. He reported he had discussed this with the ACU Director about using metal outlet covers since they would be harder to break, but the facility had not purchased or tried the metal covers yet. During an interview on 02/06/17 at 3:40 p.m., the director of nursing (DON) and ACU Director identified Resident #69 as the one who was known to pull electrical cover plates off the walls. The DON reported the resident's behavior of pulling things from the walls had been added to his care plan on 12/09/16 They also reported when Resident #69 was up and moving around, the staff needed to keep a closer watch on him. On 02/14/17 at 3:33 p.m., the Nursing Home Administrator (NHA) and the Alzheimer Care Unit Director reported the issue of Resident #69 pulling electrical cover plates off of the walls on the ACU had not been addressed specifically. Also no interventions had been put into place to prevent electrical shock for any mobile residents on the ACU. c) These findings resulted in a determination of immediate jeopardy due to the potential for serious harm to residents. The facility was notified of the immediate jeopardy on 02/05/17 at 5:13 p.m. An acceptable plan of correction (POC) was received at 7:34 p.m. After verifying implementation of the POC, the immediate jeopardy was abated at 7:45 p.m. d) A review of the facility's Accident Investigation Procedure for Safety and Loss Control with the creation date of 06/17/15 found a Procedure Statement: Accident investigation is important in reducing the potential for accidents or incidents within the facility. It is most effective through the combined use of: --Thorough investigations --Evaluations --Recommendations When accidents or incidents are reported, they should be thoroughly investigated and evaluated. Recommendations should be developed to make changes so that a similar type of accident can be prevented in the future. Accidents taken should be the result of factual findings. Committee Responsibilities: Each Safety Committee member is responsible for: --Providing monthly reports of findings to the Safety Committee --Developing accident investigation procedures for supervisors --Reviewing supervisors' reports to determine if the cause of the accident and the corrective action is reasonable and accurate; if not, seek additional information --Making recommendations to the management team concerning the educational, instructional, and administrative controls needed in accident investigation prevention --Making periodic objective evaluation of the accident investigation problem by continually noting the efforts of: Counter measures, educational techniques and other methods used to prevent injuries. e) Plan of Correction One on one with Resident #69, one on one was started at approximately 6 p.m. and continued until all outlet covers were replaced on the ACU (one on one discontinued at 8 a.m. on 02/07/17). All outlets on ACU are to be replaced with metal covers, this process will begin on 02/06/17 and is expected to be completed by end of day on 02/07/17. Verified all outlets were replaced with metal covers by 7:00 a.m. on 02/07/17). Education will be provided to all staff before their next scheduled shift. Education will be as follows: (all staff have been educated prior to working we will continue to educate each employee before next shift until all completed). Verified all staff received the following education on 02/06/16 and 02/07/17. -- If outlet cover is seen missing or loose, this should be seen as an immediate danger to our residents. -- An employee will stay at the site of outlet until cover can be replaced. -- During normal working hours, maintenance will be notified as soon as possible. -- During off hours extra plates will be provided to supervisor who will be educated by maintenance to replace the covers. Maintenance will be notified of issue via building engines for follow up. -- All staff will be educated to report any other environmental hazards to the maintenance director or environmental services director on nature of hazard. During off hours this will need to be reported to their assigned charge nurse. -- Certified nursing assistant to check outlets during walking rounds between shifts, and follow procedure if any loose or missing covers are found.

Based on record review, observation, and staff interview, the facility failed to ensure one (1) of three (3) residents reviewed maintained acceptable parameters of nutritional status. The resident experienced a severe weight loss, and the facility failed to implement dietary recommendations to increase the resident's enteral feedings. Between 08/30/15 and 11/08/15, the resident had a cumulative weight loss of 10.63% of her total body weight. Resident identifier: #117. Facility census: 94. Findings include: a) Resident #117 Review of the medical records found Resident #117, initially admitted to the facility on [DATE], had [DIAGNOSES REDACTED]. The resident was admitted with a nothing by mouth (NPO) order and was dependent on enteral (tube) feedings for nutrition. Medical record review, on 11/11/15 at 12:30 p.m., revealed Resident #117 experienced the following weight losses, between August 2015 and November 2015: -- From 08/30/15 to 09/10/15, the resident lost 7 pounds (#), from a weight of 126# to 119.4#. This was 5.40% of her body weight in eleven (11) days, a severe weight loss. -- From 09/10/15 to 10/11/15, the resident lost an additional 2.6#, from a weight of 119.4# to 116.8#, representing a 7.3% weight loss since 08/30/15. -- From 10/11/15 to 11/08/15, the resident lost another 4.2# (3.6%) - from 116.8# to 112.6 # - between 10/11/15 to 11/08/15. From 08/30/15 to 11/08/15, the resident's weight loss was total of 13.4#, or 10.63% of her total body weight. (The percentage of weight losses were calculated using the formula: % of body weight loss = (usual body weight-actual weight) / (usual weight) X 100. The resident's last identified stable weight was used as the resident's usual weight.) Review of the Nutritional Assessment for Resident #117, completed on 08/03/15 by Dietitian #116, found the resident required 1726 total calories and 58 - 81 grams of protein daily to meet her estimated nutritional needs. The assessment was marked to indicate the resident's nutritional intake met the established needs. Review of the resident's current care plan, on 11/11/15 at 1:00 p.m., identified a focus area created on 07/30/15, indicating the resident was dependent on tube feedings. An intervention for the focus area said the resident received Glucerna 1.2, 237 milliliters (ml), to be administered by bolus, every six (6) hours, around the clock, revised on 08/31/15. Review of the physician's orders [REDACTED]. On 11/11/15 at 1:35 p.m., review of the progress notes identified several entries pertaining to the resident's nutritional status: -- 08/21/15 - a nutrition follow-up note indicated the resident was receiving Glucerna 1.2, by bolus enteral feeding, every four (4) hours, providing 1710 calories, and 85 grams of protein daily, with no further recommendations. The caloric intake of 1710 calories was 16 calories less than the estimated nutritional caloric needs established by the Dietitian on 08/03/15. -- 10/29/15 - a nutritional follow-up note indicated the resident's weight had decreased to 114.8 #, with a recommendation to increase the Glucerna 1.2 Cal bolus to five (5) times daily and an additional Glucerna 1.2 Cal bolus of 355 ml one time a day for a total of 6.5 cans daily. This was to equal 1540 ml total/day, providing 1852 calories and 92 grams of protein. -- 10/30/15 - a general note indicated the team had reviewed the nutritional recommendation, and the tube feeding was increased by one (1) can of Glucerna 1.2 Cal daily, and would continue to follow. -- 11/05/15 - a weekly weight note indicated the resident weighed 113.8 # and received Glucerna 1.2 Cal bolus feedings, every four (4) hours, providing 1710 calories and 85 grams of protein, daily. At 2:50 p.m. on 11/11/15, review of the Medication Administration Records (MARs) for October and November of 2015 for Resident #117 found the resident received bolus feeding of Glucerna 1.2 Cal, 237 ml, every four (4) hours around the clock. No evidence was found to indicate the Dietary recommendation written on 10/29/15, and again addressed in the progress notes on 10/30/15, had ever been started. The resident was still receiving 1710 calories from the 1422 ml of Glucerna administered, and continued to lose weight. On 11/12/15 at 11:45 a.m., Licensed Practical Nurse (LPN) #31 was observed administering the resident's enteral feeding. When asked the how many cans a day and how many times a day the resident received her enteral nutrition, the LPN said, she did not normally work the hall, but she would check. The LPN then reviewed the MAR for the resident and said the resident received one (1) can every four (4) hours around the clock. Observation of the can of Glucerna 1.2 Cal, identified each can contains 285 calories / 237 ml. At 12:05 p.m. on 11/12/15, the nutritional findings, as well as the resident's weight loss status, were reviewed with the Director of Nursing (DON). She agreed the recommendation and/or order to increase the resident's enteral feeding amounts had not been followed through. She verified the recommendation had never been put into the system, and the increased feeding had not been placed on the resident's MAR. She verified the resident had experienced a weight loss, and even though the resident had experienced some health complications since admission, could not say if the weight loss could have been prevented or improved if the resident had received the increase in caloric intake. On 11/13/15 at 10:00 a.m., further review of the physician's orders [REDACTED]. The order indicated an increase in the resident's enteral feedings. The resident was now to receive Glucerna 1.2 Cal bolus, one (1) can every four (4) hours and to give two (2) cans at 8:00 a.m. daily for a total of seven (7) cans, with a total caloric value of 1995 calories.