Every finding on record at Harmony Care at Stamford

Based on interviews and record review[KA73.1], the facility failed to maintain a quality assessment and assurance committee consisting at a minimum of the required committee members for 4 quarterly meetings reviewed for QAPI[KA74.1]. The facility did not ensure the Medical Director or a representative attended quarterly QAPI meetings. This failure could place residents at risk for quality deficiencies being unidentified, no appropriate plans of action developed and implemented, and no appropriate guidance developed. Findings included: Record review of the Quality Assurance Performance Improvement Attendance Sign-In forms revealed:Sign in sheet for the 3rd Quarter 2025, undated, indicated the Medical Director was not present. Sign in sheet for the 4th Quarter 2025, undated, indicated the Medical Director was not present. Sign in sheet, dated January 2026, indicated the Medical Director was not present. Sign in sheet, dated 03/10/2026, indicated the Medical Director was not present. During an interview on 06/17/2026 at 12:10 PM, the ADMN stated no Medical Director was present for QAPI during the last 4 quarters. He stated the MD either couldn't[KA75.1] , or wouldn't[KA76.1], attend. He stated the MD was making rounds, giving orders and signing orders during QAPI meetings[KA77.1]. He stated the negative outcome of the Medical Director not attending QAPI meetings made it more likely to overlook a potential process or improvement without his expertise. Record review of facility's policy titled, Quality Assurance and Performance Improvement, revised April 2014, revealed: This facility shall develop, implement, and maintain and ongoing facility wide QAPI program that builds on the Quality Assessment and Assurance Program to actively pursue quality of care and quality of life goals.Review[KA78.1] of the facility document titled, QAA[KA79.1] Committee[KA80.1], not dated revealed: Administrator, MD, DON, ADON.

Based on observation, interview, and record review, the facility failed to ensure that the assessment accurately reflected the resident's status for 4 of 5 (Resident #1, Resident #2, Resident #18, and Resident #30) reviewed for accuracy of assessments. The facility failed to ensure Resident #1, Resident #2, Resident #18, and Resident #30 had tobacco use accurately coded on the admission/annual MDS assessment. This failure could place residents at risk for inadequate care and services to meet their needs.Findings included: During record review of Resident #1's electronic face sheet, dated 06/16/2026, revealed a [AGE] year-old male, admitted on [DATE], with diagnoses of chronic obstructive pulmonary disease (a progressive, chronic lung disease that makes breathing difficult), dementia, major depressive disorder (a serious mental health condition characterized by persistent low mood and loss of interest in activities), anxiety, and high blood pressure. Record review of Resident #1's Annual MDS Assessment, dated 02/16/2026, revealed in Section C - Cognitive Patterns, subsection C0500, a BIMS score of 14 out of 15, indicating intact cognition. Section J - Health Conditions, subsection J1300 Current Tobacco Use, 0 was entered indicating No. During record review of Resident #2's electronic face sheet, dated 06/16/2026, revealed a [AGE] year-old female, admitted on [DATE], with diagnoses of chronic obstructive pulmonary disease, major depressive disorder, anxiety, high blood pressure, and emphysema (a progressive, incurable lung condition characterized by the destruction of the air sacs in the lungs). During record review of Resident #2's Annual MDS Assessment, dated 11/18/2025, revealed in Section C - Cognitive Patterns, subsection C0500, a BIMS score of 15, indicating intact cognition. Section J - Health Conditions, subsection J1300 Current Tobacco Use, 0 was entered indicating No. During review of Resident #18's electronic face sheet, dated 06/16/2026, revealed a [AGE] year-old female, admitted on [DATE], with diagnoses of chronic obstructive pulmonary disease, dementia, and high blood pressure. During record review of Resident #18's admission MDS Assessment, dated 04/30/2026, revealed in Section C - Cognitive Patterns, subsection C0500, a BIMS score of 12, indicating moderate cognitive impairment. Section J - Health Conditions, subsection J1300 Current Tobacco Use, 0 was entered indicating No. During record review of Resident #30's electronic face sheet, dated 06/16/2026, revealed an [AGE] year-old female, admitted on [DATE], with diagnoses of chronic obstructive pulmonary disease, dementia, depression, anxiety, and high blood pressure. Record review of Resident #30's admission MDS Assessment, dated 02/26/2026, revealed in Section C - Cognitive Patterns, subsection C0500, a BIMS score of 15, indicating intact cognition. Section J - Health Conditions, subsection J1300 Current Tobacco Use, 0 was entered indicating No. During an observation on 06/16/2026 at 8:32 a.m., Resident #1, Resident #2, Resident #18, and Resident #30 were sitting outside in the enclosed patio area smoking. Observation indicated dietary staff were present to supervise residents smoking. During an observation on 06/17/2026 at 10:05 a.m., Resident #2, Resident #18, and Resident #30 were assisted to the enclosed patio area to smoke. Observation indicated staff provided one cigarette to each resident and lit each cigarette. Observation further indicated no residents had supplemental oxygen or required clothing protection. During an interview on 06/17/2026 at 10:47 a.m., the DON stated her expectation was for each resident's tobacco use status to be correct on the MDS. Stated the MDS Coordinator was responsible for entering data for the MDSs. The DON was not able to state a consequence to residents if tobacco use on the MDS was not coded correctly. During a telephone interview on 06/17/2026 at 11:15 a.m., the MDS Coordinator stated she received information for the MDS through the RN assessment and correlating with the nursing staff. She stated the reason the tobacco use section may have been coded on the MDS different from the resident's current status was the resident may have started using tobacco products after admission or after the annual assessment. The MDS Coordinator stated a resident's tobacco use status not accurately documented could be unsafe for the resident. She stated the regional nurse randomly audited the MDS's for accuracy but was unable to state how often an audit was conducted. She stated she learned the responsibilities of the MDS Coordinator position through on the job training and by attending a face-to-face workshop. During an interview on 06/17/2026 at 12:38 p.m., Resident #30 stated she had been smoking since age [AGE] or 19. She stated the facility was aware of her tobacco use status when she was admitted . During an interview on 06/17/2026 at 12:41 p.m., Resident #2 stated she smoked for 50 years. She stated the facility was aware of her tobacco use status when she was admitted . During an interview on 06/17/2026 at 1:48 p.m., the ADON stated the reason a resident's tobacco use status was not correct on the admission MDS was the resident may not admit to smoking when admitted . He stated the DON was responsible for accuracy of the MDSs. He did not state how an inaccurate MDS could affect a resident. The ADON stated he randomly reviewed MDSs during the DON's recent 6-week absence. During an interview on 06/16/2026 at 9:14 a.m., the Administrator stated the facility followed the RAI guidelines for completing the MDSs. Record review of the Resident Assessment Instrument Manual v1.19.1, dated October 2024, Section J1300: Current Tobacco Use, Steps for Assessment, revealed, 2. If the resident states that they used tobacco in some form during the 7-day look-back period, code 1, yes.

Based on interview and record review, the facility failed to ensure the residents were seen by a physician at least once every 60 days for 3 of 13 Residents (Resident #2, Resident #4, and Resident #16) whose records were reviewed for physician visits.The facility failed to ensure Resident #2's, Resident #4's, and Resident #16's primary care physician met with them as required.This failure could place residents at risk for medical needs not being addressed or met.Based on interview and record review, the facility failed to ensure the residents were seen by a physician at least once every 60 days for 3 of 13 Residents (Resident #2, Resident #4, and Resident #16) whose records were reviewed for physician visits.The facility failed to ensure Resident #2's, Resident #4's, and Resident #16's primary care physician met with them as required.This failure could place residents at risk for medical needs not being addressed or met.Findings included:Resident #2Review of Resident #2's electronic face sheet, dated 6/17/2026 revealed a [AGE] year-old female, admitted [DATE], with diagnoses that included right leg fracture, anxiety, and major depression. Record review of Resident #2's significant change MDS assessment, dated 05/19/2026, revealed a BIMS of 15 which indicated no cognitive impairment.Record review of Resident #2's electronic health record, revealed physician progress notes dated 10/22/2025 through 06/08/2026, revealed no documentation from the primary physician. During an observation and interview on 06/17/2026 at 1:25 PM, Resident #2 was up in the wheelchair. Resident #2 stated she had not seen a physician for as long as she could remember. Resident #4Record review of Resident #4's electronic face sheet dated 06/17/2026 revealed a [AGE] year-old male admitted on [DATE] with diagnoses that included cirrhosis of liver and anxiety. Record review of Resident #4's Annual MDS assessment, dated 05/01/2026, revealed a BIMS of 15 which indicated no cognitive impairment.Record review of Resident #4's electronic health record revealed physician progress notes dated 10/22/2025 through 05/06/2026, revealed no documentation from the primary physician. During an observation and interview on 06/17/2026 at 1:30 PM, Resident #4 was seated in the wheelchair at the end of the hall. Resident #4 stated he saw the new physician in May but, prior to that, he had not seen a physician in months. Resident #16Record review of Resident #16's electronic face sheet dated 6/17/2026, revealed a [AGE] year-old male, admitted [DATE], with diagnoses that included seizures and severe intellectual disabilities. Record review of Resident #16's Annual MDS assessment, dated 05/22/2026, revealed a BIMS of 03 which indicated severe cognitive impairment.Record review of Resident #16's electronic health record, including physician progress notes, revealed no documentation from the primary physician from 10/29/2025 through 06/08/2026.During an interview on 06/16/2026 at 10:15 AM, the ADMN stated the new Medical Director started in May 2026. He stated that there was no lapse between the previous Medical Director and there was never a time when they did not have a physician. He stated the MD was making rounds, giving orders, and signing orders. He stated the MD was not sending the documentation and progress notes. During an interview on 06/17/2026 at 10:01 AM, the DON stated the MD left at the end of April 2026. She stated he made his visits, but he was not sending the progress notes. She stated she asked him to please send them, but he did not. She stated there was no written evidence of the MD making rounds on residents. Record review of the facility policy, Physician Visits, revised April 2013, revealed, The attending physician must make visits in accordance with applicable state and federal regulations. 1. The attending physician will visit residents in a timely fashion, consistent with applicable state and federal requirements, and depending on the individual's medical stability, recent and previous medical history, and the presence of medical conditions or problems that cannot be handled readily by phone. 2. The attending physician must visit his/her patients at least once every thirty (30) days for the first ninety (90) days following the resident's admission, and then at least every sixty (60) days thereafter.

Based on interviews and record reviews[KA41.1], the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the residents that meet professional standards of quality care within 48 hours of a resident's admission for 1 (Resident #25) of 13 residents reviewed for care planning.The facility failed to develop a baseline care plan for Resident #25 within 48 hours of her admission.This failure could place residents at risk of not receiving effective, person-centered care.Record review of Resident #25's electronic face sheet dated 06/17/2026 reflected an [AGE] year-old female, admitted [DATE], with the following diagnoses of depression, anxiety, and dementia. Further review reflected resident was he own responsible party. Record review of Resident #25's admission MDS Assessment, dated 06/05/2026, reflected a BIMS score of 12, indicating cognitively intact.Record review of Resident #25's electronic medical chart, accessed on 06/16/2026 reflected no evidence of a baseline care plan. During an interview on 06/17/2026 at 11:00 A.M., the DON stated a baseline care plan should be initiated within 48 hours of admission. She stated she made it her priority to review all new admissions. She stated she was out on leave when Resident #25 was admitted . She stated it was the ADON and the admitting nurse's responsibility to ensure that a baseline care plan was initiated. She stated the negative outcome would be residents not receiving the care they needed. During an interview on 06/17/2026 at 12:30 PM, the ADMN stated that all new admissions should have a baseline care plan initiated within 48 hours. He stated the DON was on leave and it must have just gotten missed. He stated the responsibility began with the charge nurse and then the ADON. He stated he was ultimately responsible. He stated the negative outcome would be residents not receiving the care they needed. Record review of facility policy titled, Care Plans-Baseline, dated March 2022, revealed the following: . A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission.

Based on interview and record review, the facility failed to ensure the resident had the right to be informed of, and participate in, his or her treatment, including the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she preferred for 1 of 13 residents (Resident #25) reviewed for informed decisions. The facility failed to ensure Resident #25 or their representative signed consent for psychotropic medication trazodone and sertraline prior to administering medication.This failure could place residents at risk of not being informed of their health status, which would allow them to make informed decisions regarding their care. Findings included: Record review of Resident #25's electronic face sheet, dated 06/17/2026 reflected an [AGE] year-old female, admitted [DATE], with the following diagnosis of depression, anxiety, and dementia. Further review reflected resident was her own responsible party. Record review of Resident #25's admission MDS Assessment, dated 06/05/2026, reflected a BIMS score of 12, indicating cognitively intact. Further review reflected Resident #25 was taking high risk antidepressant medication. Record review of Resident #25's comprehensive care plan, dated 06/07/2026, reflected Resident #25 used antidepressant medication with interventions including to educate the resident/family/caregivers about risks, benefits and side effects. Record review of Resident #25's electronic physician orders, dated 06/07/2026 reflected, Trazodone Oral Tablet 50MG Give 1 tablet by mouth in the evening for insomnia, order date 05/29/2026 and Sertraline Oral Tablet 50MG Give 1 tablet by mouth in the morning for depression, order date 05/29/2026. Record review of Resident #25's MAR, dated June 2026, reflected Resident #25 received 50mg sertraline in the A.M. every day from 06/01/2026-06/16/2026. Record review of Resident #25's MAR, dated June 2026, reflected Resident #25 received 50 mg trazodone in the PM every day from 06/01/2026-06/16/2026. Record review of Resident #25's electronic medical chart, accessed on 06/16/2026, reflected no evidence she or her representative consented to trazodone or sertraline prior to receiving the medication starting on 05/29/2026. During an interview on 06/16/2026 at 12:00 pm, Resident #25 stated she did not really know what medications she took. She stated she just took what they brought her. She stated she did not remember being educated or signing any papers for her antidepressants but that she trusted whatever the physician ordered. During an interview on 06/17/2026 at 11:00 A.M., the DON stated consent must be obtained prior to administering psychotropic medications. She stated she made it her priority to review all orders and new admissions for the need for a consent. She stated she was out on maternity leave when Resident #25 was admitted . She stated it was the ADON's and the admitting nurse's responsibility to ensure that a consent was received. She stated the negative outcome would be residents receiving psychotropic medications without knowing the possible side-effects. During an interview on 06/17/2026 at 12:30 PM, the Administrator stated that all psychotropic medications must have written consent prior to administration. He stated the DON was on maternity leave, and it must have just gotten missed. He stated the responsibility began with the charge nurse who entered the order and gave the medication. He stated he was ultimately responsible. He stated the negative outcome would be residents receiving medications without knowing why and what side-effects they could experience. Record review of facility's policy titled, Psychoactive Medication Use, revised July 2023, reflected, Policy Statement: Residents will not receive medications that are not clinically indicated to treat a specific condition. Policy Interpretation and Implementation: 1. A psychotropic medication is any mediation that affects brain activity associated with mental processes and behavior. 2. Drugs in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications: a. Anti-psychotics; b. Anti-depressants; c. Anti-anxiety medications; and d. Hypnotics. 3. Residents, families and/or the representative are involved in the medication management process. Record review of the website drugs.com, accessed on 06/22/2026 at https://www.drugs.com/trazodone.html, revealed: trazodone .Drug class: Antidepressant . Report any new or worsening symptoms to your doctor, such as: mood or behavior changes, anxiety, panic attacks, trouble sleeping, or if you feel impulsive, irritable, agitated, hostile, aggressive, restless, hyperactive (mentally or physically), more depressed, or have thoughts about suicide or hurting yourself.Record review of the website drugs.com, accessed on 06/22/2026 at https://www.drugs.com/sertraline.html, revealed: sertraline .Drug class: Antidepressant . medication used for depression Common sertraline side effects are nausea, diarrhea, indigestion, loss of appetite, increased sweating, shaking or trembling, decreased appetite, inability to ejaculate, and decreased libido. These side effects occurred in 5% or more of patients using this medicine.

Based on interview and record review, the facility failed to refer all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability or a related condition for level II resident review upon a significant change in status for 1 of 13 residents (Resident #28) reviewed for PASSR. The facility failed to follow up with the local authority for PASRR level II determination when Resident #28's PASRR level 1 dated 2.17.2024 screening reflected they were positive for Mental Illness. This failure could place residents at risk of not receiving specialized and/or habilitative services as needed to meet their needs. Findings included:Record review for Resident #28's electronic face sheet, dated 06.16.2026, revealed a [AGE] year-old female, admitted 03.01.2024, with diagnoses of bipolar disorder (a mental health condition that causes uncontrollable shifts in mood, energy and activity levels), Type II Diabetes Mellitus (metabolic disorder, high blood glucose levels), Hypertension (high blood Pressure), and Major Depressive Disorder. Record review of Resident #28's Annual MDS Assessment, dated 03.10.2026, revealed Section A-Identification information Resident #28 had level II PASRR Serious Mental Illness; Section C-cognitive status revealed Resident #28 had a BIMS score of 15, indicating cognitively intact, and Section I Active Diagnosis revealed Resident #28 had a diagnosis of Bipolar. Record review of Resident #28's Care Plan, dated 06.17.2026 revealed Resident #28 had a mood problem related to Bipolar Diagnosis. Interventions included behavioral health consults as needed, Record review on 06.16.2026 of Resident #28's PASRR level I screening, dated 2.28.2024, revealed Section C was coded yes indicating Mental Illness. Record review of Resident #28's electronic clinical record revealed no evidence of a Level II PASRR evaluation completed. During an interview on 06.17.2026 at 11:03 a.m., the DON stated any resident with a positive PASRR level I should have a level II PASRR evaluation and plan. She stated the MDS Coordinator was responsible for ensuring the PASSRs were completed and accurate. She stated she did not know why this failure occurred. She stated this failure could affect the residents as they may not get other services that they qualified to have. During a telephone interview on 06/17/2026 at 11:50 a.m., the MDS Coordinator stated Resident #28's primary diagnosis was Dementia for billing purposes and Level II PASSR Evaluation was not done. She stated this failure could affect in that she may not be getting the services she may qualify for. The MDS Coordinator stated this failure occurred due to the billing process. She stated she was responsible for ensuring PASRR level IIs were completed. During an interview on 06.24.2026 at 10:00 ama PASRR policy was requested by ADM the facility did not have a policy for PASRR

Based on observations, interviews and record reviews, the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 5 residents (Residents #1 and Resident #30) reviewed for care plans. The facility failed to ensure Resident #1 had a care plan in place for smoking. The facility failed to ensure Resident #30 had a care plan in place for smoking. This failure could place residents at risk of not receiving individualized care and services to meet their needs.Findings included: Review of Resident #1's electronic face sheet dated 06/16/2026, revealed a [AGE] year-old male admitted on [DATE] with medical diagnoses of chronic obstructive pulmonary disease, dementia, major depressive disorder, anxiety, and high blood pressure. Review of Resident #1's Annual MDS Assessment, dated 02/16/2026, revealed in Section C - Cognitive Patterns, subsection C0500 BIMS Summary Score revealed he had a BIMS score of 14 out of 15, indicating intact cognition. Section J - Health Conditions, subsection J1300 Current Tobacco Use, 0 was entered indicating No. Record review of Resident #1's Comprehensive Care Plan dated 01/19/2022, reviewed/revised 11/02/2025, 02/16/2026, 04/19/2026, 04/20/2026, and 06/15/2026, revealed his current smoking status was not addressed. Record review of Resident #30's electronic face sheet, dated 06/16/2026, revealed an [AGE] year-old female admitted on [DATE] with medical diagnoses of chronic obstructive pulmonary disease, dementia, depression, anxiety, and high blood pressure. Review of Resident #30's admission MDS dated [DATE], revealed in Section C - Cognitive Patterns, subsection C0500 BIMS Summary Score revealed he had a BIMS score of 15 out of 15, indicating intact cognition. Section J - Health Conditions, subsection J1300 Current Tobacco Use, 0 was entered indicating No. Review of Resident #30's Comprehensive Care Plan dated 02/16/2026, reviewed/revised 04/20/2026 and 06/05/2026, revealed his current smoking status was not addressed. During an observation on 06/16/2026 at 8:32 a.m., Resident #1, and Resident #30 were sitting outside in the enclosed patio area smoking. Dietary staff were present to supervise residents smoking. During an observation on 06/17/2026 at 10:05 a.m., Resident #30 was assisted to the enclosed patio area to smoke. Staff provided one cigarette to each resident and lit each cigarette. No residents had supplemental oxygen or required clothing protection. During an interview on 06/17/2026 at 10:47 a.m., the DON stated the reason Resident #1's and Resident #30's smoking status was not included on the care plans was proper education with the staff had not been done. She stated she, the ADON, and the MDS Coordinator were responsible for the care plans. She stated her expectations were for the care plans to reflect all aspects of care each resident required. The DON stated the CNO conducted care plan audits approximately every month and a half to two months and the CNO was in the process of training the DON on care plans. She was unable to state a potential consequence to residents of failing to address smoking status on the care plan. She stated the safe smoking evaluation results, and the facility policy would be followed by staff regardless of if it was included on the care plan. During an interview on 06/17/2026 at 12:35 p.m., Resident #1 stated he had been a smoker a long time. He stated he could not recall at what age he started smoking. He stated the facility was aware of his tobacco use when he was admitted and the activity director purchased his cigarettes when she did the resident's shopping. During an interview on 06/17/2026 at 12:38 p.m., Resident #30 stated she had been smoking since age [AGE] or 19. She stated the facility was aware of her tobacco use when she was admitted . During an interview on 06/17/2026 at 1:00 p.m., LVN A stated a resident's smoking status should be included on the care plan. She stated the failure to address smoking on the care plan was probably due to miscommunication. LVN A stated nursing staff had input into the care plans. She stated the DON and ADON were responsible for the accuracy of the care plans. LVN A stated potential consequences for residents would be staff would not be aware which residents smoked. She stated smoking could cause an abnormal oxygen level result and if the staff did not know a resident smoked, the resident may not receive proper care. During an interview on 06/17/2026 at 1:13 p.m., LVN B stated smoking should be on the resident's care plan so staff were aware. She stated a possible reason Resident #1 and Resident #30's smoking status was addressed on the care plan was the resident may have been a new admission and the status was not recorded properly, someone may have forgot to enter the information in the system, the resident was not asked, or the resident picked up a new habit after admission. She stated the DON was responsible for the care plans. Stated potential consequences of failing to include smoking status on the care plan may be mental, emotional, or physical issues due to the staff not knowing to include the resident during smoke breaks. During an interview on 06/17/2026 at 1:48 p.m., the ADON stated he participated in care plan development and a resident's smoking status should be addressed. He stated a reason for the failure to address smoking may be the resident did not admit to being a smoker when admitted . The ADON state the nurses, DON and ADON had input into the care plans. He stated potential consequences of failing to address a resident's smoking status may be a resident could burn up. He stated if staff were not aware of a resident's smoking status, visitors may bring the resident cigarettes and lighter, the resident could go outside and smoke unsupervised. He stated physical harm could occur if staff were not aware a resident required supervision. Record review of the facility policy titled, Care Plans, Comprehensive Person-Centered , revised March 2022, revealed, Policy Statement A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 7. The comprehensive, person-centered care plan: b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, 11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. Record review of the facility policy titled, Smoking Policy - Residents, revised October 2025, revealed, 6. Resident smoking status I evaluated upon admission, if a smoker, the evaluation includes ., 9. Any smoking-related privileges, restrictions, and concerns (for example, need for close monitoring) are noted on the care plan, and all personnel caring for the resident shall be alerted to these issues. Record review of the facility policy titled, Resident Assessment Instrument Manual v1.19.1, dated October 2024, Section J1300: Current Tobacco Use, Item Rational, Planning for Care, revealed, . a care plan that allows safe and environmental accommodation of resident preferences is needed.

Based on observations, interviews, and record reviews, the facility failed to ensure residents who on interview, and record review, the facility failed to maintain medical records on each resident that were complete and accurately documented for 1 of 13 residents (Resident #4) reviewed for medical records. The facility failed to obtain physician orders with setting and parameters for use of CPAP for Resident #4.This failure could place residents at risk for respiratory illnesses and risk for respiratory failure. Findings included:Record review of Resident #4's electronic face sheet 06.15.2026, revealed a [AGE] year-old male, admitted 04.24.2025, with diagnosis Chronic respiratory failure with hypercapnia (too much carbon dioxide in the blood stream), morbid obesity, Congestive Heart Failure (chronic condition of heart muscle is too weak), Presence of Cardiac Pacemaker(battery operated implanted device to regulate abnormal heart rhythm) Record review of Resident #4's Physician orders, dated 06.01.2026, revealed no evidence of an order for use of CPAP machine. Record review of Resident #4's Annual MDS Assessment, dated 05.01.2026, revealed Resident #4, Section C Cognitive status, a BIMS score of 15, indicating cognitively intact Resident #4's, Section I Active Diagnosis, included heart failure, respiratory failure, morbid obesity, cardiac pacemaker. Resident #4's, Section P special treatments, procedures and programs therapy. Record review of Resident #4's Care Plan04.05.2026, revealed the resident had oxygen therapy related to sleep apnea, utilized and oxygen therapy when sleeping, and on room air, while awake. Interventions included position resident to facilitate ventilation/perfusion (ventilation refers to the flow of air into and out of your lungs while perfusion refers to the flow of blood through the lungs blood vessels). During an interview and observation on 06.15.2026 at 1:48 pm, Resident #4 stated he used CPAP machine (medical device that delivers a steady stream of pressurized air through a tube and mask) at night. He stated he was able to put the CPAP on without assistance most of the time. Resident #4 stated the staff checked to verify if he was using his CPAP at night. The CPAP machine and CPAP mask were observed in Resident #4's room located on table at the bedside. During an interview on 06.17.2026 at 11:03 a.m., the DON stated residents who required the use of a CPAP should have a written physician's order and parameters for use. The DON stated this failure occurred due to Resident #4 being readmitted and orders not put in the system. The DON stated she did not feel this had a negative effect on the resident. The DON stated she and the ADON were responsible for ensuring the physician orders are entered and accurate. She stated she did end of month reviews each month Review of facility's policy titled, CPAP/BiPAP Support dated March 2015 revealed: Purpose 1. To provide the spontaneously breathing resident with continuous positive airway pressure with or without supplemental oxygen.2. To improve arterial oxygenation (PaO2) in residents with respiratory insufficiency, obstructive sleep apnea, or restrictive/obstructive lung disease.3. To promote resident comfort and safety. Preparation 3. Record review the physician's order to determine the oxygen concentration and flow, and the PEEP pressure (CPAP, IPAP and EPAP) for the machine. Steps in the Procedure 8. Set mode, CPAP, IPAP and EPAP settings on the machine, as prescribed.

Based on interview, and record review, the facility failed to maintain medical records on each resident that were complete and accurately documented for 2 of 13 residents (Resident #28 and Resident #30) reviewed for medical records. The facility failed to ensure Resident #28, and Resident #30 had safe smoking assessments completed. This failure could place residents at risk of health and safety due to no updated safe smoking assessments.Findings included:Record review of Resident #28's electronic face sheet, dated 06.16.2026, revealed [AGE] year-old female, admitted n 03.01.2024, diagnosis included of bipolar disorder (a mental health condition that causes uncontrollable shifts in mood, energy and activity levels), Type II Diabetes Mellitus (metabolic disorder, high blood glucose levels), Hypertension (high blood Pressure), Major Depressive Disorder. Record review of Resident #28's Annual MDS dated 03.10.2026 revealed Resident #28 Section A Level II PASRR (Preadmission Screening and Resident Review) Serious Mental Illness Resident #28 Section C-cognitive status BIMS=15 (cognitively intact), Section I Active Diagnosis-Bipolar. Record review of Resident #28's Care Plan, dated ??, revealed the resident was a tobacco smoker and was at risk of injury. Interventions included perform smoking assessment according to facility policy. Record review of Resident #28's Smoking Assessment, dated 11.28.2025, revealed Resident #28 was assessed at that time to be a safe smoker with supervision. No other Smoking Assessments were found in the EMR. Record review of Resident #30's electronic face sheet, dated 06.16.2026, revealed an [AGE] year-old female, admitted 02.16.2026, with diagnosis Chronic Obstructive Pulmonary Disease (lung disease), Hypertension (high blood pressure), Depression, other lack of coordination. Record review of Resident #30's admission MDS Assessment, dated 05.29.2026, indicated Resident #30's BIMS was 15, indicating cognitively intact. Resident #30 Section I Active Diagnosis chronic obstructive pulmonary disease. Resident #30 Section O Special treatments, procedures and Oxygen therapy programs. Record review of Resident #30's electronic medical record, dated 06.16.2026, revealed a Safe Smoking Assessment completed on 2.18.2026 revealed Resident #30 requires supervision when smoking. There was no evidence that quarterly smoking assessment was completed in May 2026. During an interview on 06.17.2026 at 11:03 a.m., the DON stated smoking assessments for residents that smoke should have been conducted at admission and quarterly. She stated a recent change was made, and the Activity Director was responsible for completing the smoking assessments. The DON stated she was responsible for ensuring the assessments were completed. The DON stated she did not feel this failure affected the residents negatively. She stated she felt this failure occurred due to new process being initiated and staff needed re-education on process. Review of the facility's policy titled, Smoking Policy-Residents, revision date October 2025, indicated, Policy Statement.This facility has established and maintains safe resident smoking practices.Policy Interpretation and Implementation.8. A resident's ability to smoke safely is re-evaluated quarterly, upon a significant change (physical orcognitive) and as determined by the staff.

Based on interview and record review, the facility failed to assess a resident using the quarterly review instrument specified by the State and approved by CMS not less frequently than once every three months for 7 (Resident #3, Resident #4, Resident #5, Resident #7, Resident #8, Resident #10, Resident #16) of 12 residents reviewed for MDS assessments. The facility failed to complete Resident #3's Quarterly MDS Assessment within 14 calendar days of the ARD. The facility failed to complete Resident #4's Quarterly MDS Assessment within 14 calendar days of the ARD. The facility failed to complete Resident #5's Quarterly MDS Assessment within 14 calendar days of the ARD. The facility failed to complete Resident #7's Quarterly MDS Assessment within 14 calendar days of the ARD. The facility failed to complete Resident #8's Quarterly MDS Assessment within 14 calendar days of the ARD. The facility failed to complete Resident #10's Quarterly MDS Assessment within 14 calendar days of the ARD. The facility failed to complete Resident #16's Quarterly MDS Assessment within 14 calendar days of the ARD. This failure could lead to residents not receiving the care required to meet their individual needs. Findings included: Record review of Resident #3's Admission Record revealed Resident #3 was originally admitted on [DATE] with a most recent admitted [DATE]. The Admission Record indicated a [AGE] year-old male with medical diagnoses of intellectual disabilities, anxiety disorder, high blood pressure, suicidal ideations, high blood cholesterol, overweight, heart disease, and a chronic lung disorder. Review of Resident #3's Quarterly MDS dated [DATE] revealed in Section C Cognitive Patterns, subsection C0500 BIMS Score Summary, the resident scored 11 out of 15 indicating mild cognitive impairment. Further review of Resident #3's Quarterly MDS revealed an ARD/Target Date of 02/10/25. The completion date listed on the Quarterly MDS was 04/17/2025. Record review of Resident #4's Admission Record revealed Resident #4 was originally admitted on [DATE] with a most recent admitted [DATE]. The Admission Record indicated a [AGE] year-old female with medical diagnoses of intellectual disabilities, pseudobulbar affect (a neurological condition characterized by sudden, involuntary episodes of crying or laughing, often in a response to a situation that is not emotional), high blood pressure, Type 2 diabetes mellitus, anxiety disorder, weakness, and major depressive disorder (a mood disorder characterized by persistent sadness and loss of interest in activities). Review of Resident #4's Quarterly MDS dated [DATE] revealed in Section C Cognitive Patterns, subsection C0500 BIMS Score Summary, the resident scored 10 out of 15 indicating mild cognitive impairment. Further review of Resident #4's Quarterly MDS revealed an ARD/Target Date of 02/08/25. The completion date listed on the Quarterly MDS was 04/17/2025. Record review of Resident #5's Admission Record revealed Resident #5 was admitted on [DATE]. The Admission Record indicated a [AGE] year-old female with medical diagnoses of Type 2 diabetes mellitus, high blood cholesterol, high blood pressure, alcohol dependence, heart disease, dementia, major depressive disorder, anxiety, and nightmare disorder. Review of Resident #5's Quarterly MDS dated [DATE] revealed in Section C Cognitive Patterns, subsection C0500 BIMS Score Summary, the resident scored 12 out of 15 indicating mild cognitive impairment. Further review of Resident #5's Annual MDS, revealed an ARD/Target Date of 03/09/25. The completion date listed on the Annual MDS was 04/17/2025. Record review of Resident #7's Admission Record revealed Resident #7 was admitted on [DATE]. The Admission Record indicated a [AGE] year-old male with medical diagnoses of bacteremia (bacteria in the urine), cirrhosis of the liver (liver tissue is replaced with scar tissue), anemia, acute kidney failure, rhabdomyolysis (damaged muscle tissue releases its contents into the bloodstream which could lead to kidney damage ), dyspnea (difficulty breathing), dizziness, high blood pressure, insomnia, weakness, and unsteady when walking. Review of Resident #7's Quarterly MDS dated [DATE] revealed in Section C Cognitive Patterns, subsection C0500 BIMS Score Summary, the resident scored 12 out of 15 indicating mild cognitive impairment. Further review of Resident #7's Quarterly MDS, revealed an ARD/Target Date of 02/10/25. The completion date listed on the Quarterly MDS was 04/17/2025. Record review of Resident #8's Admission Record revealed Resident #8 was originally admitted on [DATE] with a most recent admitted [DATE]. The Admission Record indicated a [AGE] year-old male with medical diagnoses of intellectual disabilities, cerebral palsy (a group of neurological disorders that affect movement, posture, and muscle tone), paraplegia (paralysis that affects the lower half of the body), high blood pressure, high blood cholesterol, major depressive disorder, Type 2 diabetes mellitus, heartburn, weakness, bladder dysfunction, insomnia, Barrett's esophagus without dysplasia (a condition when the lining of the esophagus becomes more like the lining of the intestines due to exposure to stomach acid), and arthritis. Review of Resident #8's Annual MDS dated [DATE] revealed in Section C Cognitive Patterns, subsection C0500 BIMS Score Summary, the resident scored 4 out of 15 indicating severe cognitive impairment. Further review of Resident #8's Annual MDS, revealed an ARD/Target Date of 01/17/25. The completion date listed on the Annual MDS was 04/17/2025. Record review of Resident #10s Admission Record revealed Resident #10 was originally admitted on [DATE] with a most recent admitted [DATE]. The Admission Record indicated an [AGE] year-old female with medical diagnoses of dementia, low blood potassium, weakness, high blood pressure, anxiety, malnutrition, history of falls, and low thyroid function. Review of Resident #10's Quarterly MDS dated [DATE] revealed in Section C Cognitive Patterns, subsection C0500 BIMS Score Summary, the resident scored 11 out of 15 indicating mild cognitive impairment. Further review of Resident #10's Quarterly MDS, revealed an ARD/Target Date of 02/05/25. The completion date listed on the Quarterly MDS was 04/17/2025. Record review of Resident #16's Admission Record revealed Resident #16 was admitted on [DATE]. The Admission Record indicated a [AGE] year-old male with medical diagnoses of lung cancer, high blood pressure, anxiety, insomnia, heart failure, heart disease, chronic lung disease, schizoaffective disorder (A condition characterized by a combination of symptoms from schizophrenia and mood disorders), arthritis, amputation of right leg above the knee, chronic pain, heartburn, and constipation. Review of Resident #16's Quarterly MDS dated [DATE] revealed in Section C Cognitive Patterns, subsection C0500 BIMS Score Summary, the resident scored 14 out of 15 indicating intact cognition. Further review of Resident #16's Quarterly MDS, revealed an ARD/Target Date of 02/22/25. The completion date listed on the Quarterly MDS was 04/17/2025. During an interview on 04/30/25 at 12:45 PM, the DON stated the MDS nurse was responsible for completing and updating the MDS. She stated she did not know why failing to complete the MDS on time occurred. She stated it was ultimately her responsibility to ensure that everything was completed but she just started this position and was playing catch up. During an interview on 04/30/25 at 12:50 PM, the Administrator stated the delay in completing the MDS's was due to the facility going through transition during a change of ownership. She stated the MDS Coordinator was responsible for preparing the MDS. The Administrator explained the MDS Coordinator covered 3 buildings and was in the process of transferring all residents to new identification numbers. She stated she was aware that MDS's were late. The Administrator stated her expectation was for MDS's to be complete and submitted on time. She stated the person responsible for monitoring MDS's was a corporate nurse. The Administrator stated she did not think failing to complete MDSs on time would directly affect the residents. She stated possible indirect effects because the facility did not get paid until the MDSs were submitted. During an interview on 04/30/25 at 01:26 PM, the MDS Coordinator stated she was responsible for entering data and transmitting MDS's. She explained MDS's were not completed timely because the facility did not have a DON until recently. She stated the MDSs were not currently being transmitted due to the change in ownership process. The MDS Coordinator stated she was told by corporate not to transmit until the PL1 (assignment of new facility ID and providers number) process was complete. She stated her expectation, under normal circumstances, was to finish an MDS as soon as the ARD hits. The MDS Coordinator stated she had done MDSs for [AGE] years and was unable to state any effect on residents in failing to complete or transmit MDS's timely. During an interview on 04/30/25 at 02:12 PM, the Administrator clarified a PL1 was tasks corporate took care of to be assigned new identifying numbers. She stated MDSs were being kicked back due to incorrect identifying numbers because the change in ownership process was not complete. Review of facility policy titled MDS Completion and Submission Timeframes, revised July 2017, revealed Policy Statement Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes. Policy Interpretation and Implementation 2. Timeframes for completion and submission of assessment is based on the current requirements published in the Resident Assessment Instrument Manual. Review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.1.9.1 dated October 2024 revealed in Chapter 2 Assessments for the Resident Assessment Instrument; section 2.6 Required OBRA Assessments for the MDS; subsection 05 Quarterly Assessment (A0320A = 02) The Quarterly assessment is an OBRA non-comprehensive assessment for a resident that must be completed at least every 92 days . The MDS completion date (item Z0500B) must be no later than 14 days after the ARD (ARD + 14 calendar days). 45732

Based on interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan based on assessed needs with measurable objectives that have the ability to be evaluated or quantified to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 (Resident #11, Resident #70) of 14 residents reviewed for comprehensive person-centered care plans. The facility failed to develop care plans based on the assessed needs with measurable objectives and timeframes for hospice services for Resident #11. The facility failed to develop care plans based on the assessed needs with measurable objectives and timeframes for Oxygen use for Resident #70. This failure could place the residents at risk for decreased quality of life and not having their needs met. Findings include: Record review of Resident #11's electronic face sheet 04/30/2025 revealed [AGE] year-old male admitted [DATE] and diagnosis included Chronic Obstructive Pulmonary Disease (lung disease), Unspecified Dementia, Hypertension (high blood pressure), Seizures (sudden temporary disruption of brain activity) Record review of Resident #11's Physician Orders dated 04/30/24 revealed hospice to evaluate and treat if appropriate. Record review of Resident #11's significant change MDS dated [DATE] revealed Cognitive Patterns, Resident #11's BIMS (Brief Interview of Mental status) score 12 (moderated cognitive impairment) Special Treatments, Procedures, and Programs-Hospice care. Record review of Resident #11's Care Plan dated 02/18/2025 revealed no documented Focus, Goal, or Interventions for hospice care for Resident #11. Record review of Resident #70's electronic face sheet on 04/30/2025 revealed [AGE] year-old male admitted [DATE] with diagnosis that included Secondary Malignant Neoplasm (abnormal growth of cells, tumor) of Bone, Hypertension (high blood pressure), Unspecified Dementia, Chronic Pain. Record review of Resident #70's hospice orders dated 03/06/2025 revealed no physician order for oxygen use. Record review of Resident # 70's Admission MDS dated [DATE] revealed Cognitive Patterns- Resident #70's BIMS score 03-severe cognitive impairment. Record review of Resident #70's Care Plan dated 04/29/2025 revealed no documented Focus, Goal, Interventions for oxygen use. Record review of Resident #70's Physician orders dated 04/30/2025 revealed no physician order for oxygen use. During an observation on 04/28/2025 at 10:20 AM Resident #70 was lying in bed with oxygen via nasal cannula at 5 LPM in place. During an observation on 04/28/2025 at 02:06 PM Resident #11 had oxygen at 4 LPM vis nasal cannula in place. Oxygen in use sign outside Resident #11's door. During an observation on 04/29/2025 at 11:15 AM Resident #70 lying in bed with oxygen via nasal cannula at 5 LPM in place. Resident #70's room did not have an oxygen in use sigh posted. During an interview on 04/30/2025 at 01:26 PM with MDS Coordinator stated she was responsible for participating in care plan development. The MDS Coordinator stated she did not know how the failure occurred for residents to not have complete comprehensive care plan. The MDS Coordinator was unable the state effect on residents in failing to ensure care plans included all serviced provided to resident. During an interview on 04/30/2025 at 2:00 PM The DON stated oxygen use should be care planned. The DON stated the effect on resident not having oxygen care planned would be that the staff may not know resident needed to have the oxygen. The DON stated she did not know how this failure occurred. The DON stated MDS Coordinator was responsible for initiating care plans. The DON stated she was responsible for checking care plans quarterly and when a resident had a change in condition that required additional interventions on care plan. 04/30/2025 at 03:10 PM at time of exit there had been no return call from MDS Coordinator. Record review of facility's policy titled Comprehensive Care Planning (not dated) revealed.: The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the residents' rights that includes measurable objectives, and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan will describe the following--- The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, psychosocial well-being; and Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and addresses the resident's medical, physical, mental and psychosocial needs The comprehensive care plan will be developed within 7 days after the completion of the comprehensive assessment . The facility will ensure that services provided or arranged are delivered by individuals who have the skills, experience, and knowledge to do a particular task or activity. This includes proper licensure or certification if required. 45732

Based on observation, interview and record review, the facility failed to ensure that residents who needed respiratory care were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 2 (Resident #2 Resident #70) of 3 residents reviewed for respiratory care. 1. The facility failed to obtain a Physician's order for Resident #2's continuous supplemental oxygen. 2. The facility failed to obtain a Physician's order for Resident #70's continuous supplemental oxygen. 3. The facility failed to post oxygen in use sign for Resident #70. These failures could place residents at risk of not receiving the necessary respiratory care to meet their needs. Findings included: Record review of Resident #2's electronic face sheet reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: pneumonia, chronic pulmonary disease, emphysema. ( Lung disease) Record review of Resident #2's Admission MDS assessment, dated 12/15/24, reflected a BIMS score of 15 which indicated no cognitive impairment. Review of Section O reflected Resident #1 was on continuous oxygen. Record review of Resident #2's facility records reflected no evidence of a comprehensive care plan or a baseline care plan. During observation and interview on 04/28/25 at 02:06 PM, Resident #2 sitting up in bed doing a crossword puzzle. She stated she is here for therapy and has no concerns. Resident #2 was on oxygen at 4LPM via nasal cannula and an oxygens sign was observed outside of her door. Record review of Resident #2's electronic physicians orders reflected no evidence of an order for oxygen. Record review of Resident #70's on 04/30/2025 electronic face sheet revealed [AGE] year-old male admitted [DATE] with diagnosis that included Secondary Malignant Neoplasm (abnormal growth of cells, tumor) of Bone, Hypertension (high blood pressure), Unspecified Dementia, Chronic Pain. Record review of Resident #70's Physician orders dated 04/30/2025 revealed no physician order for oxygen use . Record review of Resident #70's hospice orders dated 03/06/2025 revealed no physician order for oxygen use. Record review of Resident # 70's Admission MDS dated [DATE] revealed Cognitive Patterns- Resident #70's BIMS score 03-severe cognitive impairment. Record review of Resident #70's Care Plan dated 04/29/2025 revealed no documented Focus, Goal, Interventions for oxygen use. During an observation on 04/28/2025 at 10:20 AM Resident #70 was lying in bed with oxygen via nasal cannula at 5 LPM in place. Resident #70's room did not have an oxygen in use sign posted. During an observation on 04/29/2025 at 11:15 AM Resident #70 lying in bed with oxygen via nasal cannula at 5 LPM in place. Resident #70's room did not have an oxygen in use sigh posted. During an interview on 04/30/2025 at 2:00 PM the DON stated there should have been an order for any resident with oxygen and there should have been a sign outside the resident's room stating that oxygen was in use. The DON stated she did not think the resident was affected due to the resident was receiving the needed oxygen. The DON stated she did not know how this failure occurred. The DON stated she was responsible for checking the physician's orders for accuracy. 04/30/2025 at 03:10 PM at time of exit there had been no return call from MDS Coordinator regarding comprehensive care plans. Record review of facility's policy titled Oxygen Administration (no date) revealed: Purpose The purpose of this procedure is to provide guideline for safe oxygen administration. Preparation 1. Verify that there is a physician's order for this procedure. Review the physician's order or facility protocol for oxygen administration. 2. Review the resident's care plan to assess for any special needs of the resident. 3. Assemble the equipment and supplies as needed Equipment and Supplies 1. Portable oxygen cylinder (strapped to the stand); 2. Nasal cannula, nasal catheter, mask (as ordered) 3. Humidifier bottle 4. No Smoking/Oxygen in Use signs . 45732

Based on interview and record review, the facility failed to ensure residents with PRN orders for psychotropic drugs were limited to 14 days and to ensure psychotropic medications were not given unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 3 (Resident #10, Resident #127, and Resident #147) of 12 residents reviewed for unnecessary medications. The facility failed to ensure Resident #10's PRN Lorazepam (medicine used to treat the symptoms of anxiety) was discontinued after 14 days or a documented rational for the continued provision of the medication. The facility failed to ensure Resident #127's PRN Alprazolam (medicine used to treat the symptoms of anxiety) was discontinued after 14 days or a documented rational for the continued provision of the medication. The facility failed to ensure Resident #147's PRN Lorazepam (medicine used to treat the symptoms of anxiety) and Haloperidol (medicine used to treat agitation) was discontinued after 14 days or a documented rational for the continued provision of the medication. This failure could place residents at risk for adverse reactions and negative side effects from the administration of medication that was not indicated for use to treat medical conditions and symptoms and dependence on unnecessary medications. Findings included: Resident # 10 Review of Resident #10's electronic face sheet revealed resident was an [AGE] year-old female who was admitted on [DATE] with diagnoses that included: Dementia, Anxiety, and high blood pressure. Review of Resident #10's Quarterly MDS dated [DATE] revealed: Section C- Cognitive Patterns a BIMS score of 12 (no cognitive impairment); Section N- Medication's resident received Antianxiety medication in the last 7 days of review period. Review of Resident #10's Comprehensive Care Plan last revised 10/25/2021, revealed: Focus: Resident uses anti-anxiety medications r/t anxiety disorder. Goal: Resident will be free from discomfort or adverse reactions related to anti-anxiety therapy. Interventions: Administer anti-anxiety medications as ordered by physician . Review of Resident #10's electronic physician orders revealed: Lorazepam Oral tablet 1 mg give 1 tablet by mouth every 4 hours as needed for anxiety with a start date of 10/20/2024 and no end date and Lorazepam Concentrate 2 MG/ML Give 0.5 ml by mouth every 6 hours as needed for anxiety with a start date of 08/02/2024 and no end date. Review of Resident #10's physician progress notes from January 2025- April 2025 revealed no documented rationale for the continued provision of Lorazepam. Review of Resident #10's electronic MAR for April 2025 revealed 7 doses of Lorazepam oral tablet had been administered and Lorazepam Concentrate 1 dose had been administered. Review of Drugs.com for Lorazepam accessed on 04/29/2025 at https://www.drugs.com/lorazepam.html revealed: Lorazepam belongs to a class of medications called benzodiazepines. It is thought that benzodiazepines work by enhancing the activity of certain neurotransmitters in the brain. Lorazepam is used in adults and children at least [AGE] years old to treat anxiety disorders. Resident #127 Review of Resident #127's electronic face sheet revealed resident was an [AGE] year-old male who was admitted on [DATE] and readmitted on [DATE], with diagnoses that included: Anxiety, Diabetes, and high blood pressure. Review of Resident #127's admission MDS dated [DATE] revealed: Section C- Cognitive Patterns a BIMS score of 15 (no cognitive impairment); Section N- Medication's resident received Antianxiety medication 0 days out of the last 7 days of review period. Review of Resident #127's Baseline Care Plan dated 04/25/2025, revealed resident was not taking any PRN psychotropic medications. Review of Resident #127's electronic physician orders revealed: Alprazolam tablet 0.25 mg Give 1 tablet by mouth every 8 hours as needed for Anxiety with a start date of 04/11/2025 and no end date. Review of Resident #127's physician progress notes from April 2025 revealed no documented rationale for the continued provision of alprazolam. Review of Resident #127's electronic MAR for April 2025 revealed no doses of Alprazolam had been administered for anxiety. Review of Drugs.com for Alprazolam accessed on 04/29/2025 at https://www.drugs.com/alprazolam.html revealed: Alprazolam is a benzodiazepine. It is thought that it works by enhancing the activity of certain neurotransmitters in the brain. Alprazolam is used to treat anxiety disorders, panic disorders, and anxiety caused by depression. Resident # 147 Review of Resident #147's electronic face sheet revealed resident was an [AGE] year-old female who was admitted on [DATE] with diagnoses that included: Dementia, Anxiety, and high blood pressure. Review of Resident #174's Quarterly MDS dated [DATE], reflected a BIMS score of 03 which indicated severe cognitive impairment. Review of Resident #174's Comprehensive Care Plan last revised 07/29/2024, reflected: Focus: resident has a mood problem r/t agitation. Goal: resident will have improved mood state. Interventions: Administer medications as ordered . Review of Resident #147's electronic physician orders revealed: Lorazepam Oral tablet 1 mg give 1 tablet by mouth every 4 hours as needed for anxiety with a start date of 09/18/2024 and no end date and Haloperidol Lactate Oral Concentrate 2 MG/ML Give 0.5 ml by mouth every 6 hours as needed for agitation with a start date of 02/05/2025 and no end date. Review of Resident #147's physician progress notes from January 2025- April 2025 revealed no documented rationale for the continued provision of Lorazepam or Haloperidol. Review of Resident #147's electronic MAR for April 2025 revealed 0 doses of Lorazepam oral tablet had been administered and Haloperidol 3 doses had been administered. Review of Drugs.com for Lorazepam accessed on 04/29/2025 at https://www.drugs.com/lorazepam.html revealed: Lorazepam belongs to a class of medications called benzodiazepines. It is thought that benzodiazepines work by enhancing the activity of certain neurotransmitters in the brain. Lorazepam is used in adults and children at least [AGE] years old to treat anxiety disorders. Review of Drugs.com for Haloperidol accessed on 04/29/2025 at https://www.drugs.com/haloperidol.html revealed: Haloperidol is the first of the butyrophenone series of major antipsychotics. More common side effects difficulty with speaking or swallowing, inability to move the eyes, and loss of balance control. During an interview on 04/30/25 at 12:45 PM, the DON stated that all prn psychotropic medications should have a 14 day stop date and a physician should reevaluate if the medication is needed longer and re-order. She stated the floor nurses were responsible for entering orders when they were received and that currently no one was reviewing or verifying new orders. She stated it was ultimately her responsibility to ensure that orders were entered correctly and that the prn psychotropics have a 14 day stop date. She stated this failure could lead to residents receiving unnecessary medications. She stated this failure possibly occurred due to change in staff and not having a DON in the facility until recently. She stated that the ADON had been responsible for reviewing and completing the pharmacy recommendations. She stated the failure of not completing the recommendations probably occurred due to not having a DON and the ADON having too many responsibilities. Review of facility policy titled; Psychotropic Medication Use dated 2001 revealed in part: Policy Statement: Residents will not receive medications that are not clinically indicated to treat a specific condition. Policy Interpretation and Implementation: .12. Psychotropic medications are not prescribed or given on a PRN basis unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. a. PRN orders for psychotropic medications are limited to 14 days.

Based on interview and record review, the facility failed to ensure each resident's drug regimen was free of significant medication errors for 2 (Resident #15 and Resident #174) of 12 residents reviewed for medications. The facility failed to hold Carvedilol (medication to lower blood pressure) per parameters stated in physicians' orders for a total of 15 doses in April 2025 for Resident #15. The facility failed to hold Lisinopril (medication to lower blood pressure) per parameters stated in physicians' orders for a total of 5 doses in April 2025 for Resident #15. The facility failed to hold Midodrine (medication to increase blood pressure) per parameters stated in physicians' orders for a total of 19 doses in April 2025 for Resident #15. The facility failed to administer Clonidine (medication to lower blood pressure) per parameters stated in physicians' orders for a total of 31episodes of high blood pressure in April 2025 for Resident #174. The deficient practice placed the residents at risk of harm or not receiving desired outcomes from medications not administered according to physician's orders and manufacturer's specifications. Findings Included: Resident #15 Review of Resident #15's electronic face sheet reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include: high blood pressure, respiratory failure, and kidney failure. Review of Resident #15's Quarterly MDS dated [DATE], reflected a BIMS score of 06 which indicated severe cognitive impairment. Review of Resident #15's Comprehensive Care Plan last revised 10/13/2024, reflected: Focus: Hypertension: resident has a potential for fluctuations in blood pressure, low blood pressure and high blood pressure. Goal: residents blood pressure will stay within normal limits and will not have signs or symptoms of low or high blood pressure. Interventions: .Give medications per order-monitor labs- report results to doctor . Review of Resident #15's electronic physicians' orders reflected: Carvedilol Oral Tablet 3.125 MG Give 1 tablet by mouth two times a day for hypertension Hold for SBP (top number of blood pressure) less than 110, order date 01/09/2025. Review of Resident #15's electronic MAR for April 2025 reflected carvedilol was given on: 4/4/25 at 9pm for BP of 103/56 by LVN A, 4/5/25 at 9am for BP of 109/55 by LVN B, 4/5/25 at 9pm for BP of 103/53 by LVN A, 4/9/25 at 9am for BP of 105/62 by ADON, 4/9/25 at 9pm for BP of 107/61 by LVN C, 4/10/25 at 9pm for BP of 101/62 by DON, 04/12/25 at 9am for BP of 104/64 by LVN D, 04/12/25 at 9pm for BP of 101/73 by LVN E, 4/14/25 at 9am for BP of 86/62 by ADON, 04/14/25 at 9pm for BP of 86/62 by LVN C, 4/15/25 at 9am for BP of 86/62 by ADON, 4/15/25 at 9pm for BP of 91/60 by LVN C, 4/16/25 at 9pm for BP of 102/62 by LVN E, 4/18/25 at 9pm for BP of 100/73 by LVN C, and 4/28/25 at 9pm for BP of 97/65 by LVN C. Review of Resident #15's electronic physicians' orders reflected: Lisinopril Oral Tablet 2.5 MG Give 1 tablet by mouth in the morning for hypertension Hold for SBP (top number of blood pressure) less than 110, order date 01/09/2025. Review of Resident #15's electronic MAR for April 2025 reflected lisinopril was given on: 4/5/25 at 9am for BP of 109/55 by LVN B, 4/9/25 at 9am for BP of 105/62 by ADON, 04/12/25 at 9am for BP of 104/64 by LVN C, 4/14/25 at 9am for BP of 86/62 by ADON, and 4/15/25 at 9am for BP of 86/62 by ADON. Review of Resident #15's electronic physicians' orders reflected: Midodrine Oral Tablet 2.5 MG Give 1 tablet by mouth two times a day for low blood pressure Hold for SBP (top number of blood pressure) greater than 110, order date 01/09/2025. Review of Resident #15's electronic MAR for April 2025 reflected Midodrine was given on: 4/4/25 at 9am for BP of 120/64 by RN G, 4/6/25 at 9am for BP of 113/61 by LVN B, 4/6/25 at 9pm for BP of 121/60 by ADON, 4/7/25 at 9am for BP of 117/74 by LVN A, 4/8/25 at 9am for BP of 112/64 by LVN A, 4/13/25 at 9am for BP of 130/80 by LVN F, 4/17/25 at 9am for BP of 121/65 by LVN F, 4/19/25 at 9am for BP of 116/64 by LVN A, 4/19/25 at 9pm for BP of 136/73 by LVN C, 4/20/25 at 9am for BP of 136/73 by LVN F, 4/20/25 at 9pm for BP of 115/66 by LVN C, 4/21/25 at 9am for BP of 115/64 by ADON, 4/23/25 at 9pm for BP of 136/99 by LVN C, 4/24/25 at 9pm for BP of 121/97 by LVN C, 4/25/25 at 9am for BP of 136/61 by LVN F, 4/26/25 at 9am for BP of 120/71 by RN H, 4/26/25 at 9pm for BP of 120/71 by LNV E, 4/27/25 at 9am for BP of 120/71 by RN H, 4/27/25 at 9pm for BP of 128/74 by LVN E. Resident #174 Review of Resident #174's electronic face sheet reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: anxiety, dementia, and high blood pressure. Review of Resident #174's Quarterly MDS dated [DATE], reflected a BIMS score of 03 which indicated severe cognitive impairment. Review of Resident #174's Comprehensive Care Plan last revised 07/29/2024, reflected: Focus: resident has hypertension. Goal: resident will remain free for signs or symptoms of high blood pressure. Interventions: .Give anti-hypertensive medications as ordered . Review of Resident #174's electronic physicians' orders reflected: Clonidine Oral Tablet Give 0.1 mg by mouth every 8 hours as needed for SBP (top number of blood pressure) over 160, order date 02/05/2025. Review of Resident #174's electronic Blood Pressure Flow Sheet reflected: 04/01/25 at 10:04 am BP 194/98, 04/01/25 at 6:21 pm BP 173/90, 04/02/25 at 7:38 am BP 192/113, 04/03/25 at 6:22 am BP 168/94, 04/05/25 at 6:18 am BP 177/83, 04/07/25 at 6:29 am BP 188/98, 04/08/25 at 6:19 am BP 183/110, 04/08/25 at 6:10 pm BP 196/106, 04/09/25 at 6:27 am BP 179/99, 04/09/25 at 6:12 pm BP 180/94, 04/10/25 at 6:06 am BP 177/97, 04/10/25 at 6:24 pm BP 171/88, 04/11/25 at 7:03 am BP 179/97, 04/11/25 at 7:49 pm BP 171/84, 04/12/25 at 8:46 am BP 181/84, 04/13/25 at 6:47 am BP 184/96, 04/16/25 at 6:31 am BP 164/83, 04/18/25 at 6:15 am BP 169/88, 04/18/25 at 6:34 pm BP 175/93, 04/19/25 at 9:31 am BP 195/94, 04/19/25 at 6:19 pm BP 176/90, 04/20/25 at 7:06 am BP 186/93, 04/20/25 at 6:23 pm BP 166/93, 04/23/25 at 6:10 am BP 175/91, 04/23/25 at 6:56 pm BP 169/91, 04/24/25 at 6:27 am BP 189/96, 04/24/25 at 6:16 pm BP 170/98, 04/28/25 at 6:24 am BP 182/99, 04/28/25 at 6:18 pm BP 161/87, 04/29/25 at 6:38 am BP 187/98, 04/29/25 at 6:38 am BP 187/98. Review of Resident #174's electronic MAR for April 2025 reflected clonidine was not given on: 04/01/25 at 10:04 am BP 194/98, 04/01/25 at 6:21 pm BP 173/90, 04/02/25 at 7:38 am BP 192/113, 04/03/25 at 6:22 am BP 168/94, 04/05/25 at 6:18 am BP 177/83, 04/07/25 at 6:29 am BP 188/98, 04/08/25 at 6:19 am BP 183/110, 04/08/25 at 6:10 pm BP 196/106, 04/09/25 at 6:27 am BP 179/99, 04/09/25 at 6:12 pm BP 180/94, 04/10/25 at 6:06 am BP 177/97, 04/10/25 at 6:24 pm BP 171/88, 04/11/25 at 7:03 am BP 179/97, 04/11/25 at 7:49 pm BP 171/84, 04/12/25 at 8:46 am BP 181/84, 04/13/25 at 6:47 am BP 184/96, 04/16/25 at 6:31 am BP 164/83, 04/18/25 at 6:15 am BP 169/88, 04/18/25 at 6:34 pm BP 175/93, 04/19/25 at 9:31 am BP 195/94, 04/19/25 at 6:19 pm BP 176/90, 04/20/25 at 7:06 am BP 186/93, 04/20/25 at 6:23 pm BP 166/93, 04/23/25 at 6:10 am BP 175/91, 04/23/25 at 6:56 pm BP 169/91, 04/24/25 at 6:27 am BP 189/96, 04/24/25 at 6:16 pm BP 170/98, 04/28/25 at 6:24 am BP 182/99, 04/28/25 at 6:18 pm BP 161/87, 04/29/25 at 6:38 am BP 187/98, 04/29/25 at 6:38 am BP 187/98. During an interview on 04/30/25 at 12:45 PM, the DON she stated she expected her nurses to follow physicians' orders. She stated she expected her nurses to read the MAR and follow parameters. She stated any component nurse should have identified a low or high blood pressure and then looked at the orders to see the parameters. She stated the failure was probably caused by nurses not paying attention. The DON stated that anytime a resident's blood pressure was high she would expect them to look to see if the resident had any standing PRN orders. She stated not following the parameters could lead to residents not receiving the proper treatment for their blood pressures which could lead to pressures not being controlled. During an interview on 04/30/25 at 01:04 PM, the Medical Director stated he just took over this facility and he was unsure why Resident #15 was on medications to decrease and increase his blood pressure. He stated that it was his expectation for nurses to follow the parameters set in the physician's orders. He stated Lisinopril and Carvedilol should never be given at the same time as Midodrine because they will counteract each other. He stated he did not feel that this would have too negative of an outcome. He stated not holding the BP medications could cause the residents blood pressure to get too low, but Resident #15 had not had any issues as of now. He stated PRN blood pressure medications should always be given if ordered when a resident has a high blood pressure. He stated this could lead to residents' blood pressure not being controlled adequately. He stated he did not expect to be notified every time a medication is held, or a PRN was given unless it was a substantial change in condition. During an interview on 04/30/25 at 1:20 PM, the Administrator stated she expected her staff to following physicians' orders and to be competent enough to notice a high or low blood pressure and to check the orders for parameters. She stated the failure probably occurred because of nurses not paying attention. The Administrator stated she was unable to find a policy regarding medication administrator or following physicians' orders.

Based on interviews and record review, the facility failed to develop a baseline care plan within 48 hours of admission for 1 (Resident #2) of 12 residents reviewed for baseline care plans. The facility failed to ensure that Resident #2 had baseline care plan developed within 48 hours after being admitted to the facility on [DATE]. These failures placed the residents at risk of not having continuity of care to safeguard against adverse events that are most likely to occur right after admission. Findings included: Review of Resident #2's electronic face sheet reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: pneumonia, chronic pulmonary disease, emphysema. Review of Resident #2's Admission MDS assessment, dated 12/15/24, reflected a BIMS score of 15 which indicated no cognitive impairment. Review of Section O reflected Resident #1 was on continuous oxygen. Review of Resident #2's facility records reflected no evidence of a baseline care plan. During an interview on 04/30/25 at 12:45 PM, the DON stated that Resident #2 should have had a new baseline care plane when she readmitted in December. She stated that the admitting nurse was responsible for completing the baseline care plan. She stated she did not know why this failure occurred. She stated it was untimely her responsibility to ensure that everything was completed but she just started this position and was playing catch up. Record review of facility policy labeled Care Plans-Baseline dated 20001 reflected: a baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within 48 hours of admission.

Based on interviews and record reviews, the facility failed to provide a resident environment that was free of pests and rodents for 1 of 1 facility reviewed for effective pest control in that: The facility failed to maintain an affective pest control program. This deficient practice could place residents at risk of remaining in an environment that was not free of pests and rodents. The findings included: Record review of grievance log for January, February and March 2025 revealed 1 grievance about pest control. Record review of pest control log for the past 3 months revealed mice were targeted during visit by pest control vendor. Pest Control Vendor visits once per month. Interview on 4/17/25 at 9:50am, Administrator stated that they were having issues with mice in the facility. The Admin stated that their pest control vendor was working on problem. The admin stated that with the facility being located next to fields and an abandoned building next door is causing the mouse situation. Interview on 4/17/25 at 10:50am, Resident #1 stated she had rodent dropping in her room and had seen mice run along her wall several times in the past week. Resident #1 stated she reported incident to Administrator. Observation on 4/17/25 at 10:50am investigator observed 2 rodent droppings in the floor next to wall in Resident #1's room. Interview on 4/17/25 at 11:20am, Resident #3 stated she had seen a mouse running down the hallway of Hall 4. Resident #3 stated she had not seen a mouse in her room. Interview on 4/17/25 at 11:30am, Resident #4 stated she had seen mice from time to time in the hall but had not seen one in the last week. Resident #4 stated she did tell staff about the sighting. Interview on 4/17/25 at 2:00pm, LVN J stated she had not seen any mice but had been told by residents they had seen a mouse running in the hall. LVN J stated she did report sighting to Maintenance. Interview on 4/17/25 at 2:20pm, CNA G stated she had seen a mouse a few days ago in Hall 4 earlier this week. CNA G stated she reported the sighting to Maintenance. Observation on 4/17/25 at 2:34pm, investigator observed a mouse eating bird feed in the bird cage located on Hall 4. The mouse jumped out of the cage and ran under the wall. Interview on 4/17/25 at 2:38pm, Maintenance stated he had only worked for facility for one month and was aware of the rodent problem, Maintenance stated the pest control vendor had set out traps all around the outside of facility and at door entrance. Maintenance stated he is unaware of how the rodents are entering the facility. Maintenance stated he was unaware that the water heater closets drywall was damaged and that rodents can be entering through holes in the drywall. Interview on 4/18/25 at 10:00am, Pest Control Vendor stated the facility has had a rodent problem for the past several months. The Vendor stated that he had placed traps around the outside of facility, checked entry doors to ensure that they are tight and leaves no gaps for entry. The Vendor stated that he has informed Maintenance that the drywalls in the water heater rooms need to be repaired and that the damaged drywall was an entry way for rodents to enter facility. The Vendor stated that not repairing damage has made it difficult to control the rodent problem. Observation on 04/18/2025 at 2:15pm revealed the following: Hot water closets for 5 of 6 halls had outside entry doors, all water heater closets had damaged drywalls at the bottom allowing access for rodents into inside walls of facility. Rodent droppings were observed in 5 of 6 closets around damaged drywall holes in water heater closet. Record review of Facility's Pest Control Policy, undated, states: Our facility shall maintain an effective pest control program. 1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents for 1 of 1 facility reviewed for environmental concerns. The facility failed to repair damaged walls in hot water closets located outside2, 3, 4, and 5 halls has damaged drywall with holes at the bottom and signs of rodent droppings. This deficient practice could place resident, staff, and the public at risk of an unsafe and unsanitary environment. The findings include: Observation on 04/17/2025 beginning at 2:15pm revealed the following: Hot water closets for halls 1, 2, 3, 4 and 5 had outside entry doors, all water heater closets had damaged drywalls at the bottom allowing access for rodents into inside walls of facility. Rodent droppings were observed in 5 of 6 closets around damaged drywall holes in water heater closet. Interview on 4/17/25 at 9:50am, the Administrator stated they were having issues with mice in facility, mice have been seen in halls and resident's rooms. The admin stated that their pest control vendor was working on the problem. The admin stated that with the facility being located next to fields and an abandoned building next door is causing the mouse situation. Interview on 4/17/25 at 10:50am, Resident #1 stated she had rodent dropping in her room and had seen mice run along her wall several times in the past week. Resident #1 stated she reported incident to Administrator. Observation on 4/17/25 at 10:50am investigator observed 2 rodent droppings in the floor next to wall in Resident #1's room. Resident #1's room was next to the hot water closet for hall 4 that had drywall damage and signs of rodent activity leading into the holes in the drywall. Interview on 4/17/25 at 11:20am, Resident #3 stated she had seen a mouse running down the hallway of Hall 4. Resident #3 stated she had not seen a mouse in her room. Interview on 4/17/25 at 11:30am, Resident #4 stated she had seen mice from time to time in the hall but had not seen one in the last week. Resident #4 stated she did tell staff about the sighting. Interview on 4/17/25 at 2:00pm, LVN J stated she had not seen any mice but had been told by residents they had seen a mouse running in the hall. LVN J stated she did report the sighting to Maintenance. Interview on 4/17/25 at 2:20pm, CNA G stated she had seen a mouse a few days ago in Hall 4 earlier this week. CNA G stated she reported the sighting to Maintenance. Observation on 4/17/25 at 2:34pm, investigator observed a mouse eating bird feed in the bird cage located on Hall 4. The mouse jumped out of cage and ran under the wall. Interview on 4/17/25 at 2:38pm, Maintenance stated he had only worked for the facility for one month and was aware of rodent problem but did not know how long the facility had problem. Maintenance stated the pest control vendor visits once per month and has set out traps all around the outside of facility and at door entrance. Maintenance stated he was unaware of how the rodents are entering the facility. Maintenance stated he was unaware that the water heater closets drywall was damaged and that rodents can be entering through holes in the drywall. Interview on 4/18/25 at 10:00am, Pest Control Vendor stated they visit facility once per month since 2022. Vendor stated that facility has had a rodent problem for the past 3 months. Vendor stated that he has placed traps around the outside of facility, checked entry doors to ensure that are tight and leaves no gaps for entry. Vendor stated that he has informed Maintenance that the drywalls in the water heater rooms need to be repaired and that the damaged drywall was an entry way for rodents to enter facility. Vendor stated that not repairing damage has made it difficult to control rodent problem.

Based on observation, interview, and record review, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior environment in 1 of 3 halls (Hall 1) observed for environmental conditions for Resident #1 and #2, in that: 1. The facility failed to prevent the temperature from being 86 F in Resident #1's room. 2. The facility failed to prevent the temperature from being 86 F in Resident #2's room The facility's failure placed the residents at risk for harm by a diminished quality of life and discomfort. The findings included: Resident #1 Record Review of the resident #1's Face Sheet dated 04/17/2024, revealed a [AGE] year-old male, admitted to the facility on [DATE], with a Diagnoses of Cerebral Infarction (stroke), diabetes, depression and hypertension (high blood pressure). Resident #1's MDS, dated [DATE], Section C revealed a BIMS score of 12 (moderately impaired). During an observation of temperature on 04/17/2024 at 2:56 PM of Resident #1's room revealed a temperature of 86 F. During an interview on 04/17/2023 at 10:53 AM, Resident #1 stated there had been a problem with the air conditioning on hall 100. He stated his room, when warm outside affected the temperature in his room, and had felt warm. He stated he had to get fans in his room but was only moving the warm air around. During an interview on 04/17/2024 at 4:20 PM, Resident #1's Representative stated she had thought it was really warm in the room while visiting. Resident #2 Record Review of the resident #2's Face Sheet dated 04/17/2024, revealed a [AGE] year. old male, admitted to the facility on [DATE], with a Diagnoses of Congestive heart Failure, open wounds, and skin conditions. Resident #14's MDS, dated [DATE], Section C revealed a BIMS score of 12 (moderately impaired). During an observation of temperature on 04/17/2024 at 2:58 PM of Resident #2's room revealed a temperature of 86 F. During an interview on 04/17/2023 at 10:53 AM, Resident #2 stated it was hot in his room and had previously asked had told the staff several times if or when the A/C would be repaired. During an interview on 04 /17/2024 at 1:12 PM the facility Maintenance stated the temperatures should have been between 71 F and 77 F. He stated if the resident room temperatures go up to 79 F, he would open a window on hall 1 to help the cooler air flow circulate to/through that area from the cooler halls. The maintenance stated he felt there should have been temperature logs when the air conditioning failed to cool properly. He also stated he was recently hired and had not looked for any temperature logs. He stated the ADMN had told him that she was waiting on the approval for the repairs from corporate and did not know how long it would take to repair. The maintenance man stated he had been busy repairing other things in the facility and had not checked the room temperatures. During an interview on 04/17/2024 at 3:12 PM the ADMN stated the staff had not voiced any complaints from residents that it was hot in any rooms. She stated she had spoken to corporate, and he stated to her he was still getting quotes. The ADMN stated maintenance and housekeeping were the staff to monitor the air conditioning and temperatures for resident rooms. She stated the negative impact to residents would be, being uncomfortable and dehydration. The ADMN stated the failure would have been the pending quotes from corporate, with her expectations to improve the air conditioning and cooling system on hall 1 so that the residents would be comfortable. During an interview on 04/17/2024 at 3:29 PM the Corporate Owner stated with the fact that the facility is in a rural area it was harder and took longer to get parts for air conditioner this time of year. He stated the issues were waiting for all the parts to still come in. He stated he had made a promise to maintenance that it was supposed to had been installed previously and it did not happen. He stated he told him exactly when it would be arriving then it had not. The corporate owner stated the issue that they were having was getting ordered to correct part and then not receiving it at all. He stated it had not done the repairs because they were hoping the parts were in. He stated it would inconvenient residents to install window units for them in the meantime and they could move to a different room on another hall that had air conditioning. The corporate owner stated the monitoring of the temperatures in rooms should be the facility administrator. He stated there would be no negative impact to residents with 90 F weather outside and no a/c for them. He stated his expectations would be to have the air conditioner fixed and correct the problem with the facility administrator and maintenance man. Review of https://www.wunderground.com/history/weekly/us/tx/stamford/KABI/date/2024-4-17 on 04/17/2024 at 3:21 PM the temperature was 89 F outside. Record Review of facility Description of Work receipt dated 03/05/2024 revealed: Provided diagnosis of hall 100 RTU; found that (1) of (2) compressors is grounded and the second compressor circuit is low of refrigerant charge, due to an active refrigerant leak; given the severity of the issues facing this RTU it is recommended that it be replaced; Record Review of facility policy Section IV: Emergency Preparedness and Planning dated August 2019 revealed: C. Temperature Regulation 1. Temperature regulation for resident health, safety and comfort (between 71 and 81 F), as well as to protect supplies and subsistence needs, will be maintained by the alternate power source. 2. If unable to maintain safe temperatures throughout the entire facility, the residents and provisions are, in a safe and timely manner

Based on interview and record review, the facility failed to electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS for 1 of 4 FY quarters reviewed (FY Quarter 1 2024 (October1-December 31) reviewed for administration. The facility failed to submit data to CMS for FY Quarter 1 2024 (October1-December 31). This failure could place residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment. Findings included: Record review of the facility's Civil Rights form (3761) dated 03/11/2024 provided by the Administrator indicated a total of 27 residents and 47 staff that included: 5-Registered Nurses 6-Licensed Vocational Nurses 12-Direct Care Staff 6-Dietary Staff 4-Housekeeping and Laundry 14-All others Record Review of the CMS PBJ report for CMS for FY Quarter 1 2024 (October1-December 31) indicated the facility had failed to submit data for the quarter triggered. During an interview on 03/13/2024 at 11:54 AM, the Administrator stated there was no submission for last quarter. She stated the management office verified with IQIES and tried to pull a report, but it was blank. She stated the former accountant who was responsible to submit failed to do so. The Administrator stated hours were submitted from facility to managing accountant for PBJ reporting. She stated the facility's nurse consultant now had access for the facility and was in the process of submitting for this quarter. Record review of a facility policy titled Reporting Direct-Care Staffing Information (Payroll-Based Journal) undated indicated, Policy Statement: Staffing and census information will be reported electronically to CMS through the Payroll-Based Journal system in compliance with 6106 of the Affordable Care Act. Interpretation and Implementation: l. Beginning with the fiscal quarter of 2016 (beginning July 1, 2016), direct-care staffing and census information will be reported electronically to CMS through the Payroll-Based Journal (PBJ) system. 2. Direct-care staffing information will include staff hired directly by the facility, those hired through an agency, and contract employees .9. Staffing information will be collected daily and reported for each fiscal quarter no later than 45 days after the end of the reporting quarter . 45732

45216 Based on interview and record review, the facility failed to develop and implement a person-centered, comprehensive care plan for each resident, consistent with resident rights, that included measurable objectives and timeframes to meet residents medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment for 5 (Resident #1, Resident #4, Resident #8, Resident #14, and Resident #24) of 5 residents reviewed for care plans. The facility failed to ensure care plans specified measurable objectives that could be evaluated or quantified for Resident #1, Resident #4, Resident #8, Resident #14, and Resident #24. This failure could place residents at risk for not receiving care and services individualized to meet their specific physical, mental, and/or emotional needs. Findings included: Review of Resident #1's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with medical diagnoses of malnutrition (lack of proper nutrition), traumatic brain injury, major depression, high blood pressure, osteoarthritis, schizoaffective disorder (mental health disorder that is a combination of schizophrenia symptoms like hallucinations, and mood disorder symptoms like depression or mania), weakness, psychotic disorder (collection of symptoms that affect the mind, where there has been some loss of contact with reality), and anxiety. Review of Resident #1's Medicare 5-day MDS dated [DATE], revealed in Section C - Cognitive Patterns C0500. BIMS Summary Score, Resident #1 scored 6 out of 15 indicating severe cognitive impairment. Review of Resident #1's Comprehensive Care Plan review start date of 09/20/2023 revealed the following focus care areas with objectives that were not measurable: Focus: [Resident] has impaired cognitive thought processes r/t Head Injury (HX of TBI), Impaired decision making; Dementia with an objective of The resident will maintain current level of cognitive function ., Focus: [Resident] has potential to be physically aggressive (SPECIFY: hitting/swinging at/attempting to stab, staff/residents) r/t Dementia, history of harm to others, Poor impulse control with an objective of The resident will demonstrate effective coping skills ., Focus: [Resident] has an ADL self-care performance deficit r/t Alzheimer's, Confusion, Dementia with an objective of She will maintain current level of function in ADLs ., Focus: [Resident] express desire to return to community but due to inability to manage medications, prepare meals, provide ADLs without assistance, identify change in medical condition, manage appointments/test or fiances they require long term care with an objective of 'Resident will adjust to facility and need for placement ., and Focus: [Resident] does wander around facility with/without purpose. Has no history of attempting to leave facility. She wanders in and out of other resident's rooms into bathrooms with an objective of Resident will be redirected from other residents rooms, out of unauthorized area with out injury to self or others . Review of Resident #4's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with medical diagnoses of arthritis in both knees, dementia, overactive bladder, high blood pressure, and weakness. Review of Resident #4's Annual MDS dated [DATE], revealed in Section C - Cognitive Patterns C0500. BIMS Summary Score, Resident #4 scored 12 out of 15 indicating moderate cognitive impairment. Review of Resident #4's Comprehensive Care Plan review start date 10/04/2023 revealed the following focus care areas with objectives that were not measurable: Focus: [Resident] attends Activities of interest. Attends (specify Activity). Resident requires (specify) assistance to attend. [Resident] refuses to come out of room to any activity or meal, offer activity in room she declines states she just wants the quiet and to watch TV undisturbed. with an objective of Resident will continue to attend activities daily ., Focus: [Resident] is at risk for weight loss due to: her diagnosis with an objective of {Resident] nutritional status will remain stable AEB no reports of significant weight change ., Focus: [Resident] is incontinent-by choice, will request to be laid in the bed to have BM in brief, refuses to sit on BSC or bed pan with an objective of Episodes of incontinence will decrease ., Focus: [Resident] has an ADL self-care performance deficit r/t Activity Intolerance. Fatigue, Impaired balance with an objective of The resident will maintain current level of function . , and Focus: [Resident] is at risk for chest pin r/t a dx A-FIB (irregular heart rhythm); is at risk for side effects of medications-ASA; Apixaban with an objective of The resident will demonstrate an understanding of the disease process (SPECIFY: A-FIB) and the importance of compliance with treatment . Review of Resident #8's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with medical diagnoses of osteomyelitis (inflammation of bone or bone marrow), suicidal ideations, pseudobulbar affect (condition characterized by episodes of sudden uncontrollable and inappropriate laughing or crying), high blood pressure, Type 2 diabetes, anxiety, cataracts (cloudy area in the lens of the eye), weakness, and major depression. Review of Resident #8's Quarterly MDS dated [DATE], revealed in Section C - Cognitive Patterns C0500. BIMS Summary Score, Resident #8 scored 11 out of 15 indicating moderate cognition impairment. Review of Resident #8's Comprehensive Care Plan dated 09/27/2023 revealed the following focus care areas with objectives that were not measurable: Focus: [resident] has a DX of Diabetes. Is at risk for Hypo/hyperglycemic (low/high blood sugar) episodes and complications related to disease process and is risk for side effect to medication-actos/metformin/Levemir/Humulin R per sliding scale with an objective of Resident will be compliant with dietary restrictions., Focus: [Resident] has DX of Depression. Is at risk for side effects to medication . with an objective of Resident will have no S/S or reports of side effects to medication. , Focus: [Resident] has Edema (swelling) +2 to both lower extremity, with an objective of Resident will have no complication related to edmea . , Focus: [Resident] is at risk for weight loss due to: dementia with an objective of [Resident's] nutritional status will remain stable with no reports of significant weight change ., Focus: [Resident] express desire to return to community but due to inability to manage medication, prepare meals, provide ADLs without assistance, identify change in medication condition, manage appointment/test or finances they require long term care. Family/resident request that they be asked about discharge goal only on comprehensive assessments with an objective of [Resident} will adjust to facility and need for placement ., Focus: [Resident] has (SPECIFY: Impaired visual function/unable to determine visual function) R/T Bilateral (both sides) cataract with an objective of Will have no indications of acute eye problems . , Focus: [Resident] has long and short term memory problems. Needs verbal cue, redirection. Needs supervision for decisions with an objective of Resident right to refuse will be respected . , Focus: [Resident] has an ADL self-care performance deficit r/t Disease Process ID; activity intolerance; weakness with an objective of The resident will maintain current level of function in all ADL's. , Focus: [Resident] has had an actual fall on 7/2/18 during transfer . with an objective of The resident will resume usual activities without further incident. Review of Resident #14's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with medical diagnoses of malnutrition, down's syndrome (a condition which a person has an extra chromosome that causes intellectual disability, developmental delays and a distinct facial appearance), convulsions, hearing loss, heart burn, osteoporosis (a condition in which the bones become brittle and fragile), high level of fat in the blood, high blood pressure, and overactive bladder. Review of Resident #14's Quarterly MDS dated [DATE], revealed in Section C - Cognitive Patterns C0500. BIMS Summary Score, Resident #14 scored 99 indicating the resident was unable to complete the interview. Review of Resident #14's Comprehensive Care Plan dated 08/09/2023 revealed the following focus care areas with objectives that were not measurable: Focus: [Resident] is at risk for weight loss and dehydration due to her diagnosis . with an objective of [Resident] nutritional status will remain stable no reports of significant weight change ., Focus: [Resident] is at risk for skin breakdown r/t (specify decreased mobility, incontinence nutritional status) with an objective of Resident will have not reports of skin breakdown ., Focus: [Resident] has an ADL self-care performance deficit r/t Activity Intolerance. Limited Mobility. Limited ROM with an objective of The resident will maintain current level of function in ADLs ., and Focus [Resident] has impaired cognitive function/dementia or impaired thought processes r/t Developmentally delayed, Disease Process (SPECIFY: down's syndrome) with an objective of The resident will maintain current level of cognitive function . Review of Resident #24's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with medical diagnoses of Alzheimer's, high blood pressure, gout (a type of arthritis affecting smaller bones such as in the feet), benign prostatic hyperplasia (an enlarged prostate), major depression, and diverticulitis (bulging pouches in the digestive tract). Review of Resident #24's Quarterly MDS dated [DATE] revealed in Section C - Cognitive Patterns C0500. BIMS Summary Score, Resident #24 scored 01 out of 15 indicating severe cognitive impairment. Review of Resident #24's Comprehensive Care Plan dated 08/09/2023 revealed the following focus care areas with objectives that were not measurable: Focus: [Resident] is at risk for weight loss and dehydration due to his diagnosis of alzheimer's with an objective of [Resident] nutritional status will remain stable with no reports of significant weight change . , Focus: [Resident] is at risk for pain due to (specify: dx of gout, general aches/pains) with an objective of Resident will show signs/symptoms of pain control ., Focus: [Resident] has DX of BPH. AT risk for difficulty starting/stopping urinary flow, urinary retention, UTI, urinary obstruction and adverse reaction to medications . with an objective of Resident will have no S/S of complications due to BPH ., Focus: FALLS: [Resident] is at risk for falls and injuries AEB multiple falls, poor safety awareness, think fragile skin with an objective of [Resident's] dignity will be maintained ., Focus: ANTIBIOTICS: (resident name) is on antibiotics and is at risk for adverse reactions/side effects AEB - Antibiotic: Levaquin - Dx: UTI no objective was documented for this focus care area, Focus: [Resident] has an ADL self-care performance deficit r/t Activity Intolerance, Confusion, Dementia with an objective of He will maintain current level of function ., Focus: [Resident] is an elopement risk/wanderer r/t History of attempts to leave facility unattended, Impaired safety awareness, Resident wanders aimlessly with an objective of The resident's safety will be maintained . , and Focus: [Resident] has impaired cognitive function/dementia or impaired thought processes r/t Alzheimer's, Dementia, Impaired decision making with an objective of The resident will maintain current level of cognitive function . During an interview on 03/13/24 at 11:34 AM, the DON stated she and the MDS coordinator were responsible for developing and updating the care plans. The DON stated she started working at the facility in November 2023 and the MDS coordinator started working at the facility on 03/09/2024. She stated objectives on care plans need to be measurable so the facility could determine if the care plan interventions were effective, and she was not able to provide an explanation of why the failure do document measurable objectives occurred other than the recent turnover in nursing leadership. The DON stated changes in the plan of care for residents was communicated to staff via in-services, nurse meetings, shift change reports, and CNA room to room reports. She explained the effect on residents of failing to have measurable objectives on the care plans was that the care plans should coincide with the care needed and the care provided. The DON acknowledged the examples of objectives given such as nutritional status will remain stable with no reports of significant weight change . and She will maintain current level of function in ADLs . were not measurable and needed to be written in a way that was individualized to each resident. The DON stated the reason care area needs identified in resident records but were not addressed on the care plan was because revising the care plan had been overlooked. She stated the same was true for care needs listed on care plan that were no longer needed. The DON explained certain tasks for the nursing staff to complete were triggered on the care plans. She stated training for developing care plans was received in nursing school and during her more than [AGE] years working as a nurse. During an interview on 03/13/24 at 11:46 AM, LVN A stated she did not look at the care plans, she did not know what was on a care plan. LVN A stated the DON was responsible for the care plans. Review of the facility policy titled Care Plans, Comprehensive Person-Centered, no date, revealed A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed for each resident.

Based on observation, interviews and record review the facility failed to immediately consult the resident, resident's family, or resident's physicians for 3 of 6 residents (Resident #1, #5, and #9) reviewed for notifications when significant changes occurred in their health, mental or psychosocial status and the need to alter treatment. A. Resident #5's January 2017 Medication Administration Record identified Resident #5 was not administered his enteral feedings for twelve days in January 2017. On 01/27/17 it was identified that Resident #5 had experienced a significant weight loss of over 5% in the last 30 days. Resident #5 was not receiving the correct amount of enteral formula as ordered, when they had been administered or his enteral feeding pump was not functioning properly. The facility failed to consult the physician regarding the tube feedings not being administered. B. Resident #9 had been seen by the Dietician on 01/09/17 regarding weight loss, however the facility failed to implement the recommendations of weekly weights, contact Resident #9's physician regarding the weight loss. Resident #9 had experienced significant weight loss of 22% in the last 30 days. C. Failure to notify Physician B that Resident #1 (a) had not completed his antibiotic therapy for a UTI (urinary tract infection) due to refusal of his medications, (b) refused meals with increased frequency, (c) and had exhibited verbal and physical aggression with increased frequency. Resident #1 had an untreated urinary tract infection and an unidentified significant weight loss of over 15% in less than 30 days. On 01/27/17 an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 02/02/17, the facility remained out of compliance at a severity level of Actual harm that is not Immediate Jeopardy and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place 45 residents (including Residents #1, 5, and 9) who resided in the facility at risk for life-threatening complications that could lead to death due to not receiving appropriate treatments when significant changes in their health occurs. Findings include: Resident #5 Record review of Resident #5's Admission Record, dated 10/31/16, revealed he was an [AGE] year old male admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review of Resident #5's Admission MDS assessment, dated 11/07/16, revealed a BIMS score of 08, indicating moderate cognitive impairment; Section G revealed that he was totally dependent upon staff for all activities of daily living, specifically eating. Section K revealed that his height was 68 inches and his weight was 137 pounds, he had a feeding tube, which provided 26-50% of total calories the resident received through [MEDICATION NAME] or tube feeding and a mechanically altered diet was also indicated. Record review of Resident #5's Care Plan dated 11/04/16, revised on 01/18/17, revealed a focus area of: (Resident #5) is at risk for malnutrition and weight loss due to requires Pureed diet with Nectar thick liquids, Does have a [DEVICE] for nutritional support, (Resident #5) will be encouraged and assisted to consume greater than 50% of meals daily through next review date-Target Date: 4/18/17. (Resident #5's) nutritional status will remain stable as evidenced by (AEB) no reports of significant weight change. Interventions: Assess reports of signs and symptoms of aspiration/difficulty chewing or swallowing, implement appropriate interventions within code status. Notify MD and refer to speech therapy (ST) as appropriate. Dietician to review quarterly and as needed (PRN). Encourage (Resident #5) to eat meal out of bed. Encourage/assist (Resident #5) to upright position for intake by mouth. Encourage/remind to remain in upright position for at least 30 minutes after meals as indicated. Observe tolerance to diet and liquids, notify MD and refer to ST as appropriate. Observe for/record and notify MD, registered dietician (RD) of change in eating habits. Observe meal intake, record and offer alternative if eats less than 50% of meal. Observe weight as ordered. Notify MD, RD and responsible party (RP) of weight change greater than 5% in 30 days, 7.5% in 90 days and/or 10% in 180 days. Offer preferences when available. Offer encourage snacks within dietary restrictions. Provide REGULAR PUREED diet as ordered with NECTAR THICKENED liquids. Provide set-up, supervision, verbal cue and physical assistance as needed to complete meals. Intervention: Eating The resident is totally dependent on (1x) staff for eating. According to the United States National Library of Medicine, accessed on 02/03/17, a [DEVICE] is A gastrostomy feeding tube insertion is the placement of a feeding tube through the skin and the stomach wall. It goes directly into the stomach. Gastrostomy feeding tubes are put in for different reasons. They may be needed for a short time or permanently. This procedure may be used for: oPersons who cannot swallow correctly oPersons who cannot take enough food by mouth to stay healthy oPersons who often breathe in food when eating https://medlineplus.gov/ency/article/ 7.htm. Record review of Resident #5's signed Physician orders [REDACTED]. o Order start date: 10/31/16 for [MEDICATION NAME] 2.0 Liquid (Nutritional Supplement). Give 540cc via PE[DEVICE] in the evening related to unspecified protein calorie malnutrition. Give at 45ml/hr. o Order start date: 10/31/16 for Regular diet Pureed texture, nectar thick liquids consistency. Record review of Resident #5's malnutrition risk assessment dated [DATE] revealed a score of 21, indicating he was at a high risk for malnutrition. Record review of Resident #5's January 2017 Medication Administration Record (MAR) revealed the following order and dates that nurses' had initialed and circled and there were some handwritten explanations as to why the enteral feeding was not administered. [MEDICATION NAME] 2.0 Liquid (Nutritional Supplements) Give 540cc via PE[DEVICE] in the evening related to Unspecified Protein Calorie Malnutrition, give at 45ml/hr. Start date: 10/31/16 at 1800 (6:00 PM). o 01/03/17 was initialed and indicated the feeding was administered, however nurses notes reflected that the enteral feeding was withheld due to the feeding pump not functioning. LVN I o 01/04/17 initialed on MAR as given, and no documentation in nurses notes regarding enteral feeding. LVN A o 01/05/17- out of supplement- LVN F o 01/06/17- LVN E o 01/07/17-out of supplement-LVN I o 01/08/17- out of supplement-LVN I o 01/09/17- out of supplement- LVN I o 01/10/17- LVN A o 01/11/17- LVN A o 01/12/17- LVN I (this particular date, Resident #5 was noted to be out of the facility at Hospital B due to lethargy) o 01/13/17-LVN I o 01/14/17- Initialed on MAR as administered, no documentation in nurses notes regarding the enteral feeding- LVN I o 01/15/17- Need supplies-LVN D o 01/16/17 and 01/17/17 were initialed and indicated they were administered, however nurses notes reflected that the enteral feeding was withheld due to the feeding pump not functioning. (According to facility provided invoices, Resident #5's enteral nutrition was available on 01/12/17 for nursing staff to administer, however Resident #5's enteral feedings were not administered until 01/18/17 due to the feeding pump was not functioning properly.) Record review of Resident #5's January 2017 MAR, Nurses Notes revealed the following twelve days in January 2017 where Resident #5 was not administered his enteral feeding due to not having his enteral nutrition available and/or the feeding pump not functioning properly. 1/3/17, 1/5/17, 1/6/17, 1/7/17, 1/8/17, 1/9/17, 1/10/17, 1/11/17, 1/13/17, 1/15/17, 1/16/17, 1/17/17. Record review of Resident #5's January 2017 MAR and nurses notes from 01/19/2017 thru 01/26/17 revealed that Resident #5 had received his enteral feedings. In an observation and interview on 1/27/17 at 7:55 a.m. Resident #5 was lying in his bed on his back. A feeding pump was in the room disconnected from Resident #5's gastrostomy tube and turned off. He said he was hungry. When asked if he was able to eat by mouth, he said yes ma'am. He said he had not had any breakfast this morning. He said they get me up and take me to the dining room, but that he had not been this morning. Observation on 01/27/17 at 8:15 AM revealed Resident #5 in his bed. His bed was noted to be in a low position and a fall mat at his bedside. Resident #5 was observed with his feet on the floor mat, his upper body lying flat on the bed and he was attempting to get out of the bed, he verbalized he was hungry. Resident #5 could not verbalize when he last was fed orally or via his gastrostomy tube. In an interview on 01/27/17 at 8:20 AM, CNA E said that she did not have any residents on Hall 1 that still needed assistance to get up for breakfast or that would require a breakfast tray. When asked about getting Resident #5 up for breakfast, she said she had attempted to get him up but (Resident #5) refused. She said that she had only attempted to get him up one time, but had alerted the nurse as to his refusal. She said that Resident #5 had not been offered anything for breakfast. In an interview on 1/27/17 at 8:20 a.m. LVN A, who was not Resident #5's nurse that morning, but had been his nurse previously for the month of January, said recently Resident #5's feeding pump had not been working and that they had run out of formula. She said she told the ADON when they were starting to run low and reported the pump not functioning. She said she had notified the ADON verbally, but could not recall the exact date and that she had also put a note in her box, but could not recall the exact date. She said Resident #5 was able to eat by mouth and took his medications by mouth. She said on days when she assisted him with eating he would eat 100%. She said he was always up for supper but she did not know about breakfast or lunch. She said she always made sure Resident #5 ate supper and that she assisted him. Observation on 01/27/17 at 8:22 AM revealed CNA E providing incontinent care to Resident #5. Resident #5 verbalized to CNA E that he was hungry. In an interview on 01/27/17 at 8:24 AM with Cook B, she said that she had been told earlier that morning on 01/27/17 not to fix Resident #5 a breakfast tray. She was unable to recall who told her not to fix Resident #5 a breakfast tray. In an interview on 1/27/17 at 8:25 a.m. LVN F said she was Resident #5's nurse for the day and that Resident #5 would go to the dining room but sometimes when he was groggy he stayed in his room. She said on those days she did not think he was being fed in his room but was not sure the reason. She said the CNA who was assigned the hall trays for that day was supposed to notify the nurse and dietary and a tray would be sent to the room. She said if the resident required assistance to eat the CNA assigned to the hall trays was supposed to assist. She said she had not been told that Resident #5 had not gotten up for breakfast this morning or dietary had not prepared him a breakfast tray. In an interview on 01/27/17 at 8:26 AM with the Dietary Manager, she said that she had asked LVN G if Resident #5 was going to need a hall tray for breakfast on 01/27/17. The Dietary Manager said that LVN G told her Not to fix him one, he is not eating, he has a feeding tube. In an interview on 01/27/17 at 8:28 AM with LVN G, she said that she had not told the Dietary Manager or Cook B anything regarding Resident #5's breakfast tray and that LVN F was his nurse. In an interview on 01/27/17 at 8:29 AM with LVN F, she said that she had not told the Dietary Manager or Cook B to not fix Resident #5 a breakfast tray on the morning of 01/27/17. She also said that she had not been told by CNA E that Resident #5 had refused to get up for breakfast. She said that Resident #5 received a puree diet and received supplement feedings via his gastrostomy tube. In an interview on 01/27/17 at 8:40 AM with Resident #5, he was able to verbalize his name, the name of the facility he was in and when asked if he needed anything, he said Yes ma'am, I'm Hungry. In an interview on 01/27/17 at 8:43 AM with LVN F, she said that CNA E should have attempted at least three different times to offer Resident #5 breakfast and if he still refused she should have verbalized the refusal to her. She said that she thought he was okay and had eaten. She said she was unaware he wasn't fed breakfast until around 8:30 AM. In an interview on 01/27/17 at 8:45 AM with the Dietary Manager, she said she had been asked to make Resident #5 a breakfast tray by CNA E and she was preparing his meal now. In an interview on 1/27/17 at 8:55 a.m. LVN F said Resident #5 only had two days left of his formula and she did not know if it had been ordered. She said she fed him at lunch yesterday (1/26/17) and he ate 100%. Observation and interview on 01/27/17 at 9:16 AM revealed CNA E weighed Resident #5 on the facility scale and said Resident #5's weight was 129.3 pounds. Record review of Resident #5's monthly weight log revealed: November 2016- 137.0 pounds December 2016- 136.4 pounds January 2017-138.1 pounds Based on the above weights, the surveyor identified an 8.8 pound weight loss, >5% in less than 30 days. (An exact date that the weights were obtained could not be identified on the weight log) Observation on 01/27/17 at 9:27 AM revealed Resident #5 was served 8 oz. of nectar thick orange juice, 8 oz. of nectar thick water, a bowl of cream of wheat with milk and butter for breakfast. CNA E was assisting Resident #5 in the dining room with his breakfast and he consumed 100%. In an interview on 01/27/17 at 9:30 AM with the Dietary Manager, she said that the nursing staff has told the dietary staff to hold a tray or not make one due to residents refusal. She said that if it was a one-time occurrence the dietary staff follow the request of the nursing staff, however if the nursing staff request to hold a tray for longer than one meal she would need to clarify with a physician's orders [REDACTED].#5 puree meal trays three times a day regularly for the month of January and felt that it was a one time occurrence the morning of 01/27/17. In an interview on 01/27/17at 9:52 AM with the DON, she said that Resident #5 was able to eat a puree diet along with his enteral feedings and she said (Resident #5) always gets up and doesn't ever refuse a meal. She said that when she arrived at the facility the morning of 01/27/17 at approximately 8:00 AM, LVN F told her Resident #5 had refused to get up for breakfast and he had not received a breakfast tray on 01/27/17. When asked by the surveyor what her expectations were regarding resident refusal and not offering a resident breakfast, she said it was Unacceptable, that he had not been offered but once to get up for breakfast this morning. The DON said that it had not been brought to her attention until addressed by the surveyor at this time that Resident #5 had gone without his enteral feeding for twelve days. She said that no one had reported to her that he was out of his enteral feeding formula and the feeding pump had been malfunctioning. She said that CNA H was in charge of the monthly weights and that to her knowledge Resident #5 had not been weighed since the first part of January, but could not give an exact date of when CNA H obtained his weight. When the surveyor asked if she was aware he had lost 8 pounds since the weight obtained the first part of January she replied Oh my gosh NO!. In an observation and interview with the ADON on 1/27/17 at 10:25 a.m. five cartons of [MEDICATION NAME] 2.0 (formula) each containing 250 ml (milliliters) were in the cabinet in the medication room. The ADON said Resident #5 receives 540 ml every 24 hours. She said if she orders the formula by noon it was delivered the next day. She said the staff needs to let her know every week what was needed because I order every week. She said depending on where items are shipped from it could take 2-4 days for them to arrive. She said Resident #5 had two feedings and one partial feed left. She said Resident #5 was the only resident in the facility with tube feedings. In an interview on 1/27/17 at 11:10 a.m. LVN A, who normally worked 2pm-10pm shift and had been Resident #5's nurse, said there have been no problems with Resident #5 getting up for supper. She said she noted on the 24-hour report the feeding pump was having issues the first part of January 2017. She said within a day of putting it on the 24-hour report she verbally told the ADON the feeding pump was not working. LVN A said the ADON said she did not look at the 24-hour report-the DON does. LVN A asked the ADON if the facility had a spare feeding pump and the ADON said no. She said it was hard to say how long the pump did not work-maybe at least a week. She said she works two days on one side of the building, two days on the other side of the building and then she was off two days. She said the pump was still not working when she returned. She said she thinks she may have faxed a note to the doctor-can't say for sure I did. She said if she sent a fax it would be in the chart under the Nurse's Notes. She said she verbally notified the ADON face to face, but was unable to recall the date, of the formula starting to run low and that they also needed the tubing for the pump. She said at that point they still had a half case or less. She said when she discovered they were out of the formula and tubing she verbally notified the ADON, but was unable to recall the exact date, and asked what are we doing? She said the ADON said they were changing supply companies. She said she discussed the issue with LVN I who was working the other side but doesn't remember if LVN I mentioned it to anyone. LVN A said she had a few conversations with the ADON about it when she was back on duty. LVN A said when she sets up the pump she would put two cartons in the bag. She said the other nurses who come in after her shift could check the bag and put more in and that she would tell the on-coming shift that she put in two cartons. In an interview on 01/27/17 at 11:16 AM, the ADON said that she was responsible for ordering Resident #5's enteral feeding supplement. She did not recall Resident #5 being out of his enteral feeding beginning on 01/05/17 through the 01/17/17. She denied being notified by any staff member on or around January 5th that Resident #5 was out of his [MEDICATION NAME]. She said that she did not have a tracking or monitoring system in place to keep up with the supply of Resident #5's [MEDICATION NAME] and that the nurses let her know when she needed to reorder it. She said that Resident #5's entire supply of [MEDICATION NAME] was kept in the medication room and there was not any other place it would be stored. She said that she was unaware until about thirty minutes ago that there was only 5 cartons of [MEDICATION NAME] 2.0 and that she must have missed the need to order more this week. Record review of the facility's invoices provided by the ADON and THE CORPORATE RN from 10/31/16 through 01/26/17 revealed the following dates and amounts of [MEDICATION NAME] 2.0 that the facility had purchased for Resident #5: Date: 10/31/16 [MEDICATION NAME] 2.0 1000ml Ultrapak 6/case Quantity Ordered: 1 case Date: 11/07/16 [MEDICATION NAME] 2.0 8 oz. 24/case Quantity Ordered: 4 cases Date: 01/10/17 [MEDICATION NAME] 2.0 8.45oz 24/case Quantity Ordered: 1 case Received: 01/12/17 In an interview on 1/27/17 at 11:50 a.m. LVN F said she uses two cartons of formula for Resident #5's feeding. She said Resident #5 needs to be fed. She said staff takes him to the dining room due to being a choking risk. She said staff had been getting him up for breakfast. She said she thinks the girls (CNAs) think if he says no they don't ask again. She said she thinks that's what happened this morning. She said the method of notifying someone when a resident was out formula was to verbally tell the DON. She said she had not told the DON when Resident #5 was out of formula because LVN A said she had already told the DON. She said sometimes she notifies the DON by text. Observation and interview on 01/27/17 at 11:55 AM, the ADON identified two cartons of [MEDICATION NAME] 2.0 (250ml each carton) in the trash can in the medication room and stated that this was from the evening shift on 01/26/17 and would have been what Resident #5 received for his enteral nutrition that evening. The tubing and bag the enteral nutrition was placed in was unable to be located anywhere in the facility's trash containers. She did identify that there was a supply of feeding bags and tubing available for administration at this time. Record review of the 24 hour report/change of condition report for station/unit 1-2 for the month of January 2017 revealed the following entries: o 01/01/17, 01/02/17, 01/03/17, and 01/04/17 - Remarks Night Shift- (Resident #5) needs new kangaroo pump o 01/05/17- Remarks Evening Shift- (Resident #5) needs [MEDICATION NAME] 2.0 out of feeding o 01/06/17- Remarks Night Shift- (Resident #5) needs [MEDICATION NAME] 2.0, out o 01/07/17- Remarks Evening Shift- (Resident #5) No [MEDICATION NAME], ate 75% o 01/07/17- Remarks Night Shift- (Resident #5) needs [MEDICATION NAME] 2.0 o 01/08/17- Remarks Night Shift- (Resident #5) Need [MEDICATION NAME] o 01/09/17- Remarks Day, Evening and Night Shift- (Resident #5) Need food for PEG. o 01/10/17- Remarks Night Shift- (Resident #5) need food for PEG. o 01/11/17- Remarks Night Shift -(Resident #5) needs bag/Peg Formula o 01/12/17- Remarks Day Shift- (Resident #5) sent to emergency room at 12:00 PM for lethargic, shallow, labored breathing. o 01/12/17- Remarks Night Shift-(Resident #5) Needs feeding. o 01/13/17- Remarks Deaths/Discharges/Leave of Absence- (Resident #5) at (Hospital B for observations). o 01/14/17- Remarks Evening Shift-(Resident #5) [MEDICATION NAME]. o 01/15/17-Remarks Evening shift-(Resident #5) Feeding infusing-no distress. o 01/16/17- Remarks under Admission/Readmission/Leave of Absence Returns- (Resident #5) [MEDICATION NAME] 2.0 feeding held due to pump not working. o 01/17/17- Remarks Evening Shift- (Resident #5) No feeding, pump will not work. o 01/18/17- Remarks Evening Shift- (Resident #5) New pump replaced. o 01/19/17 through 01/26/17 the 24 hour report did not have any recorded issues regarding the supply of his enteral feedings or the feeding pump not functioning properly for Resident #5. Record review of Resident #5's Admission History and Physical to Hospital B on 01/12/17 at 1:21 PM revealed the following This is an [AGE] year old male who was brought in by ambulance with an acute change of mental status. Seen in his normal status yesterday by the son; he presents to the emergency room unable to speak clearly, positive weakness. He reports that he does feel badly and he feels badly all over. Otherwise cannot elicit any complaints. Physical Examination: Vital Signs: BP:193/82, HR 49, Respirations 20, Temperature 97.5, Oxygen 99%, Weight 139 pounds. Record review of Resident #5's medical records from Hospital B, dated 01/12/17 revealed the following: Intravenous (IV) [MEDICATION NAME] Ringer's infusing at 125cc/hr initiated at 12:22 PM. Laboratory Values were obtained the following morning on 01/13/17 at 10:00 AM after resident had received IV fluids and there was no evidence of electrolyte imbalance or dehydration. [MEDICATION NAME] was low at 2.78. According to Medline Plus, accessed on 02/08/17, [MEDICATION NAME] is a protein made by the liver. A serum [MEDICATION NAME] test measures the amount of this protein in the clear liquid portion of the blood. The normal range is 3.4 to 5.4 g/dL. Decreased blood [MEDICATION NAME] may occur when your body does not get or absorb enough nutrients. https://medlineplus.gov/ency/article/ 0.htm Record review of the discharge patient care instructions from Hospital B dated 01/13/17 at 10:44 AM, revealed Resident #5 to have received patient care instructions regarding Altered Mental Status .causes .Low blood sugar or diabetes, severe loss of body fluids (dehydration) or a body salt (electrolyte imbalance) An infection .Patient instructions: Continue nursing home care as ordered. Follow up as needed with primary care physician. Record review of Resident #5's skilled daily nurse's note's revealed the following: o 01/03/17 at 6:00 PM, LVN I made the following entry Residual noted at 35ml. Peg tube flushed with 100cc of water. Peg tube pump not functioning correctly. 75% of supper ate. Peg tube feeding held at this time. o From 01/04/17 to 01/12/17 there were no entries in the nurses notes that addressed Resident #5's enteral feedings. o 01/12/17 at 12:00 PM, LVN G made the following entry Resident in dining room in wheelchair with head tilted back and beginning to slide out of wheelchair. Resident #5 states I am not feeling . Resident #5 unable to complete sentence. When asked how he feels, states Not worth a damn .will send to emergency room . o From 01/13/17 to 01/16/17 there were no entries in the nurses notes that addressed Resident #5's enteral feedings. o 01/16/17 2-10PM, LVN A made the following entry Feeding held due to pump not working. o 01/17/17 2-10 PM, LVN A made the following entry Held feeding due to pump not working. DON notified. o 01/18/17 10:00 PM, LVN D made the following entry new feeding pump delivered, [MEDICATION NAME] at 45ml/hour initiated, tolerated feeding well. o Record review of entries 01/19/17 through 01/26/17 did not reveal any remarkable findings pertinent to his enteral feedings. Record review of the Food Intake Record for Resident #5 dated January 2017 and nurses notes between 1/1/17 and 1/26/17, revealed the following documentation for Resident #5's meal intake: Breakfast: 01/01/17 75% consumed 01/02/17 100% consumed 01/03/17 No documentation provided. 01/04/17 100% consumed 01/05/17- No documentation provided. 01/06/17 Refused 01/07/17 thru 01/14/17 there was no record documenting that Resident #5 had any meal intake for breakfast. 01/15/17 - Nurses notes revealed ate breakfast in dining room LVN L 01/16/17 Refused, however nurses notes revealed pocketing food at breakfast 01/17/17 Refused 01/18/17 thru 01/26/17 there was no record documenting that Resident #5 had any meal intake for breakfast. Lunch: 01/01/17 100% consumed 01/02/17 100% consumed 01/03/17 thru 01/15/17 there was no record documenting that Resident #5 had any meal intake for lunch. 01/16/17 75% consumed 01/17/17 thru 01/24/17 there was no record documenting that Resident #5 had any meal intake for lunch. 01/25/17 95% consumed 01/26/17 95% consumed Dinner: 01/01/17 thru 01/02/17 there was no record documenting that Resident #5 had any meal intake for dinner. 01/03/17 Nurses notes revealed 75% supper LVN I 01/04/17 No documentation provided. 01/05/17 100% consumed 01/06/17 thru 01/14/17 there was no record documenting that Resident #5 had any meal intake for dinner. 01/15/17 50% consumed 01/16/17 30% consumed 01/17/17 Nurses notes revealed Up in dining room for supper LVN A 01/18/17 Nurses notes revealed Ate fair at supper. LVN A 01/19/17 thru 01/23/17 there was no record documenting that Resident #5 had any meal intake for dinner. 01/24/17 Nurses notes revealed 75% Supper LVN D 01/25/17 No documentation provided. 01/26/17 100% consumed In an interview on 01/27/17 at 11:12 AM, Resident #5 was unable to recall if he had received his enteral feeding last night on 01/26/17. In an interview on 01/27/17 at 12:10 PM with Resident #5's responsible party, he said that he had not been contacted by the facility in regards to his father not receiving his enteral feedings the earlier part of January or that the feeding pump was not working properly. Resident #5's son said that he had noticed Resident #5 had lost weight recently. Observation on 01/27/17 at 12:16 PM revealed Resident #5 sitting in dining room eating his lunch tray. Resident #5 was being assisted with his feeding by LVN F. Resident consumed 100 % of his puree lunch. In an interview on 1/27/17 at 12:40 p.m. the ADON said word of mouth notification that supplies are needed was not good enough. She said staff should notify her in writing by using an inventory sheet or place a note in her box or underneath her door. She said she did not monitor the 24-hour report and that she had never been asked to monitor it and that the task had never been delegated to her. She said she would take the 24-hour report to the morning meeting when the DON was not working. She said maybe the other day (unable to recall the exact date) LVN A told her they were running low on Resident #5's formula but she could not recall the physician being notified of the pump not working or being out of formula. She said the charge nurses were responsible for notifying the doctor. She said she could not recall how long it took to get another pump delivered. She said she considered neglect to be not caring for a resident. She said the system for a resident refusing a meal was that the CNA should check three times to get them up for a meal, notify the charge nurse verbally, document on the ADL sheets when the resident refuses, and the charge nurses were supposed to monitor the meal intake on the intake sheets. She said that she had observed Resident #5 during lunch and sometimes during dinner during the month of January eating his dinner in the dining room with assistance from the staff. Observation and interview with the DON on 01/27/17 at 12:45 PM revealed the DON performed a test on Resident #5's feeding pump and she said it was working efficiently. At this time, she said that she was responsible for monitoring the 24 hour report. She said that she usually looks at it every morning. She said that Honestly, I had stopped looking at the 24 hour report a few weeks ago due to being gone a lot during the mornings for personal reasons. She said that the ADON should have been looking at the 24 hour report if she was not there but did not recall specifically if she had told her to look at it. In an interview on 01/27/17 at 1:34 PM, Physician A said that he had not been notified by the facility of Resident #5 missing his enteral feedings 01/03/17 thru 01/17/17 or that he had not been notified of Resident #5's weight loss. He said that malnutrition could occur as a result of the missed enteral feedings. He said he recalled Resident #5 being sent to Hospital B for lethargy on 01/12/17 and that when the hospital was ready to discharge he was contacted by the facility and notified that he could not return to the facility because at that time the facility did not have his enteral feeding supplement. He said that he gave a telephone order at that time to use whatever the facility had in house for his enteral feeding. He did not recall who he spoke with from the facility. He said if he would have been notified of the feeding pump malfunctioning he would have given an order for [REDACTED].#5 was discharged with altered mental status and he had not seen Resident #5 since that time. In an interview on 1/27/17 at 3:00 p.m. CNA G said she had worked with Resident #5 last week. She said he got up for dinner and that he eats decently' in the dining room. She said it was a day by day thing as to how well he ate. She said she had noticed he had gotten slightly weaker and had not moved as much lately. She said Resident #5 seemed to be losing energy. In an interview on 01/27/17 at 3:10 PM, the Dietician said that she was unaware that Resident #5 had not received his enteral feedings

Based on observation, interview and record review, the facility failed to ensure residents were free from neglect for one (Resident #5) of ten residents reviewed for neglect. A. Resident #5 was not administered his enteral feedings for twelve days in January 2017. The facility was either out of stock for Resident #5's enteral feeding formula or Resident #5's feeding pump was not functioning properly. Resident #5 was not receiving the correct amount of enteral formula as ordered, when they had been administered. On 01/27/17 it was identified that Resident #5 had experienced a significant weight loss of over 5% in the last 30 days. In addition, Resident #5's [MEDICATION NAME] level on 01/13/17 was low at 2.78 g/dl. B. On 1/27/17, Resident #5 was not assisted out of bed and offered a breakfast tray. Resident #5 was verbally stating I'm Hungry. Inconsistent documentation to indicate Resident #5 was being fed during January was found on the Meal Intake Record and Nurses Notes. On 01/27/17 an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 02/02/17, the facility remained out of compliance at a severity level of Actual harm that is not Immediate Jeopardy and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. These failures placed one resident (Resident #5) in the facility that received nutrition via a gastrostomy tube at risk for malnutrition, dehydration, electrolyte imbalance, weight loss and the potential for even death. Findings included: Record review of Resident #5's Admission Record, dated 10/31/16, revealed he was an [AGE] year old male admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review of Resident #5's Admission MDS assessment, dated 11/07/16, revealed a BIMS score of 08, indicating moderate cognitive impairment; Section G revealed that he was totally dependent upon staff for all activities of daily living, specifically eating. Section K revealed that his height was 68 inches and his weight was 137 pounds, he had a feeding tube, which provided 26-50% of total calories the resident received through [MEDICATION NAME] or tube feeding and a mechanically altered diet was also indicated. Record review of Resident #5's Care Plan dated 11/04/16, revised on 01/18/17, revealed a focus area of: (Resident #5) is at risk for malnutrition and weight loss due to requires Pureed diet with Nectar thick liquids, Does have a [DEVICE] for nutritional support, (Resident #5) will be encouraged and assisted to consume greater than 50% of meals daily through next review date-Target Date: 4/18/17. (Resident #5's) nutritional status will remain stable as evidenced by (AEB) no reports of significant weight change. Interventions: Assess reports of signs and symptoms of aspiration/difficulty chewing or swallowing, implement appropriate interventions within code status. Notify MD and refer to speech therapy (ST) as appropriate. Dietician to review quarterly and as needed (PRN). Encourage (Resident #5) to eat meal out of bed. Encourage/assist (Resident #5) to upright position for intake by mouth. Encourage/remind to remain in upright position for at least 30 minutes after meals as indicated. Observe tolerance to diet and liquids, notify MD and refer to ST as appropriate. Observe for/record and notify MD, registered dietician (RD) of change in eating habits. Observe meal intake, record and offer alternative if eats less than 50% of meal. Observe weight as ordered. Notify MD, RD and responsible party (RP) of weight change greater than 5% in 30 days, 7.5% in 90 days and/or 10% in 180 days. Offer preferences when available. Offer encourage snacks within dietary restrictions. Provide REGULAR PUREED diet as ordered with NECTAR THICKENED liquids. Provide set-up, supervision, verbal cue and physical assistance as needed to complete meals. Intervention: Eating The resident is totally dependent on (1x) staff for eating. According to the United States National Library of Medicine, accessed on 02/03/17, a [DEVICE] is A gastrostomy feeding tube insertion is the placement of a feeding tube through the skin and the stomach wall. It goes directly into the stomach. Gastrostomy feeding tubes are put in for different reasons. They may be needed for a short time or permanently. This procedure may be used for: oPersons who cannot swallow correctly oPersons who cannot take enough food by mouth to stay healthy oPersons who often breathe in food when eating https://medlineplus.gov/ency/article/ 7.htm. Record review of Resident #5's signed Physician orders [REDACTED]. o Order start date: 10/31/16 for [MEDICATION NAME] 2.0 Liquid (Nutritional Supplement). Give 540cc via PE[DEVICE] in the evening related to unspecified protein calorie malnutrition. Give at 45ml/hr. o Order start date: 10/31/16 for Regular diet Pureed texture, nectar thick liquids consistency. Record review of Resident #5's malnutrition risk assessment dated [DATE] revealed a score of 21, indicating he was at a high risk for malnutrition. Record review of Resident #5's January 2017 Medication Administration Record (MAR) revealed the following order and dates that nurses' had initialed and circled and there were some handwritten explanations as to why the enteral feeding was not administered. [MEDICATION NAME] 2.0 Liquid (Nutritional Supplements) Give 540cc via PE[DEVICE] in the evening related to Unspecified Protein Calorie Malnutrition, give at 45ml/hr. Start date: 10/31/16 at 1800 (6:00 PM). o 01/03/17 was initialed and indicated the feeding was administered, however nurses notes reflected that the enteral feeding was withheld due to the feeding pump not functioning. LVN I o 01/04/17 initialed on MAR as given, and no documentation in nurses notes regarding enteral feeding. LVN A o 01/05/17- out of supplement- LVN F o 01/06/17- LVN E o 01/07/17-out of supplement-LVN I o 01/08/17- out of supplement-LVN I o 01/09/17- out of supplement- LVN I o 01/10/17- LVN A o 01/11/17- LVN A o 01/12/17- LVN I (this particular date, Resident #5 was noted to be out of the facility at Hospital B due to lethargy) o 01/13/17-LVN I o 01/14/17- Initialed on MAR as administered, no documentation in nurses notes regarding the enteral feeding- LVN I o 01/15/17- Need supplies-LVN D o 01/16/17 and 01/17/17 were initialed and indicated they were administered, however nurses notes reflected that the enteral feeding was withheld due to the feeding pump not functioning. (According to facility provided invoices, Resident #5's enteral nutrition was available on 01/12/17 for nursing staff to administer, however Resident #5's enteral feedings were not administered until 01/18/17 due to the feeding pump was not functioning properly.) Record review of Resident #5's January 2017 MAR, Nurses Notes revealed the following twelve days in January 2017 where Resident #5 was not administered his enteral feeding due to not having his enteral nutrition available and/or the feeding pump not functioning properly. 1/3/17, 1/5/17, 1/6/17, 1/7/17, 1/8/17, 1/9/17, 1/10/17, 1/11/17, 1/13/17, 1/15/17, 1/16/17, 1/17/17. Record review of Resident #5's January 2017 MAR and nurses notes from 01/19/2017 thru 01/26/17 revealed that Resident #5 had received his enteral feedings. In an observation and interview on 1/27/17 at 7:55 a.m. Resident #5 was lying in his bed on his back. A feeding pump was in the room disconnected from Resident #5's gastrostomy tube and turned off. He said he was hungry. When asked if he was able to eat by mouth, he said yes ma'am. He said he had not had any breakfast this morning. He said they get me up and take me to the dining room, but that he had not been this morning. Observation on 01/27/17 at 8:15 AM revealed Resident #5 in his bed. His bed was noted to be in a low position and a fall mat at his bedside. Resident #5 was observed with his feet on the floor mat, his upper body lying flat on the bed and he was attempting to get out of the bed, he verbalized he was hungry. Resident #5 could not verbalize when he last was fed orally or via his gastrostomy tube. In an interview on 01/27/17 at 8:20 AM, CNA E said that she did not have any residents on Hall 1 that still needed assistance to get up for breakfast or that would require a breakfast tray. When asked about getting Resident #5 up for breakfast, she said she had attempted to get him up but (Resident #5) refused. She said that she had only attempted to get him up one time, but had alerted the nurse as to his refusal. She said that Resident #5 had not been offered anything for breakfast. In an interview on 1/27/17 at 8:20 a.m. LVN A, who was not Resident #5's nurse that morning, but had been his nurse previously for the month of January, said recently Resident #5's feeding pump had not been working and that they had run out of formula. She said she told the ADON when they were starting to run low and reported the pump not functioning. She said she had notified the ADON verbally, but could not recall the exact date and that she had also put a note in her box, but could not recall the exact date. She said Resident #5 was able to eat by mouth and took his medications by mouth. She said on days when she assisted him with eating he would eat 100%. She said he was always up for supper but she did not know about breakfast or lunch. She said she always made sure Resident #5 ate supper and that she assisted him. Observation on 01/27/17 at 8:22 AM revealed CNA E providing incontinent care to Resident #5. Resident #5 verbalized to CNA E that he was hungry. In an interview on 01/27/17 at 8:24 AM with Cook B, she said that she had been told earlier that morning on 01/27/17 not to fix Resident #5 a breakfast tray. She was unable to recall who told her not to fix Resident #5 a breakfast tray. In an interview on 1/27/17 at 8:25 a.m. LVN F said she was Resident #5's nurse for the day and that Resident #5 would go to the dining room but sometimes when he was groggy he stayed in his room. She said on those days she did not think he was being fed in his room but was not sure the reason. She said the CNA who was assigned the hall trays for that day was supposed to notify the nurse and dietary and a tray would be sent to the room. She said if the resident required assistance to eat the CNA assigned to the hall trays was supposed to assist. She said she had not been told that Resident #5 had not gotten up for breakfast this morning or dietary had not prepared him a breakfast tray. In an interview on 01/27/17 at 8:26 AM with the Dietary Manager, she said that she had asked LVN G if Resident #5 was going to need a hall tray for breakfast on 01/27/17. The Dietary Manager said that LVN G told her Not to fix him one, he is not eating, he has a feeding tube. In an interview on 01/27/17 at 8:28 AM with LVN G, she said that she had not told the Dietary Manager or Cook B anything regarding Resident #5's breakfast tray and that LVN F was his nurse. In an interview on 01/27/17 at 8:29 AM with LVN F, she said that she had not told the Dietary Manager or Cook B to not fix Resident #5 a breakfast tray on the morning of 01/27/17. She also said that she had not been told by CNA E that Resident #5 had refused to get up for breakfast. She said that Resident #5 received a puree diet and received supplement feedings via his gastrostomy tube. In an interview on 01/27/17 at 8:40 AM with Resident #5, he was able to verbalize his name, the name of the facility he was in and when asked if he needed anything, he said Yes ma'am, I'm Hungry. In an interview on 01/27/17 at 8:43 AM with LVN F, she said that CNA E should have attempted at least three different times to offer Resident #5 breakfast and if he still refused she should have verbalized the refusal to her. She said that she thought he was okay and had eaten. She said she was unaware he wasn't fed breakfast until around 8:30 AM. In an interview on 01/27/17 at 8:45 AM with the Dietary Manager, she said she had been asked to make Resident #5 a breakfast tray by CNA E and she was preparing his meal now. In an interview on 1/27/17 at 8:55 a.m. LVN F said Resident #5 only had two days left of his formula and she did not know if it had been ordered. She said she fed him at lunch yesterday (1/26/17) and he ate 100%. Observation and interview on 01/27/17 at 9:16 AM revealed CNA E weighed Resident #5 on the facility scale and said Resident #5's weight was 129.3 pounds. Record review of Resident #5's monthly weight log revealed: November 2016- 137.0 pounds December 2016- 136.4 pounds January 2017-138.1 pounds Based on the above weights, the surveyor identified an 8.8 pound weight loss, >5% in less than 30 days. (An exact date that the weights were obtained could not be identified on the weight log) Observation on 01/27/17 at 9:27 AM revealed Resident #5 was served 8 oz. of nectar thick orange juice, 8 oz. of nectar thick water, a bowl of cream of wheat with milk and butter for breakfast. CNA E was assisting Resident #5 in the dining room with his breakfast and he consumed 100%. In an interview on 01/27/17 at 9:30 AM with the Dietary Manager, she said that the nursing staff has told the dietary staff to hold a tray or not make one due to residents refusal. She said that if it was a one-time occurrence the dietary staff follow the request of the nursing staff, however if the nursing staff request to hold a tray for longer than one meal she would need to clarify with a physician's orders [REDACTED].#5 puree meal trays three times a day regularly for the month of January and felt that it was a one time occurrence the morning of 01/27/17. In an interview on 01/27/17at 9:52 AM with the DON, she said that Resident #5 was able to eat a puree diet along with his enteral feedings and she said (Resident #5) always gets up and doesn't ever refuse a meal. She said that when she arrived at the facility the morning of 01/27/17 at approximately 8:00 AM, LVN F told her Resident #5 had refused to get up for breakfast and he had not received a breakfast tray on 01/27/17. When asked by the surveyor what her expectations were regarding resident refusal and not offering a resident breakfast, she said it was Unacceptable, that he had not been offered but once to get up for breakfast this morning. The DON said that it had not been brought to her attention until addressed by the surveyor at this time that Resident #5 had gone without his enteral feeding for twelve days. She said that no one had reported to her that he was out of his enteral feeding formula and the feeding pump had been malfunctioning. She said that CNA H was in charge of the monthly weights and that to her knowledge Resident #5 had not been weighed since the first part of January, but could not give an exact date of when CNA H obtained his weight. When the surveyor asked if she was aware he had lost 8 pounds since the weight obtained the first part of January she replied Oh my gosh NO!. In an observation and interview with the ADON on 1/27/17 at 10:25 a.m. five cartons of [MEDICATION NAME] 2.0 (formula) each containing 250 ml (milliliters) were in the cabinet in the medication room. The ADON said Resident #5 receives 540 ml every 24 hours. She said if she orders the formula by noon it was delivered the next day. She said the staff needs to let her know every week what was needed because I order every week. She said depending on where items are shipped from it could take 2-4 days for them to arrive. She said Resident #5 had two feedings and one partial feed left, which will not be enough to get him through the weekend and said she would place an order right now. She said Resident #5 was the only resident in the facility with tube feedings. In an interview on 1/27/17 at 11:10 a.m. LVN A, who normally worked 2pm-10pm shift and had been Resident #5's nurse, said there have been no problems with Resident #5 getting up for supper. She said she noted on the 24-hour report the feeding pump was having issues the first part of January 2017. She said within a day of putting it on the 24-hour report she verbally told the ADON the feeding pump was not working. LVN A said the ADON said she did not look at the 24-hour report-the DON does. LVN A asked the ADON if the facility had a spare feeding pump and the ADON said no. She said it was hard to say how long the pump did not work-maybe at least a week. She said she works two days on one side of the building, two days on the other side of the building and then she was off two days. She said the pump was still not working when she returned. She said she thinks she may have faxed a note to the doctor-can't say for sure I did. She said if she sent a fax it would be in the chart under the Nurse's Notes. She said she verbally notified the ADON face to face, but was unable to recall the date, of the formula starting to run low and that they also needed the tubing for the pump. She said at that point they still had a half case or less. She said when she discovered they were out of the formula and tubing she verbally notified the ADON, but was unable to recall the exact date, and asked what are we doing? She said the ADON said they were changing supply companies. She said she discussed the issue with LVN I who was working the other side but doesn't remember if LVN I mentioned it to anyone. LVN A said she had a few conversations with the ADON about it when she was back on duty. LVN A said when she sets up the pump she would put two cartons in the bag. She said the other nurses who come in after her shift could check the bag and put more in and that she would tell the on-coming shift that she put in two cartons. In an interview on 01/27/17 at 11:16 AM, the ADON said that she was responsible for ordering Resident #5's enteral feeding supplement. She did not recall Resident #5 being out of his enteral feeding beginning on 01/05/17 through the 01/17/17. She denied being notified by any staff member on or around January 5th that Resident #5 was out of his [MEDICATION NAME]. She said that she did not have a tracking or monitoring system in place to keep up with the supply of Resident #5's [MEDICATION NAME] and that the nurses let her know when she needed to reorder it. She said that Resident #5's entire supply of [MEDICATION NAME] was kept in the medication room and there was not any other place it would be stored. She said that she was unaware until about thirty minutes ago that there was only 5 cartons of [MEDICATION NAME] 2.0 and that she must have missed the need to order more this week. Record review of the facility's invoices provided by the ADON and Corporate RN from 10/31/16 through 01/26/17 revealed the following dates and amounts of [MEDICATION NAME] 2.0 that the facility had purchased for Resident #5: Date: 10/31/16 [MEDICATION NAME] 2.0 1000ml Ultrapak 6/case Quantity Ordered: 1 case Date: 11/07/16 [MEDICATION NAME] 2.0 8 oz. 24/case Quantity Ordered: 4 cases Date: 01/10/17 [MEDICATION NAME] 2.0 8.45oz 24/case Quantity Ordered: 1 case Received: 01/12/17 In an interview on 1/27/17 at 11:50 a.m. LVN F said she uses two cartons of formula for Resident #5's feeding. She said Resident #5 needs to be fed. She said staff takes him to the dining room due to being a choking risk. She said staff had been getting him up for breakfast. She said she thinks the girls (CNAs) think if he says no they don't ask again. She said she thinks that's what happened this morning. She said the method of notifying someone when a resident was out formula was to verbally tell the DON. She said she had not told the DON when Resident #5 was out of formula because LVN A said she had already told the DON. She said sometimes she notifies the DON by text. Record review of the 24 hour report/change of condition report for station/unit 1-2 for the month of January 2017 revealed the following entries: o 01/01/17, 01/02/17, 01/03/17, and 01/04/17 - Remarks Night Shift- (Resident #5) needs new kangaroo pump o 01/05/17- Remarks Evening Shift- (Resident #5) needs [MEDICATION NAME] 2.0 out of feeding o 01/06/17- Remarks Night Shift- (Resident #5) needs [MEDICATION NAME] 2.0, out o 01/07/17- Remarks Evening Shift- (Resident #5) No [MEDICATION NAME], ate 75% o 01/07/17- Remarks Night Shift- (Resident #5) needs [MEDICATION NAME] 2.0 o 01/08/17- Remarks Night Shift- (Resident #5) Need [MEDICATION NAME] o 01/09/17- Remarks Day, Evening and Night Shift- (Resident #5) Need food for PEG. o 01/10/17- Remarks Night Shift- (Resident #5) need food for PEG. o 01/11/17- Remarks Night Shift -(Resident #5) needs bag/Peg Formula o 01/12/17- Remarks Day Shift- (Resident #5) sent to emergency room at 12:00 PM for lethargic, shallow, labored breathing. o 01/12/17- Remarks Night Shift-(Resident #5) Needs feeding. o 01/13/17- Remarks Deaths/Discharges/Leave of Absence- (Resident #5) at (Hospital B for observations). o 01/14/17- Remarks Evening Shift-(Resident #5) [MEDICATION NAME]. o 01/15/17-Remarks Evening shift-(Resident #5) Feeding infusing-no distress. o 01/16/17- Remarks under Admission/Readmission/Leave of Absence Returns- (Resident #5) [MEDICATION NAME] 2.0 feeding held due to pump not working. o 01/17/17- Remarks Evening Shift- (Resident #5) No feeding, pump will not work. o 01/18/17- Remarks Evening Shift- (Resident #5) New pump replaced. o 01/19/17 through 01/26/17 the 24 hour report did not have any recorded issues regarding the supply of his enteral feedings or the feeding pump not functioning properly for Resident #5. In an interview on 02/01/17 at 2:50 PM with LVN F, she said that the circles on the MAR indicated that the [MEDICATION NAME] 2.0 was not administered. She said that she normally does not work 2-10 shift and that she just happened to be covering on 01/05/17. She said that she looked in the medication room, the central supply room off of Hall 5 for his formula and was unable to locate it. She said she asked LVN A if she knew where his formula was stored. She said LVN A told her there was not any and that the DON was already aware Resident #5 was out. LVN F said she did not call the DON since LVN A said she was already aware and that she just wrote it on the 24 hour report. She said she should have notified Physician B to see if he would change the order but she said she did not contact him. In an interview on 02/01/17 at 3:05 PM, LVN E said she was the nurse for Resident #5 on 01/06/17 and that the circle on the MAR indicated that Resident #5 did not receive his [MEDICATION NAME] 2.0 enteral feeding on 01/06/17 due to not having the formula in stock at the facility. She said that her and a co-worker looked everywhere that evening for his formula. She said in the medication room, central supply room off of hall 5 and another supply closet. She said that when she received report from LVN G at shift change that afternoon on 01/06/17, she informed her that Resident #5 was out of his [MEDICATION NAME] 2.0 and that the DON and ADON were aware. She said that she also recorded it on the 24 hour report. She said that she should have clarified herself that the DON and ADON were aware that he was out. She said she was overwhelmed on this day because it was her first time working the 2-10 shift. She said she could have contacted Physician B to get the order changed but she did not. In a telephone interview on 2/1/17 at 3:35 p.m. LVN I said she had gone to the DON and ADON several times about not having Resident #5's [MEDICATION NAME] 2.0 and was told it had been ordered, but had not come in and to make sure Resident #5 was eating, which she stated she did observe him consume his dinner but did not recall if she had documented specifically his consumption. She said that the meal intake at that time was done by the CNAs and it was not something she had been told to monitor, the CNAs would alert them if a resident refused a meal or if there intake was less than usual. She said when she first notified the ADON, they were down to three cartons and the ADON said it had been ordered and she would look into it. She said she told the DON, who said she would look into it. She said she did not tell the Administrator. She said she made sure Resident #5 ate his meals and that the circled initials on the MAR meant he had not received the [MEDICATION NAME] 2.0 feeding. She said at one point during the time the MAR reflected Resident #5 was not receiving his feeding was because the feeding pump was not functioning. She said she used two cans of the [MEDICATION NAME] 2.0 for the feeding. She said on the dates that Resident #5 was in the hospital, the hospital called to asked what he was receiving through his [DEVICE] and asked for the [MEDICATION NAME] 2.0 to be sent over, but they didn't have any. She said when she notified the DON, the DON said the hospital will give him something. When asked about her initials being on the MAR on 1/14/17, when other initials were circled on 1/13/17 and 1/15/17 she said there was one night when they had one carton left, she gave it to him so he got a half feeding on 01/14/17. She said she did not think to notify the doctor and said my mistake and that she thought since Resident #5 was eating and since the DON and ADON had been notified it would be taken care of. In an interview on 2/1/17 at 4:25 p.m. LVN D said the circled initials on the January 2017 MAR for Resident #5's enteral feeding meant it was not given. She said she worked the 2:00 p.m. to 10:00 p.m. shift on 1/15/17. She said this was her first day on that shift and LVN I was supposed to provide orientation, but she was a no-show. She said on 1/15/17 she was going to administer the enteral feeding and looked for it in the med room. She said that she did not administer Resident #5's enteral feeding on 01/15/17. She said she asked another nurse (she would not identify) and was told the pump was broken. She said she documented on the MAR on 1/18/17 that the new pump was delivered. She reviewed all of the dates circled on the MAR that indicated Resident #5 had not received his enteral feeding and said she was responsible for his feeding on 01/15/17 and did not administer it. She said I assumed the DON and ADON knew about it. She said she would consider the feeding to be nutrition but was told when he was admitted that it was a supplement. She said she did sit with Resident #5 at his meals and made sure he ate. She said in looking back at what she could have done differently was to personally call the DON and make sure she knew the feeding pump was broken and that she could have called the doctor to ask for an order for [REDACTED]. She said it was common knowledge in a small town and was told by fell ow nurses if you call the doctor's office there is no answer after hours. She said the DON had physician's numbers, not the nurses. She said she has to call the hospital but the hospital will not give out the physician's numbers and would say if it was an emergency, send the resident over. She said she wished this had not happened. In an interview on 2/2/17 at 8:55 a.m. LVN A said the circled initials on the MAR beside Resident #5's enteral feeding meant it was not given. She said she verbally notified the ADON when they were running low but she could not remember the date and that she had documented it on the 24-hour report. She said the reason she documented on the 24-hour report was that she felt she was not getting the appropriate response from the ADON. She said one of the reasons offered by the ADON for not having the formula was that they had changed suppliers. She said the ADON did not advise her on what to do. She said the ADON worked a shift, but could not recall the date, and instructed her that the pump was not working and to let the DON know the next morning, but she said the DON did not come to work the following day so she could tell her. She said she went to the Administrator and was told the DON was sick, but she did not think to tell the Administrator about the pump not working. LVN A reviewed the MAR for the enteral feeding and said she did not give the feeding on 1/10/17 and 1/11/17 but could not remember if it was because there was no formula or if the feeding pump was not working. She reviewed a copy of the 24-hour report provided by the surveyor and confirmed she did not write anything on it. She said she should have notified Resident #5's physician immediately. She said she didn't think about if they had the formula she could have gotten an order for [REDACTED]. She said she felt she was being pushy about verbally harassing the DON and ADON and thought she was doing everything she could do and even talking to other nurses about it. She said she felt like she was shouting it from the mountain tops but now thinks she should have done more. She said she never intended for Resident #5 to be harmed. She said she thought she kept pushing and going to the DON and ADON verbally that she wouldn't need something in writing. She said when she documented on the 24-hour report her mind did not go to abuse or neglect but that she felt when she started seeing the circled initials on the MAR it was becoming serious and she wanted them to see it on a legal document that state would review . She confirmed she wrote on the report on 1/16/17 that the feeding was held due to the pump not working but forgot to circle her initials on the MAR for that date to indicate the feeding was not given. LVN A said she thought the order in which the situation happened was initially they were running low on formula, then the pump stopped functioning and then they ran out of formula. She said when the pump quit working she looked in the medication room and supply closet for a second pump but the ADON said there wasn't one. She said she thought she wrote it high on the page of the 24-hour reported and starred it to get their attention. LVN A said she thought on two different occasions the pump went out before they ran out of formula. She said she remembered a another pump being in the facility from a previous resident but the ADON said it had been sent back to the supply company and that after that they ran out of formula. LVN A said one evening (she could not remember the date) LVN I came to her and said she could not find any formula. She said when she walked down hall 5 later she noticed two cases of formula stacked outside the supply room on Hall 5 and told LVN I about the formula. She said later that night she saw the formula on a shelf in the central supply closet and took it to the medication room where it was stored. LVN A said there are nutritional consequences to feedings being held. She said when she was on duty during the time the feedings were not being given she made sure he was up in the dining room and fed. She said she knew he ate supper because she fed him herself on 01/16/17 and 01/17/17 and had documented in the nurses notes. In an interview on 2/2/17 at 1:40 p.m. the ADON said the circled initials on the January 2017 MAR beside Resident #5's enteral feedings meant the feedings were not done. She said I don't recall it when asked if she was notified on 1/5/17 that they were out of Resident #5's formula. She reviewed the invoices from the formula that had been ordered and said to her knowledge it had only been ordered three times-twice in November 2016 and then on 1/10/17 which was delivered on 1/12/17. She said she was the only who orders the feedings and said she ordered 4-5 cases but she did not calculate how long the amount ordered would last. She said couldn't say how she kept track or monitored how long the supply would last and that she had no tracking system. She said not that I recall when asked if she was told the supply was running low. She said if she saw that Resident #5 had missed twelve feedings the effects could be weight loss, infection, or maln

Based on observation, interview and record review, the facility failed to implement their written policies that prohibited neglect for one (Resident #5) of ten residents reviewed for neglect. A. Resident #5 was not administered his enteral feedings for twelve days in January 2017. The facility was either out of stock for Resident #5's enteral feeding formula or Resident #5's feeding pump was not functioning properly. Resident #5 was not receiving the correct amount of enteral formula as ordered, when they had been administered. On 01/27/17 it was identified that Resident #5 had experienced a significant weight loss of over 5% in the last 30 days. In addition, Resident #5's [MEDICATION NAME] level on 01/13/17 was low at 2.78 g/dl. B. On 1/27/17, Resident #5 was not assisted out of bed and offered a breakfast tray. Resident #5 was verbally stating I'm Hungry. Inconsistent documentation to indicate Resident #5 was being fed during January was found on the Meal Intake Record and Nurses Notes. On 01/27/17 an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 02/02/17, the facility remained out of compliance at a severity level of Actual harm that is not Immediate Jeopardy and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. These failures placed one resident (Resident #5) in the facility that received nutrition via a gastrostomy tube at risk for malnutrition, dehydration, electrolyte imbalance, weight loss and the potential for even death. Findings included: Record review of the facility policy entitled Reporting Abuse to Facility Management, undated, received from the facility Administrator on 01/31/17 at approximately 3:00 PM, revealed, Policy Statement: It is the responsibility of our employees, facility consultants, attending physicians, .to promptly report any incident or suspected incident of neglect . to the administrator or his/her designee. If such incidents occur or are discovered after normal business office hours, the administrator or his/her designee must be called at home or must be paged and informed of such incidents. 4. When an alleged or suspected case of . neglect, . is reported, the facility administrator, or his/her designee, will notify the appropriate persons or agencies of such incident: a. The State Licensing/certification agency responsible for surveying/licensing the facility; . c. The resident's representative (sponsor) of record; . f. The resident's attending physician; and g. The facility medical director. Record review of the facility policy entitled Investigating Allegations of Neglect, undated, received from the facility Administrator on 01/31/17 at approximately 3:00 PM, revealed, Policy Statement All reported incidents of neglect are promptly and thoroughly investigated. 1. Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, mental illness or the deterioration of a resident's physical or mental condition. Neglect is repeated conduct or a single incident of carelessness which produces or could reasonably be expected to result in serious physical or psychological injury or a substantial risk of death. 2. When conducting an investigation of neglect, implement the following protocol: a. determine what goods or services were not provided to the resident; b. determine if physical harm, mental anguish, mental illness or deterioration in the resident's physical or mental condition resulted from the failure of the facility to provide goods or services; and c. determine if the intent of the negligence was willful. 3. Conduct the investigation in accordance with established policy. Record review of Resident #5's Admission Record, dated 10/31/16, revealed he was an [AGE] year old male admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review of Resident #5's Admission MDS assessment, dated 11/07/16, revealed a BIMS score of 08, indicating moderate cognitive impairment; Section G revealed that he was totally dependent upon staff for all activities of daily living, specifically eating. Section K revealed that his height was 68 inches and his weight was 137 pounds, he had a feeding tube, which provided 26-50% of total calories the resident received through [MEDICATION NAME] or tube feeding and a mechanically altered diet was also indicated. Record review of Resident #5's Care Plan dated 11/04/16, revised on 01/18/17, revealed a focus area of: (Resident #5) is at risk for malnutrition and weight loss due to requires Pureed diet with Nectar thick liquids, Does have a [DEVICE] for nutritional support, (Resident #5) will be encouraged and assisted to consume greater than 50% of meals daily through next review date-Target Date: 4/18/17. (Resident #5's) nutritional status will remain stable as evidenced by (AEB) no reports of significant weight change. Interventions: Assess reports of signs and symptoms of aspiration/difficulty chewing or swallowing, implement appropriate interventions within code status. Notify MD and refer to speech therapy (ST) as appropriate. Dietician to review quarterly and as needed (PRN). Encourage (Resident #5) to eat meal out of bed. Encourage/assist (Resident #5) to upright position for intake by mouth. Encourage/remind to remain in upright position for at least 30 minutes after meals as indicated. Observe tolerance to diet and liquids, notify MD and refer to ST as appropriate. Observe for/record and notify MD, registered dietician (RD) of change in eating habits. Observe meal intake, record and offer alternative if eats less than 50% of meal. Observe weight as ordered. Notify MD, RD and responsible party (RP) of weight change greater than 5% in 30 days, 7.5% in 90 days and/or 10% in 180 days. Offer preferences when available. Offer encourage snacks within dietary restrictions. Provide REGULAR PUREED diet as ordered with NECTAR THICKENED liquids. Provide set-up, supervision, verbal cue and physical assistance as needed to complete meals. Intervention: Eating The resident is totally dependent on (1x) staff for eating. According to the United States National Library of Medicine, accessed on 02/03/17, a [DEVICE] is A gastrostomy feeding tube insertion is the placement of a feeding tube through the skin and the stomach wall. It goes directly into the stomach. Gastrostomy feeding tubes are put in for different reasons. They may be needed for a short time or permanently. This procedure may be used for: oPersons who cannot swallow correctly oPersons who cannot take enough food by mouth to stay healthy oPersons who often breathe in food when eating https://medlineplus.gov/ency/article/ 7.htm. Record review of Resident #5's signed Physician orders dated 01/03/17 revealed the following orders: o Order start date: 10/31/16 for [MEDICATION NAME] 2.0 Liquid (Nutritional Supplement). Give 540cc via PE[DEVICE] in the evening related to unspecified protein calorie malnutrition. Give at 45ml/hr. o Order start date: 10/31/16 for Regular diet Pureed texture, nectar thick liquids consistency. Record review of Resident #5's malnutrition risk assessment dated [DATE] revealed a score of 21, indicating he was at a high risk for malnutrition. Record review of Resident #5's January 2017 Medication Administration Record (MAR) revealed the following order and dates that nurses' had initialed and circled and there were some handwritten explanations as to why the enteral feeding was not administered. [MEDICATION NAME] 2.0 Liquid (Nutritional Supplements) Give 540cc via PE[DEVICE] in the evening related to Unspecified Protein Calorie Malnutrition, give at 45ml/hr. Start date: 10/31/16 at 1800 (6:00 PM). o 01/03/17 was initialed and indicated the feeding was administered, however nurses notes reflected that the enteral feeding was withheld due to the feeding pump not functioning. LVN I o 01/04/17 initialed on MAR as given, and no documentation in nurses notes regarding enteral feeding. LVN A o 01/05/17- out of supplement- LVN F o 01/06/17- LVN E o 01/07/17-out of supplement-LVN I o 01/08/17- out of supplement-LVN I o 01/09/17- out of supplement- LVN I o 01/10/17- LVN A o 01/11/17- LVN A o 01/12/17- LVN I (this particular date, Resident #5 was noted to be out of the facility at Hospital B due to lethargy) o 01/13/17-LVN I o 01/14/17- Initialed on MAR as administered, no documentation in nurses notes regarding the enteral feeding- LVN I o 01/15/17- Need supplies-LVN D o 01/16/17 and 01/17/17 were initialed and indicated they were administered, however nurses notes reflected that the enteral feeding was withheld due to the feeding pump not functioning. (According to facility provided invoices, Resident #5's enteral nutrition was available on 01/12/17 for nursing staff to administer, however Resident #5's enteral feedings were not administered until 01/18/17 due to the feeding pump was not functioning properly.) Record review of Resident #5's January 2017 MAR, Nurses Notes revealed the following twelve days in January 2017 where Resident #5 was not administered his enteral feeding due to not having his enteral nutrition available and/or the feeding pump not functioning properly. 1/3/17, 1/5/17, 1/6/17, 1/7/17, 1/8/17, 1/9/17, 1/10/17, 1/11/17, 1/13/17, 1/15/17, 1/16/17, 1/17/17. Record review of Resident #5's January 2017 MAR and nurses notes from 01/19/2017 thru 01/26/17 revealed that Resident #5 had received his enteral feedings. In an observation and interview on 1/27/17 at 7:55 a.m. Resident #5 was lying in his bed on his back. A feeding pump was in the room disconnected from Resident #5's gastrostomy tube and turned off. He said he was hungry. When asked if he was able to eat by mouth, he said yes ma'am. He said he had not had any breakfast this morning. He said they get me up and take me to the dining room, but that he had not been this morning. Observation on 01/27/17 at 8:15 AM revealed Resident #5 in his bed. His bed was noted to be in a low position and a fall mat at his bedside. Resident #5 was observed with his feet on the floor mat, his upper body lying flat on the bed and he was attempting to get out of the bed, he verbalized he was hungry. Resident #5 could not verbalize when he last was fed orally or via his gastrostomy tube. In an interview on 01/27/17 at 8:20 AM, CNA E said that she did not have any residents on Hall 1 that still needed assistance to get up for breakfast or that would require a breakfast tray. When asked about getting Resident #5 up for breakfast, she said she had attempted to get him up but (Resident #5) refused. She said that she had only attempted to get him up one time, but had alerted the nurse as to his refusal. She said that Resident #5 had not been offered anything for breakfast. In an interview on 1/27/17 at 8:20 a.m. LVN A, who was not Resident #5's nurse that morning, but had been his nurse previously for the month of January, said recently Resident #5's feeding pump had not been working and that they had run out of formula. She said she told the ADON when they were starting to run low and reported the pump not functioning. She said she had notified the ADON verbally, but could not recall the exact date and that she had also put a note in her box, but could not recall the exact date. She said Resident #5 was able to eat by mouth and took his medications by mouth. She said on days when she assisted him with eating he would eat 100%. She said he was always up for supper but she did not know about breakfast or lunch. She said she always made sure Resident #5 ate supper and that she assisted him. Observation on 01/27/17 at 8:22 AM revealed CNA E providing incontinent care to Resident #5. Resident #5 verbalized to CNA E that he was hungry. In an interview on 01/27/17 at 8:24 AM with Cook B, she said that she had been told earlier that morning on 01/27/17 not to fix Resident #5 a breakfast tray. She was unable to recall who told her not to fix Resident #5 a breakfast tray. In an interview on 1/27/17 at 8:25 a.m. LVN F said she was Resident #5's nurse for the day and that Resident #5 would go to the dining room but sometimes when he was groggy he stayed in his room. She said on those days she did not think he was being fed in his room but was not sure the reason. She said the CNA who was assigned the hall trays for that day was supposed to notify the nurse and dietary and a tray would be sent to the room. She said if the resident required assistance to eat the CNA assigned to the hall trays was supposed to assist. She said she had not been told that Resident #5 had not gotten up for breakfast this morning or dietary had not prepared him a breakfast tray. In an interview on 01/27/17 at 8:26 AM with the Dietary Manager, she said that she had asked LVN G if Resident #5 was going to need a hall tray for breakfast on 01/27/17. The Dietary Manager said that LVN G told her Not to fix him one, he is not eating, he has a feeding tube. In an interview on 01/27/17 at 8:28 AM with LVN G, she said that she had not told the Dietary Manager or Cook B anything regarding Resident #5's breakfast tray and that LVN F was his nurse. In an interview on 01/27/17 at 8:29 AM with LVN F, she said that she had not told the Dietary Manager or Cook B to not fix Resident #5 a breakfast tray on the morning of 01/27/17. She also said that she had not been told by CNA E that Resident #5 had refused to get up for breakfast. She said that Resident #5 received a puree diet and received supplement feedings via his gastrostomy tube. In an interview on 01/27/17 at 8:40 AM with Resident #5, he was able to verbalize his name, the name of the facility he was in and when asked if he needed anything, he said Yes ma'am, I'm Hungry. In an interview on 01/27/17 at 8:43 AM with LVN F, she said that CNA E should have attempted at least three different times to offer Resident #5 breakfast and if he still refused she should have verbalized the refusal to her. She said that she thought he was okay and had eaten. She said she was unaware he wasn't fed breakfast until around 8:30 AM. In an interview on 01/27/17 at 8:45 AM with the Dietary Manager, she said she had been asked to make Resident #5 a breakfast tray by CNA E and she was preparing his meal now. In an interview on 1/27/17 at 8:55 a.m. LVN F said Resident #5 only had two days left of his formula and she did not know if it had been ordered. She said she fed him at lunch yesterday (1/26/17) and he ate 100%. Observation and interview on 01/27/17 at 9:16 AM revealed CNA E weighed Resident #5 on the facility scale and said Resident #5's weight was 129.3 pounds. Record review of Resident #5's monthly weight log revealed: November 2016- 137.0 pounds December 2016- 136.4 pounds January 2017-138.1 pounds Based on the above weights, the surveyor identified an 8.8 pound weight loss, >5% in less than 30 days. (An exact date that the weights were obtained could not be identified on the weight log) Observation on 01/27/17 at 9:27 AM revealed Resident #5 was served 8 oz. of nectar thick orange juice, 8 oz. of nectar thick water, a bowl of cream of wheat with milk and butter for breakfast. CNA E was assisting Resident #5 in the dining room with his breakfast and he consumed 100%. In an interview on 01/27/17 at 9:30 AM with the Dietary Manager, she said that the nursing staff has told the dietary staff to hold a tray or not make one due to residents refusal. She said that if it was a one-time occurrence the dietary staff follow the request of the nursing staff, however if the nursing staff request to hold a tray for longer than one meal she would need to clarify with a physician's order . She said that she had been making Resident #5 puree meal trays three times a day regularly for the month of January and felt that it was a one time occurrence the morning of 01/27/17. In an interview on 01/27/17at 9:52 AM with the DON, she said that Resident #5 was able to eat a puree diet along with his enteral feedings and she said (Resident #5) always gets up and doesn't ever refuse a meal. She said that when she arrived at the facility the morning of 01/27/17 at approximately 8:00 AM, LVN F told her Resident #5 had refused to get up for breakfast and he had not received a breakfast tray on 01/27/17. When asked by the surveyor what her expectations were regarding resident refusal and not offering a resident breakfast, she said it was Unacceptable, that he had not been offered but once to get up for breakfast this morning. The DON said that it had not been brought to her attention until addressed by the surveyor at this time that Resident #5 had gone without his enteral feeding for twelve days. She said that no one had reported to her that he was out of his enteral feeding formula and the feeding pump had been malfunctioning. She said that CNA H was in charge of the monthly weights and that to her knowledge Resident #5 had not been weighed since the first part of January, but could not give an exact date of when CNA H obtained his weight. When the surveyor asked if she was aware he had lost 8 pounds since the weight obtained the first part of January she replied Oh my gosh NO!. In an observation and interview with the ADON on 1/27/17 at 10:25 a.m. five cartons of [MEDICATION NAME] 2.0 (formula) each containing 250 ml (milliliters) were in the cabinet in the medication room. The ADON said Resident #5 receives 540 ml every 24 hours. She said if she orders the formula by noon it was delivered the next day. She said the staff needs to let her know every week what was needed because I order every week. She said depending on where items are shipped from it could take 2-4 days for them to arrive. She said Resident #5 had two feedings and one partial feed left, which will not be enough to get him through the weekend and said she would place an order right now. She said Resident #5 was the only resident in the facility with tube feedings. In an interview on 1/27/17 at 11:10 a.m. LVN A, who normally worked 2pm-10pm shift and had been Resident #5's nurse, said there have been no problems with Resident #5 getting up for supper. She said she noted on the 24-hour report the feeding pump was having issues the first part of January 2017. She said within a day of putting it on the 24-hour report she verbally told the ADON the feeding pump was not working. LVN A said the ADON said she did not look at the 24-hour report-the DON does. LVN A asked the ADON if the facility had a spare feeding pump and the ADON said no. She said it was hard to say how long the pump did not work-maybe at least a week. She said she works two days on one side of the building, two days on the other side of the building and then she was off two days. She said the pump was still not working when she returned. She said she thinks she may have faxed a note to the doctor-can't say for sure I did. She said if she sent a fax it would be in the chart under the Nurse's Notes. She said she verbally notified the ADON face to face, but was unable to recall the date, of the formula starting to run low and that they also needed the tubing for the pump. She said at that point they still had a half case or less. She said when she discovered they were out of the formula and tubing she verbally notified the ADON, but was unable to recall the exact date, and asked what are we doing? She said the ADON said they were changing supply companies. She said she discussed the issue with LVN I who was working the other side but doesn't remember if LVN I mentioned it to anyone. LVN A said she had a few conversations with the ADON about it when she was back on duty. LVN A said when she sets up the pump she would put two cartons in the bag. She said the other nurses who come in after her shift could check the bag and put more in and that she would tell the on-coming shift that she put in two cartons. In an interview on 01/27/17 at 11:16 AM, the ADON said that she was responsible for ordering Resident #5's enteral feeding supplement. She did not recall Resident #5 being out of his enteral feeding beginning on 01/05/17 through the 01/17/17. She denied being notified by any staff member on or around January 5th that Resident #5 was out of his [MEDICATION NAME]. She said that she did not have a tracking or monitoring system in place to keep up with the supply of Resident #5's [MEDICATION NAME] and that the nurses let her know when she needed to reorder it. She said that Resident #5's entire supply of [MEDICATION NAME] was kept in the medication room and there was not any other place it would be stored. She said that she was unaware until about thirty minutes ago that there was only 5 cartons of [MEDICATION NAME] 2.0 and that she must have missed the need to order more this week. Record review of the facility's invoices provided by the ADON and Corporate RN from 10/31/16 through 01/26/17 revealed the following dates and amounts of [MEDICATION NAME] 2.0 that the facility had purchased for Resident #5: Date: 10/31/16 [MEDICATION NAME] 2.0 1000ml Ultrapak 6/case Quantity Ordered: 1 case Date: 11/07/16 [MEDICATION NAME] 2.0 8 oz. 24/case Quantity Ordered: 4 cases Date: 01/10/17 [MEDICATION NAME] 2.0 8.45oz 24/case Quantity Ordered: 1 case Received: 01/12/17 In an interview on 1/27/17 at 11:50 a.m. LVN F said she uses two cartons of formula for Resident #5's feeding. She said Resident #5 needs to be fed. She said staff takes him to the dining room due to being a choking risk. She said staff had been getting him up for breakfast. She said she thinks the girls (CNAs) think if he says no they don't ask again. She said she thinks that's what happened this morning. She said the method of notifying someone when a resident was out formula was to verbally tell the DON. She said she had not told the DON when Resident #5 was out of formula because LVN A said she had already told the DON. She said sometimes she notifies the DON by text. Record review of the 24 hour report/change of condition report for station/unit 1-2 for the month of January 2017 revealed the following entries: o 01/01/17, 01/02/17, 01/03/17, and 01/04/17 - Remarks Night Shift- (Resident #5) needs new kangaroo pump o 01/05/17- Remarks Evening Shift- (Resident #5) needs [MEDICATION NAME] 2.0 out of feeding o 01/06/17- Remarks Night Shift- (Resident #5) needs [MEDICATION NAME] 2.0, out o 01/07/17- Remarks Evening Shift- (Resident #5) No [MEDICATION NAME], ate 75% o 01/07/17- Remarks Night Shift- (Resident #5) needs [MEDICATION NAME] 2.0 o 01/08/17- Remarks Night Shift- (Resident #5) Need [MEDICATION NAME] o 01/09/17- Remarks Day, Evening and Night Shift- (Resident #5) Need food for PEG. o 01/10/17- Remarks Night Shift- (Resident #5) need food for PEG. o 01/11/17- Remarks Night Shift -(Resident #5) needs bag/Peg Formula o 01/12/17- Remarks Day Shift- (Resident #5) sent to emergency room at 12:00 PM for lethargic, shallow, labored breathing. o 01/12/17- Remarks Night Shift-(Resident #5) Needs feeding. o 01/13/17- Remarks Deaths/Discharges/Leave of Absence- (Resident #5) at (Hospital B for observations). o 01/14/17- Remarks Evening Shift-(Resident #5) [MEDICATION NAME]. o 01/15/17-Remarks Evening shift-(Resident #5) Feeding infusing-no distress. o 01/16/17- Remarks under Admission/Readmission/Leave of Absence Returns- (Resident #5) [MEDICATION NAME] 2.0 feeding held due to pump not working. o 01/17/17- Remarks Evening Shift- (Resident #5) No feeding, pump will not work. o 01/18/17- Remarks Evening Shift- (Resident #5) New pump replaced. o 01/19/17 through 01/26/17 the 24 hour report did not have any recorded issues regarding the supply of his enteral feedings or the feeding pump not functioning properly for Resident #5. In an interview on 02/01/17 at 2:50 PM with LVN F, she said that the circles on the MAR indicated that the [MEDICATION NAME] 2.0 was not administered. She said that she normally does not work 2-10 shift and that she just happened to be covering on 01/05/17. She said that she looked in the medication room, the central supply room off of Hall 5 for his formula and was unable to locate it. She said she asked LVN A if she knew where his formula was stored. She said LVN A told her there was not any and that the DON was already aware Resident #5 was out. LVN F said she did not call the DON since LVN A said she was already aware and that she just wrote it on the 24 hour report. She said she should have notified Physician B to see if he would change the order but she said she did not contact him. In an interview on 02/01/17 at 3:05 PM, LVN E said she was the nurse for Resident #5 on 01/06/17 and that the circle on the MAR indicated that Resident #5 did not receive his [MEDICATION NAME] 2.0 enteral feeding on 01/06/17 due to not having the formula in stock at the facility. She said that her and a co-worker looked everywhere that evening for his formula. She said in the medication room, central supply room off of hall 5 and another supply closet. She said that when she received report from LVN G at shift change that afternoon on 01/06/17, she informed her that Resident #5 was out of his [MEDICATION NAME] 2.0 and that the DON and ADON were aware. She said that she also recorded it on the 24 hour report. She said that she should have clarified herself that the DON and ADON were aware that he was out. She said she was overwhelmed on this day because it was her first time working the 2-10 shift. She said she could have contacted Physician B to get the order changed but she did not. In a telephone interview on 2/1/17 at 3:35 p.m. LVN I said she had gone to the DON and ADON several times about not having Resident #5's [MEDICATION NAME] 2.0 and was told it had been ordered, but had not come in and to make sure Resident #5 was eating, which she stated she did observe him consume his dinner but did not recall if she had documented specifically his consumption. She said that the meal intake at that time was done by the CNAs and it was not something she had been told to monitor, the CNAs would alert them if a resident refused a meal or if there intake was less than usual. She said when she first notified the ADON, they were down to three cartons and the ADON said it had been ordered and she would look into it. She said she told the DON, who said she would look into it. She said she did not tell the Administrator. She said she made sure Resident #5 ate his meals and that the circled initials on the MAR meant he had not received the [MEDICATION NAME] 2.0 feeding. She said at one point during the time the MAR reflected Resident #5 was not receiving his feeding was because the feeding pump was not functioning. She said she used two cans of the [MEDICATION NAME] 2.0 for the feeding. She said on the dates that Resident #5 was in the hospital, the hospital called to asked what he was receiving through his [DEVICE] and asked for the [MEDICATION NAME] 2.0 to be sent over, but they didn't have any. She said when she notified the DON, the DON said the hospital will give him something. When asked about her initials being on the MAR on 1/14/17, when other initials were circled on 1/13/17 and 1/15/17 she said there was one night when they had one carton left, she gave it to him so he got a half feeding on 01/14/17. She said she did not think to notify the doctor and said my mistake and that she thought since Resident #5 was eating and since the DON and ADON had been notified it would be taken care of. In an interview on 2/1/17 at 4:25 p.m. LVN D said the circled initials on the January 2017 MAR for Resident #5's enteral feeding meant it was not given. She said she worked the 2:00 p.m. to 10:00 p.m. shift on 1/15/17. She said this was her first day on that shift and LVN I was supposed to provide orientation, but she was a no-show. She said on 1/15/17 she was going to administer the enteral feeding and looked for it in the med room. She said that she did not administer Resident #5's enteral feeding on 01/15/17. She said she asked another nurse (she would not identify) and was told the pump was broken. She said she documented on the MAR on 1/18/17 that the new pump was delivered. She reviewed all of the dates circled on the MAR that indicated Resident #5 had not received his enteral feeding and said she was responsible for his feeding on 01/15/17 and did not administer it. She said I assumed the DON and ADON knew about it. She said she would consider the feeding to be nutrition but was told when he was admitted that it was a supplement. She said she did sit with Resident #5 at his meals and made sure he ate. She said in looking back at what she could have done differently was to personally call the DON and make sure she knew the feeding pump was broken and that she could have called the doctor to ask for an order for [REDACTED]. She said it was common knowledge in a small town and was told by fell ow nurses if you call the doctor's office there is no answer after hours. She said the DON had physician's numbers, not the nurses. She said she has to call the hospital but the hospital will not give out the physician's numbers and would say if it was an emergency, send the resident over. She said she wished this had not happened. In an interview on 2/2/17 at 8:55 a.m. LVN A said the circled initials on the MAR beside Resident #5's enteral feeding meant it was not given. She said she verbally notified the ADON when they were running low but she could not remember the date and that she had documented it on the 24-hour report. She said the reason she documented on the 24-hour report was that she felt she was not getting the appropriate response from the ADON. She said one of the reasons offered by the ADON for not having the formula was that they had changed suppliers. She said the ADON did not advise her on what to do. She said the ADON worked a shift, but could not recall the date, and instructed her that the pump was not working and to let the DON know the next morning, but she said the DON did not come to work the following day so she could tell her. She said she went to the Administrator and was told the DON was sick, but she did not think to tell the Administrator about the pump not working. LVN A reviewed the MAR for the enteral feeding and said she did not give the feeding on 1/10/17 and 1/11/17 but could not remember if it was because there was no formula or if the feeding pump was not working. She reviewed a copy of the 24-hour report provided by the surveyor and confirmed she did not write anything on it. She said she should have notified Resident #5's physician immediately. She said she didn't think about if they had the formula she could have gotten an order for [REDACTED]. She said she felt she was being pushy about verbally harassing the DON and ADON and thought she was doing everything she could do and even talking to other nurses about it. She said she felt like she was shouting it from the mountain tops but now thinks she should have done more. She said she never intended for Resident #5 to be harmed. She said she thought she kept pushing and going to the DON and ADON verbally that she wouldn't need something in writing. She said when she documented on the 24-hour report her mind did not go to abuse or neglect but that she felt when she started seeing the circled initials on the MAR it was becoming serious and she wanted them to see it on a legal document that state would review . She confirmed she wrote on the report on 1/16/17 that the feeding was held due to the pump not working but forgot to circle her initials on the MAR for that date to indicate the feeding was not given. LVN A said she thought the order in which the situation happened was initially they were running low on formula, then the pump stopped functioning and then they ran out of formula. She said when the pump quit working she looked in the medication room

Based on observation, interview, and record review, the facility failed to ensure appropriate treatment and services were provided to prevent complications of enteral feedings in accordance with each resident's comprehensive assessment for 1 (Resident #5) of 1 resident reviewed for a gastrostomy tube. Resident #5 was not administered his enteral feedings for twelve days in January 2017. The facility was either out of stock for Resident #5's enteral feeding formula or Resident #5's feeding pump was not functioning properly. Resident #5 was not receiving the correct amount of enteral formula as ordered, when they had been administered. On 01/27/17 it was identified that Resident #5 had experienced a significant weight loss of over 5% in the last 30 days. In addition, Resident #5's [MEDICATION NAME] level during a hospital visit on 01/13/17 at 2.78 g/dL. On 01/27/17 an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 02/02/17, the facility remained out of compliance at a severity level of Actual harm that is not Immediate Jeopardy and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. These failures placed one resident (Resident #5) in the facility that received nutrition via a gastrostomy tube at risk for malnutrition, dehydration, electrolyte imbalance, weight loss and the potential for even death. Findings included: Record review of Resident #5's Admission Record, dated 10/31/16, revealed he was an [AGE] year old male admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review of Resident #5's Admission MDS assessment, dated 11/07/16, revealed a BIMS score of 08, indicating moderate cognitive impairment; Section G revealed that he was totally dependent upon staff for all activities of daily living, specifically eating. Section K revealed that his height was 68 inches weight was 137 pounds, he had a feeding tube, which provided 26-50% of total calories the resident received through [MEDICATION NAME] or tube feeding and a mechanically altered diet was also indicated. Record review of Resident #5's Care Plan dated 11/04/16, revised on 01/18/17, revealed a focus area of: (Resident #5) is at risk for malnutrition and weight loss due to requires Pureed diet with Nectar thick liquids, Does have a [DEVICE] for nutritional support, (Resident #5) will be encouraged and assisted to consume greater than 50% of meals daily through next review date-Target Date: 4/18/17. (Resident #5's) nutritional status will remain stable as evidenced by (AEB) no reports of significant weight change. Interventions: Assess reports of signs and symptoms of aspiration/difficulty chewing or swallowing, implement appropriate interventions within code status. Notify MD and refer to speech therapy (ST) as appropriate. Dietician to review quarterly and as needed (PRN). Encourage (Resident #5) to eat meal out of bed. Encourage/assist (Resident #5) to upright position for intake by mouth. Encourage/remind to remain in upright position for at least 30 minutes after meals as indicated. Observe tolerance to diet and liquids, notify MD and refer to ST as appropriate. Observe for/record and notify MD, registered dietician (RD) of change in eating habits. Observe meal intake, record and offer alternative if eats less than 50% of meal. Observe weight as ordered. Notify MD, RD and responsible party (RP) of weight change greater than 5% in 30 days, 7.5% in 90 days and/or 10% in 180 days. Offer preferences when available. Offer encourage snacks within dietary restrictions. Provide REGULAR PUREED diet as ordered with NECTAR THICKENED liquids. Provide set-up, supervision, verbal cue and physical assistance as needed to complete meals. Intervention: Eating The resident is totally dependent on (1x) staff for eating. According to the United States National Library of Medicine, accessed on 02/03/17, a [DEVICE] is A gastrostomy feeding tube insertion is the placement of a feeding tube through the skin and the stomach wall. It goes directly into the stomach. Gastrostomy feeding tubes are put in for different reasons. They may be needed for a short time or permanently. This procedure may be used for: oPersons who cannot swallow correctly oPersons who cannot take enough food by mouth to stay healthy oPersons who often breathe in food when eating https://medlineplus.gov/ency/article/ 7.htm. Record review of Resident #5's signed Physician orders [REDACTED]. o Order start date: 10/31/16 for [MEDICATION NAME] 2.0 Liquid (Nutritional Supplement). Give 540cc via PE[DEVICE] in the evening related to unspecified protein calorie malnutrition. Give at 45ml/hr. o Order start date: 10/31/16 for Regular diet Pureed texture, nectar thick liquids consistency. Record review of Resident #5's malnutrition risk assessment dated [DATE] revealed a score of 21, indicating he was at a high risk for malnutrition. Record review of Resident #5's January 2017 Medication Administration Record (MAR) revealed the following order and dates that nurses' had initialed and circled and there were some handwritten explanations as to why the enteral feeding was not administered. [MEDICATION NAME] 2.0 Liquid (Nutritional Supplements) Give 540cc via PE[DEVICE] in the evening related to Unspecified Protein Calorie Malnutrition, give at 45ml/hr. Start date: 10/31/16 at 1800 (6:00 PM). o 01/03/17 was initialed and indicated the feeding was administered, however nurses notes reflected that the enteral feeding was withheld due to the feeding pump not functioning. LVN I o 01/04/17 initialed on MAR as given, and no documentation in nurses notes regarding enteral feeding. LVN A o 01/05/17- out of supplement- LVN F o 01/06/17- LVN E o 01/07/17-out of supplement-LVN I o 01/08/17- out of supplement-LVN I o 01/09/17- out of supplement- LVN I o 01/10/17- LVN A o 01/11/17- LVN A o 01/12/17- LVN I (this particular date, Resident #5 was noted to be out of the facility at Hospital B due to lethargy) o 01/13/17-LVN I o 01/14/17- Initialed on MAR as administered, no documentation in nurses notes regarding the enteral feeding- LVN I o 01/15/17- Need supplies-LVN D o 01/16/17 and 01/17/17 were initialed and indicated they were administered, however nurses notes reflected that the enteral feeding was withheld due to the feeding pump not functioning. (According to facility provided invoices, Resident #5's enteral nutrition was available on 01/12/17 for nursing staff to administer, however Resident #5's enteral feedings were not administered until 01/18/17 due to the feeding pump was not functioning properly.) Record review of Resident #5's January 2017 MAR, Nurses Notes revealed the following twelve days in January 2017 where Resident #5 was not administered his enteral feeding due to not having his enteral nutrition available and/or the feeding pump not functioning properly. 1/3/17, 1/5/17, 1/6/17, 1/7/17, 1/8/17, 1/9/17, 1/10/17, 1/11/17, 1/13/17, 1/15/17, 1/16/17, 1/17/17. Record review of Resident #5's January 2017 MAR and nurses notes from 01/19/2017 thru 01/26/17 revealed that Resident #5 had received his enteral feedings. In an observation and interview on 1/27/17 at 7:55 a.m. Resident #5 was lying in his bed on his back. A feeding pump was in the room disconnected from Resident #5's gastrostomy tube and turned off. In an interview on 01/27/17 at 8:20 AM LVN A, who was not Resident #5's nurse that morning, but had been his nurse previously for the month of January, said recently Resident #5's feeding pump had not been working and that they had run out of formula. She said she told the ADON when they were starting to run low and reported the pump not functioning. She said she had notified the ADON verbally, but could not recall the exact date and that she had also put a note in her box, but could not recall the exact date. In an interview on 1/27/17 at 8:55 a.m. LVN F said Resident #5 only had two days left of his formula and she did not know if it had been ordered. Observation and interview on 01/27/17 at 9:16 AM revealed CNA E weighed Resident #5 on the facility scale and said Resident #5's weight was 129.3 pounds. Record review of Resident #5's monthly weight log revealed: November 2016- 137.0 pounds December 2016- 136.4 pounds January 2017-138.1 pounds Based on the above weights, the surveyor identified an 8.8 pound weight loss, >5% in less than 30 days. (An exact date that the weights were obtained could not be identified on the weight log) In an interview on 01/27/17at 9:52 AM with the DON, she said that it had not been brought to her attention until addressed by the surveyor at this time that Resident #5 had gone without his enteral feeding for twelve days. She said that no one had reported to her that he was out of his enteral feeding formula and the feeding pump had been malfunctioning. She said that CNA H was in charge of the monthly weights and that to her knowledge Resident #5 had not been weighed since the first part of January, but could not give an exact date of when CNA H obtained his weight. When the surveyor asked if she was aware he had lost 8 pounds since the weight obtained the first part of January she replied Oh my gosh NO!. In an observation and interview with the ADON on 1/27/17 at 10:25 a.m. five cartons of [MEDICATION NAME] 2.0 (formula) each containing 250 ml (milliliters) were in the cabinet in the medication room. The ADON said Resident #5 receives 540 ml every 24 hours. She said if she orders the formula by noon it was delivered the next day. She said the staff needs to let her know every week what was needed because I order every week. She said depending on where items are shipped from it could take 2-4 days for them to arrive. She said Resident #5 had two feedings and one partial feed left, which will not be enough to get him through the weekend and said she would place an order right now. She said Resident #5 was the only resident in the facility with tube feedings. In an interview on 1/27/17 at 11:10 a.m. LVN A, who normally worked 2pm-10pm shift and had been Resident #5's nurse, said she noted on the 24-hour report the feeding pump was having issues the first part of January 2017. She said within a day of putting it on the 24-hour report she verbally told the ADON the feeding pump was not working. LVN A said the ADON said she did not look at the 24-hour report-the DON does. LVN A asked the ADON if the facility had a spare feeding pump and the ADON said no. She said it was hard to say how long the pump did not work-maybe at least a week. She said she works two days on one side of the building, two days on the other side of the building and then she was off two days. She said the pump was still not working when she returned. She said she thinks she may have faxed a note to the doctor-can't say for sure I did. She said if she sent a fax it would be in the chart under the Nurse's Notes. She said she verbally notified the ADON face to face, but was unable to recall the date, of the formula starting to run low and that they also needed the tubing for the pump. She said at that point they still had a half case or less. She said when she discovered they were out of the formula and tubing she verbally notified the ADON, but was unable to recall the exact date, and asked what are we doing? She said the ADON said they were changing supply companies. She said she discussed the issue with LVN I who was working the other side but doesn't remember if LVN I mentioned it to anyone. LVN A said she had a few conversations with the ADON about it when she was back on duty. LVN A said when she sets up the pump she would put two cartons in the bag. She said the other nurses who come in after her shift could check the bag and put more in and that she would tell the on-coming shift that she put in two cartons. In an interview on 01/27/17 at 11:16 AM, the ADON said that she was responsible for ordering Resident #5's enteral feeding supplement. She did not recall Resident #5 being out of his enteral feeding beginning on 01/05/17 through the 01/17/17. She denied being notified by any staff member on or around January 5th that Resident #5 was out of his [MEDICATION NAME]. She said that she did not have a tracking or monitoring system in place to keep up with the supply of Resident #5's [MEDICATION NAME] and that the nurses let her know when she needed to reorder it. She said that Resident #5's entire supply of [MEDICATION NAME] was kept in the medication room and there was not any other place it would be stored. She said that she was unaware until about thirty minutes ago that there was only 5 cartons of [MEDICATION NAME] 2.0 and that she must have missed the need to order more this week. Record review of the facility's invoices provided by the ADON and CORPORATE RN from 10/31/16 through 01/26/17 revealed the following dates and amounts of [MEDICATION NAME] 2.0 that the facility had purchased for Resident #5: Date: 10/31/16 [MEDICATION NAME] 2.0 1000ml Ultrapak 6/case Quantity Ordered: 1 case Date: 11/07/16 [MEDICATION NAME] 2.0 8 oz. 24/case Quantity Ordered: 4 cases Date: 01/10/17 [MEDICATION NAME] 2.0 8.45oz 24/case Quantity Ordered: 1 case Received: 01/12/17 In an interview on 1/27/17 at 11:50 a.m. LVN F said she uses two cartons of formula for Resident #5's feeding. She said the method of notifying someone when a resident was out formula was to verbally tell the DON. She said she had not told the DON when Resident #5 was out of formula because LVN A said she had already told the DON. She said sometimes she notifies the DON by text. Record review of the 24 hour report/change of condition report for station/unit 1-2 for the month of January 2017 revealed the following entries: o 01/01/17, 01/02/17, 01/03/17, and 01/04/17 - Remarks Night Shift- (Resident #5) needs new kangaroo pump o 01/05/17- Remarks Evening Shift- (Resident #5) needs [MEDICATION NAME] 2.0 out of feeding o 01/06/17- Remarks Night Shift- (Resident #5) needs [MEDICATION NAME] 2.0, out o 01/07/17- Remarks Evening Shift- (Resident #5) No [MEDICATION NAME], ate 75% o 01/07/17- Remarks Night Shift- (Resident #5) needs [MEDICATION NAME] 2.0 o 01/08/17- Remarks Night Shift- (Resident #5) Need [MEDICATION NAME] o 01/09/17- Remarks Day, Evening and Night Shift- (Resident #5) Need food for PEG. o 01/10/17- Remarks Night Shift- (Resident #5) need food for PEG. o 01/11/17- Remarks Night Shift -(Resident #5) needs bag/Peg Formula o 01/12/17- Remarks Day Shift- (Resident #5) sent to emergency room at 12:00 PM for lethargic, shallow, labored breathing. o 01/12/17- Remarks Night Shift-(Resident #5) Needs feeding. o 01/13/17- Remarks Deaths/Discharges/Leave of Absence- (Resident #5) at (Hospital B for observations). o 01/14/17- Remarks Evening Shift-(Resident #5) [MEDICATION NAME]. o 01/15/17-Remarks Evening shift-(Resident #5) Feeding infusing-no distress. o 01/16/17- Remarks under Admission/Readmission/Leave of Absence Returns- (Resident #5) [MEDICATION NAME] 2.0 feeding held due to pump not working. o 01/17/17- Remarks Evening Shift- (Resident #5) No feeding, pump will not work. o 01/18/17- Remarks Evening Shift- (Resident #5) New pump replaced. o 01/19/17 through 01/26/17 the 24 hour report did not have any recorded issues regarding the supply of his enteral feedings or the feeding pump not functioning properly for Resident #5. In an interview on 1/29/17 at 2:30 p.m. RN A said she works every other weekend and no one had told her Resident #5 was out of formula. In an interview on 1/31/17 at 2:28 p.m. LVN C said she was not working when Resident #5 was out of formula and that she only remembers that the machine was not working but could not recall the exact date. In an interview on 02/01/17 at 2:50 PM with LVN F, she said that the circles on the MAR indicated that the [MEDICATION NAME] 2.0 was not administered. She said that she normally does not work 2-10 shift and that she just happened to be covering on 01/05/17. She said that she looked in the medication room, the central supply room off of Hall 5 for his formula and was unable to locate it. She said she asked LVN A if she knew where his formula was stored. She said LVN A told her there was not any and that the DON was already aware Resident #5 was out. LVN F said she did not call the DON since LVN A said she was already aware and that she just wrote it on the 24 hour report. She said she should have notified Physician B to see if he would change the order but she said she did not contact him. In an interview on 02/01/17 at 3:05 PM, LVN E said she was the nurse for Resident #5 on 01/06/17 and that the circle on the MAR indicated that Resident #5 did not receive his [MEDICATION NAME] 2.0 enteral feeding on 01/06/17 due to not having the formula in stock at the facility. She said that her and a co-worker looked everywhere that evening for his formula. She said in the medication room, central supply room off of hall 5 and another supply closet. She said that when she received report from LVN G at shift change that afternoon on 01/06/17, she informed her that Resident #5 was out of his [MEDICATION NAME] 2.0 and that the DON and ADON were aware. She said that she also recorded it on the 24 hour report. She said that she should have clarified herself that the DON and ADON were aware that he was out. She said she was overwhelmed on this day because it was her first time working the 2-10 shift. She said she could have contacted Physician B to get the order changed but she did not. In a telephone interview on 2/1/17 at 3:35 p.m. LVN I said she had gone to the DON and ADON several times about not having Resident #5's [MEDICATION NAME] 2.0 and was told it had been ordered, but had not come in and to make sure Resident #5 was eating, which she stated she did observe him consume his dinner but did not recall if she had documented specifically his consumption. She said when she first notified the ADON, they were down to three cartons and the ADON said it had been ordered and she would look into it. She said she told the DON, who said she would look into it. She said she did not tell the Administrator. She said she made sure Resident #5 ate his meals and that the circled initials on the MAR meant he had not received the [MEDICATION NAME] 2.0 feeding. She said at one point during the time the MAR reflected Resident #5 was not receiving his feeding was because the feeding pump was not functioning. She said she used two cans of the [MEDICATION NAME] 2.0 for the feeding. She said on the dates that Resident #5 was in the hospital, the hospital called to asked what he was receiving through his [DEVICE] and asked for the [MEDICATION NAME] 2.0 to be sent over, but they didn't have any. She said when she notified the DON, the DON said the hospital will give him something. When asked about her initials being on the MAR on 1/14/17, when other initials were circled on 1/13/17 and 1/15/17 she said there was one night when they had one carton left, she gave it to him so he got a half feeding on 01/14/17. She said she did not think to notify the doctor and said my mistake and since the DON and ADON had been notified it would be taken care of. In an interview on 2/1/17 at 4:25 p.m. LVN D said the circled initials on the January 2017 MAR for Resident #5's enteral feeding meant it was not given. She said she worked the 2:00 p.m. to 10:00 p.m. shift on 1/15/17. She said this was her first day on that shift and LVN I was supposed to provide orientation, but she was a no-show. She said on 1/15/17 she was going to administer the enteral feeding and looked for it in the med room. She said that she did not administer Resident #5's enteral feeding on 01/15/17. She said she asked another nurse (she would not identify) and was told the pump was broken. She said she documented on the MAR on 1/18/17 that the new pump was delivered. She reviewed all of the dates circled on the MAR that indicated Resident #5 had not received his enteral feeding and said she was responsible for his feeding on 01/15/17 and did not administer it. She said I assumed the DON and ADON knew about it. She said she would consider the feeding to be nutrition but was told when he was admitted that it was a supplement. She said in looking back at what she could have done differently was to personally call the DON and make sure she knew the feeding pump was broken and that she could have called the doctor to ask for an order for [REDACTED]. She said it was common knowledge in a small town and was told by fell ow nurses if you call the doctor's office there is no answer after hours. She said the DON had physician's numbers, not the nurses. She said she has to call the hospital but the hospital will not give out the physician's numbers and would say if it was an emergency, send the resident over. She said she wished this had not happened. In an interview on 2/2/17 at 8:55 a.m. LVN A said the circled initials on the MAR beside Resident #5's enteral feeding meant it was not given. She said she verbally notified the ADON when they were running low but she could not remember the date and that she had documented it on the 24-hour report. She said the reason she documented on the 24-hour report was that she felt she was not getting the appropriate response from the ADON. She said one of the reasons offered by the ADON for not having the formula was that they had changed suppliers. She said the ADON did not advise her on what to do. She said the ADON worked a shift, but could not recall the date, and instructed her that the pump was not working and to let the DON know the next morning, but she said the DON did not come to work the following day so she could tell her. She said she went to the Administrator and was told the DON was sick, but she did not think to tell the Administrator about the pump not working. LVN A reviewed the MAR for the enteral feeding and said she did not give the feeding on 1/10/17 and 1/11/17 but could not remember if it was because there was no formula or if the feeding pump was not working. She reviewed a copy of the 24-hour report provided by the surveyor and confirmed she did not write anything on it. She said she should have notified Resident #5's physician immediately. She said she didn't think about if they had the formula she could have gotten an order for [REDACTED]. She said she felt she was being pushy about verbally harassing the DON and ADON and thought she was doing everything she could do and even talking to other nurses about it. She said she felt like she was shouting it from the mountain tops but now thinks she should have done more. She said she never intended for Resident #5 to be harmed. She said she thought she kept pushing and going to the DON and ADON verbally that she wouldn't need something in writing. She said when she documented on the 24-hour report her mind did not go to abuse or neglect but that she felt when she started seeing the circled initials on the MAR it was becoming serious and she wanted them to see it on a legal document that state would review . She confirmed she wrote on the report on 1/16/17 that the feeding was held due to the pump not working but forgot to circle her initials on the MAR for that date to indicate the feeding was not given. LVN A said she thought the order in which the situation happened was initially they were running low on formula, then the pump stopped functioning and then they ran out of formula. She said when the pump quit working she looked in the medication room and supply closet for a second pump but the ADON said there wasn't one. She said she thought she wrote it high on the page of the 24-hour reported and starred it to get their attention. LVN A said she thought on two different occasions the pump went out before they ran out of formula. She said she remembered a another pump being in the facility from a previous resident but the ADON said it had been sent back to the supply company and that after that they ran out of formula. LVN A said one evening (she could not remember the date) LVN I came to her and said she could not find any formula. She said when she walked down hall 5 later she noticed two cases of formula stacked outside the supply room on Hall 5 and told LVN I about the formula. She said later that night she saw the formula on a shelf in the central supply closet and took it to the medication room where it was stored. LVN A said there are nutritional consequences to feedings being held. She said when she was on duty during the time the feedings were not being given she made sure he was up in the dining room and fed. In an interview on 2/2/17 at 1:40 p.m. the ADON said the circled initials on the January 2017 MAR beside Resident #5's enteral feedings meant the feedings were not done. She said I don't recall it when asked if she was notified on 1/5/17 that they were out of Resident #5's formula. She reviewed the invoices from the formula that had been ordered and said to her knowledge it had only been ordered three times-twice in November 2016 and then on 1/10/17 which was delivered on 1/12/17. She said she was the only who orders the feedings and said she ordered 4-5 cases but she did not calculate how long the amount ordered would last. She said couldn't say how she kept track or monitored how long the supply would last and that she had no tracking system. She said not that I recall when asked if she was told the supply was running low. She said if she saw that Resident #5 had missed twelve feedings the effects could be weight loss, infection, or malnutrition. She said she was not aware of the documentation on the 24-hour report that they were out of the formula. She said the 24-hour report was reviewed sometimes in their morning stand-up meeting. She said she had never looked at the 24-hour report, that it was not part of her daily routine. She said if she had been aware that they were out of formula she would have gotten more within 24 hours. She said she considered it neglect to let Resident #5 go twelve days without the feedings. In an interview on 1/31/17 at 9:45 a.m. the DON said the enteral feed formulas are stored in the med room. She said on 1/12/17 she thought it was in the supply closet on hall 5 but then was moved to the med room. She said the days circled from 1/12/17 forward she believed the nurses thought they were out of stock. She said she doesn't think the nurses looked. She said she doesn't manage how the supplies are ordered. In an interview on 1/30/17 at 12:50 p.m. the Administrator said the LVNs should communicate with the ADON regarding the need for nursing supplies to be ordered. She said if the facility was totally out of formula, immediately go to the store or another facility and get the supplement or call the doctor for a substitute supplement. She said she should be notified if the stocker (ADON for nursing supplies or CNA H for personal care supplies) does not respond for requests of re-ordering/restocking. The Administrator said the DON was responsible for checking and scrubbing (for needed follow-ups, removal of resolved issues, etc.) the 24-hour report. She said the DON should take the 24-hour report to their stand-up meetings which were implemented a couple of weeks ago, and discuss what was going on and what was and was not working. She said prior to the implementation of the DON and the ADON scrubbing the 24-hour report and taking to their stand-up meetings, the DON was meeting with the nursing staff in the Rotunda and the charge nurses were responsible for discussing it during shift change. The Administrator said she was unaware Resident #5 had been without his enteral feedings for twelve days. In an interview on 2/1/17 at 10:30 a.m. Physician B said Resident #5 not receiving his tube feedings was unacceptable. When asked what should be done if another resident's doctor cannot be reached he said all of his career he has had to be available or someone had to be available to take care of the patients otherwise it would be abandonment. He said the staff made excuses why they didn't notify him that Resident #5 was out of formula and the pump was not working and that he told them that was inappropriate and the IJ was deserved. He said if there was a problem the staff should notify their supervisor and the supervisor should call the doctor. Record review of Resident #5's Admission History and Physical to Hospital B on 01/12/17 at 1:21 PM revealed the following This is an [AGE] year old male who was brought in by ambulance with an acute change of mental status. Seen in his normal status yesterday by the son; he presents to the emergency room unable to speak clearly, positive weakness. He reports that he does feel badly and he feels badly all over. Otherwise cannot elicit any complaints. Physical Examination: Vital Signs: BP:193/82, HR 49, Respirations 20, Temperature 97.5, Oxygen 99%, Weight 139 pounds. Record review of Resident #5's medical records from Hospital B, dated 01/12/17 revealed the following: Intravenous (IV) [MEDICATION NAME] Ringer's infusing at 125cc/hr initiated at 12:22 PM. Laboratory Values were obtained the following morning on 01/13/17 at 10:00 AM after resident had received IV fluids and there was no evidence of electrolyte imbalance or dehydration. [MEDICATION NAME] was low at 2.78. According to Medline Plus, accessed on 02/08/17, [MEDICATION NAME] is a protein made by the liver. A serum [MEDICATION NAME] test measures the amount of this protein in the clear liquid portion of the blood. The normal range is 3.4 to 5.4 g/dL. Decreased blood [MEDICATION NAME] may occur when your body does not get or absorb enough nutrients. https://medlineplus.gov/ency/article/ 0.htm Record review of the discharge patient care instructions from Hospital B dated 01/13/17 at 10:44 AM, revealed Resident #5 to have received patient care instructions regarding Altered Mental Status .causes .Low blood sugar or diabetes, severe loss of body fluids (dehydration) or a body salt (electrolyte imbalance) An infection .Patient instructions: Continue nursing home care as ordered. Follow up as needed with primary care physician. Record review of Resident #5's skilled daily nurse's note's revealed the following: o 01/03/17 at 6:00 PM, LVN I made the following entry Residual noted at 35ml. Peg tube flushed with 100cc of water. Peg tube pump not functioning correctly. 75% of supper ate. Peg tube feeding held at this time. o From 01/04/17 to 01/12/17 there were no entries in the nurses notes that addressed Resident #5's enteral feedings. o 01/12/17 at 12:00 PM, LVN G made the following entry Resident in dining room in wheelchair with head tilted back and beginning to slide out of wheelchair. Resident #5 states I am not feeling . Resident #5 unable to complete sentence. When asked how he feels, states Not worth a damn .will send to emergency room . o From 01/13/17 to 01/16/17 there were no entries in the nurses notes that addressed Resident #5's enteral feedings. o 01/16/17 2-10PM, LVN A made the following entry Feeding held due to pump not working. o 01/17/17 2-10 PM, LVN A made the following entry Held feeding due to pump not working. DON notified. o 01/18/17 10:00 PM, LVN D made the following entry new feeding pump delivered, [MEDICATION NAME] at 45ml/hour initiated, tolerated feeding well. o Record review of entries 01/19/17 through 01/26/17 did not reveal any remarkable findings pertinent to his enteral feedings. In an interview on 01/27/17 at 12:10 PM with Resident #5's responsible party, he said that he had not been contacted by the facility in regards to his father not receiving his enteral feedings the earlier part of January or that the feeding pump was not working properly. Resident #5's son said that he had noticed Resident #5 had lost weight recently. In an interview on 1/27/17 at 12:40 p.m

Based on observation, interview and record review the facility failed to maintain acceptable parameters of nutritional status to ensure desirable body weight range based on the residents' comprehensive assessment for three (Resident #1, Resident #5, and Resident #9) of 10 residents reviewed for nutrition. A. Resident #9 had been seen by the Dietician on 01/09/17 regarding weight loss, however the facility failed to implement the recommendations of weekly weights, contact Resident #9's physician regarding the weight loss. Resident #9 had experienced significant weight loss of 22% in the last 30 days. B. Resident #1 had significant weight loss that was not evaluated or addressed by the health care team. On 01/28/17, Resident #1 was weighed by the DON. At that time, a significant weight loss of over 15% in the last 30 days was identified. C. Resident #5's January 2017 Medication Administration Record [REDACTED]. On 01/27/17 it was identified that Resident #5 had experienced a significant weight loss of over 5% in the last 30 days. Resident #5 was not receiving the correct amount of enteral formula as ordered, when they had been administered or his enteral feeding pump was not functioning properly. In addition, Resident #5's [MEDICATION NAME] level during a hospital visit on 01/13/17 at 2.78 g/dL. On 01/27/17 an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 02/02/17, the facility remained out of compliance at a severity level of Actual harm that is not Immediate Jeopardy and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure placed 3 residents (Resident #1, Resident #5 and Resident #9) at harm and could place 14 residents in the facility that were at risk for avoidable weight loss, malnutrition, dehydration, electrolyte imbalance, decline in physical status, mental status, weakness, skin breakdown, and the potential for even death. Findings include: Resident #9 Record review of Resident #9's Admission Record, dated 08/24/16, revealed she was a [AGE] year old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review of Resident #9's significant change MDS assessment, dated 12/31/16, revealed a BIMS score of 08, indicating moderate cognitive impairment; Section G revealed that she needed assistance with meal setup and supervision. Section K revealed that her height was 66 inches and her weight was 173 pounds, and weight loss was not indicated. Resident #9 was not on any nutritional approaches such as a mechanically altered diet or a therapeutic diet. Record review of Resident #9's care plan dated 10/05/16 revealed Focus: (Resident #9) has an ADL self-care performance deficit related to physical limitations. Goal: (Resident #9) Will maintain current level of function in all ADL's through the review date. Intervention: Eating: (Resident #9) Requires supervision and setup assistance by (1X) staff to eat. Record review of Resident #9's physician orders dated 01/03/17 and signed on 01/05/17 by Physician B revealed Order start date: 07/06/16 Regular diet, Regular Texture, Regular/Thin Liquids consistency. In an interview on 01/31/17 at 11:17 AM with Resident #9, she said she sometimes goes to the dining room and sometimes chooses to stay in her room and eat. She said the food was good, she was always offered an alternate if she did not like what she was served. She said that staff will help her setup her meal tray, but that she was able to feed herself without needing any assistance. She said that she had recently had a bowel obstruction and had not been as hungry since her surgery. Record review of Resident #9's physician progress notes [REDACTED]. Record review of Resident #9's weight recorded on January 2017 (date unknown), revealed a weight of 156.4 pounds. Reweigh on 01/28/17 was noted to be 138.3 pounds, which revealed an 18.1 pound weight loss, since the first part of January 2017 and a 39.6 pound weight loss since 12/17/16, when she was in Hospital C. Record review of Resident #9's Dietary Progress Notes on 01/09/17 revealed Resident #9 to have the following weights recorded: July 177.8, October 176.9 , and a January weight of 156.4 pounds. On yogurt/shake B.I.D., Be sure on weekly weights. Record review of Resident #9's nurse's notes from 01/09/17 to 01/28/17 did not reveal entries that addressed her weight loss, placing her on weekly weights or her dietician consultation. On 01/28/17, an entry was made at 12:15 PM by LVN K, Resident exhibits a 17 pound weight loss in last 60 days. Current weight 156 pounds. Resident was recently hospitalized [DATE] - 12/19/16. Resident is on a regular diet. Appetite fair. Fax sent to Physician B to request weekly weight and recommendations. Family notified. Vital Signs: B/P 136/76, Respirations 18, Temperature 98.4. In an interview on 01/31/17 at 1:12 PM, CNA H said that she was responsible for the monthly and weekly weights in the facility. She said that she was also the facility's transportation driver and had recently informed the DON that her schedule due to transportation was making it difficult for her to obtain the weekly weights. She said that she could not recall the exact date that she performed the weights for January 2017 but remembered she started the last weekend of December and finished the first weekend of January 2017 with them. She said that Resident #1, Resident #5 and Resident #9 had not refused when asked to weigh them. She said that she had not had any issues with the scales malfunctioning or being off. She said that it had been awhile since they had been calibrated by a professional scale company. She said that she always uses the shower chair to weigh Resident #1, Resident #5 and Resident #9. She said that the shower chair usually weighed around 20 pounds and that she would subtract that from the weight that the scale displayed. She said that she gives the weight measurements to the DON each month. She said if there was a 3 pound difference loss or gain, she notified the DON at that time. In an interview on 01/31/17 at 1:30 PM, the DON said that the Dietician comes monthly unless called for a special concern. She said that she always comes to her office and discusses the residents that she has reviewed during her visit. She said that on 01/09/17 she did not recall the Dietician addressing Resident #9's weight loss of 17 pounds. She said that she did receive a copy of the Dietician's recommendations and must have overlooked Resident #9's evaluation from the Dietician that day. She said that until all residents were reweighed on 01/28/17, she had been unaware of Resident #9's weight loss. She said that Resident #9 had not been weighed weekly. In an interview on 1/31/17 at 1:47 p.m. the DON provided the names of the residents who were to be weighed weekly. She said she had missed placing one resident on the schedule but was going to correct that one. She said the Dietitian had recommended weekly weights on Resident #9 but her name had not been placed on the schedule. On 02/01/17 at 8:36 AM a telephone interview was attempted with the Dietician. In an interview on 02/01/17 at 10:35 AM, Physician B said that he was notified on 01/31/17 regarding Resident #1 and Resident #9's weight loss. He said that he had not been notified on 01/09/17 regarding Resident #9's weight loss. In an interview on 2/2/17 at 11:07 a.m. the Administrator said she was not aware of the Dietitian's recommendation for Resident #9 on 1/9/17. She said the DON was responsible for carrying out the Dietitian's recommendations and notifying the physician. She said the recommendation for weekly weights should be implemented by the DON and that she should also notify the physician. Record review of the facility policy entitled Weight and Height Measurement, undated, received by the facility Administrator on 01/31/17 at approximately 3:00 PM, revealed Basic Responsibility: Licensed Nurse, Nursing Assistant and Restorative Nursing Assistant. Purpose: To obtain accurate weight and height of each resident. To maintain constant control of weight changes. To assess nutrition and hydration status of resident. To identify significant change in condition. Assessment Guidelines: May include, but are not limited to: Nutritional status, location of pain or discomfort, ability to feed self, contractures, deformity, hydration status, diuretic use, incontinence, ideal body weight, usual body weight. Procedure: 1. Calibrate scale according to manufacturer's instructions. Assist resident into wheelchair or scale chair. Place wheelchair on scale platform properly, according to manufacturer's direction. 4. Weigh according to manufacturer's directions and subtract weight of wheelchair from total weight to obtain resident's weight.Documentation Guidelines: Documentation may include: Date and weight. Height on appropriate form(s). Notify the charge nurse or physician of all weight changes of five pounds (or 5%) or more in a 30 day period or ten percent in a 180 day period or per state requirement. Signature and title. Care Plan Documentation Guidelines: Problem: Identify the appropriate problem under which to list the weight and height measurement as an approach. Consider listing possible risks and complications. Goal: List MEASURABLE goal(s) to be accomplished. Consider a goal related to the usual, lifetime body weight rather than the ideal body weight. List target date. Approaches: List responsible discipline for each approach. List instructions unique to this resident. List necessary monitoring and observation of the resident's weight and nutrition/hydration status. List method of feeding and the amount of assistance the resident required. List assistive devices for eating. List monitoring for pressure ulcers, List frequency of weight measurement if other than routine. List the type of diet and nourishment, if ordered. Resident #1 Record review of Resident #1's Admission Record dated 1/19/16 revealed he was a [AGE] year old male admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #1's Physician's Orders dated 1/3/17 revealed the following Diagnoses: [REDACTED]. Record review of Resident #1's quarterly MDS (Minimum Data Set) dated 12/15/16 revealed he required limited assistance with his ADLs (Activities of Daily Living) and his BIMS (Brief Interview for Mental Status) score was 1 which indicated his cognitive status was severely impaired. The record revealed he had exhibited rejection of care and verbal behavior symptoms directed toward others during the look-back period of the assessment. Section G revealed he required supervision (oversight, encouragement, cueing) with eating. Section K revealed a height of 67 inches, weight of 179.0 and Resident #1 was on a mechanically altered diet. Record review of Resident #1's Care Plan Revision date 11/29/16 revealed Focus: the resident has a nutritional problem or potential nutritional problem r/t lack of ability to make good judgments. Goal: The resident will comply with recommended diet for weight daily maintenance through next review date. Interventions: Explain and reinforce to the resident the importance of maintaining the diet ordered. Encourage the resident to comply. Explain consequences of refusal, obesity/malnutrition risk factors. Provide, serve diet as ordered. Monitor intake and record every meal. RD (registered dietitian) to evaluate and make diet change recommendations PRN (as needed). Record review of Resident #1's weights for the past three months were as follows: January 28th, 2017 148.8 January 2017 176.7 December 2016 178.5, November 2016 180.4 Observation on 1/26/17 at 12:25 p.m. revealed Resident #1 lying on the edge of his bed on his left side with the head of his bed elevated approximately 30 degrees. His lunch tray was on his overbed table and Resident #1 was observed slightly raised up on his left upper arm and shoulder drinking a yellow colored liquid from a Styrofoam cup. A tray containing a Styrofoam plate with his uneaten breakfast, covered with plastic wrap was sitting in his wheelchair at his bedside positioned toward the foot of the bed. Observation and interview on 1/26/17 at 12:27 p.m. revealed Resident #1's breakfast tray had been removed. He was lying uncovered on the edge of his bed on his right side with his eyes closed, and was wearing a brief, shirt and socks. His pillow and bottom sheet at shoulder level were wet and stained with the yellow colored liquid. His lunch was uneaten. He would only answer yes or no questions. He said no when asked if he got enough to eat. He said no when asked if he receives help eating. He said yes when asked if he was still hungry. He said huh? when asked three times if he needed someone to help him eat. Observation on 1/26/17 at 2:08 p.m. revealed Resident #1 lying on the edge of his bed on his left side. His lunch meal remained on his overbed table untouched. In an interview on 1/26/17 at 3:15 p.m. LVN H said Resident #1 had refused to take showers and medications, but was able to feed himself. She said he prefers to lean up on his elbow while lying on his side to eat. She said he was able to sit up. She said he resists care and medications sometimes, but that she has a good rapport with him and she was able to get him to comply. She said there are certain other staff in the facility that he likes and will take his medication from them also. Observation on 01/27/17 at 5:10 PM revealed Resident #1's breakfast tray was still untouched and on bedside tray table. Observation and interview on 1/27/17 at 7:00 a.m. revealed Resident #1 lying on the edge of his bed on his left side. His uneaten supper tray from the night before was sitting on his bedside table. He answered yes when asked if he could feed himself. He did not answer when asked if he eats when he wants to. In an interview on 1/27/17 at 11:10 a.m. LVN A said if a resident refused meals the CNA was supposed to notify the nurse and the nurse was supposed to go to the resident to ask the reason for refusal if the resident was able to communicate. She said if the resident was okay, she leaves for a little bit then goes back to talk to the resident again. She said if the resident wished, she notified the CNA and dietary to have a meal tray delivered to the resident's room. She said the CNA on the hall should assist if the resident was an assisted diner. She said she follows-up to ensure the resident eats. Observation on 1/27/17 at 2:30 p.m. revealed Resident #1 lying on the edge of his bed on his right side; his back was towards the door. He did not respond to surveyor's knock. A meal tray was sitting on his bedside table. Observation and interview on 1/27/17 at 5:08 p.m. revealed a partially eaten meal tray identified by LVN H as Resident #1's breakfast tray sitting on his bedside table. LVN H said she was only able to get him to eat a few bites of biscuit and gravy. Observation and interview on 1/27/17 at 5:50 p.m. revealed Resident #1 groomed and dressed, sitting in his wheelchair in the dining room feeding himself with a fork. CNA C was sitting at the table beside him. She said if she could get Resident #1 up in the evenings for a shower he would go to the dining room to eat. She said it depended on his mood. She said if he was good and asleep he got really mad when you woke him up. She said he listens to music and lays in his bed a lot. She said she would take him his meal tray, wake him up and tell him here's your food, he would say 'uh, huh', and maybe would get up to eat it 20 minutes later. She said that recently Resident #1 had not been eating as good as he used to. In an interview on 1/27/17 at 6:15 p.m. CNA I said CNA H usually weighed the residents on Wednesday. Observation on 01/28/17 at 12:08 revealed CNA D delivered Resident #1's lunch tray to Resident #1's room. Resident #1 sat up on the edge of the bed to feed himself. CNA D removed the coverings from the lunch tray and asked Resident #1 if he needed assistance with eating, he said No. Observation on 01/28/17 at 12:17 PM revealed Resident #1 had lain back down on the bed and did not consume any portion of his lunch. Observation on 01/28/17 at 12:33 PM revealed the ADON answered Resident #1's call light. Resident #1 was sitting up on the side of the bed eating his lunch. He said he wanted to go somewhere, when the ADON asked if he was finished eating, he said No. His lunch tray was left on the bedside table. The ADON asked LVN H to assist her with understanding where Resident #1 was wanting to go. At this time, LVN H asked Resident #1 what's wrong? Resident #1 said he did not want any more of his lunch and approximately 25% of his meal was consumed. Observation on 01/28/17 at 12:45 PM revealed Resident #1 being weighed on the facility's scale. He weighed 148.8 pounds, which indicated a 27.9 pound weight loss since the beginning of January 2017 from 176.7 pounds. Observation on 01/28/17 at 12:47 PM revealed Corporate RN checked the scales to see if there was a discrepancy. Corporate RN weighed a can of peas that indicated a weight of 6 pounds 9 ounces. The scale indicated the can of peas weighed 7 pounds 5 ounces, therefore it was discovered that there was a 12 ounce discrepancy in the scales. In an interview on 01/28/17 at 1:15 PM, the DON said that Resident #1 had been sick and had a lot of nausea and vomiting this past month. In an interview on 01/28/17 at 1:20 PM, CNA E said that she had noticed Resident #1 losing weight just recently. She denied Resident #1 to have had any episodes of nausea and vomiting that she had seen on her shift. In an interview on 01/28/17 at 1:33 PM, CNA A said that she had noticed a drastic change in weight. She said that she had recently returned from being on leave the beginning of January 2017 and noticed a big difference. She said that he had not been eating like he used to. She said that she did not recall any episodes of nausea and vomiting that Resident #1 displayed. She said that she had told the nurse when he refused to eat. In an interview on 01/28/17 at 1:38 PM, the Dietary Manager said that Resident #1 hardly ever ate in the dining room or even came out of his room anymore. She said that until about a month ago he would come to the dining room for at least two meals a day. She said that she had seen a big change in him. In an interview on 01/28/17 at 1:35 PM with Resident #1, he said that he had been hungry but doesn't know why he hadn't been eating. He said he wants different food. When asked what type of different food, he said he doesn't know. In an observation on 01/28/17 at 1:38 PM, Resident #1 was noted to voice complaints of chest pain to LVN H. LVN H alerted Corporate RN of his complaint and at this time, Physician B was contacted and Resident #1 was sent to Hospital A. Observation and interview on 1/30/17 at 12:23 p.m. revealed Resident #1 dressed and groomed sitting in the dining room. The BOM (Business Office Manager) was sitting beside him at the table. There was a lunch plate in front of him but he was not eating. The BOM said he didn't like the meatloaf he was given so the kitchen was making him a sandwich. He was calm and quiet. In an interview on 1/30/17 at 12:30 p.m. Corporate RN said he had put a system in place to provide consistency in staff who work with Resident #1 so that he will not be confused about who was coming into his room to provide care. He said Resident #1 got up and ate breakfast this morning, took a shower and we were able to get a UA (urine for analysis). In an interview on 1/30/17 at 12:50 p.m. the Administrator said it was not acceptable for a breakfast tray to be left on the tray at the resident's bedside until 5:00 p.m. She said if a resident refuses a meal tray, he/she can ask it to be held, or if the tray if left for the resident, the CNA should go back and check on the resident. She said if the resident needs assistance the CNA should assist. She said if the resident continues to not eat the meal, the cold food should be removed and other choices offered. She said we don't want a meal sitting there for 6-7 hours. She said after the meal tray was delivered the CNA should tell the resident he/she will be back in a few minutes, continue to pass the other hall trays go back then re-check. If the resident still refuses the CNA should remove the meal tray and notify dietary and the charge nurse so alternatives can be offered. The charge nurse should assess the resident and notify the doctor and/or dietitian if needed. She said it is not our policy to leave meal trays in rooms all day. The administrator said there was a lack of communication between the DON, LVNs, and CNAs and that if they knew Resident #1 was refusing his meals they should have notified the dietitian and doctor and offer him a hamburger because he likes and will eat them, and go get it from an outside/fast-food restaurant if necessary. In an interview on 01/30/17 at 1:06 PM, CNA F said that Resident #1 almost always eats everything. She said the past few weeks he had not refused any meals with her and that on occasion he had chased her out of his room when attempting to check on him. She said she would tell the nurse when he exhibited this behavior, but usually if she just allowed him some time, she could go back and try again. She said sometimes she will get another CNA to assist him and that worked well. In an interview on 01/30/17 at 2:30 PM, CNA C said she had noticed Resident #1 having a hard time chewing his food recently and had noticed a lot of food in the trash can that he had chewed and spit out. She said that he has not been eating much over the past few weeks. She said that she had informed LVN I about the refusals and when she observed him spitting his food in the trash. She said that a lot of the CNA's would just let him be and that is not okay with me. She said that she had addressed her concern with the DON and that the DON's response was if you can't get the other CNA's to care for him, you can switch halls and work with Resident #1. In an interview on 1/31/17 at 9:45 a.m. Corporate RN said he was worried about Resident #1. He said Resident #1 had gone to the dining room twice for meals but he didn't do well with the hamburger he ate for breakfast (Resident #1's choice). Corporate RN said Resident #1 wanted Dr. Pepper so the facility offered him a Dr. Pepper float and he threw it up. He said he did not know if the result of Resident #1's UA. Corporate RN said when staff notices a resident losing weight his expectation was to place the resident on weekly weights. In an observation and interview on 1/31/17 at 11:15 a.m. the ADON looked through Resident #1's medical chart for his December 2016 intake record but could not find it. She said some of the December intake records were in the dining room in the intake book. She reviewed the residents' December 2016 intake records that were in the intake book, but there was not a record with Resident #1's name on it. This surveyor pointed out a December 2016 intake record with no name on it. The ADON took it, looked at it and sat it to the side on the counter at the nurse's station and said I don't know whose that'd be and continued to look for Resident #1's December 2016 intake record in his medical chart. No December 2016 intake record was found. Record review of Resident #1's Food Intake Record for January 2017 from 1/1/17 through 1/27/17 revealed: Breakfast: 1/1/17 100% consumed 1/2/17 100% consumed 1/3/17 100% consumed 1/4/17 100% consumed 1/5/17 100% consumed 1/6/17-1/15/17 There was no documentation that indicated Resident #1 had a meal intake 1/16/17 Refused 1/17/17 50% consumed 1/18/17-1/27/17 There was no documentation that indicated Resident #1 had a meal intake Lunch: 1/1/17 100% consumed 1/2/17 80% consumed 1/3/17-1/15/17 There was no documentation that indicated Resident #1 had a meal intake 1/16/17 70% consumed 1/17/17-1/25/17 There was no documentation that indicated Resident #1 had a meal intake 1/26/17 50% consumed 1/27/17 There was no documentation that indicated Resident #1 had a meal intake Dinner: 1/1/17-1/13/17 There was no documentation that indicated Resident #1 had a meal intake 1/14/17 Refused 1/15/17 Refused 1/16/17 Refused 1/17/17-1/26/17 There was no documentation that indicated Resident #1 had a meal intake 1/27/17 50% consumed Record review of the Dietitian Recommendations dated 11/7/16 revealed a documented weight of 180.4 pounds and the recommendation May DC House Supplement as needed. Record review of a Physician's Telephone Order dated 11/16/16 at 1:00 p.m. revealed an order to discontinue the house supplement and signed by Physician B on 12/8/16. In an interview on 1/31/17 at 1:45 p.m. Corporate RN said Resident #1 had been placed on the schedule to be weighed twice weekly. In an interview on 1/31/17 at 2:28 p.m. LVN C said Resident #1 used to eat well, but the last couple of weeks he has not eaten as well. She said prior to a couple of weeks ago, Resident #1's usual routine was to stay in bed in his room during the day. She said he would get up and go to the bathroom during the day and at night after supper he would come to the nurse's station in his wheelchair and get snacks. She said in the last couple of weeks, he has stayed in his room and not come out. She said the nurses were charting on him for a while but that she did not remember documenting any condition changes on the 24-hour report. In an interview on 01/31/17 at 1:12 PM, CNA H said that she was responsible for the monthly and weekly weights in the facility. She said the Resident #1 has never refused to weigh for her. In an interview on 2/1/17 at 10:30 a.m. Physician B said he has known Resident #1 and been his physician on and off for approximately [AGE] years and that he has been under psychiatric care all that time. He said last night (1/31/17) was the first time he was notified that Resident #1 was losing weight. He said his instructions to the staff are that if there was something he needs to know to call his cell phone 24/7. He said he has a concern there are times that doesn't happen as often as he would like. He said when taking care of people, communication was so important. He said communication could be better and if the facility was seeing that a resident was losing weight they should pick up the phone and call him. He said he would expect the staff to weigh the resident before calling. He said if they notice a change in condition the staff should investigate, assess and call him. He said he would have taken action sooner if he had known Resident #1 had lost over 20 pounds. He said he comes to the facility every two weeks. He said he asked his office staff this morning if there had been any faxes related to Resident #1. He said his nurse practitioner showed him a fax dated 1/20/17. He said he saw the fax this morning, but Resident #1 needed to have been evaluated at the point of the fax notice. He said he would have either seen Resident #1 in his clinic or the emergency room . He said if he had seen Resident #1 and that he was acting differently and had weight loss he would have obtained labs on him. He said there had not been adequate communication about Resident #1 in the past 30 days. In an interview on 2/1/17 at 2:30 p.m. CNA E said Resident #1 had gone down a lot in the last 30 days. She said he would not eat and had lost a lot of weight. She said she did not recall Resident #1 refusing meals prior to the last 30 days. She said he would go to the dining room in his wheelchair, ask for a sandwich, take it back to his room to eat it. She said he would pull his light to let us know what he needed, but he had not done that in a while. She said she told the nurses about Resident #1's change in condition, but could not say how long ago she told the nurses or who she told. In an interview on 2/2/17 at 11:30 a.m. Corporate RN said Resident #1 had eaten breakfast and that consistency in staff was the key for his improved compliance. Resident #5 Record review of Resident #5's Admission Record, dated 10/31/16, revealed he was an [AGE] year old male admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review of Resident #5's Admission MDS assessment, dated 11/07/16, revealed a BIMS score of 08, indicating moderate cognitive impairment; Section G revealed that he was totally dependent upon staff for all activities of daily living, specifically eating. Section K revealed that his height was 68 inches and his weight was 137 pounds, he had a feeding tube, which provided 26-50% of total calories the resident received through [MEDICATION NAME] or tube feeding and a mechanically altered diet was also indicated. Record review of Resident #5's Care Plan dated 11/04/16, revised on 01/18/17, revealed a focus area of: (Resident #5) is at risk for malnutrition and weight loss due to requires Pureed diet with Nectar thick liquids, Does have a [DEVICE] for nutritional support, (Resident #5) will be encouraged and assisted to consume greater than 50% of meals daily through next review date-Target Date: 4/18/17. (Resident #5's) nutritional status will remain stable as evidenced by (AEB) no reports of significant weight change. Interventions: Assess reports of signs and symptoms of aspiration/difficulty chewing or swallowing, implement appropriate interventions within code status. Notify MD and refer to speech therapy (ST) as appropriate. Dietician to review quarterly and as needed (PRN). Encourage (Resident #5) to eat meal out of bed. Encourage/assist (Resident #5) to upright position for intake by mouth. Encourage/remind to remain in upright position for at least 30 minutes after meals as indicated. Observe tolerance to diet and liquids, notify MD and refer to ST as appropriate. Observe for/record and notify MD, registered dietician (RD) of change in eating habits. Observe meal intake, record and offer alternative if eats less than 50% of meal. Observe weight as ordered. Notify MD, RD and responsible party (RP) of weight change greater than 5% in 30 days, 7.5% in 90 days and/or 10% in 180 days. Offer preferences when available. Offer encourage snacks within dietary restrictions. Provide REGULAR PUREED diet as ordered with NECTAR THICKENED liquids. Provide set-up, supervision, verbal cue and physical assistance as needed to complete meals. Intervention: Eating The resident is totally dependent on (1x) staff for eating. According to the United States National Library of Medicine, accessed on 02/03/17, a [DEVICE] is A gastrostomy feeding tube insertion is the placement of a feeding tube through the skin and the stomach wall. It goes directly into the stomach. Gastrostomy feeding tubes are put in for different reasons. They may be needed for a short time or permanently. This procedure may be used for: oPersons who cannot swallow correctly oPersons who cannot take enough food by mouth to stay healthy oPersons who often breathe in food when eating https://medlineplus.gov/ency/article/ 7.htm. Record review of Resident #5's signed Physician orders dated 01/03/17 revealed the following orders: o O

Based on observation, interview and record review the facility failed to report and thoroughly investigate an incident of fall with injury for 1(Resident #1) of 4 residents reviewed for incidents/accidents . Resident #1, who was determined by the facility to be at risk for falls, was taken to her room after lunch on 12-13-15 and left there without being checked on for approximately 3 hours. Resident #1 fell out of her wheelchair and was found in a pool of blood that had coagulated. Resident #1 was transported to the hospital via ambulance and was treated. Resident #1 returned to the facility the next day (12-14-15) with sutures to her head. Resident #1 had a slow decline and passed away 10 days after the incident on 12-23-15. Facility administrative staff failed to investigate the incident, prevent further potential abuse, and to report the incident to the Department of Aging and Disability Services (DADS). An Immediate Jeopardy (IJ) was identified on 1/7/16. While the IJ was removed on 1/11/16, the facility remained out of compliance at a scope and severity of actual harm that is not immediate jeopardy, pattern, because the facility had not monitored their plan for effectiveness. These facility failure resulted in harm for Resident #1 and could affect the 19 residents who are dependent on staff for transfers and place them at risk falls with injuries. Findings included: Resident ID #1 Review of Resident #1 ' s admission record revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1 ' s recent annual Minimum Data Set ((MDS) dated [DATE] documented Resident #1 was dependent on staff to move from a seated position to standing or surface to surface transfers (transfer between bed and chair or wheelchair) due to her inability to stabilize herself without the assistance of a staff member. Resident had a BIMS score of 7 which indicated severe impairment to her mental status. Review of the Care Plan Conference held on 11-13-15 with the DON, Social Worker, and Resident #1's daughter, they discussed her continued risk for falls. The plan was to continue her current care of treatment to have a one person assistance for all ADLs and transfers. Review of the CNA Tracking Form for the month of November 2015 documented Resident # 1 required extensive assistance of 1 staff member for all transfers, bed mobility, and toillet use. Review of Incident report dated 12-13-15 at 1640 (4:40 pm) documented by LVN A: Resident found on the floor by door in her room face down in a pool of blood. Large gash to left forehead, small gash to bridge of nose, left side of face bruised and swollen. The resident was transferred to the ER (emergency room ) via ambulance at 1710 (5:10 pm). In an interview with LVN A on 1-6-16 at 1:50pm she stated she was the nurse in charge for Resident #1 at the time of the incident. LVN A stated she was in the medication room when CNA C came to the medication room and stated Resident #1 was on the floor face down. LVN A reported CNA C was assigned to Resident #1 but when she started her shift at 2:00 pm she was told CNA C left the building during lunch time and was not sure what time she returned. LVN A said she was told by CNA C around 4:40 pm that Resident #1 was on the floor. When she got to Resident #1 ' s room, she was lying in a pool of blood. LVN A asked one of the CNA D to help pick her head up slightly off the floor. At that time, LVN A said she noticed a flap of skin on the left side of Resident #1 ' s face, the left side of her face was swollen and the blood was had already started to clot. LVN A said she called 911. LVN A stated Resident #1 was supposed to be taken to her room and put in her recliner with her oxygen on after meals. LVN A reported at the time of the incident Resident #1 did not have on her oxygen and had appeared to have fallen from her wheelchair. LVN A stated the emergency responders came and placed a cervical collar on Resident #1 and used a flat board to transport her. LVN A stated the emergency responders had to add more gauze to Resident #1 ' s head because it was still actively bleeding. LVN A stated after the resident returned to the facility the next day, she was put on a puree diet. A few days after readmission Resident #1 couldn't take her medications and started declining. Resident #1 passed on December 23, 2015 (10 days after her fall). In an interview on 1-7-16 at 11:00am the EMT (emergency medical technician) stated when she responded to the emergency call at the facility the resident was lying on the floor with a towel under her head. Resident #1 reported to her that she kept calling for help but no one came. Resident #1's head was a couple of steps away from the doorway. The EMT reported Resident #1 left eye was swollen shut. In an interview on 1-7-16 at 10:18 am the hospital nurse stated Resident #1 lost a massive amount of blood. Resident #1's head was full of blood and looked like a ' red helmet. ' The hospital nurse also reported Resident #1 was soiled with feces and urine and she had to clean her up. Review of the hospital patient chart report dated 12-13-15 for Resident #1 documented: Patient suffered ground level fall at facility. Fall was unwitnessed, help (CNA) noticed patient shouting for help. Possible that she laid in floor for about 30 minutes. Resident #1 suffered multiple lacerations to her face. In an interview on 1-6-16 at 2:20 pm with CNA D, she stated she was the one who found Resident #1 on the floor on 12-13-15. CNA D stated Resident #1 was a fall risk and was to be placed in her recliner after all meals. CNA D said she was walking down the hall on 12-13-15 when she heard someone say ' help me. Please help me. ' Resident #1 was found lying face down by the door in a pool of blood. CNA D said she called to CNA C to get the nurse. CNA D said the facility did not do an investigation of the incident. CNA D said LVN A asked her to write a statement and she wrote it right after the event happened. CNA D said it was never brought up again. In an interview on 1-6-16 at 2:38 pm with CNA C, she stated she was in charge of Resident #1 the day of the incident. CNA C said she left the facility the day of the incident (12-13-15) for about 20 minutes and returned to the facility. CNA C stated they are not allowed to leave the building while residents are having meals but she needed to run home. She stated after she returned (CNA C was unsure of the time) she went to the break room and began to prepare her own lunch. CNA C stated she did not check on Resident #1 or any of her residents that she was assigned to that day from the time she left the building (between 1:00- 1:30pm) until the time Resident #1 was found on the floor ( around 4:40 pm). CNA C stated she assumed the other aides would have taken care of her residents and she did not want to ask them if they did because she did not want them to get upset at her for questioning their work. CNA C stated ' I should have gone to check on her (after she returned), she was my resident. ' CNA C stated she was aware that Resident #1 was a high risk for falls and has tried to get out of her wheelchair before and needed to be placed in her recliner after meals. In a telephone interview with CNA E on 1-7-16 at 11:06 am she stated on the day of the incident (12-13-15) she had taken the resident out of the dining room after lunch (1:00-1:30) and put her at the nurse ' s station in her wheelchair. CNA E stated she did not take the resident to her room but left her at the nurse ' s station because she had to take her assigned resident to the restroom. CNA E said she does not know who took Resident #1 to her room and left her in the wheelchair. CNA E stated ' I know she is a fall risk and would not have left her in her wheelchair in her room. She always gets transferred to the recliner. ' In an interview on 1-6-16 at 3:19pm the DON stated Resident #1 was a fall risk and always needed to be placed in her recliner after any meals. The DON stated on 12-13-15 Resident #1 stated to her ( after her return from the hospital) she was leaning forward trying to take her sweater off when she fell hit her head and ' busted it open. ' The DON reported the resident was in the hospital for 12 days ( the resident actually returned back to the facility the next day, 12-14-15). The DON then reported after the resident retuned to the facility she ' lived for a while then passed. That is all I know. I was not here when the incident happened. ' When this surveyor asked the DON about an investigation to the incident she stated she had the Accident/ Incident form the nurse filled out but she has not completed her portion of the form (Investigation Follow Up) where she inputs the final disposition. The DON stated the Investigation Follow Up form should be completed right after an incident but she had been busy. The DON stated no further investigation had been completed as of 1-6-16. The DON stated the resident was on hospice and was going to die anyways. A copy of the Accident/ Incident form and Investigation Follow Up form were requested. Record review of the Accident/ Incident form was completed by the nurse on duty. The Investigation Follow Up was blank as of 1-6-16. There was no other documentation provided to show an investigation had been completed or new interventions implemented. In an interview with the Administrator on 1-6-16 at 4:14pm he stated he was the abuse/ neglect coordinator. When asked regarding the events involving Resident #1 he stated he was aware of what happened because he had spoken to the nurses. The administrator stated the resident returned to the facility after being out for 4 days (the resident actually returned back to the facility the next day, 12-14-15). When asked what nurses or investigation was conducted the Administrator stated he only spoke to the DON. The Administrator stated the incident was reviewed in morning meeting to see if anything needed to be further investigated but he decided it was ' pretty clear cut ' what happened and nothing further was done. Review of the hospice communication form dated 12-21-15 documented: Resident pocketing food and having difficulty swallowing, needs reminders from the staff. Please advise. Review of the hospice communication form dated 12-23-15 documented: resident condition worse, hospice notified at 9am. The resident later passed away that day (12-23-15). In an interview with LVN B on 1-6-16 at 1:07pm, she stated before the fall Resident #1 needed some help with ADL care but could feed herself, was responsive and alert with some confusion. After the fall LVN B stated she noticed a changed in Resident #1. She stated Resident #1 didn't respond to questions like she normally would, stopped feeding herself, and started pocketing food. Review of Routine Resident Checks policy (undated) stated in part: staff shall make routine checks to help maintain residents ' safety and well-being. Routine checks involve entering the resident ' s room to determine if the resident ' s needs are being met. Review of Accidents and Incidents- Investigating and Reporting policy dated April 2013, documented in part: 1. The Nurse supervisor shall promptly initiate and document investigation of the accident or incident 5. The supervisor shall complete a Report of Incident/ Accident and submit to the DON within 24 hours. 6. The DON shall ensure that the Administrator receives a copy of the form An Immediate Jeopardy (IJ) was identified on 1-7-16. The administrator was notified. A Plan of Removal was submitted by the facility on 1-8-16, and included: - Investigation of incident was made by DON on 12-14-15 - Regarding post fall huddling: This is new to our facility. In post fall huddle you have a group of staff that evaluates why the fall happened, and what could have been done to prevent it. To reduce falls, minimize risk, injury. The Fall committee is the same as the Post fall Huddle . - Staff has a 2 hour round service of which is monitored by the charge nurses, and the CNAs. - A new intervention of which is being put in pace (sic) is a round sheet. The CNAs will initial the round sheet on their resident they have been assigned to and this will eliminate problems in the future. - Inservices are ongoing for future reference on falls and fall prevention. - Training for administrator .was completed at 2:30 pm on 1-07-16 on incident and investigation and reporting . - Inservice training for all staff has been done by ADON for fall prevention and safety of transfer, and reporting of injuries. Training was done on 1-7-16 at 1600 hours .The other staff will be inserviced by 1-8-16. - CNAs will have access to the chart to identify any needs that are above standard care. DNR status, Fall risk status, and this will be given in report between the shifts as walking founds are made. At the change of shift the LVNs and the CNAs will meet for report. All fall risks will be noted on the 24 hour report. All CNAs will make walking rounds with the oncoming shift to ensure no patient is wet, and that no problems are noted. The implementation of the Plan of Removal was verified on 1-11-16 as follows: Review of facility investigation revealed written statements from staff dated 1/8/16. Disciplinary actions for CNA C and E were dated 1/8/16. Observation of Resident #2 on 1-11-16 at 3:15 pm revealed geri sleeves were in place. Interviews with LVNs and CNAs on 1-9-16 and 1-10-16 revealed they understood the inservices conducted about fall prevention and monitoring residents. On 1-11-16 at 3:25 pm the Administrator and DON were informed that the IJ was removed. The facility remained out of compliance at a level of Actual Harm, pattern. The facility had not yet monitored their plan for effectiveness. According to the CMS 672 dated 1-7-16, 19 residents needed help with transfers.

Based on observation, interview and record review the facility failed to supervise and prevent accidents for 2 (Resident #1 and #2) of 4 residents reviewed for accidents. Resident #1, who was determined by the facility to be at risk for falls, was taken to her room after lunch on 12-13-15 and left there without being checked on for approximately 3 hours. Resident #1 fell out of her wheelchair and was found in a pool of blood that had coagulated. Resident #1 was transported to the hospital via ambulance and was treated. Resident #1 returned to the facility the next day (12-14-15) with sutures to her head. Resident #1 had a slow decline and passed away 10days after the incident on 12-23-15. Resident ID #2 experienced multiple skin tears and bruises caused during transfers with the resident. Resident ID #2 had 8 injuries within 2 months. The facility failed to implement interventions to prevent injuries. An Immediate Jeopardy (IJ) was identified on 1-7-16. While the IJ was removed on 1-11-16, the facility remained out of compliance at a scope and severity of actual harm that is not immediate jeopardy, pattern, because the facility had not monitored their plan for effectiveness. These facility failures resulted in harm for Resident #1 and could affect the 19 residents who are dependent on staff for transfers, placing them at risk falls with injuries. Findings included: Resident ID #1 Review of Resident #1 ' s admission record revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1 ' s recent annual Minimum Data Set ((MDS) dated [DATE] documented Resident #1 was dependent on staff to move from a seated position to standing or surface to surface transfers (transfer between bed and chair or wheelchair) due to her inability to stabilize herself without the assistance of a staff member. Resident had a BIMS score of 7 which indicated severe impairment to her mental status. Review of the Care Plan Conference held on 11-13-15 with the DON, Social Worker, and Resident #1's daughter, they discussed her continued risk for falls. The plan was to continue her current care of treatment to have a one person assistance for all ADLs and transfers. Review of the CNA Tracking Form for the month of November 2015 documented Resident # 1 required extensive assistance of 1 staff member for all transfers, bed mobility, and toillet use. Review of Incident report dated 12-13-15 at 1640 (4:40 pm) documented by LVN A: Resident found on the floor by door in her room face down in a pool of blood. Large gash to left forehead, small gash to bridge of nose, left side of face bruised and swollen. The resident was transferred to the ER (emergency room ) via ambulance at 1710 (5:10 pm). In an interview with LVN A on 1-6-16 at 1:50pm she stated she was the nurse in charge for Resident #1 at the time of the incident. LVN A stated she was in the medication room when CNA C came to the medication room and stated Resident #1 was on the floor face down. LVN A reported CNA C was assigned to Resident #1 but when she started her shift at 2:00 pm she was told CNA C left the building during lunch time and was not sure what time she returned. LVN A said she was told by CNA C around 4:40 pm that Resident #1 was on the floor. When she got to Resident #1 ' s room, she was lying in a pool of blood. LVN A asked one of the CNA D to help pick her head up slightly off the floor. At that time, LVN A said she noticed a flap of skin on the left side of Resident #1 ' s face, the left side of her face was swollen and the blood was had already started to clot. LVN A said she called 911. LVN A stated Resident #1 was supposed to be taken to her room and put in her recliner with her oxygen on after meals. LVN A reported at the time of the incident Resident #1 did not have on her oxygen and had appeared to have fallen from her wheelchair. LVN A stated the emergency responders came and placed a cervical collar on Resident #1 and used a flat board to transport her. LVN A stated the emergency responders had to add more gauze to Resident #1 ' s head because it was still actively bleeding. LVN A stated after the resident returned to the facility the next day, she was put on a puree diet. A few days after readmission Resident #1 couldn't take her medications and started declining. Resident #1 passed on December 23, 2015 (10 days after her fall). In an interview on 1-7-16 at 11:00am the EMT (emergency medical technician) stated when she responded to the emergency call at the facility the resident was lying on the floor with a towel under her head. Resident #1 reported to her that she kept calling for help but no one came. Resident #1's head was a couple of steps away from the doorway. The EMT reported Resident #1 left eye was swollen shut. In an interview on 1-7-16 at 10:18 am the hospital nurse stated Resident #1 lost a massive amount of blood. Resident #1's head was full of blood and looked like a ' red helmet. ' The hospital nurse also reported Resident #1 was soiled with feces and urine and she had to clean her up. Review of the hospital patient chart report dated 12-13-15 for Resident #1 documented: Patient suffered ground level fall at facility. Fall was unwitnessed, help (CNA) noticed patient shouting for help. Possible that she laid in floor for about 30 minutes. Resident #1 suffered multiple lacerations to her face. In an interview on 1-6-16 at 2:20 pm with CNA D, she stated she was the one who found Resident #1 on the floor on 12-13-15. CNA D stated Resident #1 was a fall risk and was to be placed in her recliner after all meals. CNA D said she was walking down the hall on 12-13-15 when she heard someone say ' help me. Please help me. ' Resident #1 was found lying face down by the door in a pool of blood. CNA D said she called to CNA C to get the nurse. CNA D said the facility did not do an investigation of the incident. CNA D said LVN A asked her to write a statement and she wrote it right after the event happened. In an interview on 1-6-16 at 2:38 pm with CNA C, she stated she was in charge of Resident #1 the day of the incident. CNA C said she left the facility the day of the incident (12-13-15) for about 20 minutes and returned to the facility. CNA C stated they are not allowed to leave the building while residents are having meals but she needed to run home. She stated after she returned (CNA C was unsure of the time) she went to the break room and began to prepare her own lunch. CNA C stated she did not check on Resident #1 or any of her residents that she was assigned to that day from the time she left the building(between 1:00- 1:30pm) until the time Resident #1 was found on the floor ( around 4:40 pm). CNA C stated she assumed the other aides would have taken care of her residents and she did not want to ask them if they did because she did not want them to get upset at her for questioning their work. CNA C stated ' I should have gone to check on her (after she returned), she was my resident. ' CNA C stated she was aware that Resident #1 was a high risk for falls and has tried to get out of her wheelchair before and needed to be placed in her recliner after meals. In a telephone interview with CNA E on 1-7-16 at 11:06 am she stated on the day of the incident (12-13-15) she had taken the resident out of the dining room after lunch (1:00-1:30) and put her at the nurse ' s station in her wheelchair. CNA E stated she did not take the resident to her room but left her at the nurse ' s station because she had to take her assigned resident to the restroom. CNA E said she does not know who took Resident #1 to her room and left her in the wheelchair. CNA E stated ' I know she is a fall risk and would not have left her in her wheelchair in her room. She always gets transferred to the recliner. ' In an interview on 1-6-16 at 3:19pm the DON stated Resident #1 was a fall risk and always needed to be placed in her recliner after any meals. The DON stated on 12-13-15 Resident #1 stated to her ( after her return from the hospital) she was leaning forward trying to take her sweater off when she fell hit her head and ' busted it open. ' The DON reported the resident was in the hospital for 12 days ( the resident actually returned back to the facility the next day, 12-14-15). The DON then reported after the resident retuned to the facility she ' lived for a while then passed. That is all I know. I was not here when the incident happened. ' When this surveyor asked the DON about an investigation to the incident she stated she had the Accident/ Incident form the nurse filled out but she has not completed her portion of the form (Investigation Follow Up) where she inputs the final disposition. The DON stated the Investigation Follow Up form should be completed right after an incident but she had been busy. The DON stated no further investigation had been completed as of 1-6-16. The DON stated the resident was on hospice and was going to die anyways. A copy of the Accident/ Incident form and Investigation Follow Up form were requested. Record review of the Accident/ Incident form was completed by the nurse on duty. The Investigation Follow Up was blank as of 1-6-16. There was no other documentation provided to show an investigation had been completed or new interventions implemented. In an interview with the Administrator on 1-6-16 at 4:14pm he stated he was the abuse/ neglect coordinator. When asked regarding the events involving Resident #1 he stated he was aware of what happened because he had spoken to the nurses. The administrator stated the resident returned to the facility after being out for 4 days (the resident actually returned back to the facility the next day, 12-14-15). Review of the hospice communication form dated 12-21-15 documented: Resident pocketing food and having difficulty swallowing, needs reminders from the staff. Please advise. Review of the hospice communication form dated 12-23-15 documented: resident condition worse, hospice notified at 9am. The resident later passed away that day (12-23-15). In an interview with LVN B on 1-6-16 at 1:07pm, she stated before the fall Resident #1 needed some help with ADL care but could feed herself, was responsive and alert with some confusion. After the fall LVN B stated she noticed a changed in Resident #1. She stated Resident #1 didn't respond to questions like she normally would, stopped feeding herself, and started pocketing food. Review of Routine Resident Checks policy (undated) stated in part: staff shall make routine checks to help maintain residents ' safety and well-being. Routine checks involve entering the resident ' s room to determine if the resident ' s needs are being met. Resident ID #2 Review of Resident ID #2 ' s Face Sheet dated 11-11-15 revealed she was a [AGE] year old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident ID #2 latest MDS dated [DATE] revealed the resident was totally dependent on staff for bathing, turning and repositioning, dressing, toileting and personal hygiene. The resident was still able to feed herself with supervision. The resident had long term and short term memory problems. Review of the current Care Plan dated 11-18-15 revealed no plan to address transfers. A plan initiated 5-20-15 indicated the Resident had very fragile skin, at risk for skin tears, bruises and other complications related to wound healing. Interventions included Dietician to review quarterly, remind to use call light, observe the skin, offer and encourage lotion daily, provide assistance with showers and bath per schedule, provide diet and fluids as ordered. Review of Resident ID #2 incident/accident reports for November, December 2015 and January 2016 revealed the resident had numerous skin tears for as follows: 11-12-15 Resident ID #2 was eased down to the floor transferring to shower chair and started going down and aides eased her to the floor. Did not fall. The intervention stated none. 11-12-15 Resident ID #2 was transferring to wheelchair from shower chair, aide had a hold of right arm and resident received a 6 centimeter (cm) X 10 cm skin tear. The intervention was to use arm protectors and to cover arms at all times to prevent the skin from tearing. 11-13-15 Resident ID #2 was found to have a skin tear to the right forearm above recent skin tear. The intervention was to monitor daily and to use the proper transfer techniques when transferring. 11-14-15 Resident ID #2 was being provided wound care and was found to have a 2 cm skin tear to the left forearm and had a dark purple discoloration. The intervention was to monitor skin and ensure the arm sleeves are worn at all times. 11/24/15 Resident ID #2 was found with a skin tear to the right hand. The intervention was to ensure that transfers were done properly. 11-20-15 Resident ID #2 was found to have a 1 cm open area to the back of the right calf. The documentation stated it was an old hematoma that had burst. No interventions. 12-9-15 Resident ID #2 was found to have a large bruise to the side of her right breast. The bruise measured 24cm X 25 cm. The intervention was to monitor the positioning of the resident, keep off the right side, and monitor until healed. It was unknown how the bruise occurred. 1-7-16 Resident ID #2 had a skin tear noted to the left outer forearm before getting resident out of bed. The skin tear measured 3 cm X 2.5 cm. The intervention was to monitor until resolved. Review of physician's order [REDACTED].#2 was to wear protective sleeves (geri sleeves) daily to each arm. Observation of Resident ID # 2 on 1-7-16 at 12:15 PM revealed the resident was sitting in her wheelchair with bandages behind her right calf, her front right shin, and her left forearm. There were no geri sleeves on her upper or lower extremities. There was a Hoyer lift in the corner of the resident ' s room. Observation of Resident ID #2 on 1-7-16 at 1:42 PM revealed no geri sleeves on the resident ' s arms or legs and the Hoyer was in the corner of the room. Interview with Charge nurse LVN C on 1-7-16 at 12:47 pm revealed Resident #2 was supposed to wear geri sleeves and long pants, and stated she realized they are not on today (1-7-16). Interview with CNA F on 1-7-16 at 1:55 pm revealed the DON says to shower Resident #2 every day, but the aide feels that with her fragile skin she doesn ' t need a shower every day. She realized the resident was supposed to wear geri sleeves, but that they were off today. Interview with the DON on 1-7-16 at 2:10 pm revealed Resident ID #2 did not have an order for [REDACTED]. The DON stated that geri sleeves were to be on the resident at all times but had seen her not wearing them as ordered. The DON stated she was going to get an order for [REDACTED]. Interview on 1-7-16 at 1:49 PM with Resident ID #2 ' s responsible party revealed the Resident had been at the facility for [AGE] years and the staff call her often with reports of skin tears to the resident ' s arms and legs. The responsible party stated she felt there were too many and she realized her skin was fragile but that staff could prevent some of the injuries. An Immediate Jeopardy (IJ) was identified on 1-7-16. The administrator was notified. A Plan of Removal was submitted by the facility on 1-8-16, and included: - Investigation of incident was made by DON on 12-14-15 - Regarding post fall huddling: This is new to our facility. In post fall huddle you have a group of staff that evaluates why the fall happened, and what could have been done to prevent it. To reduce falls, minimize risk, injury. The Fall committee is the same as the Post fall Huddle . - Staff has a 2 hour round service of which is monitored by the charge nurses, and the CNAs. - A new intervention of which is being put in pace (sic) is a round sheet. The CNAs will initial the round sheet on their resident they have been assigned to and this will eliminate problems in the future. - Inservices are ongoing for future reference on falls and fall prevention. - Training for administrator .was completed at 2:30 pm on 1-07-16 on incident and investigation and reporting . - Inservice training for all staff has been done by ADON for fall prevention and safety of transfer, and reporting of injuries. Training was done on 1-7-16 at 1600 hours .The other staff will be inserviced by 1-8-16. - CNAs will have access to the chart to identify any needs that are above standard care. DNR status, Fall risk status, and this will be given in report between the shifts as walking founds are made. At the change of shift the LVNs and the CNAs will meet for report. All fall risks will be noted on the 24 hour report. All CNAs will make walking rounds with the oncoming shift to ensure no patient is wet, and that no problems are noted. The implementation of the Plan of Removal was verified on 1-11-16 as follows: Review of facility investigation revealed written statements from staff dated 1/8/16. Disciplinary actions for CNA C and E were dated 1/8/16. Observation of Resident #2 on 1-11-16 at 3:15 pm revealed geri sleeves were in place. Interviews with LVNs and CNAs on 1-9-16 and 1-10-16 revealed they understood the inservices conducted about fall prevention and monitoring residents. On 1-11-16 at 3:25 pm the Administrator and DON were informed that the IJ was removed. The facility remained out of compliance at a level of Actual Harm, pattern. The facility had not yet monitored their plan for effectiveness. According to the CMS 672 dated 1-7-16, 19 residents needed help with transfers.

Based on observation, interview and record review the facility failed to implement written policies and procedures that prohibit neglect that resulted in a fall with injury for 1(Resident #1) of 4 residents reviewed for incidents/accidents. Resident #1, who was determined by the facility to be at risk for falls, was taken to her room after lunch on 12-13-15 and left there without being checked on for approximately 3 hours. Resident #1 fell out of her wheelchair and was found in a pool of blood that had coagulated. Resident #1 was transported to the hospital via ambulance and was treated. Resident #1 returned to the facility the next day (12-14-15) with sutures to her head. Resident #1 had a slow decline and passed away 10 days after the incident on 12-23-15. Facility administrative staff failed to investigate the incident, prevent further potential abuse, and to report the incident to the Department of Aging and Disability Services (DADS). An Immediate Jeopardy (IJ) was identified on 1/7/16. While the IJ was removed on 1/11/16, the facility remained out of compliance at a scope and severity of actual harm that is not immediate jeopardy, pattern, because the facility had not monitored their plan for effectiveness. These facility failure resulted in harm for Resident #1 and could affect the 19 residents who are dependent on staff for transfers and place them at risk falls with injuries. Findings included: Review of Accidents and Incidents- Investigating and Reporting policy dated April 2013, documented in part: 1. The Nurse supervisor shall promptly initiate and document investigation of the accident or incident 5. The supervisor shall complete a Report of Incident/ Accident and submit to the DON within 24 hours. 6. The DON shall ensure that the Administrator receives a copy of the form Resident ID #1 Review of Resident #1 ' s admission record revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1 ' s recent annual Minimum Data Set ((MDS) dated [DATE] documented Resident #1 was dependent on staff to move from a seated position to standing or surface to surface transfers (transfer between bed and chair or wheelchair) due to her inability to stabilize herself without the assistance of a staff member. Resident had a BIMS score of 7 which indicated severe impairment to her mental status. Review of the Care Plan Conference held on 11-13-15 with the DON, Social Worker, and Resident #1's daughter, they discussed her continued risk for falls. The plan was to continue her current care of treatment to have a one person assistance for all ADLs and transfers. Review of the CNA Tracking Form for the month of November 2015 documented Resident # 1 required extensive assistance of 1 staff member for all transfers, bed mobility, and toillet use. Review of Incident report dated 12-13-15 at 1640 (4:40 pm) documented by LVN A: Resident found on the floor by door in her room face down in a pool of blood. Large gash to left forehead, small gash to bridge of nose, left side of face bruised and swollen. The resident was transferred to the ER (emergency room ) via ambulance at 1710 (5:10 pm). In an interview with LVN A on 1-6-16 at 1:50pm she stated she was the nurse in charge for Resident #1 at the time of the incident. LVN A stated she was in the medication room when CNA C came to the medication room and stated Resident #1 was on the floor face down. LVN A reported CNA C was assigned to Resident #1 but when she started her shift at 2:00 pm she was told CNA C left the building during lunch time and was not sure what time she returned. LVN A said she was told by CNA C around 4:40 pm that Resident #1 was on the floor. When she got to Resident #1 ' s room, she was lying in a pool of blood. LVN A asked one of the CNA D to help pick her head up slightly off the floor. At that time, LVN A said she noticed a flap of skin on the left side of Resident #1 ' s face, the left side of her face was swollen and the blood was had already started to clot. LVN A said she called 911. LVN A stated Resident #1 was supposed to be taken to her room and put in her recliner with her oxygen on after meals. LVN A reported at the time of the incident Resident #1 did not have on her oxygen and had appeared to have fallen from her wheelchair. LVN A stated the emergency responders came and placed a cervical collar on Resident #1 and used a flat board to transport her. LVN A stated the emergency responders had to add more gauze to Resident #1 ' s head because it was still actively bleeding. LVN A stated after the resident returned to the facility the next day, she was put on a puree diet. A few days after readmission Resident #1 couldn't take her medications and started declining. Resident #1 passed on December 23, 2015 (10 days after her fall). In an interview on 1-7-16 at 11:00am the EMT (emergency medical technician) stated when she responded to the emergency call at the facility the resident was lying on the floor with a towel under her head. Resident #1 reported to her that she kept calling for help but no one came. Resident #1's head was a couple of steps away from the doorway. The EMT reported Resident #1 left eye was swollen shut. In an interview on 1-7-16 at 10:18 am the hospital nurse stated Resident #1 lost a massive amount of blood. Resident #1's head was full of blood and looked like a ' red helmet. ' The hospital nurse also reported Resident #1 was soiled with feces and urine and she had to clean her up. Review of the hospital patient chart report dated 12-13-15 for Resident #1 documented: Patient suffered ground level fall at facility. Fall was unwitnessed, help (CNA) noticed patient shouting for help. Possible that she laid in floor for about 30 minutes. Resident #1 suffered multiple lacerations to her face. In an interview on 1-6-16 at 2:20 pm with CNA D, she stated she was the one who found Resident #1 on the floor on 12-13-15. CNA D stated Resident #1 was a fall risk and was to be placed in her recliner after all meals. CNA D said she was walking down the hall on 12-13-15 when she heard someone say ' help me. Please help me. ' Resident #1 was found lying face down by the door in a pool of blood. CNA D said she called to CNA C to get the nurse. CNA D said the facility did not do an investigation of the incident. CNA D said LVN A asked her to write a statement and she wrote it right after the event happened. CNA D said it was never brought up again. In an interview on 1-6-16 at 2:38 pm with CNA C, she stated she was in charge of Resident #1 the day of the incident. CNA C said she left the facility the day of the incident (12-13-15) for about 20 minutes and returned to the facility. CNA C stated they are not allowed to leave the building while residents are having meals but she needed to run home. She stated after she returned (CNA C was unsure of the time) she went to the break room and began to prepare her own lunch. CNA C stated she did not check on Resident #1 or any of her residents that she was assigned to that day from the time she left the building (between 1:00- 1:30pm) until the time Resident #1 was found on the floor ( around 4:40 pm). CNA C stated she assumed the other aides would have taken care of her residents and she did not want to ask them if they did because she did not want them to get upset at her for questioning their work. CNA C stated ' I should have gone to check on her (after she returned), she was my resident. ' CNA C stated she was aware that Resident #1 was a high risk for falls and has tried to get out of her wheelchair before and needed to be placed in her recliner after meals. In a telephone interview with CNA E on 1-7-16 at 11:06 am she stated on the day of the incident (12-13-15) she had taken the resident out of the dining room after lunch (1:00-1:30) and put her at the nurse ' s station in her wheelchair. CNA E stated she did not take the resident to her room but left her at the nurse ' s station because she had to take her assigned resident to the restroom. CNA E said she does not know who took Resident #1 to her room and left her in the wheelchair. CNA E stated ' I know she is a fall risk and would not have left her in her wheelchair in her room. She always gets transferred to the recliner. ' In an interview on 1-6-16 at 3:19pm the DON stated Resident #1 was a fall risk and always needed to be placed in her recliner after any meals. The DON stated on 12-13-15 Resident #1 stated to her ( after her return from the hospital) she was leaning forward trying to take her sweater off when she fell hit her head and ' busted it open. ' The DON reported the resident was in the hospital for 12 days ( the resident actually returned back to the facility the next day, 12-14-15). The DON then reported after the resident retuned to the facility she ' lived for a while then passed. That is all I know. I was not here when the incident happened. ' When this surveyor asked the DON about an investigation to the incident she stated she had the Accident/ Incident form the nurse filled out but she has not completed her portion of the form (Investigation Follow Up) where she inputs the final disposition. The DON stated the Investigation Follow Up form should be completed right after an incident but she had been busy. The DON stated no further investigation had been completed as of 1-6-16. The DON stated the resident was on hospice and was going to die anyways. A copy of the Accident/ Incident form and Investigation Follow Up form were requested. Record review of the Accident/ Incident form was completed by the nurse on duty. The Investigation Follow Up was blank as of 1-6-16. There was no other documentation provided to show an investigation had been completed or new interventions implemented. In an interview with the Administrator on 1-6-16 at 4:14pm he stated he was the abuse/ neglect coordinator. When asked regarding the events involving Resident #1 he stated he was aware of what happened because he had spoken to the nurses. The administrator stated the resident returned to the facility after being out for 4 days (the resident actually returned back to the facility the next day, 12-14-15). When asked what nurses or investigation was conducted the Administrator stated he only spoke to the DON. The Administrator stated the incident was reviewed in morning meeting to see if anything needed to be further investigated but he decided it was ' pretty clear cut ' what happened and nothing further was done. Review of the hospice communication form dated 12-21-15 documented: Resident pocketing food and having difficulty swallowing, needs reminders from the staff. Please advise. Review of the hospice communication form dated 12-23-15 documented: resident condition worse, hospice notified at 9am. The resident later passed away that day (12-23-15). In an interview with LVN B on 1-6-16 at 1:07pm, she stated before the fall Resident #1 needed some help with ADL care but could feed herself, was responsive and alert with some confusion. After the fall LVN B stated she noticed a changed in Resident #1. She stated Resident #1 didn't respond to questions like she normally would, stopped feeding herself, and started pocketing food. Review of Routine Resident Checks policy (undated) stated in part: staff shall make routine checks to help maintain residents ' safety and well-being. Routine checks involve entering the resident ' s room to determine if the resident ' s needs are being met. An Immediate Jeopardy (IJ) was identified on 1-7-16. The administrator was notified. A Plan of Removal was submitted by the facility on 1-8-16, and included: - Investigation of incident was made by DON on 12-14-15 - Regarding post fall huddling: This is new to our facility. In post fall huddle you have a group of staff that evaluates why the fall happened, and what could have been done to prevent it. To reduce falls, minimize risk, injury. The Fall committee is the same as the Post fall Huddle . - Staff has a 2 hour round service of which is monitored by the charge nurses, and the CNAs. - A new intervention of which is being put in pace (sic) is a round sheet. The CNAs will initial the round sheet on their resident they have been assigned to and this will eliminate problems in the future. - Inservices are ongoing for future reference on falls and fall prevention. - Training for administrator .was completed at 2:30 pm on 1-07-16 on incident and investigation and reporting . - Inservice training for all staff has been done by ADON for fall prevention and safety of transfer, and reporting of injuries. Training was done on 1-7-16 at 1600 hours .The other staff will be inserviced by 1-8-16. - CNAs will have access to the chart to identify any needs that are above standard care. DNR status, Fall risk status, and this will be given in report between the shifts as walking founds are made. At the change of shift the LVNs and the CNAs will meet for report. All fall risks will be noted on the 24 hour report. All CNAs will make walking rounds with the oncoming shift to ensure no patient is wet, and that no problems are noted. The implementation of the Plan of Removal was verified on 1-11-16 as follows: Review of facility investigation revealed written statements from staff dated 1/8/16. Disciplinary actions for CNA C and E were dated 1/8/16. Observation of Resident #2 on 1-11-16 at 3:15 pm revealed geri sleeves were in place. Interviews with LVNs and CNAs on 1-9-16 and 1-10-16 revealed they understood the inservices conducted about fall prevention and monitoring residents. On 1-11-16 at 3:25 pm the Administrator and DON were informed that the IJ was removed. The facility remained out of compliance at a level of Actual Harm, pattern. The facility had not yet monitored their plan for effectiveness. According to the CMS 672 dated 1-7-16, 19 residents needed help with transfers.

Citation Text for Tag 0323, Regulation FF08 Based on observations, interviews and record review the facility failed to ensure Resident # 8 received adequate supervision and assistance to prevent accidents for one of eight residents (Resident #8) reviewed for accidents and hazards. The facility failed to ensure adequate supervision to prevent Resident # 8 from wandering into a Hall that is un-occupied and is being renovated. Resident #8 sustained a fall resulting in a fracture to his hip requiring surgery. The facility's deficient practice could place any of the 32 residents residing in the facility identified as ambulating independently or self- propel their wheelchairs by increasing their risk for injury causing a physical decline in their health. Findings included: Review of Resident #8's facility's "Admitting Record" dated 06/18/2013 revealed a [AGE] year old male admitted to the facility 6/18/2013 with the following Diagnoses: [REDACTED]. Review of the facility ' s Medication Administration Record (MAR) revealed that Resident # 8 was administered Norco 5/325 mg (narcotic Analgesic) on 6/28/2013 at 2100 (9:00 p.m.). This was the initial dose and only dose of Norco that was administered to the resident. Review of the facility ' s " Pain Management Flow sheet " dated 6/28/2013 at 2100 (9:00 p.m.) revealed Resident # 8 had complaints of generalized pain. Review of the facility ' s Nurses Notes dated 6/28/2013 at 2245 (10:45 p.m.), Resident # 8 was ambulating in hallway with walker down at the end of Hall Two. Resident # 8 resided on Hall six. Resident was noted with confusion; states he was " looking for his bedroom " . Resident ambulated to nurses ' station, where he complained of shortness of breath. Resident was assisted to sit in the chair at the nurses ' station. Oxygen saturation on room air was 92%. When resident was ready to ambulate, resident was assisted with his walker back to his bedroom. Resident continued to be confused and disoriented. Review of the facility's " Skilled Daily Nurses Notes ", dated 6/28/2013 revealed Resident # 8 was assessed as requiring one person assist for transfers, locomotion, and toileting. Further review of the Nurses Notes dated 6/28/2013 at 2320 (11:20 p.m.) revealed that Resident #8 ambulated by himself to the nurse ' s station. Resident was noted to be standing at the nurse's station without his walker and was looking for his bedroom, the nurse went to check on another resident and to retrieve Resident #8's walker. When she returned to the nurse's station Resident #8 was gone, while looking for resident the nurse heard someone yelling for help. Resident # 8 was found at the end of Hall one (which is currently being renovated and is unoccupied). He was noted to have a skin tear; Resident was able to move all extremities without problems. Resident denied hitting his head, denied pain, no other injuries noted. Nurse assisted resident to standing position, resident stood on both lower extremities, pivoted and sat in wheelchair without problems. No complaints of pain, no signs or symptoms of discomfort noted. Resident #8 was assisted back to his room; he remained confused and disoriented throughout the rest of the night. A personal alarm was applied to resident' s recliner to ensure safety, call light within reach. No signs or symptoms of distress noted. Review of the facility ' s " Communication with MD " (Medical Doctor) dated 6/28/2013, with a hand written notation was faxed 6/28/13 2420 (12:20 a.m.) revealed the following concerns: Resident fell while ambulating in facility causing 5 cm (centimeters) "C" shaped skin tear to left outer elbow, no further injuries noted, resident denies pain, denies hitting head, moves all extremities. Vital signs; Temp 99 degrees Fahrenheit, Pulse 78, Respirations, 20, Blood Pressure 171/116, Oxygen saturation 92% on room air, Neurological checks initiated. Skin tear cleansed, edges approximated, and steri strips applied, will monitor every day until healed. Personal alarm applied to ensure resident safety. Resident is disoriented times two at this time. Review of the facility's "Incident/Accident Report" for Resident #8 dated 06/28/13 revealed at 2330 (11:30 p.m.) that Resident #8 "ambulated on unauthorized, unlocked hall when he fell causing skin tear to his left outer elbow. Resident denied hitting his head, positive range of motion to all extremities, no further injuries noted " . Review of the facility's Fall Risk Evaluation, dated 6/18/2013 revealed Resident #8 was alert, oriented, times three, had no history of falls in the last three months, ambulating independently, and continent of bowel and bladder. Gait/Balance was documented N/A - not able to perform function. Resident #8's total score was four. (Total score of ten or above represents High Risk for falls). Review of the facility's " Interdisciplinary Post-Fall Assessment " dated 6/28/2013 revealed Resident # 8's mental status, resident was confused and disoriented times two, his gait balance was unsteady, and that the resident was totally dependent on staff for physical assistance with Activities of Daily Living (ADL's- eating, bed mobility, transferring, locomotion, and toileting). Resident #8 was being treated with an antibiotic for urinary tract infection. Review of Resident #8 ' s Care Plan dated 6/27/2013 revealed A Problem/Need for Resident #8 was Resident Complains Pain/Discomfort and is at risk for Injury from Decrease in Activities of Daily Living, (eating, bed mobility, transferring, locomotion, and toileting). Approaches listed for Resident #8 were as follows: 1. Monitor for signs & symptoms of increased pain/discomfort-assess resident for possible causes, give meds, treatments, and physical and relaxation modalities. etc.-assess for relief... 6. Norco 5/325 mg one by mouth every four hours as needed for pain. There was no care plan that addressed Resident # 8 ' s confusion and disorientation until post fall 6/28/2013. Further review of the Nurses notes dated 7/1/2013 at 1345 (1:45 p.m.), Resident # 8 was receiving Physical Therapy and complained of Left hip pain. A call was placed to Resident #8's Primary Care Physician's (PCP) office where an order was obtained to have an x-ray of left hip and pelvic region related to post fall and complaints of pain. Review of the Radiology report from the local hospital dated 7/1/2013 at 1650 (4:30 p.m.) revealed acute left hip sub capital femoral fracture (a fracture that occurs in the proximal end of the femur, the long bone running thought the thigh, near the hip bone). Resident # 8 was transferred and admitted to a nearby acute hospital. Review of the Operative report from the nearby hospital dated 7/2/2013 revealed Resident #8 underwent a Left femoral head substitution. (Hip replacement, a surgical procedure in which the hip joint is replaced by a prosthetic implant). In an interview with Resident #8's Primary Care Physician on 7/18/2013 at 4:00 p.m. he said that his office was made aware of the residents fall via fax dated 7/28/2013, he said that the fax did indicate resident had fallen and had sustained a skin tear but there were no other injuries noted. He said that his Nurse Practitioner was made aware of Resident #8 ' complaints of pain on 7/1/2013 and she had given an order to obtain an x-ray. He said that he was not aware of the results of the x-ray and did not get informed regarding residents admission to a nearby hospital. Observation of the entrance doors to Hall One (the hall that was under renovation) on 7/19/2013 at 9:30 a.m. revealed there was a hook latch at the top of the doors, the exit sign was illuminated and the lights were on. There was a buffer sitting in the hallway at the entrance of the hall, just past the double doors, and a hospital bed sitting in the hallway at the far end of the hall. In an interview with the Facility Administrator on 7/19/2013 at 9:45 a.m. She said that Hall One has been under renovation for the last six weeks, there is currently a hook latch to keep the doors closed and discourage access to the hall, however she said that there were at least two other residents that she is aware of that have gotten past those doors and were found in the hall, one resident is ambulatory and the other resident propels herself in the wheelchair. She said that she visually checks the latch; she knows her Maintenance Director checks the latch, but she does not know if other staff checks to ensure the latch is hooked. She said that she believes Resident #8 was too confused to un-latch the doors, but she does not know if the door was latched the night Resident #8 was found on the floor in the hall. She said that the exit light is still illuminated and the lights on the hall would still be on. She said that she does check to ensure there is no equipment or tools left sitting out. In an interview with the facility's Maintenance Director 7/19/2013 at 10:00 a.m. he said that Hall One has " fire doors " at the entrance and must remain accessible in case of an emergency so the latch is the only option they had to discourage residents from going down the hall. He stated that the exit sign was illuminated and the lights are on during the night as it is hooked into other breakers necessary for office functions. He said that staff does go down that hall upon occasion. He said that he does not know if anyone else checks the latch, he said that he does when he is in the facility. Review of the facility's Policy and Procedure on Fall Prevention dated January 12, 2005 states successful fall prevention requires a thorough clinical assessment of residents and the environment in which they live. Managing the risk of falling requires identifying both resident and environmental factors that contribute to fall risk in order to minimize the risk while maximizing each resident's independence and quality of life. Falls can lead to a loss of confidence in independent mobility, depression, helplessness, social isolation, functional decline and increased risk of subsequent falls... Review of the facility's Policy on Investigating Allegations of Neglect, undated. The Interpretation and Implementation of the policy reads neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, mental illness or the deterioration of a resident ' s physical and mental condition. Neglect also means the failure to protect the resident from abuse, neglect, or exploitation. Neglect is repeated conduct or a single incident of carelessness which produces or could reasonably be expected to result in serious physical or psychological injury or a substantial risk of death... CMS Form 672 dated 7/19/2013 documented a facility census of 52, with 32 residents residing in the facility that can ambulate independently or can propel self in wheelchairs.