Every finding on record at Hill Country Heights

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for sanitation. 1.The facility failed to ensure sanitation practices (ensuring trash receptacles were securely covered, ensuring kitchen floors were free from debris, ensuring kitchen utensils were free of dried debris, ensuring kitchen utility cart was debris free, and ensuring kitchen shelving was debris free)2.The facility failed to label and date all food items in the kitchen. These failures could place residents at risk of foodborne illness. During an observation on 5/19/26 at 6:13 am, of the facility's kitchen revealed: -Utility cart next to steam table had dried food debris and spilled dried liquids of red and brown color on all 3 levels of the utility cart.-microwave revealed the inside top of the microwave to have dried food debris on the ceiling of the microwave.-overhead shelf near cooktop revealed a container of [NAME] Krispie cereal labeled cereal and dated 2026 unsure of what the open date or discard date was. Further observation revealed a container labeled Cornflakes dated 10/11/21 unsure if this is the open date or discard date.-55- gallon trash can between refrigerator and chemical closet without lid and trash inside of can.-refrigerator #1 package of sliced ham in box opened and unsecured undated and unlabeled.-refrigerator # 1 a gallon storage bag with package of sliced cheese dated 5/12/26 no discard date present.-refrigerator #1 a gallon storage bag of provolone cheese block dated 4/23/26 with use by date of 2026.-refrigerator #1 a quart storage bag of block of butter undated and unlabeled.-refrigerator # 1 a 3 lb. container of ricotta cheese dated 5/20 no discard date present.-refrigerator # 1 a gallon storage bag with a container of potato salad dated 5/6 and a use by date of 5/11.-dry storage pot/pan shelving shelf liner with dried debris stuck to shelf liner.-dry storage package of opened penne pasta dated 5/1/26 unsure if this is open date or discard date.-dry storage package of opened ziti pasta dated 4/15/26 unsure if this is open date or discard date.-dry storage package of opened spaghetti paste dated opened 4/23/26 no discard date.-dry storage 9 packages of hamburger buns undated-dry storage 3 loaves of undated bread.-dry storage 4 packages of sub rolls undated.-dry storage opened package of potato chips undated.-dry storage a gallon storage bag of opened chocolate cake mix with an open date of 5/2/26 and a use by date of 2026.-dry storage a gallon storage bag of opened yellow cake mix with an open date of 5/14/26 and a use by date of 2026.-dry storage room floor with food debris and dirt on floor and accumulated along edge of wall and edge of shelves.-utensil storage drawer a black plastic serving spoon with dried food debris.-knife storage rack dirty with dried food debris.-refrigerator # 2 a gallon storage bag of chopped lettuce unlabeled and undated.-refrigerator # 2 a gallon storage bag of shredded carrots with an open date of 5/1 and a use by date of 5/10.-refrigerator # 3 a buffet pan of pudding with a preparation date of 5/14/26 and a use by date of 5/17/26. During an interview on 5/21/26 at 11:36 am with DM she stated it was her expectation that all food items were labeled and dated correctly. DM stated if food items were removed from their original container that everything needed to be dated with the receipt date, open/preparation date, and discard date. DM stated items are kept for 3 days once prepared before being discarded. DM stated if an item is a canned or prepackaged product then those items can be kept for 7 days once opened before being discarded. DM stated the open date or the preparation date count as day 1 in the timeframe.DM stated it is ultimately her responsibility to ensure all food items are labeled and dated correctly but that it is a group effort by entire kitchen staff to label and date food items. DM stated the kitchen staff all have their food handlers license and have received training consisting of in-services, computer based training modules, and on the job training. DM stated it was her expectation that if a mess is made then it is cleaned up by whoever made ethe mess. DM stated kitchen sanitation and cleanliness were a team effort by the staff. DM there are currently no cleaning lists that the staff follow, everyone is just expected to keep the kitchen clean and orderly. DM stated it could potentially negatively impact a resident if food items are not labeled and dated because it could make residents sick because of food borne illness. DM stated it could potentially negatively impact a resident if kitchen sanitation and cleanliness are not maintained because of foodborne illness potential with compromised immune systems. During an interview 5/21/26 at 11:48 am with DON she stated she was unsure what her expectation regarding food labeling and dating would be. DON referred to the DM or Admin regarding all questions relating to the kitchen and food items. DON stated she was unsure of any regulations or requirements regarding the kitchen or food items. During an interview on 5/21/26 at 11:54 am with Admin he stated it was his expectation that no food items are expired and that all food items are labeled and dated. Admin said it is the responsibility of the cook to label and date all food items and the responsibility of the DM to supervise daily to ensure this occurs. Admin stated all items are dated upon receipt, again upon preparation or opening with the open/preparation date and the discard date. Admin stated all the kitchen staff are trained to have their food handlers and receive in-services performed by the corporate office. Admin stated it is his expectation that the kitchen is maintained in a clean manner. Admin stated all dietary staff are responsible for keeping the kitchen clean and this is supervised by the DM. Admin stated he was unsure if there are currently cleaning logs being utilized in the kitchen. Admin stated he expected trash receptacles to always be covered. Admin stated it could potentially negatively impact a resident if food items are not labeled and dated because of potentially consuming spoiled food. Admin stated it could potentially impact a resident if the kitchen sanitation and cleanliness were not maintained because of the risk of spreading food borne illness. During an interview on 5/21/26 at 1:07 pm with DA she stated it is mandatory to label and date all food items, so the staff know what the item is and when it was prepared. DA stated the rule is fresh items can be kept 3 days once prepared and canned or prepackaged items can be kept 7 days once they are opened. DA stated it is the responsibility of the CK and DA to label and date the food items. DA stated she was unsure of the policy/procedure regarding food labeling and dating. DA stated she received hands on training from the morning DA, and the previous DM. DA stated it was the responsibility of the DAs and CK to keep the kitchen clean and maintain sanitation practices. DA stated it could negatively impact a resident if food items are not labeled and dated and the kitchen is not clean because it could make a resident sick if the food is old and because of bacteria. During an interview on 5/21/26 at 1:15 pm with CK she stated that the expectation regarding food labeling and dating was that it was completed every day correctly and that it was the responsibility of the CK and DA. CK stated prepared items can be kept for 3 days and pre-packaged items can be kept for 7 days. CK stated the expectation for kitchen cleanliness and sanitation is that the staff are expected to keep up with cleaning tasks daily, weekly, and monthly. CK stated cleaning schedules are followed. CK stated it is the responsibility of CK and DA to maintain kitchen sanitation and cleanliness. CK stated all trash receptacles are to be covered. CK stated it can negatively impact a resident if food items are not labeled and dated and the kitchen sanitation is not maintained because of bacteria growth making residents sick. Record review of Food Preparation and Handling policy dated 10/1/2018 and revised on 6/1/2019 reflected under heading policy:To ensure that all food served by the facility is of good quality and safe for consumption, all food will be prepared and handled according to the state and US Food Codes and HACCP guidelines.Under heading procedure:General GuidelinesUse clean, sanitized surfaces, equipment and utensils. Wash hands properly before beginning food preparation.Prepare food with the least manual contact possible. Do not allow bare hands to touch raw food directly. Do not let surfaces, equipment or utensils that have been in contact with raw meat to come into contact with other food unless the items have been cleaned and sanitized first. Do not bring soiled food carts, food equipment or garbage containers through the food preparation area. Record review of Food Storage policy undated reflected under heading policy:To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes and HACCP guidelines. Under heading procedure:Dry storage rooms- To ensure freshness, store open and bulk items in tightly covered containers. All containers must be labeled and dated.Where possible, leave items in the original cartons placed with the date visible. Use the first-in, first-out (FIFO) rotation method. Date packages and place new items behind existing supplies, so that the older items are used first. Refrigerators- Date, label and tightly seal all refrigerated foods using clean, non-absorbent, covered containers that are approved for food storage.Use all leftovers within 72 hours. Discard items that are over 72 hours old.

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs for 1 resident (Resident #20) of 6 residents reviewed for care plans. The facility failed to ensure Resident #20 received her divided plate and small 4 oz. cups with a straw at mealtimes and was included in her care plan. These failures could affect residents and put them at risk of not receiving care and services to meet their needs.Record review of Resident #20's face sheet dated 05/20/2026, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: Cerebral palsy (a condition caused from damage or abnormal development to a part of the brain which is responsible for muscle movement and leads to movement disorders and may result in developmental delays and sensory impairments), unspecified severe protein-calorie malnutrition (condition where the body is not getting enough protein and calories leading to weight loss, weakness, and poor overall health), and paranoid Schizoaffective disorder (a chronic mental illness that combines symptoms of both schizophrenia and a mood disorder, such as depression or mania). An observation of Resident #20's lunch on 5/20.2026 at 12:52 PM revealed a standard dinner plate with no divisions and cups with no straw. Observation of meal card for Resident #20 stated under adaptive equipment: Divided plate, lid for hot beverage, straw.Record review of Resident #20's MDS dated [DATE] revealed a BIMS score of 03, indicating severe cognitive impairment. Resident #20 required Partial/Moderate assistance for eating.Record review of Resident # 20's doctor order dated 04/14/2026 and revised 05/18/2026 stated divided plate and small 4 oz. cups with straw.Record review of Resident #20's OT clarification dated 04/17/2026 stated Recommend divided plate for all meals to promote loading utensils, and use of small cups with straws for cold liquids to promote ease of accessing liquids in order to promote independence with self- feeding tasks.Record review of Resident #20's comprehensive care plan dated 05/20/26, revealed it did not address the resident requiring a divided plate or small 4 oz. cups with a straw at mealtime.During an interview on 05/21/2026 at 8:10 AM with the Occupational Therapist, he stated Resident #20 uses a divided plate to make it easier for resident to self-feed and to scoop the food onto her spoon. He said the small cups make it easier for her to hold and drink from independently. He said without the divided plates or small cups it makes it more difficult for the resident to be independent with self-feeding tasks.During an interview on 05/21/2026 at 9:15 AM the Dietary manager said when she receives a written doctor order from the DON and puts it into Point Click Care as a standing order that way it is printed on the meal ticket. She said staff read the meal ticket to know what adaptive equipment a resident needs.During an interview on 05/21/2026 at 9:45 AM, the MDS nurse stated the divided plate did not need to be on the care plan because it is on the Residents Meal Card. MDS nurse said all the adaptive equipment needs are put on the meal card.During an interview on 05/21/2026 at 10:00 AM, the DON said when there is an order from the doctor for a divided plate it should be added to the care plan. She said the information in the care plan helps staff to know how to care for the residents.During an interview on 05/21/2026, at 10:15 AM, the Administrator said during morning meetings new orders are discussed and that is how the staff becomes aware. The Administrator said if there is a doctor's order and an OT clarification order for adaptive equipment, that should be added to the care plan. Record review of the facility's policy Care Plan Development, Review, and Update Policy dated 02/2017 and revised 02/2026 reveal: To ensure that each resident receives an individualized, person-centered care plan that reflects their assessed needs, goals, preferences, risks, and strengths, and that the care plan is developed, implemented and updated in accordance with federal regulations and RAI Manual guidance.

Based on observation, interview, and record review the facility failed to ensure a resident who needed respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents goals and preferences for 1 of 1 resident (Resident #7) reviewed for tracheostomy care. The facility failed to ensure ADNS LVN used aseptic technique (a procedure that healthcare providers use to prevent the spread of germs that cause infection) during tracheostomy care and tracheostomy suctioning for Resident #7 by not performing hand hygiene, placing barriers, performing proper suction depth procedures or using sterile equipment during care on 05/20/2026. This failure could place residents at risk for respiratory infections and respiratory distress.Findings included: Review of Resident #7's face sheet dated 05/21/2026 reflected a [AGE] year old female admitted to the facility on [DATE] with the following diagnoses: cerebral infarction (the pathologic process that results in an area of necrotic tissue in the brain. It is caused by disrupted blood supply (ischemia) and restricted oxygen supply (hypoxia).), diabetes mellitus (A condition results from insufficient production of insulin, causing high blood sugar.), tracheostomy status (hole that surgeons make through the front of the neck and into the windpipe (trachea)), and cardiac arrest (stopping of the heart muscle). Review of Resident #7's quarterly MDS dated [DATE] reflected she was assessed to not have a BIMS conducted indicating she had severe cognitive impairment. Resident #7 was assessed to be on oxygen and to have a tracheostomy with tracheostomy care and suctioning performed to resident daily. Review of Resident #7's comprehensive care plan reflected a focus area dated 05/18/2026 I am at risk for experiencing shortness of breath. History of respiratory failure with hypoxia requiring trach placement. Interventions included Administer my respiratory treatments / nebulizers as ordered by my doctor; Alert my nurse for concentrator alarms and/or if my oxygen tank needs to be changed; Avoid lying flat. My position should facilitate adequate breathing; upright or slightly elevated HOB. Further review reflected a focus area dated 03/12/2026 reflected Tracheostomy related to Impaired breathing mechanics, Respiratory Failure. Interventions included .Provide trach care as ordered / indicated; Provide treatments and suctioning as ordered/recommended by my physician. Review of Resident #7's physician orders reflected orders dated 03/16/2026 to change Resident #7's disposable inner cannula twice daily; suction trach every shift and tracheostomy care with tracheostomy care kit daily and as needed. Observation on 05/20/2206 at 2:35 PM ADNS LVN and RN A had on PPE when surveyor entered the room. Without hand hygiene being conducted, the ADNS LVN was observed to touch the over bed table and nightstand and multiple other surfaces in the room to collect supplies. She then got the sterile suction kit, placed it on the overbed table that had a barrier of wax paper (not sterile); and without hand hygiene she donned the sterile gloves contaminating the gloves in the process by touching the sterile outside of the gloves with her contaminated hands. The ADNS LVN placed the sterile suction supplies on the non-sterile barrier (not using the sterile drape that comes in the trach suction kit). The ADNS LVN then grabbed the non-sterile suction tubing at the bedside with both hands and contaminated both hands (the dominant hand is to remain sterile to use the sterile suction catheter) performed suctioning by inserting the suction Cath into the trach. She did not insert the suction tubing past 1.5 to 2 cm (with the average trach length being 5 to 6 cm) the suctioning did not clear Resident #7's mucus after multiple attempts. The ADNS LVN contaminated the sterile tubing and sterile gloves multiple times during the procedure. In an interview on 05/20/2026 at 3:50 PM the ADNS LVN stated she had used hand sanitizer when she entered the room but did not perform hand hygiene prior to donning the sterile gloves. The ADNS LVN stated she placed the sterile supplies on the wax paper barrier and did not use the sterile drape. The ADNS LVN stated she did touch dirty surfaces in the room prior to donning the sterile gloves and did not perform hand hygiene and she should have. The ADNS LVN stated she grabbed the suction tubing with both hands, and she was supposed to keep one hand sterile. She further stated she did contaminate her gloves during the procedure. The ADNS LVN stated she felt like she went far enough in the trach while performing suctioning on Resident #7. In an interview on 05/21/2026 at 10:58 AM with DON stated she expected staff to maintain sterile field while preforming trach care and suctioning. She stated while suctioning, the staff should insert the suction tubing until they feel resistance then pull back and suction to ensure the airway is clear. The DON stated she would do more training for staff. Review of the facility provided policy Providing tracheostomy care Checklist (not dated) reflected Performed hand hygiene and ensured the patient's privacy. Connected the connecting tubing securely to the suction machine. Activated the suction device and adjusted the vacuum regulator to maintain a pressure setting below 150 mm Hg. Verified the suction apparatus by briefly blocking the end of the suction tubing before attaching it to the suction catheter. Prepared the single-use suction catheter:1. Using sterile technique, opened the sterile catheter package on a clean surface and utilized the inside of the wrapping as a sterile field. Opened the package partially to expose the connecting end and connected the catheter to the suction tubing.2. Placed the sterile drape on the bedside table, ensuring the suction catheter did not contact nonsterile surfaces.3. Unwrapped or opened the sterile basin on the bedside table, being careful to avoid touching the inside of the basin. Filled the basin with sterile 0.9% sodium chloride solution or sterile water. Connected the suction catheter to the connecting tubing: Carefully picked up the suction catheter with the dominant hand, ensuring no contact with nonsterile surfaces. Wrapped the suction catheter around the sterile dominant hand to prevent inadvertent contamination. With the nondominant hand, picked up the connecting tubing and connected it to the suction catheter.Ensured that the dominant hand remained sterile and did not touch the connecting tubing. With the dominant hand, gently and swiftly inserted the catheter into the tracheostomy tube while keeping the control vent of the suctioncatheter open. 1. For patients at high risk of suction-related complications, advanced the catheter into the tracheostomy tube until it emerged from the end of the airway.

Based on observations, interviews, and record reviews the facility failed to provide special eating equipment and cups with straws for resident who need them for 1 of 6 (Residents #20) residents reviewed for special eating equipment. The facility failed to provide Resident #20's physician ordered divided plate and 4 oz cup with straw with lid for drinking on 05/20/2026. This failure could place residents at risk for harm by weight loss, diminished independence, and self-esteem.Record review of Resident #20's face sheet dated 05/20/2026, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: Cerebral palsy (a condition caused from damage or abnormal development to a part of the brain which is responsible for muscle movement and leads to movement disorders and may result in developmental delays and sensory impairments), unspecified severe protein-calorie malnutrition (condition where the body is not getting enough protein and calories leading to weight loss, weakness, and poor overall health), and paranoid Schizoaffective disorder (a chronic mental illness that combines symptoms of both schizophrenia and a mood disorder, such as depression or mania).An observation of Resident #20's lunch on 5/20.2026 at 12:52 PM revealed a standard dinner plate with no divisions and cups with no straw. Observation of meal card for Resident #20 stated under adaptive equipment: Divided plate, lid for hot beverage, straw.Record review of Resident #20's MDS dated [DATE] revealed a BIMS score of 03, indicating severe cognitive impairment. Resident #20 required Partial/Moderate assistance for eating.Record review of Resident # 20's doctor order dated 04/14/2026 and revised 05/18/2026 stated divided plate and small 4 oz. cups with straw.Record review of Resident #20's OT clarification dated 04/17/2026 stated Recommend divided plate for all meals to promote loading utensils, and use of small cups with straws for cold liquids to promote ease of accessing liquids in order to promote independence with self- feeding tasks.Record review of Resident #20's comprehensive care plan dated 05/20/26, revealed it did not address the resident requiring a divided plate or small 4 oz. cups with a straw at mealtime.During an interview on 05/21/2026 at 8:10 AM with the Occupational Therapist, he stated Resident #20 uses a divided plate to make it easier for resident to self-feed and to scoop the food onto her spoon. He said the small cups make it easier for her to hold and drink from independently. He said without the divided plates or small cups it makes it more difficult for the resident to be independent with self-feeding tasks.During an interview on 05/21/2026 at 9:15 AM the Dietary manager said when she receives a written doctor order from the DON and puts it into Point Click Care as a standing order that way it is printed on the meal ticket. She said staff read the meal ticket to know what adaptive equipment a resident needs.During an interview on 05/21/2026 at 10:00 AM, the DON said when there is an order from the doctor for a divided plate it should be added to the care plan and followed. She said the information in the care plan helps staff to know how to care for the residents.

Based on interview and record review, the facility failed to immediately consult with the resident's physician when there was a significant change in the resident's health status (that is, a deterioration in health status in either life-threatening conditions or clinical complications), and need to alter treatment significantly for one (Resident #1) of six residents reviewed for notification of changes. The facility failed to notify the wound care provider when Resident #1's sacral region continued to develop new areas of MASD from 07/08/2025 to 08/22/2025. This failure could result in decreased continuity of care, and a delay in the treatment and services needed. Findings included: Review of Resident #1's face sheet dated 09/30/2025 reflected a [AGE] year-old female with an admission date of 05/12/2025 and discharge date of 09/26/2025 with diagnoses of cerebral infarction (condition where blood flow to the brain is interrupted leading to brain tissue damage), hypertensive heath and chronic kidney disease with heath failure and with stage 5 chronic kidney disease or end stage renal disease (complex condition where high blood pressure has caused heart failure and severe kidney disease), muscle weakness, dysphagia (difficulty swallowing), acute respiratory failure (life-threatening condition where the lungs cannot exchange oxygen and carbon dioxide), end stage renal disease (severe condition where the kidneys have permanently lost their ability to function properly), and type 2 diabetes mellitus (disorder in which the body is unable to use insulin effectively or produce enough insulin to manage high blood sugar levels). Review of Resident #1's admission MDS dated [DATE] reflected a BIMS of 12 (moderate cognitive impairment). Further review reflected Resident #1 was at risk of developing pressure ulcers/injuries and had moisture associated skin damage (a condition that occurs when the skin is exposed to excessive moisture for prolonged periods leading to inflammation and damage) and no wounds upon admission. Treatments included pressure reducing device for chair, pressure reducing device for bed and applications of ointments/medications. Review reflected Resident #1 required dialysis. Review of Resident #1's care plan dated 05/12/2025 reflected Resident #1 was at risk of skin concerns with a goal that resident's condition will be stable and will not experience a health decline and will tolerate medication/treatment and progress towards goals established. Interventions included administer and provide medication/treatment/care services as prescribed/recommended and to notify PCP of any change in condition as clinically indicated. Further review of care plan with revision date of 05/19/2025 reflected Resident #1 had a self-care deficit with interventions to turn and reposition on rounds and as needed. Review of care plan with revision date of 09/30/2025 reflected Resident #1 was at risk of skin impairment or had an actual skin impairment and that Resident #1 declined to be turned or repositioned at times and will turn back onto the position she was previously in. Goal for Resident #1 included that she would have intact skin, free of redness, blisters or discoloration with interventions of pressure reducing wheelchair cushion, to keep clean and dry and apply skin barrier cream as indicated, pressure reducing low air loss mattress and to turn and reposition during rounds and more often as needed. Further interventions included handling fragile skin with caution and report to nurse if any concerns arise. Review of Resident #1's care plan dated 05/12/2025 reflected she had end stage renal disease and required dialysis treatments. Review of Resident #1's care plan with revision date of 05/19/2025 reflected Resident #1 had incontinence related to previous cerebral infarction, ESRD with dialysis and diabetes with goal to remain free from any skin breakdown due to incontinence and brief use. Interventions included to check and change on rounds as needed and provided incontinent care assistance every shift and as needed. Review of Resident #1 physician orders reflected Ascorbic acid tablet with start date of 05/19/2025 to promote wound healing. Review of Resident #1 physician orders reflected an order for Zinc Sulfate for wound healing with a start date of 05/19/2025.Review of Resident #1 physician orders reflected an order to cleanse buttock with soap and water, pat dry and apply zinc paste to buttock daily and as needed with incontinent episodes to prevent skin breakdown with start day of 06/18/2025. Review of Resident #1 physician orders reflected an order for medihoney wound and burn dressed external paste and to apply to coccyx topically once a day every three days for found healing with a start date of 07/11/2025.Review of Resident #1 physician orders reflected cleanse buttock with normal saline, pat dry and apply triad paste daily with each incontinent episode one time a day for MASD with a start date of 08/29/2025. Review of Resident #1 undated Kardex (quick reference for resident information) reflected to turn and reposition resident regularly during rounds and more often as needed. Review reflected to handle fragile skin with caution and report to nurse of any skin concerns. Review also reflected Resident #1 as a skin injury risk and report to MD/NP as indicated to ensure appropriate treatment is in place. Review of Resident #1 skin assessment dated [DATE] reflected Resident #1 had MASD on left gluteus upon admission area to residents buttock is revolved with no opening noted all bright new pink tissue no drainage or bleeding noted. Resident continues to complain of discomfort from sitting for long periods of time at dialysis resident encouraged to offload while in bed as to prevent issue from reoccurring. Review reflected selection was made that practitioner was notified and it was the wound care nurse practitioner. Review of skin assessment dated [DATE] reflected Resident #1 had MASD on her coccyx and had new open area to coccyx related to excessive moisture. Review reflected wound care NP was notified, name of wound care NP was not documented. Review of picture of coccyx reflected a small area that was red around the edge and lighter pink / white in center. Area above reflected a lighter pink area. Review of skin assessment dated [DATE] reflected Resident #1 had MASD on her coccyx related to excessive moisture. Review reflected wound care NP was notified. Review of picture of coccyx reflected there were additional areas with red around the edge with lighter pink / white. Review of skin assessment dated [DATE] reflected Resident #1 had MASD on her coccyx related to excessive moisture. Review reflected wound care NP was notified. Review of picture of coccyx reflected additional white lighter pink areas on gluteus. Review of skin assessment dated [DATE] reflected Resident #1 had MASD on her coccyx with note that area to resident's buttock showed improvement with measurements smaller in size. Review reflected wound care NP was notified. Review of picture reflected 2 areas light [NAME] pink. Review of skin assessment dated [DATE] reflected Resident #1 had MASD and condition to this resident area appears stalled resident often noted lying flat in bed. Review reflected that resident was reeducated on importance of off loading and turning side to side to alleviate pressure to this area. Resident voiced understanding but does refuse care. Review reflected wound care NP was notified. Review of picture reflected several areas with a slight larger area that appeared red with light yellow in the middle with another small area that appeared scabbed. Review of progress reflected it was stalled. Review of skin assessment dated [DATE] reflected Resident #1 had MASD on her coccyx and progress appeared stalled with note that Resident would be seen by wound care NP this week before leaving to dialysis if possible. Review reflected wound care NP was notified. Review of picture reflected increased area with darker red areas on gluteus. Review reflected Resident #1 was reeducated on turning and repositioning while in bed and offered pillows and a wedges as well, but often refused wedge. Review reflected Resident sits for long periods during dialysis 3 times a week and a foam cushion was provided for her wheelchair. Review of skin assessment dated [DATE] reflected Resident #1 had MASD to her coccyx and was seen by wound care NP and educated on turning and repositioning. Review of the picture reflected larger area to resident's coccyx with varying shades of yellow, red and light pink. Review of skin assessment dated [DATE] reflected Resident #1 MASD to resident's coccyx and that resident's area to sacrum was assessed and treatment was revised to area to promote more effective healing. Healing progress reflected it was stalled. Resident #1 had new cushion added to her chair when at dialysis to aide in this healing. Review of picture reflected larger area of redden skin that appeared with some yellow in the center. Review of skin assessment dated [DATE] reflected Resident #1 had MASD to her coccyx. Progress appeared as deteriorating and review reflected wound care NP revised treatment schedule to promote healing. Review of skin assessment dated [DATE] reflected Resident #1 had a pressure wound that was unstageable to her coccyx. Review reflected progress of wound was deteriorating and wound care NP provided treatment and revised treatment orders. Review of picture reflected larger pink area with raised edges and spots of red, light pink and white in center. Review also reflected a hole on coccyx area. Review of wound care note dated 08-28-2025 reflected Resident #1 was seen as a consultation for evaluation of wounds. Resident #1 was seen for initial wound care visit and evaluation of MASD to her sacrum. No signs of symptoms of infection noted. Review of former NP note dated 08/23/2025 reflected skin was warm and dry, area on buttocks being treated with cream, no rashes, lesions, or unusual pigmentation, skin turgor normal'. Review of former NP note dated 08/19/2025 reflected skin was warm and dry, area on buttocks being treated with cream, no rashes, no itching, no skin discoloration, no bruising, no lesions and area on buttocks being treated with cream. Review of former NP note dated 08/12/2025 reflected skin was warm and dry, area on buttocks being treated with cream, no rashes, no itching, no skin discoloration, no bruising, no lesions. Review of former NP note dated 08/04/2025 reflected skin was warm and dry, area on buttocks being treated with cream, no rashes, no itching, no skin discoloration, no bruising, no lesions. Review of former NP note dated 07/22/2025 reflected area on buttocks being treated with cream, no rashes, no itching, no skin discoloration, no bruising, no lesions. Review of former NP note date 07/14/2025 reflected area on buttocks being treated with cream, no rashes, no itching, no skin discoloration, no bruising, no lesions. Review of former NP note dated 07/04/2025 reflected skin was warm and dry, area on buttocks being treated with cream, not yet an open decubitus, no rashes, lesions or unusual pigmentation, skin turgor normal. Review of former NP note dated 06/30/2025 reflected skin was warm and dry, area on buttocks being treated with cream, not yet an open decubitus, no rashes, lesions or unusual pigmentation, skin turgor normal. Review of NP note dated 06/27/2025 reflected skin was warm and dry, area on buttocks being treated with cream, not yet an open decubitus, no rashes, lesions, or unusual pigmentation, skin turgor normal and to monitor area on buttocks for progression. Review of former NP note dated 06/23/2025 reflected skin was warm and dry, area on buttocks being treated with cream, not yet an open decubitus, no rashes, lesions, or unusual pigmentation, skin turgor normal. Review of former NP note date 06/20/2025 reflected skin was warm and dry, area on buttocks being treated with cream, not yet an open decubitus, no rashes, lesions, or unusual pigmentation, skin turgor normal and to monitor area on buttocks for progression. Review of former NP note dated 06/17/2025 reflected skin was warm and dry, area on buttocks being treated with cream, not yet an open decubitus, no rashes, lesions, or unusual pigmentation, skin turgor normal and to monitor area on buttocks for progression. Review of former NP note dated 06/14/2025 reflected skin was warm and dry, area on buttocks being treated with cream, not yet an open decubitus, no rashes, lesions, or unusual pigmentation, skin turgor normal and to monitor area on buttocks for progression. Review of form NP note dated 06/09/2025 reflected skin warm and dry, area on buttocks being treated with cream, not yet an open decubitus, no rashes, lesions, or unusual pigmentation, skin turgor normal. Review of former NP note dated 06/02/2025 reflected skin warm and dry, area on buttocks being treated with cream, not yet an open decubitus, no rashes, lesions, or unusual pigmentation, skin turgor normal. Review of former NP note dated 05/30/2025 reflected skin warm and dry, area on buttocks being treated with cream, not yet an open decubitus, no rashes, lesions, or unusual pigmentation, skin turgor normal. Review of former NP note dated 05/27/2025 reflected skin was warm and dry, no rashes, lesions, or unusual pigmentation, skin turgor normal. Review of former NP note dated 05/26/2025 reflected skin was warm and dry no rashes lesions, or unusual pigmentation, skin turgor normal. Review of above for NP notes reflected no notification to former NP was made that MASD to Resident #1's buttocks was reported to former NP that new areas were developing or not healing and no changes in treatment from 05/26/2025 to 08/28/2025. During an interview on 09/30/2025 at 10:08 AM, FM stated that Resident #1 had not been seen by a wound care doctor at the facility and had a nurse that provided wound care. FM stated Resident #1 had a small wound to her bottom when she admitted and felt it got worse. During an interview on 09/30/2025 at 9:17 AM LVN A stated that changes in skin are reported to her by CNAs or the charge nurse who conducts the weekly skin assessment. LVN A stated if changes are noted staff notified her and she will gather measurements and assess and then will send to the wound care NP for orders. LVN A stated after those changes are found, the wound care NP would start weekly visits, but she was able to send pictures to the wound care NP for treatment sooner than the next weekly wound visit. LVN A stated that any break in the skin is considered a wound and if there is an open area to a resident's coccyx the wound care NP started following that resident immediately. LVN A stated that Resident #1 had an open area when she admitted and LVN A stated she took pictures and started a treatment plan with the wound care NP. LVN A stated a few months later the area started to break down again and the wound care NP came back on board and resumed previous treatment. LVN A stated that the area started to gradually get worse and wound care NP would revise treatment and then one area would get better and another area would start to breakdown. LVN A stated she was unsure why the initial wound visit note from the wound care NP was dated for 08/28/2025. During an interview on 09/30/2025 at 12:59 PM, wound care NP stated that he visited the facility at least once a week. He stated that anything pressure related or full thickness (extending beyond first two layers of skin) he should be involved from the beginning. Wound care NP stated when he first saw Resident #1's coccyx it had already advanced to full thickness. Wound care NP stated with MASD there was not full thickness, but for Resident #1 there were some elements of pressure involved and it was just past full thickness and had already progressed to a point past what he wanted it to. Wound care NP stated that he attempted to see Resident #1 the week before 08/28/2025 (on 08/22/2025), but Resident #1 had left to dialysis already. NP stated that prior to 08/22/2025 he did not communicate with the facility regarding Resident #1. Wound care NP stated when the wound goes from one open or broken down areas to more open or broken down areas he expected to be involved. Wound care NP stated he was not involved with Resident #1 prior to 08/22/2025. Wound care NP stated he felt that Resident #1's dialysis (sitting for prolonged hours without being changed) contributed to the deterioration of the MASD. Wound care NP stated initially it was documented as MASD and had to advanced to full thickness tissue erosion. Wound care NP stated he saw no signs or symptoms of infection. During an interview on 10/01/2025 at 1:28 PM, CNA B stated changes in skin were documented and reported to the nurse. CNA B stated if it was a resident's shower day then it was documented on a shower sheet and reported verbally. CNA B stated any changes in skin were reported to the charge and wound nurse. CNA B stated she would report any scratches, tears, bruises or sores. During an interview on 10/01/2025 at 1:47 PM, RN C stated that charge nurses completed skin checks weekly and if there was something new the ADON or DON would be notified. RN C stated she was not sure who was responsible to get the wound care NP involved and believed it was LVN A. During an interview on 10/01/2025 at 2:48 PM, RN D stated that nurses completed weekly skin assessments and if the resident had any wounds the wound care nurse would do the weekly skin assessment. RN D stated any changes to the skin would be reported to the wound care nurse. RN D stated LVN A notifies the wound care NP. RN D stated that anytime there is a new breakdown area on the skin the wound care NP had to be involved. She stated anything more than a skin tear that could not be treated easily. During an interview on 10/01/2025 at 3:03 PM, the DON stated that weekly skin assessments were completed between the charge nurse and treatment nurse. The DON stated if there was a wound the skin assessment would fall on the treatment nurse. The DON stated that the wound care NP would be consulted depending on the extent of the wound and if the area was more serious or chronic or having a hard time healing then the wound care NP would definitely be consulted. The DON stated if areas were not healing then she expected the wound care NP to get involved. The DON stated Resident #1 sat on her bottom for 6 hours when she was at dialysis and was not repositioning when she was at dialysis. The DON stated that she expected the wound care nurse to involve the wound care NP if there are a few weeks of continued breakdown. The DON stated if anything worsened then LVN A would let the DON know. The DON stated that Resident #1 was discussed all the time and this included getting the wound care NP involved, but was unsure when that was. The DON stated that was probably when it started to get worse and breakdown continuously. The DON stated she thought that the wound care NP was involved with Resident #1 prior to 08/28/2025. During an interview on 10/01/2025 at 3:53 PM, with the previous NP for Resident #1, he stated that staff did not inform him of any MASD for Resident #1. NP stated that he expected to be informed of MASD and areas that were new. NP stated that Resident #1 was prone to skin breakdown because she was sitting in her chair for long periods in dialysis and that put her at a higher risk of breakdown. NP stated that he expected to be involved with any changes or any new areas and expected staff to have had the wound care NP involved. During a subsequent interview on 10/01/2025 at 4:29 PM, the DON stated that Resident #1 first saw wound care NP on 08/28/2025 and missed seeing her in 08/22/2025 because she was at dialysis. The DON stated that around 08/28/2025 the area started to get worse and that being on dialysis residents do not have great skin integrity. The DON stated that it was still superficial until the wound care NP was involved. The DON stated that residents with darker skin have healed skin that is the color pink which is why there are pink areas on Resident #1's coccyx. During an attempted interview on 10/17/2025 at 10:14 AM, Resident #1 was unable to recall when she got her wound and stated staff come in and check on her and reposition her every two hours. During an interview on 10/17/2025 at 10:40 AM, the ADM stated that the treatment nurse and charge nurses were responsible to conduct weekly skin assessments. The ADM stated if there was a change in skin such as breakdown or redness he expected the charge nurse to be notified and if necessary the charge nurse should notify LVN A. The ADM stated then LVN A should notify the IDT so interventions can be put in place whether that be barrier cream or getting the wound care NP involved. The ADM stated that the wound care nurse should be involved when there was significant breakdown or treatments are not effective. The ADM stated that if the area is initially MASD and it continues to progress and look like it was going to be stageable or unstageable wound (which could happen quickly) then the facility could get the wound care NP involved. The ADM stated if breakdown continued or got larger he expected the wound care NP to be involved, especially if what the facility was doing for treatment was ineffective. The ADM stated if the wound looks the same for a bit, but if progressing and looking to potentially form a wound then the wound care NP should be involved. The ADM stated that he was unsure when Resident #1 first saw the wound care NP. Review of facility policy titled Skin and Wound Prevention and Management with revision date of January 2023 reflected the licensed nurse should communicate all newly identified wounds or skin concerns as well as the status of current wound of skin concerns to the attending medical provider. Review of facility policy titled Changes In Resident Condition with revision date of January 2023 reflected assigned medical provider should be notified when there is a need to alter treatment significantly.

Based on observation, interview and record review, the facility failed to ensure all assistive devices were maintained and free of hazards for four (Residents #13, #21, 48 and #221) of fifteen residents reviewed for essential equipment. The facility failed to properly maintain wheelchairs for Residents #13, #21, #48 and #221. These failures could place residents at risk for equipment that is in unsafe operating condition, which could cause injury. Findings included: Review of Resident #13's annual MDS assessment, dated 12/04/2024, reflected she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Cerebral Infarction (stroke), generalized weakness, and hemiplegia/hemiparesis (loss of use arms and legs). Resident #13 had a BIMs score of 00 indicating she was severely cognitively impaired and unable to make decisions for herself. Section GG of the MDS reflected wheelchair mobility for locomotion. Review of the Resident #13's plan of care dated 12/04/2024 with updates reflected goals and approaches to include wheelchair mobility for locomotion. Observation on 03/18/2025 at 9:35 a.m. revealed Resident #13 was lying in the bed sleeping with no noted skin problems. The wheelchair's right armrests were cracked with exposed foam. Review of Resident #21's quarterly MDS assessment, dated 02/06/2025, reflected she was an [AGE] year-old female admitted to the facility on [DATE], with diagnoses of cerebrovascular disease (heart dieses), abnormalities of gait and mobility (cannot walk safely), and muscles weakness. Resident #21 had a BIMs score of 12 reflecting she was moderately cognitively impaired and able to make decisions for herself. Section GG of the MDS reflected wheelchair mobility for locomotion. Review of the Resident #21's plan of care dated 02/06/2025 with updates reflected goals and approaches to include wheelchair mobility for locomotion. Observation on 03/18/2025 at 9:45 a.m. revealed Resident #21 was sitting in her wheelchair in the common area and had no skin problems. The wheelchair's left and right armrests were cracked with foam exposed. In an attempt to interview on 03/18/2025 at 11:45 a.m. Resident #21 revealed she was not interested in talking about her wheelchair. Review of Resident #48's quarterly MDS assessment, dated 02/12/2025, reflected he was a [AGE] year-old male admitted to the facility on [DATE], with diagnoses of muscle weakness, Cerebral infarction (stroke), ataxic gait (shuffling walk), and hypertension (high blood pressure). Resident #48 had a BIMs score of 8 reflecting he was moderately cognitively impaired and able to make decisions for herself. Section GG of the MDS reflected wheelchair mobility for locomotion. Review of Resident #48's plan of care dated 02/20/2025 with updates reflected goals and approaches to include wheelchair mobility. Observation and interview on 03/18/2025 at 12:00 p.m. revealed Resident #48 sitting in his wheelchair in the dining room. Resident #48 revealed the wheelchair's left and right armrests were cracked with foam exposed. Resident #48 was asked about his wheelchair, and he stated, It was needing some work, and the wheelchair had been provided to him by the facility. Resident #48 stated he had told the charge nurse but could not recall when or which nurse. There were no skin tears on the arms. Review of Resident #221's other MDS assessment, dated 02/10/2025, reflected she was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses of chronic congestive heart failure (heart does not pump correctly), respiratory failure (lungs weak), and muscle weakness. Resident #221 had a BIMs score of 15 reflecting she was cognitively alert and oriented and able to make decisions for himself. Section GG of the MDS reflected wheelchair mobility for locomotion. Review of the Resident #221's updated plan of care dated 02/20/2025 with updates reflected goals and approaches to include wheelchair mobility. Observation and interview on 03/18/2025 at 11:45 a.m. revealed Resident #221 in her wheelchair in her room eating lunch. Resident #221 stated that her arm rests were rough on the right side. The wheelchair's right armrest cracked with exposed foam. Resident #221 stated she had not been hurt, just was uncomfortable. In an interview on 03/19/2025 with the DON at 2:43 p.m. revealed the wheelchairs were repaired by the maintenance supervisor. The DON stated all the departments head did a sweep about two months ago and then the armrest requiring repair were given to the maintenance supervisor, I do not know why the wheelchairs have not been repaired. In an interview on 03/19/2025 at 3:21 p.m. the Maintenance Supervisor stated that he was responsible for the repair of wheelchairs. He stated he finds most of his information through the staff telling him, or if he sees it himself. Sometimes the department heads complete angel rounds and give him a list of what they see during rounds. The Maintenance Supervisor stated he had not had any staff members tell him about any wheelchairs needing repair, recently. In an interview on 03/20/2025 at 9:00 a.m. with the Administrator revealed the wheelchair had all been looked at, all that required armrest had been replaced and he had ordered additional armrest. The Administrator stated the facility was going to be doing monthly rounds and keep additional supply on hand for any repairs. There was no policy provided by the facility by the time of exit, that had been requested from the Adminstrator.

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 (MA A) staff members and 2 of 4 residents (Residents #47, and #221) reviewed for infection control procedures. MA A failed to disinfect the blood pressure cuff in between blood pressure checks for Residents #47 and #221. This failure could place residents at risk for cross contamination and infections. Findings included: Record review of Resident #47's quarterly MDS assessment, dated 01/25/25, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #47 had diagnoses which included: Diabetes (high blood sugar), and hypertension (high blood pressure). Resident #47 was cognitive and able to make decisions and required assistance of one staff for activities of daily living. Record review of Resident #47's physician orders dated 03/20/24 reflected, carvidol (high blood pressure) 3.125mg give one tab by mouth two times a day and to obtain blood pressure one time a day on each shift. Record review of Resident #221's other payment MDS Assessment, dated 02/10/25, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #221 had diagnoses which included: diabetes (increased blood sugar), hypertension (increased blood pressure), and heart failure (weak heart). Resident #221 was cognitively able make all decisions for herself and required one staff for assistance with activities of daily living. Record review of Resident #221's physician orders dated 03/05/25 (open ended) reflected, Coreq (high blood pressure) 10 mg give one tab by mouth every day, Lisinopril (high blood pressure med) 2.5mg one tab by mouth every day. Obtain blood pressure one time a day on each shift. Observation on 03/18/25 at 9:43 a.m., revealed MA A performing morning medication pass, during which time she checked the blood pressure on Resident #221. MA A failed to sanitize the blood pressure cuff before or after using it on Resident #221. Observation on 03/18/25 at 10:01 a.m., revealed MA A performing morning medication pass, during which time she checked the blood pressure, on Resident #47, used the same blood pressure cuff used on Resident #221. MA A failed to sanitize the blood pressure cuff before or after using it on Resident #47. An interview on 03/18/25 at 10:25 a.m., MA A stated she did not think about cleaning the blood pressure cuff between usage, she had forgotten. MA A stated she used hand sanitizer between each usage when she took the blood pressure. MA A stated if the cuff was on the residents and then not cleaned it could spread germs to others. An interview with the DON, who was the infection control preventionist on 03/19/25 at 2:43 p.m., revealed the DON stated that all direct care staff must clean equipment, including blood pressure cuffs after having contact with each resident. The DON stated, the staff has available the disinfectant wipes that will kill all germs. The DON stated the staff would be in-serviced on infection control and she would perform teaching concerning infection control. If they do not clean the blood pressure cuffs appropriately, they could spread germs to themselves and the residents. Record review of an in-service log dated 02/10/25 revealed MA A, had received cleaning and properly storing equipment after each use. Record review of the Facility's Policy titled Infection Prevention and Control dated March 2019, reflected: Compliance Guidelines: The infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program. The elements of the infection prevention and control program consist of coordination/oversight, guidance/procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety. Staff Responsible: .e. staff will receive training in community's infection prevention and control program to include but not limited to preventative measures, standard precautions . and are expected to comply with all designated precautions 9. Prevention of infection . (6) educating staff and ensuring that they adhere to proper infection prevention and control practices when performing resident care activities as it pertains to his/her role responsibilities and situation Record review of the Facility's Policy titled Cleaning and Disinfecting Resident Care items and Equipment dated February 2018 reflected: Multi-patient use equipment should be cleaned and disinfected between patient use . 1. The following categories are used to distinguish the levels of sterilization/disinfection necessary for items used in resident care: . c. Non-critical items are those that come in contact with intact skin but not mucous membranes. Non-critical resident-care items include bedpans, blood pressure cuffs, crutches and computers . 2. Multi-patient use (reusable items) equipment to That is designated reusable should be used by more than one resident . should be cleaned and disinfected between resident use . 3. Approved cleaning/disinfecting/sanitizing products should be used

Based on interview and record review, the facility failed to electronically submit to CMS complete and accurate direct care staffing information for the third quarter (April 1, 2024, to June 30, 2024) reviewed for Administration. The facility failed to submit complete PBJ staffing information to CMS for April 1, 2024, to April 30, 2024. This failure could place all 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 Casper3 PBJ report revealed the facility had four areas triggered on the FY Quarter 3 (April1- June30) report. The areas were One Star Staffing Rating, Excessively low Weekend Staffing, No Rn hours, and Failed to have Licensed Nursing Coverage 24 hours/day. The report details no RN hours for every day in April 2024. It also details Failed to have Licensed Nursing Coverage 24 hours/day for every day in April 2024. Record review of an email sent from the Administrator on 03/18/25 at 11:37 AM revealed a file with programming code entries. Employee and employee ID were listed. Workday was entered and hours were entered. Record review of an email received from the Administrator on 03/18/25 at 5:15 PM, revealed the submission email to CMS dated 05/14/2024. It showed 1 file processed, 1 file accepted, 0 rejections,0 Files submitted without authority, O Messages. This page reported 97 records and 1311 Total Staffing Hour Records. The report confirmed Total Employee Link Records Not Submitted. A second attachment listed a CMS Payroll Based Journal- Upload Date File. This confirmed the submission was received and will be checked for Errors. It also provided additional details and instructions. The third attachment was a repeat of the coding sent at 11:37 AM. Record review of an email received from the Administrator on 03/19/2025 revealed a handwritten schedule for April 2024 was provided. This schedule confirmed the shifts were covered by both RN and LVN staff for the entire month of April 2024. In an interview with the Administrator on 03/18/25 at 8:46 AM. The PBJ report was discussed during the entrance conference. The administrator was unaware the report did not include RN and Nursing hours for the month of April 2024. He stated there were no problems The administrator was asked was there was anything that happened with staffing for the month of April. He stated the management company was in bankruptcy and they switched companies on May 1 2024. He stated that corporate office enters the PBJ information. He stated that he is not sure what information they can still access but he will provide me with whatever information they have. He agreed to have to DON pull the working schedule for April 2024. In an interview with the DON on 03/18/2025 at 8:57AM. She stated that she was working during the month of April and there would have been no days without a working RN. She stated that she was unaware of any issues and stated she would pull the working schedule. She stated she did not know if she could get the punch records but would let the surveyor know during the survey. In an Interview with the Administrator on 03/18/2025 at 2:35 PM. He stated that he is not sure if they can get the punches but he has corporate looking into it. He stated that they were able to get into some records and they should be coming shortly. He stated that he doesn't know what they can find but someone from ABRI may be able to get some documents. In an interview with the Administrator on 03/20/2025 at 1:30 PM. He stated that he thinks both companies submitted the data and it could have caused the problems in reporting the hours worked by Nursing staff. He stated that he understand the need for accurate reporting to CMS and stated it could affect the care Residents receive when hours are reported. He stated that this was the only month and the error is most likely related to the change from one company to the new company and does not expect any issues in the future.

Based on observation, record reviews and interviews, the facility failed to ensure a resident's environment remained free of accident hazards and received adequate supervision and assistance devices to prevent accidents for 1 of 13 residents (Resident #1) reviewed for transfers in that: CNA A failed to provide adequate supervision and transfer assistance for Resident #1 in the shower resulting in Resident #1 falling and having an open right ankle fracture with bleeding. Resident #1 had to be hospitalized and required surgical intervention. The facility failed to update the Kardex and POC to reflect current safe transfer status requirements for Resident #1 and 12 other residents. The facility failed to ensure CNAs were knowledgeable on how to locate the Kardex to determine if 1 or 2 staff were required to safely transfer/assist a resident. An IJ was identified on 06/21/24. The IJ Template was provided to the facility on [DATE] at 04:25 PM. While the IJ was removed on 06/23/2024, the facility remained out of compliance at a scope of isolated and a severity with no actual harm due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of harm and/or injury and contribute to avoidable accidents. Findings included: Review of Resident #1's face sheet dated 06/21/24 revealed a [AGE] year-old male who was admitted to the facility on [DATE] with a diagnosis of venous insufficiency-chronic-peripheral (a condition in which the flow of blood through the veins is blocked, causing blood to pool in the legs), other secondary parkinsonism (a condition that causes tremor, muscle movement issues, rigidity, and postural instability), Alzheimer's disease (a type of dementia that affects memory, thinking, and behavior), unspecified dementia (neurodegenerative disease characterized by a general decline in cognitive abilities that affect a person's ability to perform every day activities), repeated falls, ataxic gait (a type of walking disorder caused by damage to the cerebellum the part of the brain that controls coordination and balance- it is characterized by clumsy staggering movements with a wide base of support, difficulty walking in a straight line, poor balance, and errors in the direction, speed, and rhythm of the limbs), generalized muscle weakness (muscle weakness throughout the body resulting in an inability to perform a given task on the first attempt), and chronic venous hypertension-idiopathic (high blood pressure in the legs) with inflammation of right lower extremity. The face sheet reflected Resident #1 was discharged to the hospital 05/13/2024. Review of Resident #1's fall risk evaluation dated 02/23/24 revealed unable to independently come to a standing position. Exhibits loss of balance while standing. Decreased muscle coordination. Interventions noted: He needs a two-person assistance. Review of Resident #1's fall risk evaluation dated 03/20/24 revealed: Unable to independently come to a standing position. Exhibits loss of balance while standing. Requires hands-on assistance to move from place to place. Uses an assistive device. No interventions noted. Review of Resident #1's Admission MDS dated [DATE] revealed section GG: Functional abilities tub/shower transfer was marked for total dependence, helper does ALL the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity. The MDS assessment was missing information that would have identified if the resident was a 1 or 2 person assist; the level of care required to perform a safe transfer. Review of Resident #1's Discharge MDS dated [DATE] reflected GG: Functional abilities tub/shower transfer was marked for total dependence, helper does ALL the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity. The MDS assessment was missing information that identified if the resident was a 1 or 2 person assist; the level of care required to perform a safe transfer. Review of Resident #1's care plan revealed: Resident is at risk for falls and is at risk for increased falls and injury r/t hx of repeated falls, anticoagulant use, weakness r/t recent hospital stay, poor vision, and cognition. Functional ability: GG Mobility: Tub/Shower transfer The care plan did not indicate if Resident #1 was a 1 or 2 person transfer assist. The care plan only referenced section GG Functional abilities of the MDS assessment which the MDS assessments (admission and discharge) reflected he was dependent on staff. The care plan also revealed therapy services to focus on shower transfers to decrease risk for falls and increase safety awareness with initiated date of 03/21/24. Review of the facility incident reports with date range of 03/20/24 to 06/20/24 revealed Resident #1 suffered a fall on 03/20/24 and 05/13/24. Review of Resident #1's nursing progress notes revealed a nurse progress note dated 03/20/24 which said Resident #1 suffered a fall during a shower transfer from the shower chair to the wheelchair on 03/20/24. The note stated there were 3 staff total present during the fall (to include CNA A), Resident #1 received an x-ray which returned negative for a fracture; redness to the left knee was noted. A separate nursing progress note dated 05/13/24 revealed Resident #1 suffered a fall during a 1-person shower transfer with CNA A that occurred on 05/13/24 which resulted in an open right ankle fracture with bleeding (an open fracture is type of bone fracture where the bone breaks through the skin). The progress note said 911 emergency services was immediately notified and a RN stayed with the resident until EMS arrived. Review of the facility's reported incident investigation forms dated 05/13/24 revealed, [Resident #1 care plan was updated. [Resident #1] is anticipated to return to the facility post-surgery of his ankle . An interview on 06/20/24 at 12:56 PM with CNA A she stated that in the fall incident that occurred on 05/13/24 with Resident #1- to her knowledge Resident #1 was a 1 person transfer assist in showers at that time. CNA A said that she obtained that information from asking PT. CNA A said she did not review residents care plans or the Kardex section of the EMR that provided information on a resident's required level of assistance to determine whether a resident was a 1 or 2 person assist and would only ask PT or another CNA. CNA A said that on 05/13/24 after Resident #1 finished his shower CNA A put his shirt on and then instructed Resident #1 to stand up and grab the shower bars because she was preparing to do a 1 person transfer. While Resident #1 was standing, CNA A stated she attempted to put his brief under his legs but Resident #1's legs became weak and in a matter of seconds he started to go down. CNA A said that she attempted to get him up but due to his size (Resident #1's recorded weight dated 05/14/24 was 244 pounds) she was unable to help him up alone. CNA A said that Resident #1's feet and legs were pointed inward, and she believed as he was falling down his positioning along with his weight caused his fracture. CNA A stated that as the resident was going down, he exclaimed, my ankle, my ankle! - but he was too far down at that point that she was unable to make any adjustments and needed to run out of the shower to get help. In the fall incident that occurred on 03/20/24, CNA A said she was also assisting Resident #1 with his shower and transfer at that time. CNA A stated that she believed Resident #1 was also a 1 person transfer at that time, but she did not verify that by looking at the care plan or Kardex. CNA A stated there were 2 other shower aides at the time in the shower with her but she said, they were standing off to the side talking about which residents they were going to shower next. CNA A said she was the only person hands on with Resident #1's shower and transfer. In the events CNA A described for the incident on 03/20/24, CNA A stated that Resident #1 lost his balance while being transferred from the shower chair to his wheelchair. CNA A said, he had his brief and everything pulled up and he lost his balance while turning and trying to sit in the wheelchair. CNA A said once again said she believed she had access to the Kardex but does not recall looking at documentation that would have said whether Resident #1 was a 1 or 2 person transfer assist and she was the only individual assisting Resident #1 on both occasions 03/20/24 and 05/13/24. CNA A said she believed if they are not sure what the transfer needs of the resident are they should ask a nurse or PT prior to a transfer. An interview on 06/20/24 at 03:04 PM with PTD she stated that in the care plan where it stated, therapy services to focus on shower transfers to decrease risk for falls and increase safety awareness initiated 03/21/24- that therapy assisted only once after Resident #1's fall on 03/20/24 to provide education to the resident and caregiver (CNA A) on shower transfers. PTD stated that only a verbal in-service was done for CNA A on the appropriate way to transfer and to her knowledge no other staff was provided education on transfers or use of the Kardex. The PTD stated after the incident on 03/20/24 with Resident #1 and CNA A they felt CNA A needed the in-service but at the time it was not thought of as a systemic concern where all staff needed to be re-inserviced. PTD stated that PT is used to assist in training staff on an as needed basis. An interview on 06/20/24 at 03:08 PM with CNA B, she stated if she needed to find out a residents transfer status, she would ask another CNA. CNA B stated she did not know of anywhere she could go in the medical records that detailed a resident's transfer status such as the Kardex and was not trained on it. An interview on 06/20/24 at 03:10 PM with CNA C, he stated he will sometimes receive a residents transfer status through verbal exchange when he starts his shift from the prior CNA. CNA C stated if he did not know a residents transfer status that he would ask one of the nurses on duty, he stated he did not know where to find a residents transfer assist requirements in the medical record or Kardex. CNA C said if he was assisting a resident in the shower and needed to put a brief, he would make sure to get additional assistance to be safe. An interview on 06/20/24 at 03:20 PM with CNA D she stated she would ask either a nurse or PT if she needed to know if a resident was a 1 or 2 person assist. CNA D said she was not trained on where to locate a resident's required level of transfer assistance in the Kardex. An interview and observation on 06/20/24 at 05:31 PM with the MDS Coordinator she stated a residents transfer assist is determined by nursing staff and PT which is communicated to her so she can update the care plans and Kardex as needed. A sticky note was observed on the MDS coordinators desk containing the names of individuals that were identified to have missing or incorrect transfer status in the care plans and Kardex which the MDS Coordinator stated she had corrected moments before this interview. The MDS Coordinator stated these residents were identified in an audit completed that day 06/20/24 by the DON and RDCO that took place for care plans and Kardex after the state incident investigation had started . She stated the Kardex is what CNAs should be accessing to determine the safe way to transfer a resident. She stated if the POC is not updated with the current transfer status or has missing transfer information that would mean it would most likely be missing from the Kardex as well. She stated it would be the DON or charge nurses that show the aides how to locate that information upon hire or as needed. She said a negative outcome to not having that information is residents would not be transferred correctly or safely. An interview and record review on 06/21/24 at 01:10 PM the RDCO stated that in a care plan/ Kardex audit that was completed 06/20/24 after the investigation had started, 12 other residents separate from Resident #1 were also identified as having transfer status that were either missing or inaccurate . The RDCO stated they were all corrected on 06/20/24 and each resident was assessed with no negative outcomes noted or reported. A record review of the 12 residents was conducted and revealed interventions were updated on all 12 residents POC. A record review of incident/ accident reports with date range from 03/20/24 to 06/20/24 revealed none of the 12 residents had a transfer related incident/ accident. An interview on 06/21/24 at 04:08 PM with the DON, she said it was the responsibility of the MDS coordinator to update the MDS as needed after admission with any changes of condition. The DON said it was her expectation that all CNAs knew where to locate the Kardex information related to a residents transfer needs. The DON said that a potential negative outcome with missing or incorrect Kardex information is that a resident would not get transferred correctly which means they would be provided the wrong care. The DON stated the aides are in-serviced upon hire on the Kardex and as needed. The DON stated the most recent in-service occurred 05/14/24 after Resident #1's incident and covered fall prevention measures, post fall response, monitoring post fall assessment, and reviewing Kardex. She was not aware at that time that there was information that had not been updated to reflect some of the residents' safe transfer information. The DON stated that in the incident that occurred on 03/20/24 only CNA A was in-serviced because they did not see it as a systemic issue and the training was done in an as needed basis. After the second incident with Resident #1 on 05/13/24, the facility saw the need to ensure more staff were properly trained. An interview on 06/21/24 at 04:15 PM with the RDCO she stated that it was her expectation that care plans and Kardex were updated to reflect the individualized needs of the resident. She stated that if the Kardex had incorrect or missing information they risk not being able to meet the residents needs and anything that does not match the residents' needs is a risk to the resident. The RDCO stated that care plans, MDS assessments, and Kardex information should be updated on admission, quarterly, and anytime there is a significant change. She stated, even if their condition improves it needs to be addressed in the MDS and care plans, and especially if they decline. An interview on 06/21/24 at 04:17 PM with the ADM he stated it was the role of the MDS coordinator to ensure MDS assessments, care plans, and Kardex are updated- but ultimately it is the IDT also. The ADM said its his expectation that Kardex and care plans are updated and accurate as soon as a change is identified. He stated he expects that all the CNAs are knowledgeable on how to access the Kardex information and that they use that as their source to determine how to safely transfer a resident. The ADM said failing to have updated accurate information or failing to look at that information to determine safe transfer status would mean they are not accurately following the residents plan of care. Review of the facility Safe Resident Handling/ Transfers policy last revised 01/2023 revealed: It is the policy of this community to ensure that patients/residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure, and comfortable experience for the patient/resident while keeping the team members safe in accordance with current standards and guidelines. - All patients/residents require safe handling when transferred to prevent or minimize the risk for injury to themselves and the team members that assist them. The use of mechanical lifts is a safer alternative to manual lifting for patients, residents, and caregivers. Compliance Guidelines: - The interdisciplinary team or designee will evaluate and assess individual mobility needs, considering other factors as well, such as weight and cognitive status. - The mobility needs will be addressed on admission and reviewed quarterly, after a significant change in condition or based on direct care staff observations or recommendations. - Team members will be educated on the use of safe handling/transfer practices to include use of mechanical lift devices upon hire, annually and as the need arises or changes in equipment occur. - Team members are expected to maintain compliance with safe handling/transfer practices. Failure to maintain compliance may lead to disciplinary action up to and including termination of employment. - Lifting and transferring will be performed according to the individualized plan of care. Review of the facility comprehensive assessments policy last revised 03/2023 revealed: Comprehensive resident assessment The community uses the Resident Assessment Instrument (RAI) to develop the comprehensive resident assessment. It identifies the care, services, and treatments that each resident needs to attain or maintain his or her highest practicable mental and physical functional status. The ADM. DON, and RDCO were notified on 06/21/24 at 04:25 PM that an IJ situation was identified due to the above failures and the IJ template was provided. The Plan of Removal was accepted on 06/23/24 at 11:00 AM and included: Plan of Removal Problem: F689 Free from Accidents/ Hazards Interventions: 1. DNS/Designee conducted a 100% Audit of all residents who reside in the community was conducted on 6/20/2024 to validate care plans and Kardex accuracy reflected the current care needed for each resident. 12 residents were identified during this process and care plan/Kardex was updated to reflect the current need of each resident identified. Date commenced: 6/20/2024 Date completed: 6/21/2024 2. All 12 residents identified with care plan updates were assessed on 6/21/2024 with no negative outcomes. Date completed: 6/21/2024 3. AdHoc meeting to address issue, correction, action plan and plan of removal with Administrator, Director of Nursing Services, Assistant Director of Nursing Services, Director of Clinical Operations and Medical Director was conducted on 6/22/2024. 4. DNS/ADNS/Designee (Charge Nurse) will ensure all staff on leave/agency staff /PRN staff are in serviced prior to working their shift. No licensed nurse, certified medication aide or certified nurse aide will assume an assignment of patient care until they have passed skills validation of accessing the Kardex. Community will ensure administrative nursing staff in the community to provide in-service/education prior team members working their assigned shift. These trainings will also be conducted with new hires. In-services: 5. Regional Nurse (Director of Clinical Operations) re-educated the Director of Nursing on the following: oImportance of nursing staff reviewing the Kardex before providing care to ensure proper level of care is provided according to the resident's need and adherence to the resident's plan of care. Staff should report any concerns or inaccuracies of the care plan/Kardex to the charge nurse/licensed nurse for direction prior to care being provided, so that the licensed nurse can evaluate the resident and determine the appropriate level of care necessary as well as monitoring the resident to ensure that the appropriate care is being provided in accordance to the resident's needs; thus, updating the care plan/Kardex as indicated. The licensed nurse should ensure that the appropriate care needs are communicated across all shifts by reviewing the information with the on-coming shift nurse, in order to ensure that care provided is consistently provided in a safe manner until the plan of care/Kardex has been updated. The IDT will review and update the plan of care with necessary changes within 24-72 hrs as per the RAI, which indicates that necessary changes to the plan of care should be within a reasonable period of time. Until the plan of care has been updated the charge nurses will continue to communicate necessary care to be provided during shift-to-shift report. Preventing Accidents/Fall Prevention/Promoting a Safe Environment: identifying risk, reducing risks, and promoting an accident-free environment as indicated in the plan of care. 6. All Nursing Team Members were educated on providing care to residents were re-educated/re-trained by the Director of Nursing or Designee. Nursing staff reviewing the Kardex before providing care to ensure proper level of care is provided according to the resident's need and adherence to the resident's plan of care. Staff should report any concerns or inaccuracies of the care plan/Kardex to the charge nurse/licensed nurse for direction prior to care being provided, so that the licensed nurse can evaluate the resident and determine the appropriate level of care necessary as well as monitoring the resident to ensure that the appropriate care is being provided in accordance to the resident's needs; thus, updating the care plan/Kardex as indicated. The licensed nurse should ensure that the appropriate care needs are communicated across all shifts by reviewing the information with the on-coming shift nurse, in order to ensure that care provided is consistently provided in a safe manner until the plan of care/Kardex has been updated. The licensed nurse should ensure that the appropriate care needs are communicated across all shifts by reviewing the information with the on-coming shift nurse, in order to ensure that care provided is consistently provided in a safe manner until the plan of care/Kardex has been updated. Education provided to all Nursing Department Preventing Accidents/Fall Prevention/Promoting a Safe: identifying risk, reducing risks, and promoting an accident-free environment indicated in the plan of care by DNS/Designee. The IDT will review and update the plan of care with necessary changes within 24-72 hrs as per the RAI, which indicates that necessary changes to the plan of care should be within a reasonable period of time. Until the plan of care has been updated the charge nurses will continue to communicate necessary care to be provided during shift-to-shift report. DNS/ADNS/Designee conducted 100% audits of skills validation of accessing the Kardex by return demonstration; observing the direct care team member is has verified competency by return demonstration of accessing the Kardex to review the level of care to be provided. Date commenced: 6/20/2024 Date completed: 6/22/2024 7. All licensed nurses were re-educated on the completion and accuracy of care plans to ensure they reflect the current needs of each resident. Baseline Care plans must be completed within 48 hours of admission. Care plans must be updated as clinically indicated. Kardex must be initiated upon admission and updated as clinically indicated. Date commenced: 6/20/2024. Date completed: 6/22/2024. Risk Response: Residents who currently reside in community potentially can be affected by the deficient practice. DNS/Designee conducted a 100% Audit of all residents who reside in the community was conducted on 6/20/2024 to validate care plans and Kardex accuracy reflects the current care needs for each resident. 12 residents were identified during the review process. Careplan/Kardex were updated to reflect the current need of each resident identified. Date commenced: 6/20/2024. Date completed: 6/21/2024 The DNS (Director of Nursing) will ensure all staff on leave/agency/PRN staff are in serviced prior to working their shift. No licensed nurse, certified medication aide or certified nurse aide will assume an assignment of patient care until they have passed skills validation of accessing the Kardex. The DNS will ensure administrative nursing staff will provide in-service/education prior team members working their assigned shift. These trainings will also be conducted with new hires. The Administrator is responsible for validating that all tasks assigned and monitoring efforts (as indicated on this plan) has been achieved and that compliance is maintained. Systemic Response: 100% Direct care educated on review of the Kardex before providing care to all residents assigned to them to ensure proper assistance and interventions are utilized according to the resident's need and adherence to the resident's plan of care. Reporting any concerns or inaccuracies to the charge nurse/licensed nurse for additional direction prior to care provided. 100 % Education provided to all Nursing Department Preventing Accidents/Fall Prevention/Promoting a Safe: identifying risk, reducing risks, and promoting an accident-free environment indicated in the plan of care by DNS/Designee. 100% care plans were reviewed for all residents with fall prevention interventions to ensure interventions on the Kardex are in place. 100% validation of accessing the Kardex was conducted on all nursing department. Date commenced: 6/20/2024 Date of completion: 6/22/2024 The Director of Nursing / Asst. Director of Nursing will ensure all staff on leave/agency/PRN staff are in serviced prior to working their shift. No licensed nurse, certified medication aide or certified nurse aide will assume an assignment of patient care until they have passed skills validation of accessing the Kardex. DNS will ensure administrative nursing staff will provide in-service/education prior team members working their assigned shift. These trainings will also be conducted with new hires. The Administrator is responsible for validating that all tasks assigned and monitoring efforts (as indicated on this plan) has been achieved and that compliance is maintained. Monitoring Response: The Administrator/ DNS/ designee will conduct weekly rounds to validate interventions related to fall prevention is in place 1-7 days a week for 2 months. The DNS/Designee will conduct random skills validations regarding Kardex use 3-7 days a week for 2 months to ensure direct staff is compliant with the use of the Kardex. Policies are followed to ensure the safety and wellbeing of our residents. Additional education will take place based on needs observed during this process. The Administrator is responsible for validating that all tasks assigned and monitoring efforts (as indicated on this plan) has been achieved and that compliance is maintained. All findings will be reported to the QAPI committee during monthly meeting until there is 100% compliance observed during observations. On 06/22/24 and 06/23/24 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: 06/22/24: In an interview on 06/22/24 at 09:15 AM with the DON, she stated she had already sent out the care feed system (a system that communicated with all staff via text) in services facility wide to all staff related to accessing Kardex, ANE, Fall Prevention and Care Plans. She stated that they have visually checked off staff prior to their shift to ensure they are able to access the Kardex system and training is ongoing and in progress. She stated Care plans were updated for the 12 residents of concern related to transfer status. Education will remain ongoing until 100% of staff are trained. Staff education: 28 staff were educated on Kardex 30 staff were educated on ANE 28 staff were educated on Fall Prevention 9 (nurses) staff were educated on Care Plans Record reviews were conducted by surveyor. 12 residents were identified during the review process by DON and RDCO. Care plans/Kardex were updated to reflect the current need of each resident identified. Surveyor verified updated care plans for 12 residents affected. QAPI committee meeting to address issue, correction, action plan and plan of removal with Administrator, Director of Nursing Services, Assistant Director of Nursing Services, Director of Clinical Operations and Medical Director was conducted on 6/22/2024. Sign in sheet was obtained by surveyor. An interview on 06/22/24 at 09:36 AM with RN G, she validated she knew where to find information on the care needs of the resident via the Kardex and POC. She verbalized examples of fall prevention and hazard free environment and demonstrated action to take in response to how to know about a change of condition. An interview and observation on 06/22/24 at 09:40 AM with the ADON validated training on accessing the Kardex to determine the transfer needs of the resident by accessing the Kardex and POC. The ADON was observed in return demonstration via the computer. Prevention of falls to include gait belts, ensuring correct method of transfer. The ADON stated CNAs know to consult PT when transfer needs of the resident are in question. An interview on 06/22/24 at 09:49 AM with PT H, he discussed how and when CNAs are trained and stated that they will routinely seek out PT for guidance on how best to transfer residents. An interview on 06/22/24 at 09:51 AM with CNA E verbalized the need to access Kardex to know transfer status and care needs of the resident. She stated the prevention of falls includes interventions such as appropriate socks and shoes, gait belt, get help if needed with transfers. An interview on 06/22/24 at 10:01 AM with CMA I, she confirmed recent training on Kardex and accessing information regarding the status of resident transfers. She stated she consistently assists with transfers as needed, especially in the use of the Hoyer Lift. Able to discuss various methods for fall/accident prevention: ie, appropriate shoes/socks, gait belt. An interview on 06/22/24 at 10:13 AM with CNA F she stated that was her first day working there and she was able to verbalize the process to access the Kardex and POC. An interview on 06/22/24 at 10:20 AM with LVN J she stated she had received training and then demonstrated knowledge on how to access the EMR and POC. She stated she takes that information into consideration but will also conduct her own nursing assessments. An interview on 06/22/24 at 10:45 AM with CMA K she confirmed she received training related to transfers and accessing the EMR and POC on 06/21/24. CMA K verbalized interventions for prevention of falls (low bed, making sure resident is toileted frequently, and making sure floors are clear of debris). CMA K confirmed that she also received training on 06/21/24 related to ANE and stated the ANE coordinator was the ADM. An interview on 06/22/24 at 10:54 AM with LVN L she confirmed recent training on how to locate information regarding resident transfer needs via Kardex and POC. She was able to verbalize methods of fall prevention (i.e., bed low, scoop mattress, check often, fall mat) in response to fall, nurse does the assessment. She confirmed recent training on ANE and stated the administrator was the ANE coordinator. An interview on 06/22/24 at 10:59 AM with CNA M she confirmed training on access of Kardex/POC in order to identify resident needs for assistance with transfers. She stated prevention measures may include ensure appropriate toileting times, have call light in place, checking Kardex for transfer needs. CNA M confirmed recent ANE training and stated the ANE coordinator was the administrator. An interview on 06/22/24 at 11:06 AM with LVN N she confirmed training on access of Kardex/POC to identify resident needs for assistance with transfers. She said in the event of a fall, she would first assess for a change in condition, she would then check vitals, get a gait belt, and notify the Charge Nurse. She stated prevention could include assessing toileting needs and having call light in place. She confirmed recent ANE training and states the ANE coordinator is the administrator and said, that information is posted everywhere. 06/23/24: Staff education remained ongoing [TRUNCATED]

Based on observation and interviews , the facility failed to ensure each resident received and the facility provided food and drink that was palatable, attractive and at a safe and appetizing temperature for residents who consumed foods orally from the only kitchen in the facility in that: 1. The facility failed to provide palatable food that was attractive or appetizing to residents' who complained the food was unidentifiable and did not taste good. 2. The test tray of the lunch meal foods were dry, bland, and cold. This failure could place residents at risk of decreased food intake, hunger, unwanted weight loss, and diminished quality of life. The findings included: 1. a. During a confidential interview and observation on 01/29/24 at 12:52 PM a resident stated she was not eating the unstuffed peppers being served and said, I do not eat anything I cannot look at and easily identify or know what it is. An observation of the resident's lunch plate revealed the served unstuffed peppers entree was not touched by the resident. b. During a confidential group interview on 01/30/24 at 10:00 AM 5 residents voiced complaints about the food. The resident group stated the food was tasteless and the vegetables always have too much water in them. They said the kitchen staff boil the vegetables in a lot of water and don't strain them properly before serving. They also believe all that water is the cause of the vegetables having no flavor in the end. They said, half the kitchen staff can't cook. One resident stated the person that puts the condiments on the meal trays does not always put the correct ones or any at all on some trays. They said that whenever an entree has any type of gravy or sauce it usually does not have any flavor to it. The group agreed that most of the time the food being served isn't recognizable or easy to identify what is being served. One resident said it looks like dog food. One resident stated, I am constantly having to go to the kitchen to tell them not to give me certain foods and it is on my food slip on my dislikes, and they continue to give me food I can't eat. A resident stated I am lactose intolerant and it's on the food-slip, but they will give me milk and cottage cheese. Anyone else checking the trays should know your likes and dislikes besides just the cook. c. Record review of Resident#4's face sheet dated 01/31/24 indicated Resident# 4 was a [AGE] year-old female, admitted to the facility on [DATE] with a diagnosis of retained cholelithiasis (gallstones) following cholecystectomy (removal of gallbladder), muscle weakness, hypothyroidism (condition where thyroid gland does not produce enough thyroid hormones), anxiety, and depression. During an interview on 01/31/24 at 02:30 PM with Resident# 4 spoke about the lunch meal from 01/30/24, the resident stated the pasta was overcooked. She said there was no taste to the sauce over the pasta and she didn't realize there was chicken on the plate until she moved the pasta to the side due to not being able to eat it from being overcooked. The resident said there was so much water in the vegetables she could not eat them. She said it was like eating vegetable soup cooked in water. The resident stated the roll was very hard on the bottom, so she only ate the top part. The resident stated she ate the chicken and asked for a sandwich and something else to eat which she was satisfied with since she couldn't eat the initial meal. d. Record review of Resident#7's face sheet dated 01/31/24 indicated Resident# 7 was a [AGE] year-old male, admitted to the facility on [DATE] with a diagnosis of COPD (a condition involving constriction of the airways and difficulty or discomfort in breathing), mild protein-calorie malnutrition, hypothyroidism (condition where thyroid gland does not produce enough thyroid hormones), abnormal weight loss, and anemia (deficiency of healthy red blood cells in the blood). During an interview on 01/31/24 at 03:00 PM with Resident# 7 about the lunch meal from 01/30/24, the resident stated the noodles on his plate were dry. The resident stated, If I ate a rubber band it would probably taste the same as the noodles. He said the noodles looked like rubber bands and had the same color and consistency. He said he moved the noodles to the side and said he saw the chicken which he didn't know what there because it was covered by the horrible noodles. The resident said the pasta sauce looked like vomit. The resident said the vegetables did not have flavor and laid in too much water. He stated the chocolate cake or whatever it was was not fully cooked. The resident said he requested a different meal and received a sandwich which satisfied him. 2. An observation at 01/30/24 at 02:30 PM a lunch test tray was sampled. The test tray consisted of regular textured food items. The meal tray consisted of fettuccine pasta with chicken and pasta sauce, a small roll, and a small bowl of vegetable medley to the side. A small plate with a brownie for dessert was also provided. On initial observation of the meal, unable to distinguish if there was chicken on the entree. Chicken was hidden under a large amount of sauce and over very little pasta. The pasta was overcooked and dry, it had a dark appearance to it. The pasta was extremely tough and difficult to swallow, had to have fluids to aid in swallowing. Both the sauce and the chicken had no flavor to it and did not have the appearance of seasonings, they appeared pale and bland. The vegetable medley with a variety of vegetables sat in a bowl with a lot of water and only the corn had some flavor. After pouring the water from the vegetable medley onto the entree plate it was observed covering half of the entree dinner plate. The small roll was overbaked and hard on the bottom and on the sides. The roll would not bend when squeezing. The brownie dessert was undercooked, and the center had a dough/ unfinished taste. The appearance of the brownie was thin, flat, and had no visual appeal. It did not appear to rise properly as baked goods should. During an Interview on 01/31/24 at 02:07 PM with the DM she said it is was her expectation that food looks appealing, is edible, and something that the residents enjoy. She said the residents are also offered alternatives which should be desirable and are always offered on the back of the meal ticket, choices that are developed by the resident and care team. She said if the food isn't good, it could cause residents to lose weight which could affect their health. During an Interview on 01/31/24 at 02:53 PM with the Administrator she said, the food should always look appealing because we eat with our eyes as well. It should be bright, appealing, and should not be too soggy. She said the vegetables should be separated from the main entree. She said, cold items should be cold and warm items should be warm. The administrator stated, residents should be able to identify what the food is and not have to ask. The administrator said, pleasant to eat and pleasant to smell. The administrator stated that adverse effects of having unappetizing, unappealing, and inedible food could result in the resident becoming depressed or homesick. She said that if a resident is diabetic, it would cause issued with blood sugar levels. She said it could cause a resident to lose weight, and they could also begin to look for other food sources like having family bring meals that may not adhere to their nutritional needs. She said it could also cause residents to steal food from other resident's mini fridges in their rooms.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food and nutrition services. 1. The facility failed to ensure dry storage food was properly labeled and dated. 2. The facility failed to ensure dry storage items were sealed properly. 3. The facility failed to properly label and date items in the refrigerator and freezer. 4. The facility failed to ensure expired food was discarded. 5. The facility failed to ensure kitchen staff practiced proper hand hygiene and glove use. 6. The facility failed to ensure hairnets were worn while in the kitchen. These failures could place residents at risk for food contamination and foodborne illness. Findings included: During the initial tour of the kitchen on [DATE] at 08:49 AM the following was observed: 1. Baked beans were observed in a metal pan covered with saran wrap with use by date of [DATE]. 2. Pie crust sealed in a clear bag with no label or date observed in the freezer. 3. Frozen pepperonis wrapped in saran wrap not labeled or dated in the freezer. 4. Diced chicken in a clear bag in the freezer with no label or date, bag had a baseball-size hole exposing contents to air. 5. Frozen turkey in the freezer with no label or date. 6. Pork loin in the freezer with no label or date. 7. 10 loafs of bread in dry storage with no labels or dates. 8. [NAME] rice in dry storage was kept in a container that did not seal, the lid was only placed on top. 9. Melted chocolate kept in dry storage container dated [DATE] was not sealed tightly. 10. Potatoes kept in a cardboard box on the bottom shelf in dry storage was not labeled or dated and contained 15 potatoes that appeared sprouted, wrinkled, and had an old grey appearance. 11. A bag of country style gravy mix stored in a Ziplock bag in dry storage was not labeled or dated. During an observation on [DATE] at 10:15 AM of pureed food prep, [NAME] F was observed putting the blender in the dishwashing machine, discarded gloves and did not wash her hands then began mixing and prepping unstuffed peppers for lunch. During an observation on [DATE] at 10:51 AM Kitchen aide G was observed changing gloves and not washing hands in between. He was then observed picking an item off the floor with those same gloves and then preparing the regular texture peach cobbler dessert without changing gloves or washing hands. An observation on [DATE] at 12:30 PM a residents friend not residing in the facility was observed entering the kitchen without a hairnet. During an interview on [DATE] with the DM she said she had trained staff and it wasis h ER expectation that the first items stored are the first ones used she said, first in first out. The DM said in-services for staff is done on a monthly basis. She said if something is mislabeled or past the expiration date it could affect the residents in that it could make them really sick from foodborne illness. During an interview on [DATE] with Kitchen aide G he said that contamination could occur from not washing hands or changing gloves and then prepping food. He said he was not sure why he did not change his gloves after picking the item off the floor. During an interview on [DATE] at 09:17 AM the DM stated it is her expectation that all staff wash their hands in the kitchen between meal prep, when changing gloves, and after touching trash or anything else that may cause contamination. She said staff should change their gloves when moving from one food prep item to another and should wash their hands in between. The DM said that if proper handwashing and glove use is not followed then it would lead to cross contamination of food. She said it is also an infection control issue and could make the residents very ill from foodborne illnesses. During an interview on [DATE] at 02:07 PM with the DM she said it is her expectation that anyone who enters the kitchen wears a hairnet. She said not wearing one could lead to hair in the food which is an infection control issue. The DM stated that nobody other than kitchen staff is allowed in the kitchen. During an interview on [DATE] at 02:53 PM with the Administrator, she said it is her expectation when items arrive in the kitchen that they are inspected to make sure they are intact and then be properly labeled and dated as appropriate. She said all items should cold or dry should be sealed otherwise it would promote bacterial growth. She said that if items are not labeled properly the residents could be exposed to an allergen, something could be expired and they wouldn't know, and a residents religious food aspects could be compromised. She said if items in dry storage are not sealed properly, they could be exposed to moisture or mildew and could attract pests. The administrator stated if items in the freezer were not sealed or stored properly, they could get freezer burn which would make it inedible. The Administrator stated it is her expectation that all kitchen staff follow proper handwashing and glove use. She said hands should be washed when first entering the kitchen, after removing gloves, in between activities such as dishwashing and food handling, and before and in between handling different food items. She said not following proper glove use and handwashing could expose residents to illness causing bacteria or allergens. She said you could also promote cross contamination by touching raw items and not washing your hands. The administrator said it is her expectation that hairnets are always worn by anyone in the kitchen. She said only kitchen staff should be in the kitchen and residents' family members should not be going in because they are not aware of the facilities policies and procedures. The administrator said that by not wearing a hairnet you expose food to hair or hair particles like dandruff and could cause the residents to become sick and develop diarrhea, vomiting, or upset stomach. POLICY: Facility Food and Nutrition Services, Sanitation- Food Storage policy with an effective date of ,d+[DATE] stated: All food purchased will be wholesome, manufactured, processed, and prepared in compliance with all State, Federal, and local laws, and regulations. Food will be stored in a safe and sanitary method to prevent contamination and food-borne illness. Foods should be used or discarded prior to the expiration date. Food removed from its original packaging should be dated and labeled. Tightly wrap or cover all opened containers and leftover food in clean containers. It should be labeled, dated with the opened or use by date. Facility Food and Nutrition Services, Sanitation- Hand Washing and Glove Use policy with an effective date of ,d+[DATE] stated: 1. Employees are to wash hands: a. Before starting work. b. After handling soiled dishware, equipment, or utensils and after handling boxes, cans, or crates. c. Before handling any clean dishware. d. After all work breaks, using the restroom, tobacco use, eating or any instance of coughing, sneezing, and touching face, hair, or clothing. e. When switching between working with raw food and working with ready-to eat food. f. After visiting resident rooms, when re-entering the kitchen, and prior to any food production. g. During food preparation, as often as necessary to prevent cross contamination when changing tasks. h. After handling chemicals that may affect the safety of foods. i. After cleaning or bussing tables. j. Before donning gloves to initiate a task that involves handling ready-to-eat food. k. After engaging in any other activity that may contaminate the hands. 2. Change gloves when an un-sanitized item or surface is touched and when gloves are soiled or torn. 3. The use of gloves or the use of hand sanitizer does not replace handwashing. Facility Food and Nutrition Services, General- Personnel Guidelines policy with an effective date of ,d+[DATE] under dress code stated: Hair should be fully covered with hairnet or hair bonnet within the department. Other hair restraints require approval from the Dietitian or designee. All restraints must fully cover the hair, not be worn outside of the kitchen and remain clean.

Based on observation, interview, and record review the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of their quality of life for two (Resident #3 and Resident #39) of six residents reviewed for rights. 1. The facility failed to ensure Resident #3 catheter bag was covered when out of room. 2. The facility failed to provide dignity and respect for Resident #39 by not aiding a resident that required assistance in dressing. These failures placed the residents at risk of a decline of their sense of dignity, level of satisfaction with life, and feelings of self-worth. Findings included: 1. Review of Resident #3's face sheet, dated 01/31/2022, reflected a 70 -year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of: cognitive communication disorder (difficulty with any aspect of communication that is affected by disruption of cognition such as: attention, memory, organization, and problem solving/ reasoning), complete traumatic ( related to physical injury) amputation (surgically cutting off a limb) at level between left hip and knee, pain due to internal orthopedic prosthetic devices ( used to keep fractured bones stabilized and in alignment) , implants ( replace missing body parts, and grafts (healthy tissue taken from one part of the body to replace diseased or injured tissue removed from another part of the body), obesity ( having too much body mass- a measurement of a person's weight with respect to his or her height), bipolar disorder (causes extreme mood swings that include emotional highs and lows- depression),schizophrenia (causes delusions- false believe or judgement and hallucinations- see things that are not there like objects, shapes, people or lights) and, anxiety (when the mind and body encounters stressful, dangerous, or unfamiliar situations). Review of Resident #3's Five Day Scheduled MDS, dated [DATE], reflected Resident #3 had a BIMS score of 15 indicated her cognition was intact. Resident #3 required partial/moderate assistance, and with lower body dressing and with putting on/taking off footwear (helper does more than half the effort). Resident #3 was also assessed of having indwelling catheter (a flexible tube inserted through a narrow opening into the bladder for removing fluid). Resident #3 had received scheduled pain medication. Review of Resident #3's Comprehensive Care Plan with a target date of 04/19/2024 reflected catheter was not care planned and Resident #3's preference to place own cover on catheter bag. Resident #3 request if she forgets to place the catheter cover bag prior to leaving the room and she is in public for the staff to remind her and assist her with the catheter cover bag. Resident #3 required assistance with ADL Care. Review of Resident #3's Physician Orders, dated 01/09/2024 reflected a new order on 12/16/2023 for foley care: output every shift (a medical device that helps drain urine from your bladder). Review of Social Workers progress notes from 12/30/2021- 01/19/2024 reflected Resident #3 did not express any preferences of wanting to place a bag over catheter themselves instead of staff. Review of Resident #3's Nurses Notes from 12/16/2023 - 01/30/2024 reflected facility staff did not document Resident #3 preference of placing a catheter bag on her own catheter and if she Resident #3 forgets when she was outside of her room the staff was to remind her and assist with covering her catheter bag. Review of Resident #3's Nurses Notes dated 01/19/2024 reflected IDT met to discuss resident's plan of care. Plan of care updated . Observation on 01/29/2024 at 9:55 AM Resident #3 was sitting in the hallway and her catheter was not covered. Observation on 01/29/2024 at 10:00 AM Resident # 44 was making retching noises (when the body keeps wanting to vomit but cannot). Interview on 01/29/2024 at 10:05 AM Resident #44 stated looking at that pee in the bag. It is making me sick and I almost vomited. I cannot stand to look at pee or anyone's bowels. It makes me sick to my stomach. Interview on 01/29/2023 at 10:08 AM Resident #3 stated she was so embarrassed and humiliated for people to know she wears a catheter. She stated there were times she forgets to put the bag over the catheter and several residents had explained to her it made them sick to look at the urine. Resident #3 stated she told the Social Worker and a nurse (she did not recall the nurses name) she preferred to put the catheter bag on herself but if she was out of her room and forgot to cover the catheter bag, she wanted nursing staff to remind her and assist her with covering the catheter bag. Resident #3 also stated the staff would remind her sometimes but usually the other residents would ask me the cover my catheter bag. She stated when she was overwhelmed having a catheter and it made her nervous. Resident #3 also stated she may have to re-think attempting to place the catheter bag on by herself if she continues to forget. Interview on 01/31/2023 at 9:13 AM The Administrator stated all catheters were expected to be covered. She stated it was the staff's responsibility to ensure the catheter were covered especially when a resident was outside of their room The Administrator stated if Resident #3 stated she wanted to cover her own catheter and she exited her room and went into common areas it was the staff responsibility to ensure the catheter was covered. She stated if other residents made statements, it made them sick to look at the urine in the catheter this does affect the other residents' rights. (The Administrator did not elaborate on her statement). Interview on 01/31/2024 at 9:43 MDS Coordinator/LVN stated Resident # 3's catheter was expected to be covered. She stated it was a dignity issue. She stated Resident #3 may become embarrassed for staff, visitors, or other residents to see her urine in catheter bag and Resident #3 may not want anyone to know she was wearing a catheter. She stated it was a potential for Resident #3 become anxious and depressed due to her diagnosis of anxiety and other mental diagnosis. MDS Coordinator / LVN stated there was a potential of Resident #3 becoming embarrassed if other residents, staff, and visitors to view her uncovered catheter. MDS Coordinator/LVN stated she did not know if Resident #3 told anyone she wanted to place the catheter bag on herself and if she forgot she wanted the staff to remind her if she forgets. She also stated the staff was expected to place cover on Resident #3's catheter bag if her bag was not covered. She stated it also may affect other residents' rights to view the urine in the bag. Interview on 01/31/2024 at 10:56 AM ADON stated all catheters were expected to be covered when residents are out of room. He stated if Resident #3 care plan should reflect, she had a catheter. He stated if Resident #3 was placing catheter bag over catheter herself and forgot to do this task it was the staff responsibility to ensure Resident #3 catheter was covered. He stated he was not going to comment on other residents not wanting to look at a urine in a catheter bag. ADON also stated if the uncovered catheter embarrassed and humiliated Resident #3 it was a dignity issue. 2. A record review of Resident# 39's face sheet dated 01/31/24 revealed Resident# 39 was admitted on [DATE] with a diagnosis of psychotic disturbance, mood disturbance, and anxiety (mood disorder causing feeling of fear, dread, and uneasiness); ataxic gait (failure of muscle coordination characterized by an irregular foot placement, wide base, and instability), heart failure, age-related physical debility, gout (inflammatory arthritis that causes pain and swelling in joints), hypertension (high blood pressure), unspecified convulsions (seizure disorder), and hyperlipidemia (elevated level of lipids or fats such as cholesterol and triglycerides in the blood). A record review of Resident# 39's MDS last revised 01/11/24 reflected a BIMS score of 5 suggesting cognitive impairment. Resident# 39's MDS functional abilities assessment reflected she required substantial/ maximal assistance in lower/upper body dressing and footwear. A record review of Resident# 39's care plan revised 01/25/24 revealed she required 1 person assist with dressing. An observation and interview on 01/30/24 beginning at 8:29 AM revealed Resident# 39 sitting in her wheelchair at her bedroom door near the hall. Resident# 39 was not wearing pants or socks and wore only a shirt and her incontinence brief. Resident# 39's eyes appeared red, watery, and her mood appeared dejected. In an interview, Resident# 39 said you can call them referring to staff, and she was observed stretching her shirt over her legs attempting to cover herself. In an interview on 01/31/24 at 12:13 PM Resident# 39 stated she was in her wheelchair near the hall attempting to get assistance with getting dressed. She said she relies on care staff for assistance putting her pants on. Resident# 39 stated well it didn't make me feel good said she was embarrassed sitting exposed near the hall. In an interview on 01/31/24 at 01:35 PM CNA E stated it was the CNA's responsibility to dress the residents that require assistance in the morning. CNA E said she was familiar with Resident# 39's care and knows that Resident# 39 requires total care or full assistance regarding getting dressed. CNA E said that Resident# 39 not having pants on and sitting near the hall in her briefs is a dignity issue and could have a negative effect on Resident# 39's mental health. In an interview on 01/31/24 at 02:53 PM the Administrator revealed it was the CNA's responsibility to dress residents that require assistance in the morning which should be done before breakfast. She said nurses will also make sure they are dressed when entering the room for morning medication administration, and that department heads are also assigned rooms/ halls to check that residents are up, dressed, and are having their needs met. The administrator said it is her expectation that those that require assistance receive assistance. She said adverse effects of someone not being dressed or left exposed could lead to or worsen depression, anxiousness, and cause undo stress. The administrator stated that it could affect a resident's self-worth; they would no longer want to come out of their room or participate in activities. It could also potentially lead them to being victimized or taken advantage of by staff or other residents. Record Review of facility Dignity policy revised February 2021 revealed: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Policy also revealed demeaning practices and standards of care that compromise dignity is prohibited. Staff are expected to promote dignity and assist residents; for example: Helping the resident to keep urinary catheter bags covered. Individual needs and preferences of the resident are identified through the assessment process. When assisting with care, residents are supported in exercising their rights. For example, residents are encouraged to dress in clothing they preferred. Under Policy Interpretation and Implementation it states, Residents are treated with dignity and respect at all times. Individual needs and preferences of the resident are identified through the assessment process. Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents. The policy references OBRA regulatory reference numbers S483.l0(a) Resident Rights; S483.l0(b) Exercise of Rights and Survey Tag F550. 49099

Based on interviews and record reviews, the facility failed to develop and implement a baseline care plan for each resident within 48 hours of the resident's admission that included instructions for providing effective person-centered care for the resident and met professional standards of quality of care for 1 of 4 residents (Resident # 58) reviewed for care plans, in that: The facility failed to develop and implement a baseline care plan for Resident #58. This failure placed residents at risk of not having their immediate care needs met or not receiving continuity of care. Findings included: Record review of Resident #58's face sheet, dated 01/31/2024, reflected an [AGE] year old female was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus without complications ( a condition that happens because of a problem in the way the body regulates and uses sugar as fuel), chronic kidney disease, stage 4 ( kidneys are moderately or severely damaged and are not working as well as they should be to filter waste from your blood), cutaneous abscess of abdominal wall ( a pocket of pus- collection of dead, white blood cells that accumulates when the body's immune system activates in response to an infection- located in the abdomen), acute cholecystitis (a redness and swelling of the gallbladder), hypertension ( occurs when you have abnormally high blood pressure that's not the result of a medical condition), infective myositis ( uncommon group of inflammatory myopathies-( any disease that affects the muscles that control voluntary movement in the body) caused by a range of infective agents such as viral, bacterial, fungal, and parasitic, depression ( a mood disorder that causes a persistent feeling of sadness and loss of interest), generalized anxiety disorder (a condition of excessive worry about everyday issue and situations), and other malaise (a feeling of general discomfort, uneasiness or lack of wellbeing and often the first sign of an infection or other disease). Record review of Resident #58's Admission MDS Assessment, dated 12/31/2023, reflected Resident #58 had a BIMS score of 15. Resident #58 required assistance with ADLs. She had medically complex conditions (usually involve multiple body systems and are often chronic in nature. Persist over a long time, usually for a person's lifetime). Resident #58 had a surgical wound. She was at risk of developing pressure ulcers/injuries. Resident #58 was receiving OT (Occupational Therapy- assist people to overcome various problems to live more independent lives). Record review of Resident #58's clinical record reflected her baseline care plan was not completed within 48 hours. Resident #58's baseline care plan was initiated on 01/02/2024 and was not completed. Interview on 01/31/2024 at 9:13 AM with the Administrator stated all baseline care plans were to be completed within 48 hours of admission. She stated if a resident was admitted on a Friday afternoon the baseline care plan was expected to be completed over the weekend. The Administrator stated the social worker, admitting nurse either on weekend or during week, DON, and MDS nurse was responsible for completing the baseline care plan. She stated if a resident was admitted on a Friday afternoon, she expected the baseline to begin at that time and throughout the 48 hours until it was completed. She also stated if the baseline were not completed there was a potential of a resident would not receive personalize care to meet their physical and mental needs such as: proper transfers, incontinent care, the correct wound care, and emotional support. The administrator stated it was the MDS nurse responsibility to monitor the baseline care plan to ensure it was completed. Interview on 01/31/2024 at 9:43 AM, MDS Coordinator/LVN stated the baseline care plan was required to be completed within 48 hours of the resident's admitted . MDS Coordinator/LVN reviewed the baseline care plan during the interview and agreed the baseline care plan for Resident #58 was not completed and the baseline care plan was late. She stated Resident #58's baseline care plan was expected to be completed within 48 hours of her admitted . She stated Resident #58's admitted was 12/29/2024 in the afternoon. She also stated the baseline care plan was dated on 01/02/2024. MDS Coordinator/ LVN stated the baseline care plan was used as a tool to know what type of care a resident needed. She stated the Nurses does complete a nurse assessment; however, the baseline care plan gave more information of what type of care the resident required. She stated the nurses did not document in their admission assessment everything on the baseline care plan. MDS Coordinator/ LVN stated if the nursing staff did not have the information from the baseline care plan there was a potential of the resident not receiving proper care such as improper transfers. She stated if a resident was not transferred properly there was a possibility a resident may injure themselves with an improper transfer. She stated the staff would not know the personalize care the resident needed at time of admission. Interview on 01/31/2024 at 10:56 AM, the ADON stated all baseline care plans were to be completed within 48 hours of admission. He stated the resident would continue to receive care from the staff. The baseline care plan had more information of personalize care for the residents. The staff would not have all the information to give care to residents without the baseline care plan. He stated to refer to the MDS Coordinator for further information on baseline care plans and possible negative outcomes of a resident if the baseline care plan was not completed. Review of the Facility's Baseline Care Plan Policy, dated 03/2022, reflected 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. The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality of care and must include the minimum healthcare information necessary to properly care for the resident including, but not limited to the following: A. Initial goals based on admission orders and discussion with the resident/ representative. B. Physician orders. C. Dietary orders. D. Therapy Services. E. Social Services. F. PASARR recommendations, if applicable. (PASARR- a federal requirement to help ensure that individuals are not appropriately placed in nursing homes for long term care)

47795 Based on, interviews, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident medical, nursing and mental and psychosocial needs for 3 (Resident # 3, 52 and 55) 16 residents reviewed for care plans. 1. The facility failed to ensure Resident # 3's Catheter was addressed on her care plan. 2. The Facility failed to ensure Resident # 52's care plan was updated by removing isolation when the resident no longer medically required it. 3. The facility failed to ensure Resident # 55's Fluid restriction and noncompliance with restrictions was on the care plan. This failure placed the resident at risk for not having their individual needs met in a timely manner and communicated to provide and could result in injury and a decline in physical well-being. Findings included. 1. Review of Resident #3's face sheet, dated 01/31/2022, reflected a 70 -year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of: cognitive communication disorder (difficulty with any aspect of communication that is affected by disruption of cognition such as: attention, memory, organization, and problem solving/ reasoning), complete traumatic( related to physical injury) amputation (surgically cutting off a limb) at level between left hip and knee, pain due to internal orthopedic prosthetic devices ( used to keep fractured bones stabilized and in alignment), implants ( replace missing body parts, and grafts (healthy tissue taken from one part of the body to replace diseased or injured tissue removed from another part of the body), obesity ( having too much body mass- a measurement of a person's weight with respect to his or her height), bipolar disorder (causes extreme mood swings that include emotional highs and lows- depression),schizophrenia (causes delusions- false believe or judgement and hallucinations- see things that are not there like objects, shapes, people or lights) and, anxiety (when the mind and body encounters stressful, dangerous, or unfamiliar situations). 2. Review of Resident # 52 face sheet, dated 1/29/2024, reflected an [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of Unspecified Dementia, moderate, with mood disturbance ( A group of thinking and social symptoms that interferes with daily functioning mood disturbances can include apathy, anxiety and agitation) Essential Hypertension( elevated Blood pressure), Hypothyroidism( a disorder of the thyroid where it does not produce enough hormones) Insomnia( the ability to fall or stay asleep) 3. Review of Resident # 55's face sheet, dated, 1/29/2024, reflected a [AGE] year-old male admitted to the facility on [DATE] with the diagnosis of Hemiplegia and hemiparesis following Cerebral infarction affecting the left side (a paralysis of partial or total body function on one side of the body and weakness as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it. ) Chronic obstructive pulmonary disease (a group of lung disease that block airflow and make it difficult to breathe.), Essential Hypertension (elevated blood pressure), Dysphagia (Difficulty swallowing can have causes that aren't due to underlying disease) 1. Review of Resident #3's Five Day Scheduled MDS, dated [DATE], reflected Resident #3 had a BIMS score of 15 indicated her cognition was intact. Resident #3 was assessed to have an indwelling catheter (a flexible tube inserted through a narrow opening into the bladder for removing fluid). 2. Review of Resident # 52 's Quarterly MDS dated [DATE], reflected Resident # 52 had a BIMS Score of 5 which indicates her cognition was severely impaired. 3. Review of Resident # 55 Quarterly MDS dated [DATE] reflects Resident # 55 had a BIMS score of 10 which indicates his cognition was moderately impaired. Review of Resident #3's Comprehensive Care Plan with a target date of 04/19/2024 reflected Resident #3's catheter was not care planned. Resident #3 required assistance with ADL Care. Review of Resident # 54's comprehensive Care plan with a target date of 3/7/2023 indicates that Resident # 54 on 1/16/2024 requires transmission-based precautions due to a positive covid test. The resident had completed the required 10-day isolation per policy and was asymptomatic on 01/26/2024. Review of Resident # 55's Comprehensive Care Plan with a target date of 3/20/2024, reflected Resident #55's fluid restriction was not on the care plan, nor was his non-compliance with the restriction documented on the care plan. Interview on 01/31/2024 at 9:13 AM The Administrator stated Resident #3's catheter was expected to be on the care plan. She stated to refer to the MDS coordinator concerning any questions about the care plans. She also stated to refer to MDS Coordinator for any possible negative outcomes if catheter was not care planned. She stated the MDS Coordinator was responsible for monitoring care plans. Interview on 01/31/2024 at 11:30 am with the ADM stated her expectations are that the MDS Coordinator keeps the care plans up to date and refer to the DON for that process as she only has a passing knowledge of the process. She was not sure if harm could occur if the care plan was not updated. She was not aware that Resident #52's care plan reflected isolation for Covid. She stated that she was aware of Resident # 55's fluid restriction and his non-compliance with it and thought it was care planned. Interview on 1/31/2024 at 11:00 am with DON, her expectations are that the MDS Coordinator updates the care plans as the residents' needs change. She stated that if the care plan was not updated the staff are not aware how to meet the resident's needs. Interview on 01/31/2024 at 9:43 AM The MDS Coordinator / LVN stated after reviewing Resident #3's comprehensive care plan, Resident #3's catheter was not on the care plan. She stated any Resident with a catheter it was expected to be on the care plan. MDS Coordinator/LVN stated it was missed when Resident #3's care plan was revised/ updated in December 2023. She stated if the catheter was not on the care plan it would not be on the Kardex where the CNAs refer to when giving care to Resident #3. MDS Coordinator/LVN stated the catheter was on Resident #3's physician's orders. She also stated the physician's order on 12/16/2023 for Foley care was referring to Resident #3's catheter. MDS Coordinator stated it was a possibility Resident # 3 may not receive proper treatment during catheter care. She stated it was documented in the nurse's notes Resident #3 was receiving catheter care but it should have been care planned. She also stated it was assessed on the MDS Resident #3 had a catheter. MDS Coordinator/ LVN stated the care plan was developed from the MDS. She stated if the catheter was not care planned the staff would not know the individualized care Resident #13 required for her catheter. Interview on 01/31/2024 at 12:15 pm with MDS Coordinator/LVN stated that she was unaware that Resident # 55 was on a fluid restriction, she reviewed the orders and found the fluid restriction in the dietary order, stating it needed to be care planned so the staff was aware of the restriction. She stated that her plan was to update Resident # 52's care plan when the facility was cleared of all covid and not wearing masks anymore. She stated that it could be confusing for the staff that the care plan stated Resident # 52 was in isolation when there were no supplies outside of her room. Interview on 01/31/2023 at 10:39 AM CNA A stated the CNAs had been in serviced on catheter care (did not know the last time the in-service was given) and CNA B was aware Resident #3 had a catheter. CNA B stated she would need to review the Kardex to determine if catheter care was on the electronic medical record for the CNAs and would give a more definite answer later. (did not receive a response prior to exit). Interview on 01/31/2024 at 10:46 AM CNA B stated Resident #3 did have a catheter and the nurses reviewed catheter care with the staff. Interview on 1/31/2024 at 3 PM CNA K stated that she was not aware Resident # 55 was on a fluid restriction, she stated it is not on the Kardex and she did not receive it in report. She stated to her knowledge Resident #52 was taken out of isolation on 1/16/2024 and there was not any PPE outside of her room. Interview on 1/31/2024 10:40 AM Interview LVN J stated she was aware of Resident # 55's fluid restriction as she checks the trays during lunchtime, and she is aware he is non-compliant always asking for extra fluids with meals. She stated she did not document his behavior and she was unaware some of the staff were unaware of the restriction. She stated the Resident # 52 had recovered from covid and was no longer in isolation. Interview on 1/31/2024 1:00 pm Interview with RN I, she stated that she wa aware of Resident #55's fluid restriction and that he was non-compliant, she seemed surprised that some staff were not aware of it. She stated Resident # 52 was recovered and no longer required isolation. Interview on 01/31/2023 at 10:56 The ADON stated he expected catheters to be care planned. He stated he would defer to the MDS nurse to discuss any further questions about care plans or MDS. He stated the MDS Coordinator had more knowledge about care plans. He stated the MDS nurse was responsible for care plans. Record Review 1/31/2024 09:30 am of Policy Care Plans, comprehensive Person-centered revised March 2022 states 7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: (1) services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; (2) any specialized services to be provided as a result of P ASARR recommendations; and (3) which professional services are responsible for each element of care 11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

Based on observation, interview, and record review the facility failed to ensure residents unable to conduct activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene for two of eight residents (Resident # 11 and Resident # 16) reviewed for quality of life. 1. The facility failed to ensure Resident #11's nails were trimmed. 2. The facility failed to ensure Resident #16's nails were cleaned. These failures could place residents at risk for poor hygiene, dignity issues, and decreased quality of life. Findings included: 1. Record review of Resident #11's face sheet, dated 01/31/2024 reflected an [AGE] year old female admitted to the facility on [DATE] and readmitted on [DATE] with a diagnoses included muscle weakness ( a lack of strength in muscles), cerebral infarction ( caused by impaired blood flow to the brain), chronic pain syndrome ( pain that lasts longer than three months), and cognitive communication deficit (difficulty with any aspect of communication that is affected by disruption of cognition such as: attention, memory, organization, and problem solving/ reasoning). Record review of Resident #11's Quarterly MDS assessment, dated 01/17/2024, reflected Resident #11 had a BIMS score of an 8 indicated her cognition was moderately impaired. Resident #11 did not refuse care. Resident #11 required assistance with ADLs including personal hygiene. Resident #11 required partial to moderate assistance with personal hygiene-the helper does more than half the effort. Helper lifts or holds or supports trunk or limbs and provides more than half the effort. Record review of Resident #11's Comprehensive Care Plan with next review date 04/16/2024, reflected Resident #11 required ADL assist and nursing/therapy assist as needed related to cerebral infarction (caused by impaired blood flow to the brain), weakness (lack of strength), muscle spasms (when your muscles can not relax), and chronic pain issues (pain that lasts longer than three months). Intervention: assist with functioning and ADLs. Observation on 01/29/24 at 9:47 AM revealed Resident #11 was breaking off her nails during the observation. Her nails were thin. Resident #11's forefinger, middle finger and ring finger on her right hand were jagged. There was a sharp piece of nail on her ring finger, and middle finger on her left hand. The other nails on her left hand were jagged. In an interview on 01/29/2024 at 9:50 AM Resident #11 stated her nails were long and she had asked someone to cut them last week. She stated she asked a person who brought her meal tray to her and made up her bed. She stated she also asked another staff who passed out medications approximately 2 weeks ago. Resident #11 stated she was afraid she would scratch herself and cause her skin to become infected or rub her eyes and may scratch her eyeball. She stated she was having to be so careful what she did due to not wanting to scratch herself. 2. Record review of Resident # 16's face sheet dated 01/30/2024 reflected an [AGE] year old female was admitted to the facility on [DATE] and was readmitted on [DATE] with a diagnoses included type 2 diabetes (a condition that happens because of a problem in the way the body regulates and uses sugar as fuel), Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), and muscle weakness (a lack of strength in muscles). Record review of Resident#16's Quarterly MDS Assessment, dated 01/18/2024, reflected Resident #16 had a BIMS score of 2 indicated her cognitive status was severely impaired. Resident was dependent on staff for all ADLs. Resident #16 did not reject care. Record review of Resident #16's Comprehensive Care Plan with a target date of 04/17/2024 reflected Resident #16 required assistance with ADLs. Observation on 01/29/2024 at 10:10 AM revealed Resident #16's forefinger, middle finger and ring finger on her right hand had a blackish hard substance underneath the nails. In an interview on 01/29/2024 at 10:13 AM Resident #16 did not speak during conversation. She would mumble at times. Resident #16 was not interviewable. In an interview on 01/29/2023 at 9:13 AM The Administrator stated the nurses were responsible to trim and clean all resident's nails with a diagnosis of diabetes. She stated it was the CNAs responsibility to clean and trim all other residents' nails. The Administrator also stated she did not know the information of when nail care was to be completed on the residents. She stated if the residents' nails were sharp or jagged there was a possibility a resident may cut themselves or may rub their eyes and scratch the cornea (the transparent part of the eye that covers the iris (the color part of the eye that surrounds the pupil) and the pupil (opening at the center of the iris through which light passes) and allows light to enter the inside. The Administrator stated a resident had a potential of ingesting bacteria into their mouth if there was blackish substance underneath their nails. She stated there was a potential a resident may become ill such as vomiting or diarrhea if the black substance was some type of bacteria. She also stated it was the Director of Nurses responsibility to monitor nail care. In an interview on 01/29/2024 at 9:43 AM MDS Coordinator/LVN stated the nurses were responsible to trim and clean all resident's nails with a diagnosis of diabetes. She stated it was the CNA's responsibility to clean and trim all other residents' nails. MDS Coordinator/ LVN stated the CNAs report to nurses of any diabetic resident's nails needed to be trimmed or cleaned. She stated the nurses makes rounds and check residents, with diabetes, nails. She also stated the CNAs usually did nail care when residents received a shower or as needed. She stated if anyone observed a brownish and/or blackish substance underneath residents nails the nursing staff were expected to clean the resident's nails or ask the appropriate nurse to complete the nail care. She stated the blackish/ brownish substance possibility could be feces or any type of bacteria underneath the resident's nails. MDS Coordinator/LVN stated if a resident swallowed the bacteria there was a possibility a resident may become extremely ill with stomach issues such as diarrhea or vomiting. In an interview on 01/29/2024 at 10:39 AM CNA A stated the CNAs were responsible for nail care unless a resident was a diabetic. She stated the CNAs usually trimmed and cleaned nails during showers. She stated the nails can be cleaned or trimmed by nurses or CNAs as needed. CNA G stated the nursing staff was expected to clean and trim residents' nails immediately if there was a blackish substance underneath the residents' nails and/ or if their nails needed to be trimmed. CNA G stated the blackish substance may be fecal matter underneath the residents' nails. She stated if a resident swallowed the blackish substance there was a possibility a resident may become ill with stomach issues or any type of intestinal issues. She stated a resident may need to be assessed at the emergency room if they became severely ill. She stated she had been in-serviced on cleaning nails . In an interview on 01/29/2024 at 10:47 AM CNA B stated it was the nurses and the CNAs responsibility to trim, cut, and clean residents' fingernails. CNA B stated only the nurses can trim and clean residents with diagnosis of diabetes. CNA B stated if there was a blackish substance underneath a resident's nails there was a possibility the substance was feces. CNA B stated if a resident placed their finger in their mouth the feces could transfer from their fingers to their mouth. CNA B also stated if the resident swallowed bacteria a resident may develop a stomach infection. Review of the Facilities Policy on Activities of Daily Living Supporting, dated 03/2018, reflected Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living. Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene.

Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 2 (Resident # 6 and Resident # 22) of 8 reviewed for Quality of care. The facility failed to maintain the drainage bag to Resident # 6's surgical wound in a position that it could drain. The facility failed to obtain a physician's order for finger sticks for Resident # 22 who was on sliding-scale insulin. These Failures could put the residents at risk for infection, and risk for medical decline. Findings included: Review of Resident # 6's face sheet revealed an [AGE] year-old female, admitted to the facility on [DATE] and readmitted on [DATE], and 1/1/2024 with diagnoses that include Acute Cholecystitis (Inflammation of the Gallbladder), Malignant Neoplasm of Pancreas (A type of cancer that begins as a growth of cells in the pancreas), Diabetes mellitus due to underlying condition (elevated blood sugar due to a medical condition) Review of Resident # 22 face sheet revealed a [AGE] year-old female, admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that include displaced fracture of the left femur (a misaligned fracture of the left leg bone), Fracture of the left ulna and lower end of the left radius ( a break in the bones of the forearm), Type 2 diabetes mellitus with diabetic chronic Kidney disease ( elevated blood sugar that causes kidney damage ), and End Stage Kidney Disease ( the final permanent stage of kidney disease, where Kidney function has declined to the point that the kidneys can no longer function on their own) Review of Resident # 6's Quarterly MDS dated [DATE] reveals a BIMS score of 15 which indicates Resident # 6 was cognitively intact. Review of Resident # 22's Admission MDS dated [DATE] reveals a BIMS score of 13 which indicates Resident # 22 is cognitively intact. Review of Resident #6's care plan with a revision date of 1/18/2024 shows Acute Infection: Cholecystitis with extended antibiotic ordered x 90 days. I also have a drain in place to my right upper abdomen. Interventions include Monitor drain to right upper abdomen for s/s of infection. Review of Resident # 22's care plan with a revision date of 1/29/2024 revealed a listed problem of The resident has Diabetes Mellitus with retinopathy and kidney disease and is on sliding-scale insulin. Interventions include Chemsticks and fasting serum blood sugar as ordered by doctor. A review of Resident # 6's physician orders revealed a current order date of 10/10/2023 Monitor drain site to upper right abdomen for signs and symptoms of infection every shift for prophylaxis, Ordered dated 1/1/2024 Monitor drainage band and notify provide with any concerns every shift. Order dated 1/2/2024 Monitor and document output from drainage bag every shift. Review of Resident # 22's physician orders revealed a current order date of 1/13/2024 Insulin Lispro ( 1 unit dose) 110 unit/ml solution pen injector Inject as per sliding scale: if 150-199= unit, 200- 249 = 2 unit, 250 -299 = 3 unit, 300- 349 = 4 unit, 350 - 400 = 5 unit, subcutaneously three times a day for D.M. There were no orders present to obtain fingerstick for obtaining blood glucose for sliding scale. Review of Resident #6's MAR from January 2024 indicates that the resident is receiving a fingerstick four times a day to monitor for need for insulin sliding scale. Observation of Resident # 6 in the dining room on 1/29/2024 at 12:13 PM revealed drainage bag with a privacy bag (1000 mg foley drainage bag) in a to the right upper abdominal wound was hanging over the right shoulder of Resident # 6. Observation of Resident # 6 1/29/2024 at 1:30 pm in her room revealed the drainage bag was still hanging over her shoulder. Observation of Resident # 6 on 1/31/2024 at 12:34 in the dining room revealed the drainage bag in a privacy bag hanging off the back of the wheelchair. Interview on 1/31/2024 with LVN J on 01/31/2024 at 11:00 am stated she was aware of the drainage bag on Resident #6's wound but did not notice how it was positioned. She stated that the drainage bag should be hung below the wound to ensure gravity drainage. Interview on 1/30/2024 11:45 am RN I stated that she was unaware that there were no finger sticks ordered for Resident # 22 as part of documenting the medication in the MAR, you must input a blood glucose number, the program will not let you administer the medication without it documented. She states she feels there was no harm to the resident since the medication cannot be given with a fingerstick, she stated she was not aware what their policy stated on the matter. She did look up the order and noted there was no order for the actual fingerstick. Interview with DON 1/31/2024 11:00 am She stated they do not have a policy on the management of surgical wound drains. She stated drains to gravity should be below the wound and was not aware how the bag on Resident # 6 was being positioned. She stated that Resident # 6 runs the risk of clogging the drain or getting an infection if the drainage bag is not correctly positioned. DON stated that she was not aware there was not an order for finger sticks on Resident # 22, but upon review of MAR they are being done. She stated the sliding scale order in the MAR requires a blood sugar reading, so it is being done. She does not know what their policy states about having an order from the physician order for finger sticks. She stated since the MAR requires a blood sugar reading to administer the insulin, she felt the resident was not at risk of harm. Interview with ADM 1/31/2024 11:30 am stated that she was not aware of a policy on the management of surgical wound drains, as far as nursing care of the residents she referred to the DON. She referred to the DON on questions regarding Resident # 22. Record Review on 1/31/2024 9:30 am of Policy Diabetes- Clinical Protocol revised November 2020 page 3 2. As indicated, the physician will order appropriate lab tests (for example, periodic finger sticks of A1C) and adjust treatment based on their results and other parameters. (3) Monitor 3 to 4 times a day if on intensive insulin therapy or sliding scale.

Based on interviews and record review the facility failed to ensure residents maintained acceptable parameters of nutritional status for 1 resident ( Resident # 57) of 8 reviewed for accurate weights. The facility failed to establish a consistent method of weighing residents to ensure the accuracy of weight. for 1 resident (Resident # 57) of 8 reviewed for accurate weights. This failure put the residents at risk for undetected weight loss, malnutrition, medical complications poor quality of life. Findings included: Review of Resident # 57 face sheet revealed a [AGE] year-old male, admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that include Heart Failure ( a chronic condition in which the heart doesn't pump blood as well as it should), Acute Respiratory Failure with Hypoxia ( a condition where you don't have enough oxygen in the tissues in your body), Metabolic Encephalopathy ( an acute condition of global cerebral ( Brain) dysfunction in the absence of brain disease. ) Review of Resident # 57's readmission MDS dated [DATE] reveals a BIMS score of 9, which indicates Resident #57 is cognitively moderately impaired. Review of Resident # 57's Physician's order dated 11/07/2023 Weight: Upon admission/ readmission and weekly x 4 weeks. Review of Resident #57 Weight log dated 1/31/2024 revealed. 1/24/2024 155 lbs. Wheelchair 1/17/2024 165 lbs. Mechanical lift 1/12/2024 162 lbs. Wheelchair 1/10/2024 162.2 lbs. Wheelchair 1/9/2024 162 lbs. Mechanical lift 1/7/2024 163.1 lbs. Mechanical lift 1/5/2024 162.8 Wheelchair 1/4/2024 164.2 Mechanical lift 1/3/2024 164.2 Mechanical lift 12/27/2023 160. Wheelchair 12/21/2023 155.4 Mechanical lift Interview of Adm on 1/31/2024 at 11:30 am she referred all medical questions and concerns to DON. Her expectation was the nursing policy was followed. Interview on 1/31/2024 at 11:00 am with DON, her expectation was that weights are done on the same device each time, and if there was a discrepancy to report it to the nurse. DON states policy does not address using the same scale, the staff knows of her expectations of the same scale. They have a CNA who comes in once a week whose only job is to complete weekly weights. She stated that an inaccurate weight on someone with a medical need for the weight can cause potential harm from medical complications.

Based on interviews and record review , the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 1 resident reviewed for pain management (Resident #27), in that: RN C failed to assess and evaluate Resident# 27's existing pain and cause for pain in the administration of an opioid (narcotic). RN C failed to verify last administered dose of an opioid (narcotic) and available PRN pain medications putting the resident at risk for overmedication causing oversedation hypoxia oversedation respiratory failure. This failure placed Resident# 7 residents at risk for continued pain and adverse drug consequences. A record review of Resident# 27's face sheet dated 01/31/24 revealed he was admitted on [DATE] with a diagnosis of Hemiplegia and Hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side (weakness on one side of the body), Cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery (death of tissue in the brain), type 2 diabetes, pressure ulcer of left ankle stage 3, anemia (deficiency of healthy red blood cells in the blood) in chronic kidney disease, and end stage renal disease. A record review of Resident# 27's most recent quarterly MDS dated [DATE] reflected a BIMS score of 13 suggesting cognition is intact. MDS reflected current use of Opioid medication with indication for use. A record review of Resident#27's care plan revised 01/25/24 reflected resident has pain related to cerebral vascular disease (conditions affecting blood flow to the brain) affecting left non-dominant side, CKD 5 (kidney failure), and wounds. Care plan reflects interventions of administering pain meds as ordered by physician, assess for pain every shift, and assess pain for source, duration, and severity. A record review of Resident# 27's orders reflected an active order with a start date of 08/07/23 for Hydrocodone-Acetaminophen oral tablet 5-325MG , 1 tablet by mouth every 8 hours as needed for pain. It also reflected an active order for Tylenol Extra Strength Oral Tablet 500MG (Acetaminophen), 1 tablet by mouth every 6 hours as needed for pain. A record review of Resident#27's nursing medication administration record for dated 01/31/24 reflected Hydrocodone-Acetaminophen oral tablet 5-325MG, 1 tablet by mouth every 8 hours as needed for pain was administered by RN E 01/31/24 at 07:00 AM with a pain assessment of 7. It also reflected Tylenol Extra Strength Oral Tablet 500MG (Acetaminophen), 1 tablet by mouth every 6 hours as needed for pain administered by RN E 01/31/24 at 12:56 PM with a pain assessment of 8. An interview on 01/31/24 at 12:39 PM with Resident# 27 revealed he was in pain. Nursing staff was notified. An observation and interview what date beginning at 12:45 PM revealed RN E went from the nurse's station to the medication cart outside Resident# 27's room. Without assessing Resident# 27's pain or verifying last administered dose; RN E dispensed 1 tablet of Hydrocodone-Acetaminophen oral tablet 5-325MG from a pill blister card into a medicine cup. RN E picked up the medicine cup to enter Resident#27's room. An interview with RN E revealed she did not assess for Resident#27's pain or review the last administered dose of Hydrocodone-Acetaminophen oral tablet 5-325MG. RN E was then observed reviewing the MAR, and stated, oh this was given at 07:00 AM today, it's too soon to give. RN E was then observed calling for the DON in order to waste the dispensed Hydrocodone-Acetaminophen oral tablet 5-325MG that was unable to be administered. An observation 01/31/24 at 12:50 PM revealed RN E entering Resident#27's room and assessing for pain. Resident#27 stated his pain level was an 8 on a scale of 1 to 10. RN E advised Resident#27 it was too soon for Hydrocodone-Acetaminophen oral tablet 5-325MG and asked if he would like his PRN Tylenol Extra Strength Oral Tablet 500MG (Acetaminophen) to which he said yes. An observation 01/31/24 at 12:55 PM revealed RN E dispensing 1 tablet of Tylenol Extra Strength Oral Tablet 500MG (Acetaminophen) in a medicine cup and providing it to Resident#27. An Interview on 01/31/24 at 12:59 PM revealed it was not a standard of practice to dispense medication prior to a pain assessment and administration verification. She said she should assess for pain first, check the order, and verify the last administered dose before dispensing the medication. In an interview on 01/31/24 at 03:12 PM RN E said that if Resident#27 would have received Hydrocodone-Acetaminophen oral tablet 5-325MG too soon it could have caused Resident#27 to become lethargic, his respirations could decrease, and it would not have been good for his kidneys. RN E said Resident #27 was on dialysis which makes the medication harder to process by the kidneys. RN E said she should have verified the last administered dose first before attempting to dispense and administer the medication. In an interview on 01/31/24 at 02:00 PM with LVN D she said the standard process when a resident complains of pain was to first conduct a pain assessment on a scale of 1 to 10 or look for non-verbal cues was the resident is unable to communicate. LVN D said that after the pain assessment, the resident is was given a choice on their available PRN pain medications because some people will not want a narcotic as their first choice. LVN D said it was not standard practice to dispense medication prior to a pain assessment or verification of the last dose administered. In an interview on 01/31/24 at 02:29 PM with the DON, she said the standard process in pain management was to complete a pain assessment to determine intensity and type (sharp/dull) and then to verify the physician orders available to the resident. The DON said the last administered dose should be checked as well. The DON stated that it is not standard practice to dispense medication before those steps are completed and verification takes place. She said it is her expectation that pain is assessed and the last dose is verified before administration of any medication. In an interview on 01/31/24 at 02:53 PM with the Administrator she said it is her expectation that nursing staff are verifying orders to determine what is available to the resident, assessing for pain, and verifying the last administered dose. She said after administration of the medication she expects it to be documented and the resident to be monitored for adverse effects. The Administrator said giving a medication too early could result in making the resident sick or result in adverse drug effects. POLICY: Record review of Administering Medications policy revised April 2019 stated: The individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. Medications are administered in accordance with prescriber orders, including any required time frame.

Based on observation, interview, and record review, the facility failed to administer parenteral fluids consistent with professional standards of practice and in accordance with physician orders for two (Resident #1 and Resident #2) of two residents reviewed for parenteral fluids. 1. The facility failed to ensure RN A and LVN B stopped administration of TPN (nutrition administered intravenously through a large vein near the heart) which could cause tissue damage, while performing a sterile dressing change for Resident #1. 2. The facility failed to ensure Resident #1 and Resident #2 had their central lines maintained per professional standards, physician's order, or facility policy. These failures could place the residents with central lines at risk for serious infection, impaired nutrition, and hospitalization . Findings included: 1) Review of Resident #1's undated face sheet reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included hypomagnesemia (low magnesium level in the blood) , unspecified protein-calorie malnutrition (lack of sufficient nutrients), essential hypertension (high blood pressure), malignant neoplasm of cervix uteri (cancer), unspecified intestinal obstruction, fistula of the intestine (an abnormal connection of two body cavities) and gastroparesis (delay in stomach emptying). Review of Resident #1's admission MDS dated [DATE] reflected a BIMS of 15 indicating intact cognition. Section K reflected the resident received parenteral/IV feeding while not a resident at the facility and while a resident at the facility. Review of Resident #1's comprehensive care plan dated 8/23/23, reflected only a urinary tract infection and she preferred not to attend group activities. The care plan did not address the central line or the total parenteral nutrition. Review of Resident #1's physician order dated 8/25/2023 reflected, TPN 3-1. Infuse via central line at 133.3 ml/hr x 12 hrs at night. Mix vial 1 and vial 2 vitamins prior to infusion. Start 1400, stop 0200. Review of Resident #1's physician order dated 8/29/2023 reflected, Central line dressing and cap change weekly using sterile technique per protocol every day shift every Tuesday. Review of Resident #1's Medication/Treatment Administration Record for 10/1/23 through 10/31/23 reflected the central line dressing was changed on 10/3/23 by RN C. There was no documentation of a dressing change on 10/7/23 as written on the dressing. Review of Resident #1's progress noted dated 10/10/23 at 4:09 PM written by LVN B reflected, During PICC line dressing change, PICC line migrated from original site. Attempt made to locate original measurements of line, but unable to locate any documentation. TPN fluid began seeping through insertion site. On call NP notified. Received orders to discontinue existing PICC and the send resident to emergency department to receive new PICC. PICC line ended up coming all the way out of insertions site before having chance to pull it out. No bleeding noted. Remained at resident for approximately 5 minutes and applied intermittent pressure to site to ensure bleeding would not start. Afterward EMS was notified. Resident left with EMS at approximately 5:30 PM. Observation on 10/10/23 at 10:04 AM, revealed Resident #1 in her room lying in bed with the presence of a double lumen central line in her right, upper chest. Neither lumen was observed marked specifically for TPN. The transparent dressing was curled around the edges and about one third of the dressing was lifted away from her body. Resident #1 pressed on the dressing to make it flat. The dressing was labeled with initials KG and the date 10/7/23. The time of the dressing change was not on the label. Three small black dots to indicate 1cm measurements were visible on the central line. During an observation on 10/10/23 at 4:00 PM, Resident #1 was sitting up on the edge of the bed. The TPN bag was connected to the central line with IV tubing. The IV pump indicated the TPN was infusing at 133 ml/hr. The IV tubing was not taped or secured to the resident. RN A assisted Resident #1 to lay down on the bed. LVN B requested permission to move items off the table in order to use the table for her sterile field. Resident #1 consented. LVN B moved the items, performed hand hygiene, donned a face mask then sterile gloves then prepared her sterile work area. RN A stated to LVN B, I'll remove the old dressing while you do that. Wearing non-sterile gloves, RN A removed the dressing from the chest then stepped back which left the central line and IV tubing unsecured. RN A was not observed wearing a mask. Resident #1 was not observed wearing a mask. Neither RN A nor LVN B were observed to have offered Resident #1 a mask nor instructed her to look away from the procedure. Resident #1 was observed watching the dressing being removed. Resident #1 repositioned herself slightly then as she crossed her arms across her abdomen/chest which placed pressure on the IV tubing which caused the central to protrude further from the insertion site than previously observed. LVN B measured the length of the central line. LVN B stated to RN A, 14 cm or 5.5 inches. RN A was observed leaving the room to verify the length of the previously charted. LVN B was observed cleaning the skin around the insertion site with alcohol swabs from the dressing kit. A white fluid, consistent with the TPN fluid in the bag was observed as it leaked and pooled around the insertion site. LVN B walked around the bed and pushed the pause button on the IV pump. LVN B held gauze on the insertion site. Resident observed the procedure and told LVN B the central line tubing looked different than it had earlier in the day. The alarm on the pump sounded and Resident #1 asked LVN B if she should push the pause button again. LVN B replied, No, we can wait for her to come back in and push the button to stop it. During an interview on 10/10/23 at 10:04 AM, Resident #1 stated her central line dressing needed to be changed because it was not sticking to her skin. She then stated, This is missing the round thing that they usually put on there. When asked if she was referring to an antimicrobial patch she stated, Yes. Resident #1 stated the staff had changed her dressing, Every other week or so. Resident #1 stated, Last time the state was here, a week or two ago, the central line got pulled out a little, but they got right on it. Resident stated the facility got an order for an x-ray. She stated waiting for the x-ray caused a delay in the TPN being administered but, They got it back on schedule. During an interview on 10/10/23 at 3:18 PM with RN A, she stated, she had worked at the facility for about seven years, but most recently working as an agency nurse through the company's agency. She stated central line dressings were checked every shift. She stated dressings were changed every seven days and as needed. She stated she did not have any central line dressing changes scheduled on her shift. She stated she did not know when Resident #1 had been scheduled for a dressing change. RN A checked in the computer and reported the change had been scheduled for 6:00 AM today but it was not signed off as completed. She then stated the pharmacy had been notified by the day shift nurse and they were waiting for the dressing kit to be delivered as they did not have any in stock. She stated on a double lumen central line, the red lumen was used for TPN, and the purple was used for meds and things. She stated she did not know if the facility marked a lumen specifically for TPN and stated she did not know if there was a policy and procedure about the lumen being marked. RN A stated she did not remember any training at this facility regarding central line use and maintenance. She stated she had worked with central lines in the past and was familiar with maintaining central lines. During an interview on 10/10/23 at 3:35 PM with LVN B, she stated she was the treatment nurse and she occasionally changed central line dressings but usually it was done by the floor nurses. She stated she has maintained her IV certification throughout her career, and she completed the on-line course provided by the facility prior to the facility accepting residents requiring TPN. She stated dressing changes should be completed weekly. She stated an adverse outcome for a central line not properly maintained could be infection or death. During an interview on 10/10/23 at 4:38 PM with the ADON, he stated, he had been trained on central lines. His competency had been verified by the DON. He stated for central line dressing changes, he maintained sterile at the start and throughout. He stated the site was assessed prior to changing anything and abnormal findings were reported to the provider. He stated after the old dressing was removed, hand hygiene was performed, and sterile gloves applied. He stated, Use what is in the kit to change the dressing. He stated the label was marked with the date, time, and initials. He stated a mask for the nurse completing the procedure, the resident, and any others in the room during the procedure is required to prevent the spreading of droplets. He stated he expected staff to follow the policies when they changed central line dressings. He stated central line dressings should be changed every seven days unless otherwise ordered. He stated residents were at risk for infection and infections associated with lines if the central line is not properly maintained. During an interview on 10/10/23 at 4:40 PM with RN A, she stated Resident #1 would be sent out to the hospital for placement of a new central line. She stated they had received orders to remove the current central line. During a telephone interview on 10/11/23 at 12:39 PM with PHARM, when asked if TPN solution could be caustic or cause damage to tissue if the central line became dislodged, he stated, it depended on the pH, osmolarity, and the ingredients, but TPN could potentially be caustic if it got in the tissues. Review of the facility's policy titled Parenteral Nutrition, revised March 2022, reflected the following: Preparation 1. A physician's order is necessary for this treatment. The PN order should include the formula or a list of all individual ingredients/nutrients in the base solution, total volume and rate of administration as well as orders for monitoring laboratory results on a routine basis. Safety Precautions 1. Parenteral nutrition orders will include an order for dextrose 10% IV to run at the same rate as PN, in case the PN has to be stopped or discontinued suddenly. 4. Administer PN via an electronic pump. The solution must be filtered. 8. For multi-lumen catheters, specify/label one lumen for PN use only. Do not use this lumen for other infusions or blood sampling. Steps in the procedure 18. Check connections. Secure tubing to resident with tape. Documentation The following should be documented in the resident's medical record. 3. Rate and volume infused. Review of the policy titled Central Venous Catheter Care and Dressing Changes, revised March 2022, reflected the following: General Guidelines 1. Perform site care and dressing change at established intervals or immediately if the integrity of the dressing is compromised (e.g., damp, loosened, or visibly soiled). 3 Change the dressing if it becomes damp, loosened or visibly soiled and: c. immediately if the dressing or cite appear compromised. 5. d. palpate and inspect the skin, dressing and securement device for signs of complications including: dislodgement, redness, tenderness, swelling, infiltration, induration, elevated body temperature or drainage. e. Ask the resident if he or she is experiencing pain, tingling, or numbness. 6. Measure the length of the external central vascular access device with each dressing change or if catheter dislodgement is suspected. Compare with the length documented at insertion. Assessment Observe insertion site and surrounding area for complications. Steps in the Procedure 1. Clean over the bed table with soap and water, or alcohol. 4. Resident should be lying on bed, with head facing opposite direction from dressing site 5. Ask resident to keep arms at side of body or have someone help him or her to do this. 7. e. Label with initials, date and time. Review of the National Library of Medicine website Chapter 4 Manage Central Lines - Nursing Advanced Skills - NCBI Bookshelf (nih.gov) accessed on 10/16/23 read, High osmolarity solutions refer to a highly concentrated solution expressed as the total number of solute particles per liter. High osmolarity solutions, such as total parenteral nutrition and hypertonic IV fluids, are irritating to peripheral vessels and increase the client's risk for phlebitis, thrombosis, and occlusion. Additionally, vesicant medications (such as certain antineoplastic drugs, antibiotics, electrolytes, and vasopressors) can cause severe tissue injury or destruction if they extravasate. Extravasation refers to leakage of fluid into the tissues around the IV site, causing tissue injury when the catheter has dislodged from the blood vessel but is still in the nearby tissue. For this reason, infusions of high osmolarity solutions and vesicant medications are administered through a CVAD into a large vein such as the superior vena cava. When these solutions enter this larger vessel, the solution is hemodiluted, thus minimizing the risk of these complications from occurring. Infiltration or extravasation Palpate over the catheter insertion site dressing and around the surrounding area for sponginess and observe for redness or swelling. Note any labored breathing exhibited by the client or complaints of pain with infusions. Observe IV flow rate for free-flowing fluid. Aspirate for blood return. Stop the infusion and/or administration of the vesicant solution. If extravasation occurs, aspirate any remaining medication from the catheter after disconnection to prevent further damage to vessels. To maintain skin integrity, administer antidote or therapeutic medication as appropriate per protocol.[20] Discontinue IV solutions. Apply warm/cold compresses as recommended by agency policy. Notify the provider and anticipate an order for a chest X-ray to evaluate catheter integrity and placement. 2.) Review of Resident #1's physician order dated 10/11/23 reflected Dextrose Intravenous solution 10% (dextrose) Use 133 ml/hr intravenously as needed for TPN DC or must be stopped Start Dextrose 10% @ 126 ml/hr if suddenly discontinued or TPN must be stopped. Review of Resident #1's Medication Administration Record for 10/1/23 through 10/31/23 did not reflect administration of IV dextrose after the TPN had been stopped. Review of Resident #1's progress notes dated 9/29/23 reflected, Resident reported that during dressing reinforcement yesterday PICC line came out a little bit and was pushed back in by nurse. The dressing was changed and NP notified. Orders received for chest x-ray to verify placement. Review of Resident #1's Medication Administration Record for 9/1/23 through 9/30/23 reflected the central line dressing was changed on 9/26/23. There was no documentation of a dressing change on 9/29/23. Review of Resident #2's undated face sheet reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included postsurgical malabsorption not elsewhere classified, decreased white blood cell count, compression of the first, second, and fifth lumbar vertebra, chronic heart failure, and chronic obstructive pulmonary disease. Review of Resident #2's admission MDS dated [DATE] reflected a BIMS of 14 reflecting intact cognition. Section K reflected the resident received parenteral/IV feeding while not a resident at the facility and while a resident at the facility. Review of Resident #2's comprehensive care plan initiated 8/17/23 reflected the problem The resident requires TPN r/t short gut syndrome. The goal reflected, The resident will remain free of side effects or complications related to TPN through review date. The Intervention reflected, Obtain and monitor lab/diagnostic work as ordered, Report results to MD and follow up as indicated. Another care plan problem reflected, I am on a regular diet, regular texture, regular liquids. I also receive nutrition via TPN. The goal and interventions for this problem did not address the TPN or central line. No other entries on the care plan addressed the TPN or central line. Review of Resident #2's physician order dated 8/20/23 reflected, TPN electrolytes Intravenous Concentrate Use 126.2 ml/hr intravenously one time a day for Nutrition Inject with Vial 1 and 2 of vitamins and infuse over 14 hours. Review of Resident #2's physician order dated 9/6/23 reflected, PICC line dressing and cap change weekly using sterile technique per protocol every day shift every Wednesday. Review of Resident #2's Medication Administration Record for 9/1/23 through 9/30/23 reflected PICC line dressing and cap change weekly using sterile technique per protocol. There was no check mark or initials for Wednesday 9/20/23, indicating the dressing was not changed. The previous dressing change was documented 9/13/23 and the subsequent dressing change was documented on 9/27/23. Review of Resident #2's Medication Administration Record for 10/1/23 through 10/31/23 reflected PICC line dressing and cap change weekly using sterile technique per protocol. A check mark and initials indicated the dressing was last changed on 10/4/23. Observation on 10/10/23 at 10:11 AM revealed Resident #2 lying in bed. A double lumen peripherally inserted central catheter (PICC) was observed in her left upper arm. Neither lumen was marked specifically for TPN. The dressing was not dated, timed, or initialed. Observation on 10/10/23 at 2:55 PM revealed Resident #2 lying in bed. A double lumen PICC was observed in her left upper arm. TPN was connected and infusing. The dressing was dated for 10/7/23 and initialed by RN C. The dressing was not timed. During an observation and interview on 10/11/23 at 11:12 AM, Resident #1 was lying in her bed. She stated she went out to the hospital yesterday, but the hospital wanted to wait a couple of days before replacing the central line. She stated someone was supposed to come out to the facility to insert a new line. She stated she did not get her TPN last night because she did not have a central line in place. No central lines or IV access observed on arms or chest. During an observation and interview on 10/12/23 at 10:10 AM, Resident #1 was observed lying in bed. A PICC line was observed in her left upper arm. The dressing was clean, dry, and intact. An antimicrobial patch was in place at the insertion site. Resident #1 stated she did not get her TPN last night because the x-ray had to be rescheduled. No other IV access observed. During an interview on 10/10/23 at 10:42 AM with RN C, she stated, she did not have any central line dressings scheduled to be changed on her shift. During an interview on 10/10/23 at 10:52 AM with the ADON, he stated central line dressing changes could be changed by LVNs or RNs if they had been trained or checked out first. Central line competencies were requested. During an interview on 10/10/23 at 1:38 with RN C, she stated she had received training on how to change central line dressings, flush and hook up TPN. She stated when she changed a central line dressing, she removed the old dressing, changed gloves, put a mask on herself then one on the resident. She stated she would use the supplies in the dressing kit. Once covered, she wrote her initials and date on the label. She stated they were supposed to put filters on TPN lines then added, Sometimes the filters don't work with the machines. She verified the machine was the electronic IV pump. She stated she looked at the physician orders and the care plan to determine the care needed. She stated if a central line got pulled out, she would flush the line and look at the site. She stated an adverse outcome for a resident if a central line is not properly maintained could be an infection. During an interview on 10/10/23 at 2:11 PM with the MDS nurse, she stated, she expected to find a care plan for TPN that included monitoring the PICC line, dressing changes, flushes, and weight monitoring. She stated if TPN was not care planned, the resident could be at risk for dehydration, heart failure, staff not following up or checking on the resident. During an interview on 10/10/23 at 3:40 PM with RN A, she stated, I think I may have told you wrong, it is the purple line for TPN. During an interview on 10/11/23 at 2:10 PM with the DON, she stated Central line dressings were labeled with the date of the change. She stated she was familiar with the PN policy and stated the facility does follow the policy. She stated the facility did not mark a lumen specific for TPN on double lumen lines, We just use the red one. She stated the facility did not have orders for dextrose should the TPN be stopped unexpectedly. She stated both the DON and ADON were responsible for ensuring staff were trained.

Based on observation, interview, and record revies, the facility failed to have sufficient nursing staff with appropriate competencies and skills sets to provide nursing services to assure resident safety and maintain the highest practicable, physical, well-being of the resident for two (Resident #1 and Resident #2) of two residents and three (RN A, RN C, and LVN D) of four staff reviewed for competent nursing. 1. The facility failed to ensure RN A and LVN B stopped administration of TPN (nutrition administered intravenously through a large vein near the heart) which could cause tissue damage while performing a sterile dressing change for Resident #1. 2. The facility failed to ensure nursing staff (RN A, RN C, and LVN D) who cared for residents with central lines (Resident #1 and Resident #2) were competent in providing care following physician orders and facility policy. These failures could place the residents with central lines at risk for serious infection, impaired nutrition, and hospitalization . Findings included: 1.) Review of Resident #1's undated face sheet reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included hypomagnesemia (low magnesium level in the blood), unspecified protein-calorie malnutrition (lack of sufficient nutrients), essential hypertension (high blood pressure), malignant neoplasm of cervix uteri (cancer), unspecified intestinal obstruction, fistula of the intestine (an abnormal connection of two body cavities) and gastroparesis (delay in stomach emptying). Review of Resident #1's admission MDS dated [DATE] reflected a BIMS of 15 indicating intact cognition. Section K reflected the resident received parenteral/IV feeding while not a resident at the facility and while a resident at the facility. Review of Resident #1's comprehensive care plan dated 8/23/23, reflected only a urinary tract infection and she preferred not to attend group activities. The care plan did not address the central line or the total parenteral nutrition. Review of Resident #1's physician order dated 8/25/2023 reflected, TPN 3-1. Infuse via central line at 133.3 ml/hr x 12 hrs at night. Mix vial 1 and vial 2 vitamins prior to infusion. Start 1400, stop 0200. Review of Resident #1's physician order dated 8/29/2023 reflected, Central line dressing and cap change weekly using sterile technique per protocol every day shift every Tuesday. Review of Resident #1's Medication/Treatment Administration Record for 10/1/23 through 10/31/23 reflected the central line dressing was changed on 10/3/23 by RN C. There was no documentation of a dressing change on 10/7/23 as written on the dressing. Review of Resident #1's Medication Administration Record for 10/1/23 through 10/31/23 reflected the central line dressing was changed on 10/3/23 by RN C. There was no documentation of a dressing change on 10/7/23. Review of Resident #1's progress noted dated 10/10/23 at 4:09 PM written by LVN B reflected, During PICC line dressing change, PICC line migrated from original site. Attempt made to locate original measurements of line, but unable to locate any documentation. TPN fluid began seeping through insertion site. On call NP notified. Received orders to discontinue existing PICC and the send resident to emergency department to receive new PICC. PICC line ended up coming all the way out of insertions site before having chance to pull it out. No bleeding noted. Remained at resident for approximately 5 minutes and applied intermittent pressure to site to ensure bleeding would not start. Afterward EMS was notified. Resident left with EMS at approximately 5:30 PM. Observation on 10/10/23 at 10:04 AM, revealed Resident #1 in her room lying in bed with the presence of a double lumen central line in her right, upper chest. Neither lumen was observed marked specifically for TPN. The transparent dressing was curled around the edges and about one third of the dressing was lifted away from her body. Resident #1 pressed on the dressing to make it flat. The dressing was labeled with initials KG and the date 10/7/23. The time of the dressing change was not on the label. Three small black dots to indicate 1cm measurements were visible on the central line. During an observation on 10/10/23 at 4:00 PM, Resident #1 was sitting up on the edge of the bed. The TPN bag was connected to the central line with IV tubing. The IV pump indicated the TPN was infusing at 133 ml/hr. The IV tubing was not taped or secured to the resident. RN A assisted Resident #1 to lay down on the bed. LVN B requested permission to move items off the table in order to use the table for her sterile field. Resident #1 consented. LVN B moved the items, performed hand hygiene, donned a face mask then sterile gloves then prepared her sterile work area. RN A stated to LVN B, I'll remove the old dressing while you do that. Wearing non-sterile gloves, RN A removed the dressing from the chest then stepped back which left the central line and IV tubing unsecured. RN A was not observed wearing a mask. Resident #1 was not observed wearing a mask. Neither RN A nor LVN B were observed to have offered Resident #1 a mask nor instructed her to look away from the procedure. Resident #1 was observed watching the dressing being removed. Resident #1 repositioned herself slightly then was observed as she crossed her arms across her abdomen/chest which placed pressure on the IV tubing which caused the central to protrude further from the insertion site than previously observed. LVN B was observed as she measured the length of the central line. LVN B stated to RN A, 14 cm or 5.5 inches. RN A was observed leaving the room to verify the length of the previously charted. LVN B was observed cleaning the skin around the insertion site with alcohol swabs from the dressing kit. A white fluid, consistent with the TPN fluid in the bag was observed as it leaked and pooled around the insertion site. LVN B walked around the bed and pushed the pause button on the IV pump. LVN B held gauze on the insertion site. Resident observed the procedure and told LVN B the central line tubing looked different than it had earlier in the day. The alarm on the pump sounded and Resident #1 asked LVN B if she should push the pause button again. LVN B replied, No, we can wait for her to come back in and push the button to stop it. During an interview on 10/10/23 at 3:18 PM with RN A, she stated, she had worked at the facility for about seven years, but most recently working as an agency nurse though the company's agency. She stated central line dressings were checked every shift. She stated dressings were changed every seven days and as needed. She stated she did not have any central line dressing changes scheduled on her shift. She stated she was the nurse assigned to Resident #1 but she did not know when Resident #1 had been scheduled for a dressing change. RN A checked in the computer and reported the change had been scheduled for 6:00 AM today but it was not signed off as completed. She then stated the pharmacy had been notified and they were waiting for the dressing kit to be delivered as they did not have any in stock. She stated on a double lumen central line, the red lumen was used for TPN, and the purple was used for meds and things. She stated she did not know if the facility marked a lumen specifically for TPN and stated she did not know if there was a policy and procedure about the lumen being marked. RN A stated she did not remember any training at this facility regarding central line use and maintenance. She stated she had worked with central lines in the past. During an interview on 10/10/23 at 3:35 PM with LVN B, she stated she was the treatment nurse and she occasionally changed central line dressings but usually it was done by the floor nurses. She stated she has maintained her IV certification throughout her career, and she completed the on-line course provided by the facility prior to the facility accepting residents requiring TPN. She stated dressing changes should be completed weekly. She stated an adverse outcome for a central line not properly maintained could be infection or death. During an interview on 10/10/23 at 4:38 PM with the ADON, he stated, he had been trained on central lines. His competency had been verified by the DON. He stated for central line dressing changes, he maintained sterile at the start and throughout. He stated the site was assessed prior to changing anything and abnormal findings were reported to the provider. He stated after the old dressing was removed, hand hygiene was performed, and sterile gloves applied. He stated, Use what is in the kit to change the dressing. He stated the label was marked with the date, time, and initials. He stated a mask for the nurse completing the procedure, the resident, and any others in the room during the procedure was required to prevent the spreading of droplets. He stated it did not meet his expectations if the resident and a nurse did not wear a mask during a central line dressing change. He stated if a nurse had not taken the IV class they would not participate in that practice. He stated he and the DON were responsible for monitoring the completion of training. He stated, to his knowledge, the IV Mastery course was not required. During an interview on 10/10/23 at 4:40 PM with RN A, she stated Resident #1 would be sent out to the hospital for placement of a new central line. She stated they had received orders to remove the current central line. During a telephone interview on 10/11/23 at 12:39 AM with PHARM, he stated, it depended on the pH, osmolarity, and the ingredients, but TPN could potentially be caustic if it got in the tissues. Review of the facility's policy titled Parenteral Nutrition, revised March 2022, reflected the following: Preparation 2. A physician's order is necessary for this treatment. The PN order should include the formula or a list of all individual ingredients/nutrients in the base solution, total volume and rate of administration as well as orders for monitoring laboratory results on a routine basis. Safety Precautions 2. Parenteral nutrition orders will include an order for dextrose 10% IV to run at the same rate as PN, in case the PN has to be stopped or discontinued suddenly. 5. Administer PN via an electronic pump. The solution must be filtered. 9. For multi-lumen catheters, specify/label one lumen for PN use only. Do not use this lumen for other infusions or blood sampling. Steps in the procedure 18. Check connections. Secure tubing to resident with tape. Documentation The following should be documented in the resident's medical record. 6. Rate and volume infused. Review of the policy titled Central Venous Catheter Care and Dressing Changes, revised March 2022, reflected the following: General Guidelines 2. Perform site care and dressing change at established intervals or immediately if the integrity of the dressing is compromised (e.g., damp, loosened, or visibly soiled). 4 Change the dressing if it becomes damp, loosened or visibly soiled and: c. immediately if the dressing or cite appear compromised. 5. d. palpate and inspect the skin, dressing and securement device for signs of complications including: dislodgement, redness, tenderness, swelling, infiltration, induration, elevated body temperature or drainage. e. Ask the resident if he or she is experiencing pain, tingling, or numbness. 6. Measure the length of the external central vascular access device with each dressing change or if catheter dislodgement is suspected. Compare with the length documented at insertion. Assessment Observe insertion site and surrounding area for complications. Steps in the Procedure 2. Clean over the bed table with soap and water, or alcohol. 7. Resident should be lying on bed, with head facing opposite direction from dressing site . 8. Ask resident to keep arms at side of body or have someone help him or her to do this. 8. e. Label with initials, date and time. Documentation 1. The following information should be recorded in the resident's medical record: a. Date and time dressing was changed. b. location and objective description of insertion site. e. any questions, education given to resident, resident's statement regarding IV therapy and response to procedure. Review of the National Library of Medicine website Chapter 4 Manage Central Lines - Nursing Advanced Skills - NCBI Bookshelf (nih.gov) accessed on 10/16/23, High osmolarity solutions refer to a highly concentrated solution expressed as the total number of solute particles per liter. High osmolarity solutions, such as total parenteral nutrition and hypertonic IV fluids, are irritating to peripheral vessels and increase the client's risk for phlebitis, thrombosis, and occlusion. Additionally, vesicant medications (such as certain antineoplastic drugs, antibiotics, electrolytes, and vasopressors) can cause severe tissue injury or destruction if they extravasate. Extravasation refers to leakage of fluid into the tissues around the IV site, causing tissue injury when the catheter has dislodged from the blood vessel but is still in the nearby tissue. For this reason, infusions of high osmolarity solutions and vesicant medications are administered through a CVAD into a large vein such as the superior vena cava. When these solutions enter this larger vessel, the solution is hemodiluted, thus minimizing the risk of these complications from occurring. 2.) Review of Resident #1's physician order dated 10/11/23 at reflected Dextrose Intravenous solution 10% (dextrose) Use 133 ml/hr intravenously as needed for TPN DC or must be stopped Start Dextrose 10% @ 126ml/hr if suddenly discontinued or TPN must be stopped. Review of Resident #1's Medication Administration Record for 10/1/23 through 10/31/23 did not reflect administration of IV dextrose after the TPN had been stopped. Review of Resident #1's progress notes dated 9/29/23 reflected, Resident reported that during dressing reinforcement yesterday PICC line came out a little bit and was pushed back in by nurse. The dressing was changed and NP notified. Orders received for chest x-ray to verify placement. Review of Resident #1's Medication Administration Record for 9/1/23 through 9/30/23 reflected the central line dressing was changed on 9/26/23. There was no documentation of a dressing change on 9/29/23. Review of Resident #2's undated face sheet reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included postsurgical malabsorption not elsewhere classified, decreased white blood cell count, compression of the first, second, and fifth lumbar vertebra, chronic heart failure, and chronic obstructive pulmonary disease. Review of Resident #2's admission MDS dated [DATE] reflected a BIMS of 14 reflecting intact cognition. Section K reflected the resident received parenteral/IV feeding while not a resident at the facility and while a resident at the facility. Review of Resident #2's comprehensive care plan initiated 8/17/23 reflected the problem The resident requires TPN r/t short gut syndrome. The goal reflected, The resident will remain free of side effects or complications related to TPN through review date. The Intervention reflected, Obtain and monitor lab/diagnostic work as ordered, Report results to MD and follow up as indicated. Another care plan problem reflected, I am on a regular diet, regular texture, regular liquids. I also receive nutrition via TPN. The goal and interventions for this problem did not address the TPN or central line. No other entries on the care plan addressed the TPN or central line. Review of Resident #2's physician order dated 8/20/23 reflected, TPN electrolytes Intravenous Concentrate Use 126.2 ml/hr intravenously one time a day for Nutrition Inject with Vial 1 and 2 of vitamins and infuse over 14 hours. Review of Resident #2's physician order dated 9/6/23 reflected, PICC line dressing and cap change weekly using sterile technique per protocol every day shift every Wednesday. Review of Resident #2's Medication Administration Record for 9/1/23 through 9/30/23 reflected PICC line dressing and cap change weekly using sterile technique per protocol. There was no check mark or initials for Wednesday 9/20/23, indicating the dressing was not changed. The previous dressing change was documented 9/13/23 and the subsequent dressing change was documented on 9/27/23. Review of Resident #2's Medication Administration Record for 10/1/23 through 10/31/23 reflected PICC line dressing and cap change weekly using sterile technique per protocol. A check mark and initials indicated the dressing was last changed on 10/4/23. Observation on 10/10/23 at 10:11 AM revealed Resident #2 lying in bed. A double lumen peripherally inserted central catheter (PICC) was observed in her left upper arm. Neither lumen was marked specifically for TPN. The dressing was not dated, timed, or initialed. Observation on 10/10/23 at 2:55 PM revealed Resident #2 lying in bed. A double lumen PICC was observed in her left upper arm. TPN was connected and infusing. The dressing was dated for 10/7/23 and initialed by RN C. The dressing was not timed. During an observation and interview on 10/11/23 at 11:12 AM, Resident #1 was lying in her bed. She stated she went out to the hospital yesterday, but the hospital wanted to wait a couple of days before replacing the central line. She stated someone was supposed to come out to the facility to insert a new line. She stated she did not get her TPN last night because she did not have a central line in place. No central lines or IV access observed on arms or chest. During an observation and interview on 10/12/23 at 10:10 AM, Resident #1 was observed lying in bed. A PICC line was observed in her left upper arm. The dressing was clean, dry, and intact. An antimicrobial patch was in place at the insertion site. Resident #1 stated she did not get her TPN last night because the x-ray had to be rescheduled. No other IV access observed. During an interview on 10/10/23 at 10:04 AM, Resident #1 stated her central line dressing needed to be changed because it was not sticking to her skin. She then stated, This is missing the round thing that they usually put on there. When asked if she was referring to an antimicrobial patch she stated, Yes. Resident #1 stated the staff had changed her dressing, Every other week or so. Resident #1 stated, Last time the state was here, a week or two ago, the central line got pulled out a little, but they got right on it. Resident stated the facility got an order for an x-ray. She stated waiting for the x-ray caused a delay in the TPN being administered but, They got it back on schedule. During an interview on 10/10/23 at 10:42 AM with RN C, she stated, she was the nurse for Resident #1 and Resident #2 and she did not have any central line dressings scheduled to be changed on her shift. During an interview on 10/10/23 at 10:52 AM with the ADON, he stated central line dressing changes could be changed by LVNs or RNs if they had been trained or checked out first. Central line competencies were requested. During an interview on 10/10/23 at 1:38 with RN C, she stated she had received training on how to change central line dressings, flush and hook up TPN. She stated when she changed a central line dressing, she removed the old dressing, changed gloves, put a mask on herself then one on the resident. She stated she would use the supplies in the dressing kit. Once covered, she wrote her initials and date on the label. She stated they were supposed to put filters on TPN lines then added, Sometimes the filters don't work with the machines. She verified the machine was the electronic IV pump. She stated she looked at the physician orders and the care plan to determine the care needed. She stated if a central line got pulled out, she would flush the line and look at the site. She stated an adverse outcome for a resident if a central line is not properly maintained could be an infection. During an interview on 10/10/23 at 2:11 PM with the MDS nurse, she stated, she expected to find a care plan for TPN that included monitoring the PICC line, dressing changes, flushes, and weight monitoring. She stated if TPN was not care planned, the resident could be at risk for dehydration, heart failure, staff not following up or checking on the resident. During an interview on 10/10/23 at 3:40 PM with RN A, she stated, I think I may have told you wrong, it is the purple line for TPN. During an interview on 10/11/23 at 10:51 AM with the ADON, he stated staffing was determined by the complexity, acuity, and skills required for each resident. The resident needs were determined by their assessment and care plan. He stated they were currently reviewing the process to determine how agency staff competencies were assessed. He stated there were monthly CEU requirements and they give in-services as needed. He stated about once a year they get everyone together for skills, corporate provides the checklist for those skills. Requested training records. During an interview on 10/11/23 at 1:35 PM with the DON, she stated the DON, ADON, or designee were responsible to ensure training was complete for new employees. She stated agency staff should be trained by the facility they orient at so the facility should have a file for RN A. She stated staffing was not different because of the TPN, RNs hang the TPN and LVNs maintain it. She stated LVNs were trained with IV certification. She stated it did not meet her expectations that a dressing was observed with no date in the morning then in the afternoon the dressing was observed with a date three days prior to the observation. Requested policy and procedure for staff training and competencies. Requested training records. During an interview on 10/11/23 at 2:10 PM with the DON, she stated Central line dressings were labeled with the date of the change. She stated she was familiar with the PN policy and stated the facility does follow the policy. She stated the facility did not mark a lumen specific for TPN on double lumen lines, We just use the red one. She stated the facility did not have orders for dextrose should the TPN be stopped unexpectedly. During an interview on 10/12/23 at 10:12 AM with LVN D, she stated prior to this week, she had not had any training on central lines since working at this facility. She stated she did receive IV and central line training in nursing school. She stated she has been an LVN for two years and started working at this facility at the end of July this year. She stated she was not sure if a particular line was marked for TPN since she was an LVN, she does not hang the TPN but she can flush the lines and change the dressings. She stated she has changed central line dressings at this facility. She stated clots or infections could be a possible negative outcome if central lines were not properly maintained. During an interview on 10/12/23 at 11:09 AM with the DON, she stated, they do not really have a policy about training but provided a policy about On-the-Job Training. She stated there was a list of trainings that must be completed by newly hired employees. Requested the training files for three staff members including LVN D. Review of the facility's policy titled On-the-Job Training, revised January 2008, reflected the following: 2. Department directors will be responsible for on-the-job training to assure that our established training schedules are followed. 7. Training records will be filed in the employee's personnel file or may be maintained by the department supervisor. Review of the IV-Central Vascular Access and Midline- Dressing Change Skill Assessments provided for currently employed RNs and LVNs reflected a completed skill assessment for LVN B dated 5/9/23. There was no skill assessment for RN A, RN C, or LVN D. Review of the IV Mastery Certificate of Completions provided reflected no certificate for RN A, RN C, or LVN D. No other training records were provided prior to the survey exit.

Based on interview and record review, the facility failed to ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote wound healing, prevent infection and prevent new pressure ulcers from developing for one (Resident #1) of four residents reviewed for pressure injuries, in that: The facility failed to ensure Resident #1 received treatments to his left heel pressure injury as ordered by the physician when the resident was moved to the COVID-19 unit. The wound increased in size and developed a foul odor with 100% slough (entire wound covered in yellow/white material consisting of dead cells) under an eschar (type of dead tissue that adheres to a wound bed) layer. The facility failed to ensure Resident #1 received treatment to his left heel pressure injury as ordered by the physician on 1/12/23 after being moved off the COVID-19 unit. The facility failed to ensure Resident #1 received treatments to his left lateral ankle injury as ordered by the physician when the resident was moved to the COVID-19 unit. This failure placed residents at risk of improper wound management, the development of new pressure injuries, deterioration in existing pressure injuries, infection, and pain. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including acute kidney failure, type II diabetes, stroke, and fracture of his left femur. Review of Resident #1's quarterly care plan, revised 11/23/22, reflected he was at risk for pressure ulcer/impaired skin integrity related to impaired mobility, incontinence, and diabetes, and he acquired a pressure injury to his left heel and left lateral upper ankle on 10/12/22. The interventions were providing treatment per physician orders and utilizing a heel protector while in bed (non-compliant). It further reflected [Resident #1] verbalized understanding of the benefits of pressure relief (decrease pressure, increase healing), and potential adverse effects of non-compliance (non-healing wound, infection, amputation, etc.) Review of Resident #1's quarterly MDS assessment, dated 12/09/22, reflected a BIMS of 12, indicating a moderate cognitive impairment. Section M (Skin Conditions) reflected Resident #1 had one unstageable pressure ulcer/injury and was at risk of developing pressure ulcers/injuries. Review of Resident #1's physician order, dated 12/14/22 reflected an order to cleanse left heel DTI with wound cleanser. Apply Santyl to wound bed. Cover with a non-stick dressing and wrap with kerlix QD and PRN shift. Review of Resident #1's physician order, dated 12/29/22, reflected an order to cleanse left lateral upper ankle with wound cleanser. Apply honey to wound bed. Cover with a dry dressing QD and PRN shift. Review of Resident #1's January TAR, on 02/07/23, reflected no documentation as to why treatments were missed for both wounds 01/03/23 - 01/06/23 and 01/12/23. It was documented that Resident #1 refused wound treatment on 01/02/23 and 01/07/23. Review of Resident #1's Wound Care Progress Note documented by the WCD, dated 12/27/22, reflected an unstageable pressure ulcer to the left heel, measuring 4.5 cm x 7.0 cm x 0.2 cm and a stage II pressure ulcer to the left lateral upper ankle, measuring 1.0 cm x 1.5 cm x 0.2 cm. Wound to heel remains essentially unchanged from previous assessment. There were no more wound care assessments completed by the WCD prior to the missed treatments 01/03/23 - 01/06/23. Review of Resident #1's Wound Care Progress Note documented by the WCD, dated 01/10/23, reflected an unstageable pressure ulcer to the left heel, measuring 5.0 cm x 8.0 cm x 0.5 cm and a stage II pressure ulcer to the left lateral ankle, measuring 1.5 cm x 1.0 cm x 0.1 cm. Wound to heel has a foul odor due to 100% slough under eschar layer. This was the first assessment conducted by the WCD after the four days (01/03/23 - 01/06/23) of missed treatments. Review of Resident #1's Wound Care Progress Note documented by the WCD, dated 01/24/23, reflected an unstageable pressure ulcer to the left heel, measuring 16.5 cm x 5.0 cm x 13.0 cm and a stage II pressure ulcer to the left lateral upper ankle, measuring 1.0 cm x 1.5 cm x 0.1 cm. Wound to heel is deteriorating. This was the last assessment conducted by the WCD before being sent to the hospital. Review of Resident #1's wound culture results, reported 01/23/23, reflected there was infection present to the left heel. Review of Resident #1's physician order, dated 01/24/23, reflected an order to be transferred to the hospital due to left heel infection and necrosis, per the WCD. Review of Resident #1's hospital records, dated 01/31/23, reflected the plan was for IR guided vascular intervention; will require debridement or amputation after. During a telephone interview on 02/07/23 at 10:17 AM with Resident #1's FM, she stated she was aware of his wound, but had no idea it was as bad as it was. She stated he was in a lot of pain and his left leg would be amputated the following day, 02/08/23. She stated she felt the staff at the facility had not properly cared for his wounds. During an interview on 02/07/23 at 12:58 PM with the WCD, she stated her expectations were that her treatment orders were followed. She stated she would be concerned if any treatments were missed, especially Resident #1 going four days in a row without treatment. She stated, however, she did not think the missed treatments were what led to the infection or hospitalization . She stated Resident #1 would often walk on the wound and was non-compliant with his heel protector. During an interview on 02/07/23 at 1:58 PM with LVN A, she stated when the TN was off or if it was a weekend, the DON/ADON would document on the printed schedule that the nurses were responsible for providing wound care on that specific day. She stated there was also a yellow tab that popped up in the residents' EMR that reminded the nurse to provide wound care. She stated she had not worked the isolation unit in a while, but all nurses had been educated to provide wound care and to follow physician orders while on isolation. During an interview on 02/07/23 at 2:02 PM with the DON, she stated their treatment nurse provided all wound treatments Monday - Friday. She stated on the weekends or when the TN was off, it was the responsibility of the charge nurses to provide wound treatments. She stated when the TN was off, an alert popped up in the residents' EMR. She stated she was not sure why Resident #1's wound treatments were missed on 01/12/23. She stated Resident #1 was in isolation due to contracting COVID-19 from 12/29/22 - 01/09/23. She stated she thought that the nurses in the isolation unit did not provide wound treatments because they assumed the TN would be completing them. She stated they continued to have designated staff when they had COVID-positive residents. The DON stated during those times, the TN did not go into the isolation unit. She stated it was the responsibility of herself or the ADON to communicate that to the nurses in the isolation unit. She stated the nurses knew they were supposed to be doing the treatments as it had been discussed multiple times, and she was trying to find out why they were not done, and had been unaware they had not been done. She stated it was ultimately her responsibility to ensure all wound treatments were being done. She stated it was extremely important to follow the WCD's orders as it could lead to infection or the skin breaking down further. During an interview on 02/07/23 at 2:11 PM with the TN, she stated she was responsible for all wound treatments unless it was a weekend, she was off, or if the resident was in isolation for COVID-19. She stated the nurses were well aware they were to provide wound treatments when the residents were in isolation, as they had been doing it that way since the pandemic started. She stated when she was off, it was written on the schedule for the nurses to see (that they needed to provide wound care) and a reminder would pop up in the residents' EMR. She stated it was very important to follow treatment orders. She stated if one day was missed, she did not believe there would be a negative outcome, but if multiple days were missed a wound could worsen. During an interview on 02/07/23 at 2:17 PM with the ADM, she stated her expectations were that treatment orders be followed. She stated when the TN was off, it was the responsibility of the DON/ADON to document it on the printed schedule. She stated nurses had been educated that if they were working the isolation unit, they were to provide wound care. She stated she was unsure of why it was not done. She stated the two nurses (LVN B and LVN C) who should have provided the treatment from 01/03/23 - 01/06/23 no longer worked with the company. She stated if wound care treatment orders were not followed, wounds could get worse which could lead to infections. On 02/08/23 at 3:15 PM and 3:19 PM, a message was left for LVN B and LVN C, requesting a call back. Review of the facility's Pressure Ulcers/Skin Breakdown Policy, revised April of 2018, reflected the following: Treatment/Management: 1. The physician will order pertinent wound treatments . The policy did not reference following physician orders for wound treatments.

Based on observation, interview and record review the facility failed to notify a resident's physician of a significant change of condition for one (Resident #1) of three residents reviewed for hydration, weight loss, medication refusal and critical lab values. The facility failed to consult with Resident #1's physician when she suffered a severe weight loss, had critical lab values and was refusing medications and meals. Resident #1 was hospitalized on [DATE] with [DIAGNOSES REDACTED]. Resident #1 expired in the hospital on [DATE]. These failures resulted in an identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was lowered on [DATE], the facility remained out of compliance at a level of actual harm with a scope identified as a pattern. This failure affected one resident and has the potential to affect the other 82 residents at the facility should they experience a change in condition. Findings Include: In an interview on [DATE] at 9:37 a.m., the POA called to inform the state that the resident had passed away. Record review of Resident #1's face sheet on [DATE] revealed the resident to be an [AGE] year-old woman admitted on [DATE] with a [DIAGNOSES REDACTED]. The facility did not include the [DIAGNOSES REDACTED]. Record review of Resident #1's MDS resident assessment and care screening on [DATE] revealed that the MDS did not list [MEDICAL CONDITION] as a diagnosis. MDS care area assessment revealed that the resident did not exhibit behavioral symptoms, signs of [MEDICAL CONDITION], acute onset mental status change, and had a mood severity score of zero with no potential indicators of [MEDICAL CONDITION]. Resident had an MDS BIMS score of 5. Review of MDS history revealed that the facility did not conduct an MDS assessment for a change in condition for Resident #1. Further review of MDS revealed that the MDS did not list [MEDICAL CONDITION] as a diagnosis. MDS care area assessment revealed that the resident did not exhibit behavioral symptoms, signs of [MEDICAL CONDITION], acute onset mental status change, and had a mood severity score of zero with no potential indicators of [MEDICAL CONDITION]. Resident had an MDS BIMS score of 5. Review of MDS history revealed that the facility did not conduct an MDS assessment for a change in condition for Resident #1. Record review of care plan for Resident #1 (Start dated: [DATE], Completion Date: [DATE]) created by MDSN, revealed that the facility was to monitor/document change in behavior, change in eating patterns. Monitor/document/report to PRN Change on Mental status, emaciation, weight loss. Alert dietician if consumption is poor for more than 48 hours, weight decline persists, contact physician and dietician immediately. Resident was not care planned for a GDR, [MEDICAL CONDITION], or dehydration. Review of the care plan does not have signatures from the facility staff, resident, resident POA, or resident physician. Record review on [DATE] of History and Physical electronically signed by DR on [DATE] revealed that Resident #1 had a history of [REDACTED]. Resident was admitted to the hospital on ,[DATE] for acute [MEDICAL CONDITION] related to dehydration from inadequate intake and hospitalized again on ,[DATE] for acute on [MEDICAL CONDITION] and acute UTI. Resident was seen in office on ,[DATE], the renal status was noted to be stable. Review of facility Care Area Assessments (CAA) policy (Dated: 2001) states: CAAs will be used to help analyze data to obtain from the MDS and to develop individualized care plans. CAAs are linked between assessment and care planning. Triggered Care Areas will be evaluated by the Interdisciplinary Team to determine the underlying causes, potential consequences and relationship to other trigger areas. In an interview on [DATE] at 4:47 p.m., POA stated that Resident #1's condition got so bad that she was severally dehydrated and that her kidneys are dried out and shutting down, her mouth was bloody, blistered and raw. Stated that the urine in the catheter showed a brown orange color when she was admitted because she was so dry. Stated that Resident #1 was not able to be completely revived so they have taken her off everything and are preparing for Hospice care. Stated that the resident is on [MEDICATION NAME] and IV for hydration. Stated that the DR told her that the facility never notified him about the resident's condition. POA stated that the facility never had a treatment plan meeting for Resident #1 and did not have any meetings about the resident's care. Stated the facility never called to inform her about the resident's infection. In an interview on [DATE] at 5:47 p.m. Hospital Nurse Manager stated that she was told patient was covered in feces and bruises. Stated that there was an APS referral and DR was the admitting physician. Stated that she was told Resident #1 had while yellow plaque, moaning and did not respond to any questions, severally dehydrated. Stated that the nursing home sent resident to the hospital because she was unresponsive. Stated that hospital staff stated that she came for dehydration. Stated that she worked at a nursing home and that she knows you can't make people drink but they should have done some kind of intervention. In an interview on [DATE] at 3:45 p.m. MDSN stated that she completes the MDS resident assessment and care screening for admitting residents. Stated that she put in active and pertinent [DIAGNOSES REDACTED]. Stated that a history of [MEDICAL CONDITION] and dehydration would be significant to a resident's care if they were on a medication like [MEDICATION NAME] or on a diuretic like [MEDICATION NAME]. MDSN stated that a resident's care plan would address the active and pertinent [DIAGNOSES REDACTED]. Stated that she was unaware of Resident #1's history of [MEDICAL CONDITION] caused by dehydration and that she may have overlooked it. MDSN stated that the she would do an MDS resident assessment and care screening for residents with a change in condition. Stated that nurses should be seeing the change in behaviors and do a change of condition and let the doctor know. Stated that the nurse notes would be under resident name and under assessments tab in point click care system. MDSN stated that she can conduct an MDS assessment for a change in condition if she feels it is needed. MDSN stated that she does not sign off on the MDS resident assessments because she is only an LVN and that the DON is the person that signs off on the MDS assessments. MDSN stated that she looked back at Resident #1's H&P and saw the acute chronic [MEDICAL CONDITION]. MDSN stated that the [MEDICAL CONDITION] should have been put on the resident's chart as a diagnosis. Stated that she looked over it and did not put it on the resident's chart. Stated that if she would have put the [DIAGNOSES REDACTED].#1's chart the facility could have care planned for it. In an interview on [DATE] at 9:40 a.m. RD stated there was no indication of that in Resident #1 had a [DIAGNOSES REDACTED]. In an interview on [DATE] at 11:13 a.m. DON stated she did not know about Resident #1's renal [DIAGNOSES REDACTED]. DON stated that the [MEDICAL CONDITION] caused by dehydration should have been triggered onto resident's diagnosis. DON stated that yes knowing the history of the resident would have triggered the facility to be aware of the resident's condition. DON stated that the [DIAGNOSES REDACTED]. DON stated that she did not review Resident #1's MDS assessment before signing off on it. In an interview on [DATE] at 1:00 p.m., LVN 1 stated that she did not know about Resident #1's history of [MEDICAL CONDITION] due to dehydration. Record Review of Facility Lab results for Resident #1's revealed she has labs conducted twice while at the facility, on [DATE] there is a critical Value of Glucose at 47, normal range (70 to 110), no indication of physician notification, no initials or progress notes indicating this was reported to the physician. On [DATE] there are Critical labs values of CO2 at 15, normal range (,[DATE]) and BUN 75, normal range (,[DATE]). The received date on the [DATE]. Labs are noted to be [DATE] at 2:21am, Reported date is [DATE] at 6:39am. And the report notes that the DON reviewed the results online on [DATE] at 12:47am. Record review of hospital admission records for Resident #1 on [DATE] revealed that the resident was transported by EMS on [DATE]. ER assessment shows resident was restless, crying, moaning, with slight dyspnea, acutely inflamed [MEDICATION NAME] mucosa, nonresponsive, distended neck veins at supine, scattered rhonchi, 1+ [MEDICAL CONDITION] both legs and ankle. Resident's ER lab results show her white blood count was 13.1 w/left shift, Sodium level at 137, Potassium in urine at 4.4, carbon [MEDICATION NAME] level at 19, blood urea nitrogen level at 82, creatinine level at 2.2, glomerular filtration rate at 20.2. [DIAGNOSES REDACTED]. [DATE] Resident Lab results showed Resident #1's Sodium level at 134, Potassium in urine at 3.6, blood urea nitrogen level at 71, creatinine level at 1.7, glomerular filtration rate at 27.7, white blood count at 11 with left shift. [DATE] Hospital Assessment: Acute on [MEDICAL CONDITION] due to inadequate oral intake superimposed on chronic [MEDICAL CONDITIONS] with combination of acute UTI and left lower lobe of lung pneumonia with exacerbation of [MEDICAL CONDITIONS] with status [REDACTED]. [DATE] Resident Lab results showed Resident #1's Sodium level at 146, Potassium in urine at 3.2, anion-gap at 12, blood urea nitrogen level at 35, creatinine at 1.3, glomerular filtration rate at 38.6, whit blood count at 9400. [DATE] Hospital Assessment: Acute on [MEDICAL CONDITION] due to inadequate oral intake, superimposed on [MEDICAL CONDITIONS], combination of acute UTI and left lower lobe of lung pneumonia, Hypertension with hypertensive cardiovascular disease with impending [MEDICAL CONDITION], History of multiple [MEDICAL CONDITION]. [DATE] Hospital note revealed Resident was conscious but responds only to painful stimuli. Review of link Medical News Today website accessed at https://www.medicalnewstoday.com/articles/ 7.php on [DATE] revealed, A BUN, or Blood Urea Nitrogen test, measures the level of urea nitrogen in the blood using a standard blood sample. Urea nitrogen is the natural byproduct of the breakdown of protein. According to the American Association for Clinical Chemistry, BUN tests are mainly used to assess kidney health .A rise or fall in blood urea nitrogen levels may indicate a wide range of health problems. This is because the kidneys and liver are involved in a wide range of body functions . A result higher than 50 milligrams per deciliter is likely to signal an underlying health problem . Elevated BUN levels can result from: - Kidney damage, failure, or disease - Dehydration - Shock . Typical BUN levels by age and gender . -Adult women: 6 to 20 milligrams per deciliter . In an interview on [DATE] at 5:47 p.m. Hospital Nurse Manager stated that Resident #1 had abnormal lab values. Stated that resident's mucus membranes were cracked, skin turgor not good, mouth was inflamed, nutrition not adequate, BUN was 82 and [MEDICATION NAME] was 2.2 meaning resident was in kidney failure. Interview on [DATE] at 2:38pm with RN 1 stated that ADON, or MDSN keep track of labs drawn. Stated that she will call the doctor and or the DON if she saw critical lab results, would document and would be in the progress notes. Stated that she did not know the results of Resident #1's lab results. In an interview on [DATE] at 11:13 a.m. DON stated DON stated that she looks at all the lab work. Not sure if there is a way that the DR or NP looked at the labs. DON stated that DR does not have a medical director to call if he is not available to receive critical labs. DON stated that she has the power to call the facility to ask them to have the resident sent to a hospital if she feels a resident is not doing well. DON stated that she did not call DR on Sunday at midnight because he was not going to answer his phone at that hour. DON stated that Resident #1 was dehydrated and was worried about her BUN. DON stated that she wanted to do an IV but Resident #1 would have pulled it out. In an interview on [DATE] at 1:00 p.m., LVN 1, when asked about critical lab values and procedure she stated that the lab would call when there is a critical lab value. She stated it was usually that same day via morning report. She stated that usually it is the ADON and/or DON that take care of labs that come in via the fax. LVN 1 stated she was not aware of Resident #1's critical lab values. LVN 1 stated she does not know about a policy but knows that you are supposed to notify the physician immediately. Record Review of a physician's order initiated [DATE] for Med Pass 2.0 supplement to be given three times a day. Orders revealed an active ordered for [MEDICATION NAME] 25mg a tab by mouth with a start date of [DATE] and a revision date of [DATE]. Record Review of Resident MAR revealed that Resident #1 was admitted on 50 mg BID of [MEDICATION NAME] on [DATE]. Dose for [MEDICATION NAME] reduced to 25 mg BID on [DATE] through [DATE] and then down to 25 mg QD on [DATE] and then discontinued after 7 seven days. The order was created by DON on [DATE] and revised by MDSN on [DATE]. Record review of Facility Pharmacy Consultation revealed Resident #1 was prescribed [MEDICATION NAME] by DR on [DATE] for Major [MEDICAL CONDITION]. The pharmacy consult revealed that the medication was a routine order. Record review revealed that the resident had an GDR eval for [MEDICATION NAME] on [DATE]. Resident #1 was taking trazadone for depression on routine order starting [DATE]. Resident #1 had a GDR evaluation scheduled for [DATE]. Record Review of Resident #1's Medication Administration Records (MARs) on [DATE] revealed an increase in medication administration refusals from (MONTH) (YEAR) through (MONTH) (YEAR). The amount of refusals is listed below; May (YEAR) - [MEDICATION NAME] 5mg- refused one time during the month. - Calcium 20mg- refused one time during the month. - [MEDICATION NAME] Bisulfate 75mg- refused one time during the month. - [MEDICATION NAME] Sodium 100mg- refused one time during the month. - [MEDICATION NAME] 325mg- refused one time during the month. - [MEDICATION NAME] 20mg- refused one time during the month. - Losartan Potassium 100mg- refused one time during the month. - [MEDICATION NAME] Powder 17 Gm- refused one time during the month. - [MEDICATION NAME] 20mg- refused five times during the month. - [MEDICATION NAME] 100mg- refused one time during the month. - [MEDICATION NAME] 25mg- refused one time during the month. - [MEDICATION NAME] 10mg- refused one time during the month. - [MEDICATION NAME] 50mg then 25mg- refused one time during the month. - [MEDICATION NAME] 25mg- refused one time during the month. - [MEDICATION NAME] 50mg- refused one time during the month. June (YEAR) - [MEDICATION NAME] 5mg- refused seventeen times during the month. - Calcium 20mg- refused seventeen times during the month. - [MEDICATION NAME] Bisulfate 75mg- refused seventeen times during the month. - [MEDICATION NAME] Sodium 100mg- refused seventeen times during the month. - [MEDICATION NAME] 325mg- refused seventeen times during the month. - [MEDICATION NAME] 20mg- refused seventeen times during the month. - Losartan Potassium 100mg- refused seventeen times during the month. - [MEDICATION NAME] Powder 17 Gm- refused seventeen times during the month. - [MEDICATION NAME] 20mg- refused nine times during the month. - [MEDICATION NAME] 100mg- refused seventeen times during the month. - [MEDICATION NAME] 25mg- refused seventeen times during the month. - [MEDICATION NAME] 10mg- refused seventeen times during the month. - [MEDICATION NAME] 50mg then 25mg- refused five times out of the seven times ordered during the middle of the month and refused 5 times out of the eight doses ordered at the end of the month. - [MEDICATION NAME] 25mg- refused seventeen times during the month. - [MEDICATION NAME] 50mg- refused seventeen times during the month. July (YEAR) (in the facility 9 days) - [MEDICATION NAME] 5mg- refused eight times during the month. - Calcium 20mg- refused eight times during the month. - [MEDICATION NAME] Bisulfate 75mg- refused eight times during the month. - [MEDICATION NAME] Sodium 100mg- refused eight times during the month. - [MEDICATION NAME] 325mg- refused seven times during the month. - [MEDICATION NAME] 20mg- refused eight times during the month. - Losartan Potassium 100mg- refused seven times during the month. - [MEDICATION NAME] Powder 17 Gm- refused seven times during the month. - [MEDICATION NAME] 20mg- refused seven times during the month. - [MEDICATION NAME] 100mg- refused seven times during the month. - [MEDICATION NAME] 25mg- refused seven times during the month. - [MEDICATION NAME] 10mg- refused seven times during the month. - [MEDICATION NAME] 50mg then 25mg- refused seven times during the month. - [MEDICATION NAME] 25mg- refused seven times during the month. - [MEDICATION NAME] 50mg- refused seven times during the month. In an interview on [DATE] at 12:34 p.m., the POA stated that the resident is currently at the hospital and unresponsive. The POA stated that admitting nurse at the emergency room stated that Resident #1's condition was something that took time to develop. Stated the resident started to decline after the change in medication. POA stated the facility did not call the her to inform her of the change in medications treatment. Stated that Resident #1 was taken off the medication for a week before the daughter came to visit. POA stated that the behaviors started because the facility stopped the [MEDICATION NAME] without her permission. Stated that the DON stopped her in the hallway during a visit and told her that they are going to stop giving Resident #1 the [MEDICATION NAME]. POA stated that she told the DON to not stop the [MEDICATION NAME] because Resident #1 will not respond well. Stated that her mom would become paranoid and start refusing care. Stated that she told the DON that her mom would not put dentures in and would not swallow. In an interview on [DATE] at 4:34 p.m., Resident #1's son stated that his mom was on a medication that kept her stable, but the nursing home stopped giving it to her without letting the family know. Stated that the care giver and the POA have found the resident with feces on her and disoriented and that she did not have thrush before she went to the nursing home. Stated that the facility was not cleaning her dentures and is why she did not put them back in. Resident #1's son stated that Resident #1 was supposedly taking her clothes off, and that when she talked it would be incoherent which is out of character for her. Stated that not too long ago she was driving around and taking care of herself for the most part. Interview on [DATE] at 2:38pm with RN 1 stated that she knew Resident #1 was not taking medications and that they tried to put it in her mouth or crush it but she still wouldn't take. Stated that with refusals we try again and try again, the first refusal we don't notify anybody but if it continues a 2nd day we will notify the doctor, also would document in the progress notes. Stated that she did not call the doctor and doesn't remember if Resident #1 refused medications when she worked with her or not. Stated that for meals the CNAs chart on kiosk if we offer substitutes. If resident refuses food the ST will get involved, CNA's will let nurses know. Stated that the facility does try to monitor fluids for residents with a history of [MEDICAL CONDITION]. In an interview on [DATE] at 11:13 a.m. DON stated there was an increase in behaviors for Resident #1. Stated that the DR knew she was having behaviors and apparently what he was seeing was nothing abnormal for her. Stated that she did not know if these behaviors were because of GDR. Stated that the daughter told her she was going to regret taking Resident #1 off of [MEDICATION NAME]. In an interview on [DATE] at 1:00 p.m., LVN 1 stated that Resident #1 had some behaviors when she first came in and they increased right away when she stopped taking her medications. LVN 1 stated she discussed Resident #1's medications with the resident's daughter-in-law/medical POA and she said that is what happens when they take her off the [MEDICATION NAME]. LVN 1 stated that the POA wanted Resident #1 back on the medication. LVN 1 reported she spoke to the DON, who spoke to the physician and the [MEDICAL CONDITION] was restarted around ,[DATE] before she went on vacation. LVN 1 stated that if there is ever any change of condition she would let the DON know. Record Review of Resident #1's (MONTH) (YEAR) MAR's revealed Supplement 2.0 (supplemental shake) given 3x a day starting [DATE]. Out of 72 opportunities during the month Resident #1 refused 36 times (50%). The amount of the supplement consumed on the dates Resident #1 accepted the 2.0 is not included in the documentation. Record Review of Resident #1 (MONTH) (YEAR) MAR ([DATE]st thru (MONTH) 09) revealed 26 opportunities and Resident #1 refused medication 20 times. The amount of the 2.0 supplement consumed on the dates Resident #1 accepted the 2.0 is not included in the documentation. Record Review of Resident #1's weights in total taken at facility during her 67 day stay revealed the following; On ,[DATE], her day of admission, she weighed 189 pounds. On [DATE], 186 pounds (which is a 1.5%, 3 pound weight loss in one week). On ,[DATE], 179 pounds (5.2% or 10 pounds lost since admission). On ,[DATE], 169 pounds (10.6% or 20 pounds lost since admission). On ,[DATE], 166 pounds (12% or 23 pounds in one month). The next available weight was taken on ,[DATE] as weights were taken once a month after the first month, Resident #1 weighed 149 pounds (21 % over the 2 months or 40 pound weight loss). Record Review of Review of Resident #1's Nutritional History Form dated [DATE] has that Resident #1 feeds herself and has a good meal intake. Information regarding her likes and dislikes obtained from the resident and her family. Record Review of Resident #1's Nutritional Risk Assessment Form, dated [DATE], revealed that her weight is listed as 207 pounds. Resident #1's diet is listed as regular. The form notes No recent wt (weight) changes noted. The goal for Resident #1 is noted to be gradual wt loss, ,[DATE] #/ a month, to about 175, nutr (nutritional) labs wnl (within normal limits) over the next 90 days. Review of the facility policy #6.13 regarding 2.0 Calorie Med Pass, the purpose of the supplement is noted to be; To provide a high calorie, high protein supplement in small volume for adding nutrients when other interventions are not appropriate. And . The amount of the supplement taken is documented on the MAR and signed out by the designated person passing the medication. Record review of Resident #1's Electronic Medical Chart to include MAR, Progress Notes, Weights, Daily Intakes, Physician Orders, Dietary Orders, Care Plan, MDS assessment revealed that the resident had a change in condition after the facility initiated a GDR for [MEDICATION NAME] on [DATE]. Resident medical records reveal that the resident had severe weight loss, refused medications, refused nutrition intake, refused fluids. Review of Resident #1's hospital records revealed her weight at the time of her hospital admission on [DATE] was 143 pounds. Review of the physician progress notes [REDACTED]. On [DATE] notes the reason for the visit is follow-up to post hospital care. Resident #1's weight is noted to be 207 pounds. The Physician noted Resident #1 is to be maintained on the same medications and physical therapy. On [DATE] the Physician note again includes the resident's weight as 207. The reason for the visit is noted to be a follow-up, sleepy lethargic. The Physician noted Resident #1 is to be maintained on the same medications and supportive therapy. On [DATE] there is no weight listed. The reason for the visit is noted to be a follow-up, (an illegible word), participating in PT but remains in bed most of the time, afebrile. Record Review of the facility WAR (Weekly At Risk meeeting regardings residents conditions ) meeting notes on [DATE] revealed that the DON did not take notes on Resident #1's weights, reassessment of interventions, or change in condition. The following is a review of the WAR meetings from [DATE] through [DATE]; - [DATE], Follow up summary notes revealed 10 residents were reviewed. There is no indication on the document indicating decisions made. Each name of a resident has one or two words beside the resident name, such as new admit - [DATE] Resident #1's name appears on the summary notes for the first time with new admit beside her name. - [DATE] Resident #1 is not listed on the summary. - [DATE] Resident #1 is listed with med options, illegible med name and [MEDICATION NAME] are listed. - [DATE] Resident #1 is not listed. - [DATE] Resident #1 is listed with weight loss beside her name. - [DATE] Resident #1 is listed with weight loss and 2-cal - [DATE] Resident #1 is listed with A&B (antibiotics), [MEDICAL CONDITION]. - [DATE]Resident #1 is listed with [MEDICATION NAME] restarted DON was not able to produce WAR meeting notes detailing what area of care of was discussed for each resident identified on the weekly list. WAR records revealed that the facility did not discuss interventions, weight loss, change in condition, dehydration, or reassess interventions for triggered residents identified on the WAR meeting list. Record Review of the facility Meal Intake Records on [DATE] for Resident #1 revealed a decrease in resident's meal intake starting from [DATE] through [DATE]. Records due not include fluid intake. A review of resident intake is listed below; - From [DATE] through [DATE] there was an opportunity for 19 meals. The percent eaten can be documented as ,[DATE]%- she ate this percent on 1 meal, ,[DATE]%-2 meals, ,[DATE]%-9 meals, ,[DATE]%-5 meals. Two refusals were documented. - From [DATE] through [DATE]-21 meals were documented. ,[DATE]%- 1 meal, ,[DATE]%-6 meals, ,[DATE]%-9 meals, ,[DATE]%-2 meals. Three refusals were documented. - From [DATE] through [DATE]-21 meals were documented. ,[DATE]%- 5 meals, ,[DATE]%-7 meals, ,[DATE]%-7 meals, ,[DATE]%-1 meal. One refusal was documented. - From [DATE] through [DATE]-22 meals were documented. ,[DATE]%- 8 meals, ,[DATE]%-8 meals, ,[DATE]%-3 meals, ,[DATE]%-none. Three refusals were documented. - From [DATE] through [DATE]-21 meals were documented. ,[DATE]%- 7 meals, ,[DATE]%-7 meals, ,[DATE]%-5 meals, ,[DATE]%-1 meal. One refusal was documented. - From [DATE] through [DATE]-21 meals were documented. ,[DATE]%- 7 meal, ,[DATE]%-5 meals, ,[DATE]%-4 meals, ,[DATE]%-1 meal. Four refusals were documented. - From [DATE] through [DATE]- 18 out of 21 meals were documented. ,[DATE]%- 7 meals, ,[DATE]%-5 meals, ,[DATE]%-3 meals, ,[DATE]%-none. Three refusals were documented. - From [DATE] through [DATE]-20 out of 21 meals were documented. ,[DATE]%- 5 meals, ,[DATE]%-0 meals, ,[DATE]%-3 meals, ,[DATE]%-0 meals. Twelve refusals were documented. - From [DATE] through [DATE]- 19 of 21 meals were documented. ,[DATE]%- 2 meals, ,[DATE]%-3 meals, ,[DATE]%-7 meals, ,[DATE]%-1 meal. Four refusals were documented. - From [DATE] through [DATE]- 9 of 18 meals were documented. ,[DATE]%- none, ,[DATE]%-3 meals, ,[DATE]%-3 meals, ,[DATE]%-none. Three refusals were documented. Review of the facility Policy titled Weight Program, revised ,[DATE], and revealed the following; Residents are weighed at admission, readmission, and per physician orders. Weekly weights are completed for an additional 3 weeks (or longer if not stable) on the following: Admit, Readmit, significant weight loss of 5% or more in 1 month or less, Physician's orders, on a [MEDICATION NAME] feeding And. Weekly weights- residents with a significant weight loss x30 days or less (5% or more) will be placed on weekly weights x4 weeks or until weights are stable and no weight concerns are noted. If weight concerns are noted/weights are not stable, notify your RD and continue the weekly weights until stable. Process DON or Designee will review monthly and weekly weights prior to WAR (Weekly At Risk) Meeting. WAR (Weekly At Risk) Meeting Weekly War meeting-discuss residents with greater than a 3 pound change in a week. Continue to discuss resident in weekly WAR meeting until concern is resolved. In an interview on [DATE] at 4:34 p.m., Resident #1's son stated that his mother used to be 215 pounds and is now down to 138. Stated that Resident #1 has not opened her eyes or talked since she has been here. Resident #1's son stated that the facility transferred her to the hospital because her kidneys were shutting down. In an interview on [DATE] at 12:34 p.m., the POA stated that the resident started refusing medications, food, and liquids after change in medication administration of [MEDICATION NAME]. POA stated that she showed the facility staff how to trick her mom into taking the medications. Stated that she told the facility to not take resident off the medication because DR took her off once and she began to refuse her medication and became fearful with anxiety. Stated that the resident is now going to be put on hospice. Stated that the hospital staff told her to call the state due to Resident #1's condition at admission from the facility. In an interview on [DATE] 12:55 p.m. TD stated that Resident #1 was receiving therapy for all three specialty services (PT, OT, ST). Stated that she worked with resident a couple of times, but she was definitely in the therapy room. Stated that the resident was not very active but alert, she was not able to express whether she was in pain, so it was hard to communicate with her. Stated that the resident seemed to decline and had thrush in her mouth before she left. Stated that the ST was trying to address swallowing and on her last daily notes she was trying to do her treatment during meals and trying to address feeding. Stated that on [DATE] there was a decline in oral intake, that is when the ST tried to address swallowing, on [DATE] resident refused all intake from therapist, then on [DATE] attempted again to assess resident intake but resident declined. The oral decline was not on the resident's goals but ST started addressing the issue. Stated that she believes the resident did not have her dentures at this time. Stated that she is not aware of any other residents that had thrush. Stated that the speech therapist is on vacation and cannot be reached at this time. In an interview on [DATE] at 2:54 p.m. DM stated she gets resident weights and looks for the 5% weight loss. Stated that she did notice Resident #1's loss. Stated that the resident wa

Based on observation, interview, and record review, the facility failed to ensure the rights of residents to be free from neglect for 1 of 3 residents (resident #1) reviewed for hydration, change in condition and abnormal values. 1. The facility failed to monitor Resident #1 fluid intake from [DATE] through [DATE] to ensure she was adequately hydrated. Resident #1 entered the facility at risk for dehydration. 2. The facility failed to consult with the Attending Physician when Resident #1 had a change of condition and was not taking in fluids. The facility failed to reassess interventions for resident #1 regarding weight loss. 3. The facility failed to ensure abnormal lab results received on [DATE] and [DATE] were promptly reported to the physician. Resident #1 was hospitalized on [DATE] with [DIAGNOSES REDACTED]. Resident #1 expired in the hospital on [DATE]. These failures resulted in an identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was lowered on [DATE], the facility remained out of compliance at a level of actual harm with a scope identified as a pattern. This failure affected one resident and placed an additional 2 residents with hydration concerns at risk for dehydration that were on [MEDICAL CONDITION] medications. Findings Include: Review of facility's undated policy to prohibit the mistreatment, neglect, and abuse of resident and the misappropriation of resident property revealed that each Resident has the right to be free from neglect. The facility has developed operational policies and procedures for screening and training employees for the protection of residents and for the prevention, identification, investigation, and reporting of neglect. The policy states: The facility's purpose is to assure that the facility is doing all that is within their control to prevent occurrences. Record review of Resident #1's face sheet on [DATE] revealed the resident to be an [AGE] year-old woman admitted on [DATE] with a [DIAGNOSES REDACTED]. The facility did not include the [DIAGNOSES REDACTED]. Record review of Resident #1's MDS resident assessment and care screening on [DATE] revealed that the MDS did not list [MEDICAL CONDITION] as a diagnosis. MDS care area assessment revealed that the resident did not exhibit behavioral symptoms, signs of [MEDICAL CONDITION], acute onset mental status change, and had a mood severity score of zero with no potential indicators of [MEDICAL CONDITION]. Resident had an MDS BIMS score of 5. Review of MDS history revealed that the facility did not conduct an MDS assessment for a change in condition for Resident #1. Further review of MDS revealed that the MDS did not list [MEDICAL CONDITION] as a diagnosis. MDS care area assessment revealed that the resident did not exhibit behavioral symptoms, signs of [MEDICAL CONDITION], acute onset mental status change, and had a mood severity score of zero with no potential indicators of [MEDICAL CONDITION]. Resident had an MDS BIMS score of 5. Review of MDS history revealed that the facility did not conduct an MDS assessment for a change in condition for Resident #1. Record review of care plan for Resident #1 (Start dated: [DATE], Completion Date: [DATE]) created by MDSN, revealed that the facility was to monitor/document change in behavior, change in eating patterns. Monitor/document/report to PRN Change on Mental status, emaciation, weight loss. Alert dietician if consumption is poor for more than 48 hours, weight decline persists, contact physician and dietician immediately. Resident was not care planned for a GDR, [MEDICAL CONDITION], or dehydration. Review of the care plan does not have signatures from the facility staff, resident, resident POA, or resident physician. Record review on [DATE] of History and Physical electronically signed by DR on [DATE] revealed that Resident #1 had a history of [REDACTED]. Resident was admitted to the hospital on ,[DATE] for acute [MEDICAL CONDITION] related to dehydration from inadequate intake and hospitalized again on ,[DATE] for acute on [MEDICAL CONDITION] and acute UTI. Resident was seen in office on ,[DATE], the renal status was noted to be stable. Record review of hospital admission records for Resident #1 on [DATE] revealed that the resident was transported by EMS on [DATE]. ER assessment shows resident was restless, crying, moaning, with slight dyspnea, acutely inflamed [MEDICATION NAME] mucosa, nonresponsive, distended neck veins at supine, scattered rhonchi, 1+ [MEDICAL CONDITION] both legs and ankle. Resident's ER lab results show her white blood count was 13.1 w/left shift, Sodium level at 137, Potassium in urine at 4.4, carbon [MEDICATION NAME] level at 19, blood urea nitrogen level at 82, creatinine level at 2.2, glomerular filtration rate at 20.2. [DIAGNOSES REDACTED]. [DATE] Resident Lab results showed Resident #1's Sodium level at 134, Potassium in urine at 3.6, blood urea nitrogen level at 71, creatinine level at 1.7, glomerular filtration rate at 27.7, white blood count at 11 with left shift. [DATE] Hospital Assessment: Acute on [MEDICAL CONDITION] due to inadequate oral intake superimposed on chronic [MEDICAL CONDITIONS] with combination of acute UTI and left lower lobe of lung pneumonia with exacerbation of [MEDICAL CONDITIONS] with status [REDACTED]. [DATE] Resident Lab results showed Resident #1's Sodium level at 146, Potassium in urine at 3.2, anion-gap at 12, blood urea nitrogen level at 35, creatinine at 1.3, glomerular filtration rate at 38.6, whit blood count at 9400. [DATE] Hospital Assessment: Acute on [MEDICAL CONDITION] due to inadequate oral intake, superimposed on [MEDICAL CONDITIONS], combination of acute UTI and left lower lobe of lung pneumonia, Hypertension with hypertensive cardiovascular disease with impending [MEDICAL CONDITION], History of multiple [MEDICAL CONDITION]. [DATE] Hospital note revealed Resident was conscious but responds only to painful stimuli. Record Review of a physician's order initiated [DATE] for Med Pass 2.0 supplement to be given three times a day. Orders revealed an active ordered for [MEDICATION NAME] 25mg a tab by mouth with a start date of [DATE] and a revision date of [DATE]. Record Review of Resident MAR revealed that Resident #1 was admitted on 50 mg BID of [MEDICATION NAME] on [DATE]. Dose for [MEDICATION NAME] reduced to 25 mg BID on [DATE] through [DATE] and then down to 25 mg QD on [DATE] and then discontinued after 7 seven days. The order was created by DON on [DATE] and revised by MDSN on [DATE]. Record review of Facility Pharmacy Consultation revealed Resident #1 was prescribed [MEDICATION NAME] by DR on [DATE] for Major [MEDICAL CONDITION]. The pharmacy consult revealed that the medication was a routine order. Record review revealed that the resident had an GDR eval for [MEDICATION NAME] on [DATE]. Resident #1 was taking trazadone for depression on routine order starting [DATE]. Resident #1 had a GDR evaluation scheduled for [DATE]. Record Review of Resident #1's (MONTH) (YEAR) MAR's revealed Supplement 2.0 given 3x a day starting [DATE]. Out of 72 opportunities during the month Resident #1 refused 36 times (50%). The amount of the supplement consumed on the dates Resident #1 accepted the 2.0 is not included in the documentation. Record Review of Resident #1 (MONTH) (YEAR) MAR ([DATE]st thru (MONTH) 09) revealed 26 opportunities and Resident #1 refused medication 20 times. The amount of the 2.0 supplement consumed on the dates Resident #1 accepted the 2.0 is not included in the documentation. Record Review of Facility Lab results for Resident #1's revealed she has labs conducted twice while at the facility, on [DATE] there is a critical Value of Glucose at 47, normal range (70 to 110), no indication of physician notification, no initials or progress notes indicating this was reported to the physician. On [DATE] there are Critical labs values of CO2 at 15, normal range (,[DATE]) and BUN 75, normal range (,[DATE]). The received date on the [DATE]. Labs are noted to be [DATE] at 2:21am, Reported date is [DATE] at 6:39am. And the report notes that the DON reviewed the results online on [DATE] at 12:47am. Record Review of Resident #1's weights in total taken at facility during her 67 day stay revealed the following; On ,[DATE], her day of admission, she weighed 189 pounds. On [DATE], 186 pounds (which is a 1.5%, 3 pound weight loss in one week). On ,[DATE], 179 pounds (5.2% or 10 pounds lost since admission). On ,[DATE], 169 pounds (10.6% or 20 pounds lost since admission). On ,[DATE], 166 pounds (12% or 23 pounds in one month). The next available weight was taken on ,[DATE] as weights were taken once a month after the first month, Resident #1 weighed 149 pounds (21 % over the 2 months or 40 pound weight loss). Record Review of Review of Resident #1's Nutritional History Form dated [DATE] has that Resident #1 feeds herself and has a good meal intake. Information regarding her likes and dislikes obtained from the resident and her family. Record Review of Resident #1's Nutritional Risk Assessment Form, dated [DATE], revealed that her weight is listed as 207 pounds. Resident #1's diet is listed as regular. The form notes No recent wt (weight) changes noted. The goal for Resident #1 is noted to be gradual wt loss, ,[DATE] #/ a month, to about 175, nutr (nutritional) labs wnl (within normal limits) over the next 90 days. Review of the facility policy #6.13 regarding 2.0 Calorie Med Pass, the purpose of the supplement is noted to be; To provide a high calorie, high protein supplement in small volume for adding nutrients when other interventions are not appropriate. And . The amount of the supplement taken is documented on the MAR and signed out by the designated person passing the medication. Record review of Resident #1's Electronic Medical Chart to include MAR, Progress Notes, Weights, Daily Intakes, Physician Orders, Dietary Orders, Care Plan, MDS assessment revealed that the resident had a change in condition after the facility initiated a GDR for [MEDICATION NAME] on [DATE]. Resident medical records reveal that the resident had severe weight loss, refused medications, refused nutrition intake, refused fluids. Review of Resident #1's hospital records revealed her weight at the time of her hospital admission on [DATE] was 143 pounds. Review of the physician progress notes [REDACTED]. On [DATE] notes the reason for the visit is follow-up to post hospital care. Resident #1's weight is noted to be 207 pounds. The Physician noted Resident #1 is to be maintained on the same medications and physical therapy. On [DATE] the Physician note again includes the resident's weight as 207. The reason for the visit is noted to be a follow-up, sleepy lethargic. The Physician noted Resident #1 is to be maintained on the same medications and supportive therapy. On [DATE] there is no weight listed. The reason for the visit is noted to be a follow-up, (an illegible word), participating in PT but remains in bed most of the time, afebrile. Record Review of the facility WAR meeting notes on [DATE] revealed that the DON did not take notes on Resident #1's weights, reassessment of interventions, or change in condition. The following is a review of the WAR meetings from [DATE] through [DATE]; - [DATE], Follow up summary notes revealed 10 residents were reviewed. There is no indication on the document indicating decisions made. Each name of a resident has one or two words beside the resident name, such as new admit - [DATE] Resident #1's name appears on the summary notes for the first time with new admit beside her name. - [DATE] Resident #1 is not listed on the summary. - [DATE] Resident #1 is listed with med options, illegible med name and [MEDICATION NAME] are listed. - [DATE] Resident #1 is not listed. - [DATE] Resident #1 is listed with weight loss beside her name. - [DATE] Resident #1 is listed with weight loss and 2-cal - [DATE] Resident #1 is listed with A&B (antibiotics), [MEDICAL CONDITION]. - [DATE]Resident #1 is listed with [MEDICATION NAME] restarted DON was not able to produce WAR meeting notes detailing what area of care of was discussed for each resident identified on the weekly list. Record Review of the facility Meal Intake Records on [DATE] for Resident #1 revealed a decrease in resident's meal intake starting from [DATE] through [DATE]. Records due not include fluid intake. A review of resident intake is listed below; - From [DATE] through [DATE] there was an opportunity for 19 meals. The percent eaten can be documented as ,[DATE]%- she ate this percent on 1 meal, ,[DATE]%-2 meals, ,[DATE]%-9 meals, ,[DATE]%-5 meals. Two refusals were documented. - From [DATE] through [DATE]-21 meals were documented. ,[DATE]%- 1 meal, ,[DATE]%-6 meals, ,[DATE]%-9 meals, ,[DATE]%-2 meals. Three refusals were documented. - From [DATE] through [DATE]-21 meals were documented. ,[DATE]%- 5 meals, ,[DATE]%-7 meals, ,[DATE]%-7 meals, ,[DATE]%-1 meal. One refusal was documented. - From [DATE] through [DATE]-22 meals were documented. ,[DATE]%- 8 meals, ,[DATE]%-8 meals, ,[DATE]%-3 meals, ,[DATE]%-none. Three refusals were documented. - From [DATE] through [DATE]-21 meals were documented. ,[DATE]%- 7 meals, ,[DATE]%-7 meals, ,[DATE]%-5 meals, ,[DATE]%-1 meal. One refusal was documented. - From [DATE] through [DATE]-21 meals were documented. ,[DATE]%- 7 meal, ,[DATE]%-5 meals, ,[DATE]%-4 meals, ,[DATE]%-1 meal. Four refusals were documented. - From [DATE] through [DATE]- 18 out of 21 meals were documented. ,[DATE]%- 7 meals, ,[DATE]%-5 meals, ,[DATE]%-3 meals, ,[DATE]%-none. Three refusals were documented. - From [DATE] through [DATE]-20 out of 21 meals were documented. ,[DATE]%- 5 meals, ,[DATE]%-0 meals, ,[DATE]%-3 meals, ,[DATE]%-0 meals. Twelve refusals were documented. - From [DATE] through [DATE]- 19 of 21 meals were documented. ,[DATE]%- 2 meals, ,[DATE]%-3 meals, ,[DATE]%-7 meals, ,[DATE]%-1 meal. Four refusals were documented. - From [DATE] through [DATE]- 9 of 18 meals were documented. ,[DATE]%- none, ,[DATE]%-3 meals, ,[DATE]%-3 meals, ,[DATE]%-none. Three refusals were documented. Record Review of Resident #1's Medication Administration Records (MARs) on [DATE] revealed an increase in medication administration refusals from (MONTH) (YEAR) through (MONTH) (YEAR). The amount of refusals is listed below; May (YEAR) - [MEDICATION NAME] 5mg- refused one time during the month. - Calcium 20mg- refused one time during the month. - [MEDICATION NAME] Bisulfate 75mg- refused one time during the month. - [MEDICATION NAME] Sodium 100mg- refused one time during the month. - [MEDICATION NAME] 325mg- refused one time during the month. - [MEDICATION NAME] 20mg- refused one time during the month. - Losartan Potassium 100mg- refused one time during the month. - [MEDICATION NAME] Powder 17 Gm- refused one time during the month. - [MEDICATION NAME] 20mg- refused five times during the month. - [MEDICATION NAME] 100mg- refused one time during the month. - [MEDICATION NAME] 25mg- refused one time during the month. - [MEDICATION NAME] 10mg- refused one time during the month. - [MEDICATION NAME] 50mg then 25mg- refused one time during the month. - [MEDICATION NAME] 25mg- refused one time during the month. - [MEDICATION NAME] 50mg- refused one time during the month. June (YEAR) - [MEDICATION NAME] 5mg- refused seventeen times during the month. - Calcium 20mg- refused seventeen times during the month. - [MEDICATION NAME] Bisulfate 75mg- refused seventeen times during the month. - [MEDICATION NAME] Sodium 100mg- refused seventeen times during the month. - [MEDICATION NAME] 325mg- refused seventeen times during the month. - [MEDICATION NAME] 20mg- refused seventeen times during the month. - Losartan Potassium 100mg- refused seventeen times during the month. - [MEDICATION NAME] Powder 17 Gm- refused seventeen times during the month. - [MEDICATION NAME] 20mg- refused nine times during the month. - [MEDICATION NAME] 100mg- refused seventeen times during the month. - [MEDICATION NAME] 25mg- refused seventeen times during the month. - [MEDICATION NAME] 10mg- refused seventeen times during the month. - [MEDICATION NAME] 50mg then 25mg- refused five times out of the seven times ordered during the middle of the month and refused 5 times out of the eight doses ordered at the end of the month. - [MEDICATION NAME] 25mg- refused seventeen times during the month. - [MEDICATION NAME] 50mg- refused seventeen times during the month. July (YEAR) (in the facility 9 days) - [MEDICATION NAME] 5mg- refused eight times during the month. - Calcium 20mg- refused eight times during the month. - [MEDICATION NAME] Bisulfate 75mg- refused eight times during the month. - [MEDICATION NAME] Sodium 100mg- refused eight times during the month. - [MEDICATION NAME] 325mg- refused seven times during the month. - [MEDICATION NAME] 20mg- refused eight times during the month. - Losartan Potassium 100mg- refused seven times during the month. - [MEDICATION NAME] Powder 17 Gm- refused seven times during the month. - [MEDICATION NAME] 20mg- refused seven times during the month. - [MEDICATION NAME] 100mg- refused seven times during the month. - [MEDICATION NAME] 25mg- refused seven times during the month. - [MEDICATION NAME] 10mg- refused seven times during the month. - [MEDICATION NAME] 50mg then 25mg- refused seven times during the month. - [MEDICATION NAME] 25mg- refused seven times during the month. - [MEDICATION NAME] 50mg- refused seven times during the month. Record Review of Resident #1's electronic medical record in Point Click Care System on [DATE] revealed that there is was no notification to the DR of resident's change in condition, change in behavior, severe weight loss, decreased intake, medication refusal, dental care, or critical lab results. Facility was not able to produce hard copies of communication informing DR of Resident #1's condition. Review of link Medical News Today website accessed at https://www.medicalnewstoday.com/articles/ 7.php on [DATE] revealed, A BUN, or Blood Urea Nitrogen test, measures the level of urea nitrogen in the blood using a standard blood sample. Urea nitrogen is the natural byproduct of the breakdown of protein. According to the American Association for Clinical Chemistry, BUN tests are mainly used to assess kidney health .A rise or fall in blood urea nitrogen levels may indicate a wide range of health problems. This is because the kidneys and liver are involved in a wide range of body functions . A result higher than 50 milligrams per deciliter is likely to signal an underlying health problem . Elevated BUN levels can result from: - Kidney damage, failure, or disease - Dehydration - Shock . Typical BUN levels by age and gender . -Adult women: 6 to 20 milligrams per deciliter . In an interview on [DATE] at 12:34 p.m., the POA stated that the resident is currently at the hospital and unresponsive. The POA stated that admitting nurse at the emergency room stated that Resident #1's condition was something that took time to develop. Stated the resident started to decline after the change in medication. Facility did not call the POA to inform her of the change in medications treatment. Stated that Resident #1 was taken off the medication for a week before the daughter came to visit. Stated that the resident started refusing medications, food, and liquids. Daughter stated that she showed the facility staff how to trick her mom into taking the medications. Stated that she told the facility to not take resident off the medication because DR took her off once and she began to refuse her medication and became fearful with anxiety. Stated that the resident is now going to be put on hospice. Stated that the hospital staff told her to call the state due to Resident #1's condition at admission from the facility. In an interview on [DATE] at 4:34 p.m., Resident #1's son stated that his mom was on a medication that kept her stable, but the nursing home stopped giving it to her without letting the family know. Stated that the care giver and the POA have found the resident with feces on her and disoriented and that she did not have thrush before she went to the nursing home. Stated that the facility was not cleaning her dentures and is why she did not put them back in. The facility transferred her to the facility because her kidneys were shutting down. Stated that his mother used to be 215 pounds and is now down to 138. Stated that Resident #1 has not opened her eyes or talked since she has been here. Stated that Resident #1 was supposedly taking her clothes off, and that when she talked it would be incoherent which is out of character for her. Stated that not too long ago she was driving around and taking care of herself for the most part. In an interview on [DATE] at 4:47 p.m., POA stated that the behaviors started because the facility stopped the [MEDICATION NAME] without her permission. Stated that the DON stopped her in the hallway during a visit and told her that they are going to stop giving Resident #1 the [MEDICATION NAME]. Stated that she told the DON to not stop the [MEDICATION NAME] because Resident #1 will not respond well. Stated that her mom would become paranoid and start refusing care. Stated that she told the DON that her mom would not put dentures in and would not swallow. Stated that she asked the DON to have the DR look at her mouth because Resident #1 was not swallowing, and she stopped using her dentures. Stated that she did not have the exact dates of the request because they were verbal request to the DON, but they were over two weeks before calling the DR herself on [DATE]. Stated that she called the DR directly on [DATE] and asked him to look at her mouth. Stated that Resident #1's condition got so bad that she was severally dehydrated and that her kidneys are dried out and shutting down, her mouth was bloody, blistered and raw. Stated that the DR told her that the facility never notified him about the resident's condition. Stated that the floor nurse LVN 1 was surprised at how bad the resident's condition was when she came back from vacation. Stated that the DON never informed the DR about Resident #1's condition and that the DON never informed her about the change in resident's [MEDICATION NAME] before they changed it. Stated that Resident #1 was all about her image and would not be seen without her dentures. Stated that the facility did not do anything about her dentures. Stated that the urine in the catheter showed a brown orange color when she was admitted because she was so dry. Stated that Resident #1 was not able to be completely revived so they have taken her off everything and are preparing for Hospice care. Stated that the resident is on [MEDICATION NAME] and IV for hydration. Stated that the facility never had a treatment plan meeting for Resident #1 and did not have any meetings about the resident's care. Stated the facility never called to inform her about the resident's infection. In an interview on [DATE] at 5:47 p.m. Hospital Nurse Manager stated that she was told patient was covered in feces and bruises. Stated that there was an APS referral and DR was the admitting physician. Stated that she was told Resident #1 had while yellow plaque, moaning and did not respond to any questions, severally dehydrated. Stated that the nursing home sent resident to the hospital because she was unresponsive. Stated that hospital staff stated that she came for dehydration. Stated that she worked at a nursing home and that she knows you can't make people drink but they should have done some kind of intervention. Stated that Resident #1 had abnormal lab values. Stated that resident's mucus membranes were cracked, skin turgor not good, mouth was inflamed, nutrition not adequate, BUN was 82 and [MEDICATION NAME] was 2.2 meaning resident was in kidney failure. In an interview on [DATE] at 2:54 p.m. DM stated she gets resident weights and looks for the 5% weight loss. Stated that she did notice Resident #1's loss. Stated that the resident was taking a 2.0 supplement and she does not get feedback about whether or not the resident is taking the supplement. Stated that she does not recall doing a care plan meeting for Resident #1. Stated that she knows they need to get fluids to residents that have swallowing problems. Stated that she did not know about the thrush and ST did not notify me about any problems Resident #1 had. Stated that resident weights are done by restorative aids they give them to me and I calculate loss. Stated that she thinks the facility talked about resident this month and discussed fortified/high calorie food. Stated that the dietician is notified if resident is refusing to eat, then the physician is notified if he/she is here when we have the meeting. Stated that if she has any concerns about a resident she will inform the DON. In an interview on [DATE] at 11:41 a.m. ADMIN, the administrator was asked if there were any other documents that reflected communication between the physician and the facility regarding residents health concerns. ADMIN stated that there is a communication book that the facility and physician maybe using to communicate. ADMIN stated that the DON may have notes obtained from the communication book in her office. In an interview on [DATE] at 11:41 a.m. DR's Secretary stated that the DR is not able to be reached at this time and he will be back on next Monday. Stated that the DR is on a boat. Secretary stated that the facility will call the medical director if DR cannot be reached. In an interview on [DATE] 12:55 p.m. TD stated that Resident #1 was receiving therapy for all three specialty services (PT, OT, ST). Stated that she worked with resident a couple of times, but she was definitely in the therapy room. Stated that the resident was not very active but alert, she was not able to express whether she was in pain, so it was hard to communicate with her. Stated that the resident seemed to decline and had thrush in her mouth before she left. Stated that the ST was trying to address swallowing and on her last daily notes she was trying to do her treatment during meals and trying to address feeding. Stated that on [DATE] there was a decline in oral intake, that is when the ST tried to address swallowing, on [DATE] resident refused all intake from therapist, then on [DATE] attempted again to assess resident intake but resident declined. The oral decline was not on the resident's goals but ST started addressing the issue. Stated that she believes the resident did not have her dentures at this time. Stated that she is not aware of any other residents that had thrush. Stated that the speech therapist is on vacation and cannot be reached at this time. Interview on [DATE] at 2:38pm with RN 1 stated that ADON, or MDSN keep track of labs drawn. Stated that she will call the doctor and or the DON if she saw critical lab results, would document and would be in the progress notes. Stated that she did not know the results of Resident #1's lab results. Stated that she knew Resident #1 was not taking medications and that they tried to put it in her mouth or crush it but she still wouldn't take. Stated that with refusals we try again and try again, the first refusal we don't notify anybody but if it continues a 2nd day we will notify the doctor, also would document in the progress notes. Stated that she did not call the doctor and doesn't remember if Resident #1 refused medications when she worked with her or not. Stated that for meals the CNAs chart on kiosk if we offer substitutes. If resident refuses food the ST will get involved, CNA's will let nurses know. Stated that the facility does try to monitor fluids for residents with a history of [MEDICAL CONDITION]. In an interview on [DATE] at 3:45 p.m. MDSN stated that she completes the MDS resident assessment and care screening for admitting residents. Stated that she put in active and pertinent [DIAGNOSES REDACTED]. Stated that a history of [MEDICAL CONDITION] and dehydration would be significant to a resident's care if they were on a medication like [MEDICATION NAME] or on a diuretic like [MEDICATION NAME]. Stated that a resident's care plan would address the active and pertinent [DIAGNOSES REDACTED]. Stated that the she would do an MDS resident assessment and care screening for residents with a change in condition. Stated that nurses should be seeing the change in behaviors and do a change of condition and let the doctor know. Stated that the nurse notes would be under resident name and under assessments tab in point click care system. Stated that she was unaware of Resident #1's history of [MEDICAL CONDITION] caused by dehydration and that she may have overlooked it. Stated that weight loss and change in condition is discussed in morning meetings, they were reporting that Resident #1 was refusing her medications and that the facility is supposed to call the doctor after so many days. Stated that the DON works with DR because he is very hard to understand. Stated that she can conduct an MDS assessment for a change in condition if she feels it is needed. In an interview on [DATE] at 9:20 a.m. MDSN stated that she was not aware of the weight change that was posted on [DATE] and [DATE]. Stated that the weight change should have been brought to her attention and that the CNAs should have done a stop and watch for Resident #1 and a change in condition should have been done. Stated that eh weekly weight reports are given to the DON and the kitchen. Stated that she does not sign off on the MDS resident assessments because she is only an LVN and that the DON is the person that signs off on the MDS assessments. MDSN stated that she looked back at Resident #1's H&P and saw the acute chronic [MEDICAL CONDITION]. MDSN stated that the [MEDICAL CONDITION] should have been put on the resident's chart as a diagnosis. Stated that she looked over it and did not put it on the resident's chart. Stated that if she would have put the [DIAGNOSES REDACTED].#1's chart the facility could have care planned for it. In an interview on [DATE] at 9:37 a.m., the POA called to inform the state that the resident had passed away. In an interview on [DATE] at 9:40 a.m. with the facility RD revealed she is at the facility ,[DATE] days a month. The RD stated she did Resident #1's initial assessment on [DATE]. She stated the weight 207 pounds was from the facility records when they did the admission. The RD stated there was no indication of that in Resident #1 had a [DIAGNOSES REDACTED]. The RD stated no labs were available at the point of her initial assessment, but since Resident #1 was on [MEDICATION NAME] she knew there was a fluid issue. Stated that a renal [DIAGNOSES REDACTED]. The RD stated that on [DATE] she went back to facility, she looked up weights, would expect some loss due to fluid issues due to [MEDICAL CONDITION]. Stated that something definitely changed for Resident #1

Based on observation, interview, and record review, the facility failed to apply fundamental principle to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility failed ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of three residents reviewed for MDS assessment, nutrition and hydration, and physician notification of - resident critical labs, change in condition, and severe weight loss. 1. The facility failed to monitor Resident #1 fluid intake from [DATE] through [DATE] to ensure she was adequately hydrated. Resident #1 entered the facility at risk for dehydration. 2. The facility failed to consult with the Attending Physician when Resident #1 had a change of condition and was not taking in fluids. The facility failed to reassess interventions for resident #1 regarding weight loss. 3. The facility failed to ensure abnormal lab results received on [DATE] and [DATE] were promptly reported to the physician. Resident #1 was hospitalized on [DATE] with [DIAGNOSES REDACTED]. Resident #1 expired in the hospital on [DATE]. These failures resulted in an identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was lowered on [DATE], the facility remained out of compliance at a level of actual harm with a scope identified as a pattern. This failure affected one resident and placed 2 residents reviewed at risk receiving substandard quality of life resulting in a change in condition, dehydration, decline in health, and/or death. Findings Include: In an interview on [DATE] at 9:37 a.m., the POA called to inform the state that the resident had passed away. Record review of Resident #1's face sheet on [DATE] revealed the resident to be an [AGE] year-old woman admitted on [DATE] with a [DIAGNOSES REDACTED]. The facility did not include the [DIAGNOSES REDACTED]. Record review of Resident #1's MDS resident assessment and care screening on [DATE] revealed that the MDS did not list [MEDICAL CONDITION] as a diagnosis. MDS care area assessment revealed that the resident did not exhibit behavioral symptoms, signs of [MEDICAL CONDITION], acute onset mental status change, and had a mood severity score of zero with no potential indicators of [MEDICAL CONDITION]. Resident had an MDS BIMS score of 5. Review of MDS history revealed that the facility did not conduct an MDS assessment for a change in condition for Resident #1. Further review of MDS revealed that the MDS did not list [MEDICAL CONDITION] as a diagnosis. MDS care area assessment revealed that the resident did not exhibit behavioral symptoms, signs of [MEDICAL CONDITION], acute onset mental status change, and had a mood severity score of zero with no potential indicators of [MEDICAL CONDITION]. Resident had an MDS BIMS score of 5. Review of MDS history revealed that the facility did not conduct an MDS assessment for a change in condition for Resident #1. Record review of care plan for Resident #1 (Start dated: [DATE], Completion Date: [DATE]) created by MDSN, revealed that the facility was to monitor/document change in behavior, change in eating patterns. Monitor/document/report to PRN Change on Mental status, emaciation, weight loss. Alert dietician if consumption is poor for more than 48 hours, weight decline persists, contact physician and dietician immediately. Resident was not care planned for a GDR, [MEDICAL CONDITION], or dehydration. Review of the care plan does not have signatures from the facility staff, resident, resident POA, or resident physician. Record review on [DATE] of History and Physical electronically signed by DR on [DATE] revealed that Resident #1 had a history of [REDACTED]. Resident was admitted to the hospital on ,[DATE] for acute [MEDICAL CONDITION] related to dehydration from inadequate intake and hospitalized again on ,[DATE] for acute on [MEDICAL CONDITION] and acute UTI. Resident was seen in office on ,[DATE], the renal status was noted to be stable. Review of facility Care Area Assessments (CAA) policy (Dated: 2001) states: CAAs will be used to help analyze data to obtain from the MDS and to develop individualized care plans. CAAs are linked between assessment and care planning. Triggered Care Areas will be evaluated by the Interdisciplinary Team to determine the underlying causes, potential consequences and relationship to other trigger areas. In an interview on [DATE] at 4:47 p.m., POA stated that Resident #1's condition got so bad that she was severally dehydrated and that her kidneys are dried out and shutting down, her mouth was bloody, blistered and raw. Stated that the urine in the catheter showed a brown orange color when she was admitted because she was so dry. Stated that Resident #1 was not able to be completely revived so they have taken her off everything and are preparing for Hospice care. Stated that the resident is on [MEDICATION NAME] and IV for hydration. Stated that the DR told her that the facility never notified him about the resident's condition. POA stated that the facility never had a treatment plan meeting for Resident #1 and did not have any meetings about the resident's care. Stated the facility never called to inform her about the resident's infection. In an interview on [DATE] at 5:47 p.m. Hospital Nurse Manager stated that she was told patient was covered in feces and bruises. Stated that there was an APS referral and DR was the admitting physician. Stated that she was told Resident #1 had while yellow plaque, moaning and did not respond to any questions, severally dehydrated. Stated that the nursing home sent resident to the hospital because she was unresponsive. Stated that hospital staff stated that she came for dehydration. Stated that she worked at a nursing home and that she knows you can't make people drink but they should have done some kind of intervention. In an interview on [DATE] at 3:45 p.m. MDSN stated that she completes the MDS resident assessment and care screening for admitting residents. Stated that she put in active and pertinent [DIAGNOSES REDACTED]. Stated that a history of [MEDICAL CONDITION] and dehydration would be significant to a resident's care if they were on a medication like [MEDICATION NAME] or on a diuretic like [MEDICATION NAME]. MDSN stated that a resident's care plan would address the active and pertinent [DIAGNOSES REDACTED]. Stated that she was unaware of Resident #1's history of [MEDICAL CONDITION] caused by dehydration and that she may have overlooked it. MDSN stated that the she would do an MDS resident assessment and care screening for residents with a change in condition. Stated that nurses should be seeing the change in behaviors and do a change of condition and let the doctor know. Stated that the nurse notes would be under resident name and under assessments tab in point click care system. MDSN stated that she can conduct an MDS assessment for a change in condition if she feels it is needed. MDSN stated that she does not sign off on the MDS resident assessments because she is only an LVN and that the DON is the person that signs off on the MDS assessments. MDSN stated that she looked back at Resident #1's H&P and saw the acute chronic [MEDICAL CONDITION]. MDSN stated that the [MEDICAL CONDITION] should have been put on the resident's chart as a diagnosis. Stated that she looked over it and did not put it on the resident's chart. Stated that if she would have put the [DIAGNOSES REDACTED].#1's chart the facility could have care planned for it. In an interview on [DATE] at 9:40 a.m. RD stated there was no indication of that in Resident #1 had a [DIAGNOSES REDACTED]. In an interview on [DATE] at 11:13 a.m. DON stated she did not know about Resident #1's renal [DIAGNOSES REDACTED]. DON stated that the [MEDICAL CONDITION] caused by dehydration should have been triggered onto resident's diagnosis. DON stated that yes knowing the history of the resident would have triggered the facility to be aware of the resident's condition. DON stated that the [DIAGNOSES REDACTED]. DON stated that she did not review Resident #1's MDS assessment before signing off on it. In an interview on [DATE] at 1:00 p.m., LVN 1 stated that she did not know about Resident #1's history of [MEDICAL CONDITION] due to dehydration. Record Review of Facility Lab results for Resident #1's revealed she has labs conducted twice while at the facility, on [DATE] there is a critical Value of Glucose at 47, normal range (70 to 110), no indication of physician notification, no initials or progress notes indicating this was reported to the physician. On [DATE] there are Critical labs values of CO2 at 15, normal range (,[DATE]) and BUN 75, normal range (,[DATE]). The received date on the [DATE]. Labs are noted to be [DATE] at 2:21am, Reported date is [DATE] at 6:39am. And the report notes that the DON reviewed the results online on [DATE] at 12:47am. Record review of hospital admission records for Resident #1 on [DATE] revealed that the resident was transported by EMS on [DATE]. ER assessment shows resident was restless, crying, moaning, with slight dyspnea, acutely inflamed [MEDICATION NAME] mucosa, nonresponsive, distended neck veins at supine, scattered rhonchi, 1+ [MEDICAL CONDITION] both legs and ankle. Resident's ER lab results show her white blood count was 13.1 w/left shift, Sodium level at 137, Potassium in urine at 4.4, carbon [MEDICATION NAME] level at 19, blood urea nitrogen level at 82, creatinine level at 2.2, glomerular filtration rate at 20.2. [DIAGNOSES REDACTED]. [DATE] Resident Lab results showed Resident #1's Sodium level at 134, Potassium in urine at 3.6, blood urea nitrogen level at 71, creatinine level at 1.7, glomerular filtration rate at 27.7, white blood count at 11 with left shift. [DATE] Hospital Assessment: Acute on [MEDICAL CONDITION] due to inadequate oral intake superimposed on chronic [MEDICAL CONDITIONS] with combination of acute UTI and left lower lobe of lung pneumonia with exacerbation of [MEDICAL CONDITIONS] with status [REDACTED]. [DATE] Resident Lab results showed Resident #1's Sodium level at 146, Potassium in urine at 3.2, anion-gap at 12, blood urea nitrogen level at 35, creatinine at 1.3, glomerular filtration rate at 38.6, whit blood count at 9400. [DATE] Hospital Assessment: Acute on [MEDICAL CONDITION] due to inadequate oral intake, superimposed on [MEDICAL CONDITIONS], combination of acute UTI and left lower lobe of lung pneumonia, Hypertension with hypertensive cardiovascular disease with impending [MEDICAL CONDITION], History of multiple [MEDICAL CONDITION]. [DATE] Hospital note revealed Resident was conscious but responds only to painful stimuli. Review of link Medical News Today website accessed at https://www.medicalnewstoday.com/articles/ 7.php on [DATE] revealed, A BUN, or Blood Urea Nitrogen test, measures the level of urea nitrogen in the blood using a standard blood sample. Urea nitrogen is the natural byproduct of the breakdown of protein. According to the American Association for Clinical Chemistry, BUN tests are mainly used to assess kidney health .A rise or fall in blood urea nitrogen levels may indicate a wide range of health problems. This is because the kidneys and liver are involved in a wide range of body functions . A result higher than 50 milligrams per deciliter is likely to signal an underlying health problem . Elevated BUN levels can result from: - Kidney damage, failure, or disease - Dehydration - Shock . Typical BUN levels by age and gender . -Adult women: 6 to 20 milligrams per deciliter . In an interview on [DATE] at 5:47 p.m. Hospital Nurse Manager stated that Resident #1 had abnormal lab values. Stated that resident's mucus membranes were cracked, skin turgor not good, mouth was inflamed, nutrition not adequate, BUN was 82 and [MEDICATION NAME] was 2.2 meaning resident was in kidney failure. Interview on [DATE] at 2:38pm with RN 1 stated that ADON, or MDSN keep track of labs drawn. Stated that she will call the doctor and or the DON if she saw critical lab results, would document and would be in the progress notes. Stated that she did not know the results of Resident #1's lab results. In an interview on [DATE] at 11:13 a.m. DON stated DON stated that she looks at all the lab work. Not sure if there is a way that the DR or NP looked at the labs. DON stated that DR does not have a medical director to call if he is not available to receive critical labs. DON stated that she has the power to call the facility to ask them to have the resident sent to a hospital if she feels a resident is not doing well. DON stated that she did not call DR on Sunday at midnight because he was not going to answer his phone at that hour. DON stated that Resident #1 was dehydrated and was worried about her BUN. DON stated that she wanted to do an IV but Resident #1 would have pulled it out. In an interview on [DATE] at 1:00 p.m., LVN 1, when asked about critical lab values and procedure she stated that the lab would call when there is a critical lab value. She stated it was usually that same day via morning report. She stated that usually it is the ADON and/or DON that take care of labs that come in via the fax. LVN 1 stated she was not aware of Resident #1's critical lab values. LVN 1 stated she does not know about a policy but knows that you are supposed to notify the physician immediately. Record Review of a physician's order initiated [DATE] for Med Pass 2.0 supplement to be given three times a day. Record Review of a physician's order initiated [DATE] orders revealed an active ordered for [MEDICATION NAME] 25mg a tab by mouth with a start date of [DATE] and a revision date of [DATE]. Record Review of Resident MAR revealed that Resident #1 was admitted on 50 mg BID of [MEDICATION NAME] on [DATE]. Dose for [MEDICATION NAME] reduced to 25 mg BID on [DATE] through [DATE] and then down to 25 mg QD on [DATE] and then discontinued after 7 seven days. The order was created by DON on [DATE] and revised by MDSN on [DATE]. Record review of Facility Pharmacy Consultation revealed Resident #1 was prescribed [MEDICATION NAME] by DR on [DATE] for Major [MEDICAL CONDITION]. The pharmacy consult revealed that the medication was a routine order. Record review revealed that the resident had an GDR eval for [MEDICATION NAME] on [DATE]. Resident #1 was taking trazadone for depression on routine order starting [DATE]. Resident #1 had a GDR evaluation scheduled for [DATE]. Record Review of Resident #1's Medication Administration Records (MARs) on [DATE] revealed an increase in medication administration refusals from (MONTH) (YEAR) through (MONTH) (YEAR). The amount of refusals is listed below; May (YEAR) - [MEDICATION NAME] 5mg- refused one time during the month. - Calcium 20mg- refused one time during the month. - [MEDICATION NAME] Bisulfate 75mg- refused one time during the month. - [MEDICATION NAME] Sodium 100mg- refused one time during the month. - [MEDICATION NAME] 325mg- refused one time during the month. - [MEDICATION NAME] 20mg- refused one time during the month. - Losartan Potassium 100mg- refused one time during the month. - [MEDICATION NAME] Powder 17 Gm- refused one time during the month. - [MEDICATION NAME] 20mg- refused five times during the month. - [MEDICATION NAME] 100mg- refused one time during the month. - [MEDICATION NAME] 25mg- refused one time during the month. - [MEDICATION NAME] 10mg- refused one time during the month. - [MEDICATION NAME] 50mg then 25mg- refused one time during the month. - [MEDICATION NAME] 25mg- refused one time during the month. - [MEDICATION NAME] 50mg- refused one time during the month. June (YEAR) - [MEDICATION NAME] 5mg- refused seventeen times during the month. - Calcium 20mg- refused seventeen times during the month. - [MEDICATION NAME] Bisulfate 75mg- refused seventeen times during the month. - [MEDICATION NAME] Sodium 100mg- refused seventeen times during the month. - [MEDICATION NAME] 325mg- refused seventeen times during the month. - [MEDICATION NAME] 20mg- refused seventeen times during the month. - Losartan Potassium 100mg- refused seventeen times during the month. - [MEDICATION NAME] Powder 17 Gm- refused seventeen times during the month. - [MEDICATION NAME] 20mg- refused nine times during the month. - [MEDICATION NAME] 100mg- refused seventeen times during the month. - [MEDICATION NAME] 25mg- refused seventeen times during the month. - [MEDICATION NAME] 10mg- refused seventeen times during the month. - [MEDICATION NAME] 50mg then 25mg- refused five times out of the seven times ordered during the middle of the month and refused 5 times out of the eight doses ordered at the end of the month. - [MEDICATION NAME] 25mg- refused seventeen times during the month. - [MEDICATION NAME] 50mg- refused seventeen times during the month. July (YEAR) (in the facility 9 days) - [MEDICATION NAME] 5mg- refused eight times during the month. - Calcium 20mg- refused eight times during the month. - [MEDICATION NAME] Bisulfate 75mg- refused eight times during the month. - [MEDICATION NAME] Sodium 100mg- refused eight times during the month. - [MEDICATION NAME] 325mg- refused seven times during the month. - [MEDICATION NAME] 20mg- refused eight times during the month. - Losartan Potassium 100mg- refused seven times during the month. - [MEDICATION NAME] Powder 17 Gm- refused seven times during the month. - [MEDICATION NAME] 20mg- refused seven times during the month. - [MEDICATION NAME] 100mg- refused seven times during the month. - [MEDICATION NAME] 25mg- refused seven times during the month. - [MEDICATION NAME] 10mg- refused seven times during the month. - [MEDICATION NAME] 50mg then 25mg- refused seven times during the month. - [MEDICATION NAME] 25mg- refused seven times during the month. - [MEDICATION NAME] 50mg- refused seven times during the month. In an interview on [DATE] at 12:34 p.m., the POA stated that the resident is currently at the hospital and unresponsive. The POA stated that admitting nurse at the emergency room stated that Resident #1's condition was something that took time to develop. Stated the resident started to decline after the change in medication. POA stated the facility did not call the her to inform her of the change in medications treatment. Stated that Resident #1 was taken off the medication for a week before the daughter came to visit. POA stated that the behaviors started because the facility stopped the [MEDICATION NAME] without her permission. Stated that the DON stopped her in the hallway during a visit and told her that they are going to stop giving Resident #1 the [MEDICATION NAME]. POA stated that she told the DON to not stop the [MEDICATION NAME] because Resident #1 will not respond well. Stated that her mom would become paranoid and start refusing care. Stated that she told the DON that her mom would not put dentures in and would not swallow. In an interview on [DATE] at 4:34 p.m., Resident #1's son stated that his mom was on a medication that kept her stable, but the nursing home stopped giving it to her without letting the family know. Stated that the care giver and the POA have found the resident with feces on her and disoriented and that she did not have thrush before she went to the nursing home. Stated that the facility was not cleaning her dentures and is why she did not put them back in. Resident #1's son stated that Resident #1 was supposedly taking her clothes off, and that when she talked it would be incoherent which is out of character for her. Stated that not too long ago she was driving around and taking care of herself for the most part. Interview on [DATE] at 2:38pm with RN 1 stated that she knew Resident #1 was not taking medications and that they tried to put it in her mouth or crush it but she still wouldn't take. Stated that with refusals we try again and try again, the first refusal we don't notify anybody but if it continues a 2nd day we will notify the doctor, also would document in the progress notes. Stated that she did not call the doctor and doesn't remember if Resident #1 refused medications when she worked with her or not. Stated that for meals the CNAs chart on kiosk if we offer substitutes. If resident refuses food the ST will get involved, CNA's will let nurses know. Stated that the facility does try to monitor fluids for residents with a history of [MEDICAL CONDITION]. In an interview on [DATE] at 11:13 a.m. DON stated there was an increase in behaviors for Resident #1. Stated that the DR knew she was having behaviors and apparently what he was seeing was nothing abnormal for her. Stated that she did not know if these behaviors were because of GDR. Stated that the daughter told her she was going to regret taking Resident #1 off of [MEDICATION NAME]. In an interview on [DATE] at 1:00 p.m., LVN 1 stated that Resident #1 had some behaviors when she first came in and they increased right away when she stopped taking her medications. LVN 1 stated she discussed Resident #1's medications with the resident's daughter-in-law/medical POA and she said that is what happens when they take her off the [MEDICATION NAME]. LVN 1 stated that the POA wanted Resident #1 back on the medication. LVN 1 reported she spoke to the DON, who spoke to the physician and the [MEDICAL CONDITION] was restarted around ,[DATE] before she went on vacation. LVN 1 stated that if there is ever any change of condition she would let the DON know. Record Review of Resident #1's (MONTH) (YEAR) MAR's revealed Supplement 2.0 (supplemental shake) given 3x a day starting [DATE]. Out of 72 opportunities during the month Resident #1 refused 36 times (50%). The amount of the supplement consumed on the dates Resident #1 accepted the 2.0 is not included in the documentation. Record Review of Resident #1 (MONTH) (YEAR) MAR ([DATE]st thru (MONTH) 09) revealed 26 opportunities and Resident #1 refused medication 20 times. The amount of the 2.0 supplement consumed on the dates Resident #1 accepted the 2.0 is not included in the documentation. Record Review of Resident #1's weights in total taken at facility during her 67 day stay revealed the following; On ,[DATE], her day of admission, she weighed 189 pounds. On [DATE], 186 pounds (which is a 1.5%, 3 pound weight loss in one week). On ,[DATE], 179 pounds (5.2% or 10 pounds lost since admission). On ,[DATE], 169 pounds (10.6% or 20 pounds lost since admission). On ,[DATE], 166 pounds (12% or 23 pounds in one month). The next available weight was taken on ,[DATE] as weights were taken once a month after the first month, Resident #1 weighed 149 pounds (21 % over the 2 months or 40 pound weight loss). Record Review of Review of Resident #1's Nutritional History Form dated [DATE] has that Resident #1 feeds herself and has a good meal intake. Information regarding her likes and dislikes obtained from the resident and her family. Record Review of Resident #1's Nutritional Risk Assessment Form, dated [DATE], revealed that her weight is listed as 207 pounds. Resident #1's diet is listed as regular. The form notes No recent wt (weight) changes noted. The goal for Resident #1 is noted to be gradual wt loss, ,[DATE] #/ a month, to about 175, nutr (nutritional) labs wnl (within normal limits) over the next 90 days. Review of the facility policy #6.13 regarding 2.0 Calorie Med Pass, the purpose of the supplement is noted to be; To provide a high calorie, high protein supplement in small volume for adding nutrients when other interventions are not appropriate. And . The amount of the supplement taken is documented on the MAR and signed out by the designated person passing the medication. Record review of Resident #1's Electronic Medical Chart to include MAR, Progress Notes, Weights, Daily Intakes, Physician Orders, Dietary Orders, Care Plan, MDS assessment revealed that the resident had a change in condition after the facility initiated a GDR for [MEDICATION NAME] on [DATE]. Resident medical records reveal that the resident had severe weight loss, refused medications, refused nutrition intake, refused fluids. Review of Resident #1's hospital records revealed her weight at the time of her hospital admission on [DATE] was 143 pounds. Review of the physician progress notes [REDACTED]. On [DATE] notes the reason for the visit is follow-up to post hospital care. Resident #1's weight is noted to be 207 pounds. The Physician noted Resident #1 is to be maintained on the same medications and physical therapy. On [DATE] the Physician note again includes the resident's weight as 207. The reason for the visit is noted to be a follow-up, sleepy lethargic. The Physician noted Resident #1 is to be maintained on the same medications and supportive therapy. On [DATE] there is no weight listed. The reason for the visit is noted to be a follow-up, (an illegible word), participating in PT but remains in bed most of the time, afebrile. Record Review of the facility WAR meeting notes on [DATE] revealed that the DON did not take notes on Resident #1's weights, reassessment of interventions, or change in condition. The following is a review of the WAR meetings from [DATE] through [DATE]; - [DATE], Follow up summary notes revealed 10 residents were reviewed. There is no indication on the document indicating decisions made. Each name of a resident has one or two words beside the resident name, such as new admit - [DATE] Resident #1's name appears on the summary notes for the first time with new admit beside her name. - [DATE] Resident #1 is not listed on the summary. - [DATE] Resident #1 is listed with med options, illegible med name and [MEDICATION NAME] are listed. - [DATE] Resident #1 is not listed. - [DATE] Resident #1 is listed with weight loss beside her name. - [DATE] Resident #1 is listed with weight loss and 2-cal - [DATE] Resident #1 is listed with A&B (antibiotics), [MEDICAL CONDITION]. - [DATE]Resident #1 is listed with [MEDICATION NAME] restarted WAR meetings are designed to discuss residents at risk of triggered concerns to allow facility identify concerns and intervene for resident's quality of care. DON was not able to produce WAR meeting notes detailing what area of care of was discussed for each resident identified on the weekly list. WAR records revealed that the facility did not discuss interventions, weight loss, change in condition, dehydration, or reassess interventions for triggered residents identified on the WAR meeting list. Record Review of the facility Meal Intake Records on [DATE] for Resident #1 revealed a decrease in resident's meal intake starting from [DATE] through [DATE]. Records due not include fluid intake. A review of resident intake is listed below; - From [DATE] through [DATE] there was an opportunity for 19 meals. The percent eaten can be documented as ,[DATE]%- she ate this percent on 1 meal, ,[DATE]%-2 meals, ,[DATE]%-9 meals, ,[DATE]%-5 meals. Two refusals were documented. - From [DATE] through [DATE]-21 meals were documented. ,[DATE]%- 1 meal, ,[DATE]%-6 meals, ,[DATE]%-9 meals, ,[DATE]%-2 meals. Three refusals were documented. - From [DATE] through [DATE]-21 meals were documented. ,[DATE]%- 5 meals, ,[DATE]%-7 meals, ,[DATE]%-7 meals, ,[DATE]%-1 meal. One refusal was documented. - From [DATE] through [DATE]-22 meals were documented. ,[DATE]%- 8 meals, ,[DATE]%-8 meals, ,[DATE]%-3 meals, ,[DATE]%-none. Three refusals were documented. - From [DATE] through [DATE]-21 meals were documented. ,[DATE]%- 7 meals, ,[DATE]%-7 meals, ,[DATE]%-5 meals, ,[DATE]%-1 meal. One refusal was documented. - From [DATE] through [DATE]-21 meals were documented. ,[DATE]%- 7 meal, ,[DATE]%-5 meals, ,[DATE]%-4 meals, ,[DATE]%-1 meal. Four refusals were documented. - From [DATE] through [DATE]- 18 out of 21 meals were documented. ,[DATE]%- 7 meals, ,[DATE]%-5 meals, ,[DATE]%-3 meals, ,[DATE]%-none. Three refusals were documented. - From [DATE] through [DATE]-20 out of 21 meals were documented. ,[DATE]%- 5 meals, ,[DATE]%-0 meals, ,[DATE]%-3 meals, ,[DATE]%-0 meals. Twelve refusals were documented. - From [DATE] through [DATE]- 19 of 21 meals were documented. ,[DATE]%- 2 meals, ,[DATE]%-3 meals, ,[DATE]%-7 meals, ,[DATE]%-1 meal. Four refusals were documented. - From [DATE] through [DATE]- 9 of 18 meals were documented. ,[DATE]%- none, ,[DATE]%-3 meals, ,[DATE]%-3 meals, ,[DATE]%-none. Three refusals were documented. Review of the facility Policy titled Weight Program, revised ,[DATE], and revealed the following; Residents are weighed at admission, readmission, and per physician orders. Weekly weights are completed for an additional 3 weeks (or longer if not stable) on the following: Admit, Readmit, significant weight loss of 5% or more in 1 month or less, Physician's orders, on a [MEDICATION NAME] feeding And. Weekly weights- residents with a significant weight loss x30 days or less (5% or more) will be placed on weekly weights x4 weeks or until weights are stable and no weight concerns are noted. If weight concerns are noted/weights are not stable, notify your RD and continue the weekly weights until stable. Process DON or Designee will review monthly and weekly weights prior to WAR (Weekly At Risk) Meeting. WAR (Weekly At Risk) Meeting Weekly War meeting-discuss residents with greater than a 3 pound change in a week. Continue to discuss resident in weekly WAR meeting until concern is resolved. In an interview on [DATE] at 4:34 p.m., Resident #1's son stated that his mother used to be 215 pounds and is now down to 138. Stated that Resident #1 has not opened her eyes or talked since she has been here. Resident #1's son stated that the facility transferred her to the hospital because her kidneys were shutting down. In an interview on [DATE] at 12:34 p.m., the POA stated that the resident started refusing medications, food, and liquids after change in medication administration of [MEDICATION NAME]. POA stated that she showed the facility staff how to trick her mom into taking the medications. Stated that she told the facility to not take resident off the medication because DR took her off once and she began to refuse her medication and became fearful with anxiety. Stated that the resident is now going to be put on hospice. Stated that the hospital staff told her to call the state due to Resident #1's condition at admission from the facility. In an interview on [DATE] 12:55 p.m. TD stated that Resident #1 was receiving therapy for all three specialty services (PT, OT, ST). Stated that she worked with resident a couple of times, but she was definitely in the therapy room. Stated that the resident was not very active but alert, she was not able to express whether she was in pain, so it was hard to communicate with her. Stated that the resident seemed to decline and had thr

Based on observation, interview, and record review, the facility failed to apply fundamental principle to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility failed ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of three residents reviewed for MDS assessment, nutrition and hydration, and physician notification of - resident critical labs, change in condition, and severe weight loss. 1. The facility failed to monitor Resident #1 fluid intake from [DATE] through [DATE] to ensure she was adequately hydrated. Resident #1 entered the facility at risk for dehydration. 2. The facility failed to consult with the Attending Physician when Resident #1 had a change of condition and was not taking in fluids. The facility failed to reassess interventions for resident #1 regarding weight loss. 3. The facility failed to ensure abnormal lab results received on [DATE] and [DATE] were promptly reported to the physician. Resident #1 was hospitalized on [DATE] with [DIAGNOSES REDACTED]. Resident #1 expired in the hospital on [DATE]. These failures resulted in an identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was lowered on [DATE], the facility remained out of compliance at a level of actual harm with a scope identified as a pattern. This failure affected one resident and placed 2 residents reviewed at risk receiving substandard quality of care resulting in a change in condition, dehydration, decline in health, and/or death. Findings Include: In an interview on [DATE] at 9:37 a.m., the POA called to inform the state that the resident had passed away. Record review of Resident #1's face sheet on [DATE] revealed the resident to be an [AGE] year-old woman admitted on [DATE] with a [DIAGNOSES REDACTED]. The facility did not include the [DIAGNOSES REDACTED]. Record review of Resident #1's MDS resident assessment and care screening on [DATE] revealed that the MDS did not list [MEDICAL CONDITION] as a diagnosis. MDS care area assessment revealed that the resident did not exhibit behavioral symptoms, signs of [MEDICAL CONDITION], acute onset mental status change, and had a mood severity score of zero with no potential indicators of [MEDICAL CONDITION]. Resident had an MDS BIMS score of 5. Review of MDS history revealed that the facility did not conduct an MDS assessment for a change in condition for Resident #1. Further review of MDS revealed that the MDS did not list [MEDICAL CONDITION] as a diagnosis. MDS care area assessment revealed that the resident did not exhibit behavioral symptoms, signs of [MEDICAL CONDITION], acute onset mental status change, and had a mood severity score of zero with no potential indicators of [MEDICAL CONDITION]. Resident had an MDS BIMS score of 5. Review of MDS history revealed that the facility did not conduct an MDS assessment for a change in condition for Resident #1. Record review of care plan for Resident #1 (Start dated: [DATE], Completion Date: [DATE]) created by MDSN, revealed that the facility was to monitor/document change in behavior, change in eating patterns. Monitor/document/report to PRN Change on Mental status, emaciation, weight loss. Alert dietician if consumption is poor for more than 48 hours, weight decline persists, contact physician and dietician immediately. Resident was not care planned for a GDR, [MEDICAL CONDITION], or dehydration. Review of the care plan does not have signatures from the facility staff, resident, resident POA, or resident physician. Record review on [DATE] of History and Physical electronically signed by DR on [DATE] revealed that Resident #1 had a history of [REDACTED]. Resident was admitted to the hospital on ,[DATE] for acute [MEDICAL CONDITION] related to dehydration from inadequate intake and hospitalized again on ,[DATE] for acute on [MEDICAL CONDITION] and acute UTI. Resident was seen in office on ,[DATE], the renal status was noted to be stable. Review of facility Care Area Assessments (CAA) policy (Dated: 2001) states: CAAs will be used to help analyze data to obtain from the MDS and to develop individualized care plans. CAAs are linked between assessment and care planning. Triggered Care Areas will be evaluated by the Interdisciplinary Team to determine the underlying causes, potential consequences and relationship to other trigger areas. In an interview on [DATE] at 4:47 p.m., POA stated that Resident #1's condition got so bad that she was severally dehydrated and that her kidneys are dried out and shutting down, her mouth was bloody, blistered and raw. Stated that the urine in the catheter showed a brown orange color when she was admitted because she was so dry. Stated that Resident #1 was not able to be completely revived so they have taken her off everything and are preparing for Hospice care. Stated that the resident is on [MEDICATION NAME] and IV for hydration. Stated that the DR told her that the facility never notified him about the resident's condition. POA stated that the facility never had a treatment plan meeting for Resident #1 and did not have any meetings about the resident's care. Stated the facility never called to inform her about the resident's infection. In an interview on [DATE] at 5:47 p.m. Hospital Nurse Manager stated that she was told patient was covered in feces and bruises. Stated that there was an APS referral and DR was the admitting physician. Stated that she was told Resident #1 had while yellow plaque, moaning and did not respond to any questions, severally dehydrated. Stated that the nursing home sent resident to the hospital because she was unresponsive. Stated that hospital staff stated that she came for dehydration. Stated that she worked at a nursing home and that she knows you can't make people drink but they should have done some kind of intervention. In an interview on [DATE] at 3:45 p.m. MDSN stated that she completes the MDS resident assessment and care screening for admitting residents. Stated that she put in active and pertinent [DIAGNOSES REDACTED]. Stated that a history of [MEDICAL CONDITION] and dehydration would be significant to a resident's care if they were on a medication like [MEDICATION NAME] or on a diuretic like [MEDICATION NAME]. MDSN stated that a resident's care plan would address the active and pertinent [DIAGNOSES REDACTED]. Stated that she was unaware of Resident #1's history of [MEDICAL CONDITION] caused by dehydration and that she may have overlooked it. MDSN stated that the she would do an MDS resident assessment and care screening for residents with a change in condition. Stated that nurses should be seeing the change in behaviors and do a change of condition and let the doctor know. Stated that the nurse notes would be under resident name and under assessments tab in point click care system. MDSN stated that she can conduct an MDS assessment for a change in condition if she feels it is needed. MDSN stated that she does not sign off on the MDS resident assessments because she is only an LVN and that the DON is the person that signs off on the MDS assessments. MDSN stated that she looked back at Resident #1's H&P and saw the acute chronic [MEDICAL CONDITION]. MDSN stated that the [MEDICAL CONDITION] should have been put on the resident's chart as a diagnosis. Stated that she looked over it and did not put it on the resident's chart. Stated that if she would have put the [DIAGNOSES REDACTED].#1's chart the facility could have care planned for it. In an interview on [DATE] at 9:40 a.m. RD stated there was no indication of that in Resident #1 had a [DIAGNOSES REDACTED]. In an interview on [DATE] at 11:13 a.m. DON stated she did not know about Resident #1's renal [DIAGNOSES REDACTED]. DON stated that the [MEDICAL CONDITION] caused by dehydration should have been triggered onto resident's diagnosis. DON stated that yes knowing the history of the resident would have triggered the facility to be aware of the resident's condition. DON stated that the [DIAGNOSES REDACTED]. DON stated that she did not review Resident #1's MDS assessment before signing off on it. In an interview on [DATE] at 1:00 p.m., LVN 1 stated that she did not know about Resident #1's history of [MEDICAL CONDITION] due to dehydration. Record Review of Facility Lab results for Resident #1's revealed she has labs conducted twice while at the facility, on [DATE] there is a critical Value of Glucose at 47, normal range (70 to 110), no indication of physician notification, no initials or progress notes indicating this was reported to the physician. On [DATE] there are Critical labs values of CO2 at 15, normal range (,[DATE]) and BUN 75, normal range (,[DATE]). The received date on the [DATE]. Labs are noted to be [DATE] at 2:21am, Reported date is [DATE] at 6:39am. And the report notes that the DON reviewed the results online on [DATE] at 12:47am. Record review of hospital admission records for Resident #1 on [DATE] revealed that the resident was transported by EMS on [DATE]. ER assessment shows resident was restless, crying, moaning, with slight dyspnea, acutely inflamed [MEDICATION NAME] mucosa, nonresponsive, distended neck veins at supine, scattered rhonchi, 1+ [MEDICAL CONDITION] both legs and ankle. Resident's ER lab results show her white blood count was 13.1 w/left shift, Sodium level at 137, Potassium in urine at 4.4, carbon [MEDICATION NAME] level at 19, blood urea nitrogen level at 82, creatinine level at 2.2, glomerular filtration rate at 20.2. [DIAGNOSES REDACTED]. [DATE] Resident Lab results showed Resident #1's Sodium level at 134, Potassium in urine at 3.6, blood urea nitrogen level at 71, creatinine level at 1.7, glomerular filtration rate at 27.7, white blood count at 11 with left shift. [DATE] Hospital Assessment: Acute on [MEDICAL CONDITION] due to inadequate oral intake superimposed on chronic [MEDICAL CONDITIONS] with combination of acute UTI and left lower lobe of lung pneumonia with exacerbation of [MEDICAL CONDITIONS] with status [REDACTED]. [DATE] Resident Lab results showed Resident #1's Sodium level at 146, Potassium in urine at 3.2, anion-gap at 12, blood urea nitrogen level at 35, creatinine at 1.3, glomerular filtration rate at 38.6, whit blood count at 9400. [DATE] Hospital Assessment: Acute on [MEDICAL CONDITION] due to inadequate oral intake, superimposed on [MEDICAL CONDITIONS], combination of acute UTI and left lower lobe of lung pneumonia, Hypertension with hypertensive cardiovascular disease with impending [MEDICAL CONDITION], History of multiple [MEDICAL CONDITION]. [DATE] Hospital note revealed Resident was conscious but responds only to painful stimuli. Review of link Medical News Today website accessed at https://www.medicalnewstoday.com/articles/ 7.php on [DATE] revealed, A BUN, or Blood Urea Nitrogen test, measures the level of urea nitrogen in the blood using a standard blood sample. Urea nitrogen is the natural byproduct of the breakdown of protein. According to the American Association for Clinical Chemistry, BUN tests are mainly used to assess kidney health .A rise or fall in blood urea nitrogen levels may indicate a wide range of health problems. This is because the kidneys and liver are involved in a wide range of body functions . A result higher than 50 milligrams per deciliter is likely to signal an underlying health problem . Elevated BUN levels can result from: - Kidney damage, failure, or disease - Dehydration - Shock . Typical BUN levels by age and gender . -Adult women: 6 to 20 milligrams per deciliter . In an interview on [DATE] at 5:47 p.m. Hospital Nurse Manager stated that Resident #1 had abnormal lab values. Stated that resident's mucus membranes were cracked, skin turgor not good, mouth was inflamed, nutrition not adequate, BUN was 82 and [MEDICATION NAME] was 2.2 meaning resident was in kidney failure. Interview on [DATE] at 2:38pm with RN 1 stated that ADON, or MDSN keep track of labs drawn. Stated that she will call the doctor and or the DON if she saw critical lab results, would document and would be in the progress notes. Stated that she did not know the results of Resident #1's lab results. In an interview on [DATE] at 11:13 a.m. DON stated DON stated that she looks at all the lab work. Not sure if there is a way that the DR or NP looked at the labs. DON stated that DR does not have a medical director to call if he is not available to receive critical labs. DON stated that she has the power to call the facility to ask them to have the resident sent to a hospital if she feels a resident is not doing well. DON stated that she did not call DR on Sunday at midnight because he was not going to answer his phone at that hour. DON stated that Resident #1 was dehydrated and was worried about her BUN. DON stated that she wanted to do an IV but Resident #1 would have pulled it out. In an interview on [DATE] at 1:00 p.m., LVN 1, when asked about critical lab values and procedure she stated that the lab would call when there is a critical lab value. She stated it was usually that same day via morning report. She stated that usually it is the ADON and/or DON that take care of labs that come in via the fax. LVN 1 stated she was not aware of Resident #1's critical lab values. LVN 1 stated she does not know about a policy but knows that you are supposed to notify the physician immediately. Record Review of a physician's order initiated [DATE] for Med Pass 2.0 supplement to be given three times a day. Record Review of a physician's order initiated [DATE] orders revealed an active ordered for [MEDICATION NAME] 25mg a tab by mouth with a start date of [DATE] and a revision date of [DATE]. Record Review of Resident MAR revealed that Resident #1 was admitted on 50 mg BID of [MEDICATION NAME] on [DATE]. Dose for [MEDICATION NAME] reduced to 25 mg BID on [DATE] through [DATE] and then down to 25 mg QD on [DATE] and then discontinued after 7 seven days. The order was created by DON on [DATE] and revised by MDSN on [DATE]. Record review of Facility Pharmacy Consultation revealed Resident #1 was prescribed [MEDICATION NAME] by DR on [DATE] for Major [MEDICAL CONDITION]. The pharmacy consult revealed that the medication was a routine order. Record review revealed that the resident had an GDR eval for [MEDICATION NAME] on [DATE]. Resident #1 was taking trazadone for depression on routine order starting [DATE]. Resident #1 had a GDR evaluation scheduled for [DATE]. Record Review of Resident #1's Medication Administration Records (MARs) on [DATE] revealed an increase in medication administration refusals from (MONTH) (YEAR) through (MONTH) (YEAR). The amount of refusals is listed below; May (YEAR) - [MEDICATION NAME] 5mg- refused one time during the month. - Calcium 20mg- refused one time during the month. - [MEDICATION NAME] Bisulfate 75mg- refused one time during the month. - [MEDICATION NAME] Sodium 100mg- refused one time during the month. - [MEDICATION NAME] 325mg- refused one time during the month. - [MEDICATION NAME] 20mg- refused one time during the month. - Losartan Potassium 100mg- refused one time during the month. - [MEDICATION NAME] Powder 17 Gm- refused one time during the month. - [MEDICATION NAME] 20mg- refused five times during the month. - [MEDICATION NAME] 100mg- refused one time during the month. - [MEDICATION NAME] 25mg- refused one time during the month. - [MEDICATION NAME] 10mg- refused one time during the month. - [MEDICATION NAME] 50mg then 25mg- refused one time during the month. - [MEDICATION NAME] 25mg- refused one time during the month. - [MEDICATION NAME] 50mg- refused one time during the month. June (YEAR) - [MEDICATION NAME] 5mg- refused seventeen times during the month. - Calcium 20mg- refused seventeen times during the month. - [MEDICATION NAME] Bisulfate 75mg- refused seventeen times during the month. - [MEDICATION NAME] Sodium 100mg- refused seventeen times during the month. - [MEDICATION NAME] 325mg- refused seventeen times during the month. - [MEDICATION NAME] 20mg- refused seventeen times during the month. - Losartan Potassium 100mg- refused seventeen times during the month. - [MEDICATION NAME] Powder 17 Gm- refused seventeen times during the month. - [MEDICATION NAME] 20mg- refused nine times during the month. - [MEDICATION NAME] 100mg- refused seventeen times during the month. - [MEDICATION NAME] 25mg- refused seventeen times during the month. - [MEDICATION NAME] 10mg- refused seventeen times during the month. - [MEDICATION NAME] 50mg then 25mg- refused five times out of the seven times ordered during the middle of the month and refused 5 times out of the eight doses ordered at the end of the month. - [MEDICATION NAME] 25mg- refused seventeen times during the month. - [MEDICATION NAME] 50mg- refused seventeen times during the month. July (YEAR) (in the facility 9 days) - [MEDICATION NAME] 5mg- refused eight times during the month. - Calcium 20mg- refused eight times during the month. - [MEDICATION NAME] Bisulfate 75mg- refused eight times during the month. - [MEDICATION NAME] Sodium 100mg- refused eight times during the month. - [MEDICATION NAME] 325mg- refused seven times during the month. - [MEDICATION NAME] 20mg- refused eight times during the month. - Losartan Potassium 100mg- refused seven times during the month. - [MEDICATION NAME] Powder 17 Gm- refused seven times during the month. - [MEDICATION NAME] 20mg- refused seven times during the month. - [MEDICATION NAME] 100mg- refused seven times during the month. - [MEDICATION NAME] 25mg- refused seven times during the month. - [MEDICATION NAME] 10mg- refused seven times during the month. - [MEDICATION NAME] 50mg then 25mg- refused seven times during the month. - [MEDICATION NAME] 25mg- refused seven times during the month. - [MEDICATION NAME] 50mg- refused seven times during the month. In an interview on [DATE] at 12:34 p.m., the POA stated that the resident is currently at the hospital and unresponsive. The POA stated that admitting nurse at the emergency room stated that Resident #1's condition was something that took time to develop. Stated the resident started to decline after the change in medication. POA stated the facility did not call the her to inform her of the change in medications treatment. Stated that Resident #1 was taken off the medication for a week before the daughter came to visit. POA stated that the behaviors started because the facility stopped the [MEDICATION NAME] without her permission. Stated that the DON stopped her in the hallway during a visit and told her that they are going to stop giving Resident #1 the [MEDICATION NAME]. POA stated that she told the DON to not stop the [MEDICATION NAME] because Resident #1 will not respond well. Stated that her mom would become paranoid and start refusing care. Stated that she told the DON that her mom would not put dentures in and would not swallow. In an interview on [DATE] at 4:34 p.m., Resident #1's son stated that his mom was on a medication that kept her stable, but the nursing home stopped giving it to her without letting the family know. Stated that the care giver and the POA have found the resident with feces on her and disoriented and that she did not have thrush before she went to the nursing home. Stated that the facility was not cleaning her dentures and is why she did not put them back in. Resident #1's son stated that Resident #1 was supposedly taking her clothes off, and that when she talked it would be incoherent which is out of character for her. Stated that not too long ago she was driving around and taking care of herself for the most part. Interview on [DATE] at 2:38pm with RN 1 stated that she knew Resident #1 was not taking medications and that they tried to put it in her mouth or crush it but she still wouldn't take. Stated that with refusals we try again and try again, the first refusal we don't notify anybody but if it continues a 2nd day we will notify the doctor, also would document in the progress notes. Stated that she did not call the doctor and doesn't remember if Resident #1 refused medications when she worked with her or not. Stated that for meals the CNAs chart on kiosk if we offer substitutes. If resident refuses food the ST will get involved, CNA's will let nurses know. Stated that the facility does try to monitor fluids for residents with a history of [MEDICAL CONDITION]. In an interview on [DATE] at 11:13 a.m. DON stated there was an increase in behaviors for Resident #1. Stated that the DR knew she was having behaviors and apparently what he was seeing was nothing abnormal for her. Stated that she did not know if these behaviors were because of GDR. Stated that the daughter told her she was going to regret taking Resident #1 off of [MEDICATION NAME]. In an interview on [DATE] at 1:00 p.m., LVN 1 stated that Resident #1 had some behaviors when she first came in and they increased right away when she stopped taking her medications. LVN 1 stated she discussed Resident #1's medications with the resident's daughter-in-law/medical POA and she said that is what happens when they take her off the [MEDICATION NAME]. LVN 1 stated that the POA wanted Resident #1 back on the medication. LVN 1 reported she spoke to the DON, who spoke to the physician and the [MEDICAL CONDITION] was restarted around ,[DATE] before she went on vacation. LVN 1 stated that if there is ever any change of condition she would let the DON know. Record Review of Resident #1's (MONTH) (YEAR) MAR's revealed Supplement 2.0 (supplemental shake) given 3x a day starting [DATE]. Out of 72 opportunities during the month Resident #1 refused 36 times (50%). The amount of the supplement consumed on the dates Resident #1 accepted the 2.0 is not included in the documentation. Record Review of Resident #1 (MONTH) (YEAR) MAR ([DATE]st thru (MONTH) 09) revealed 26 opportunities and Resident #1 refused medication 20 times. The amount of the 2.0 supplement consumed on the dates Resident #1 accepted the 2.0 is not included in the documentation. Record Review of Resident #1's weights in total taken at facility during her 67 day stay revealed the following; On ,[DATE], her day of admission, she weighed 189 pounds. On [DATE], 186 pounds (which is a 1.5%, 3 pound weight loss in one week). On ,[DATE], 179 pounds (5.2% or 10 pounds lost since admission). On ,[DATE], 169 pounds (10.6% or 20 pounds lost since admission). On ,[DATE], 166 pounds (12% or 23 pounds in one month). The next available weight was taken on ,[DATE] as weights were taken once a month after the first month, Resident #1 weighed 149 pounds (21 % over the 2 months or 40 pound weight loss). Record Review of Review of Resident #1's Nutritional History Form dated [DATE] has that Resident #1 feeds herself and has a good meal intake. Information regarding her likes and dislikes obtained from the resident and her family. Record Review of Resident #1's Nutritional Risk Assessment Form, dated [DATE], revealed that her weight is listed as 207 pounds. Resident #1's diet is listed as regular. The form notes No recent wt (weight) changes noted. The goal for Resident #1 is noted to be gradual wt loss, ,[DATE] #/ a month, to about 175, nutr (nutritional) labs wnl (within normal limits) over the next 90 days. Review of the facility policy #6.13 regarding 2.0 Calorie Med Pass, the purpose of the supplement is noted to be; To provide a high calorie, high protein supplement in small volume for adding nutrients when other interventions are not appropriate. And . The amount of the supplement taken is documented on the MAR and signed out by the designated person passing the medication. Record review of Resident #1's Electronic Medical Chart to include MAR, Progress Notes, Weights, Daily Intakes, Physician Orders, Dietary Orders, Care Plan, MDS assessment revealed that the resident had a change in condition after the facility initiated a GDR for [MEDICATION NAME] on [DATE]. Resident medical records reveal that the resident had severe weight loss, refused medications, refused nutrition intake, refused fluids. Review of Resident #1's hospital records revealed her weight at the time of her hospital admission on [DATE] was 143 pounds. Review of the physician progress notes [REDACTED]. On [DATE] notes the reason for the visit is follow-up to post hospital care. Resident #1's weight is noted to be 207 pounds. The Physician noted Resident #1 is to be maintained on the same medications and physical therapy. On [DATE] the Physician note again includes the resident's weight as 207. The reason for the visit is noted to be a follow-up, sleepy lethargic. The Physician noted Resident #1 is to be maintained on the same medications and supportive therapy. On [DATE] there is no weight listed. The reason for the visit is noted to be a follow-up, (an illegible word), participating in PT but remains in bed most of the time, afebrile. Record Review of the facility WAR meeting notes on [DATE] revealed that the DON did not take notes on Resident #1's weights, reassessment of interventions, or change in condition. The following is a review of the WAR meetings from [DATE] through [DATE]; - [DATE], Follow up summary notes revealed 10 residents were reviewed. There is no indication on the document indicating decisions made. Each name of a resident has one or two words beside the resident name, such as new admit - [DATE] Resident #1's name appears on the summary notes for the first time with new admit beside her name. - [DATE] Resident #1 is not listed on the summary. - [DATE] Resident #1 is listed with med options, illegible med name and [MEDICATION NAME] are listed. - [DATE] Resident #1 is not listed. - [DATE] Resident #1 is listed with weight loss beside her name. - [DATE] Resident #1 is listed with weight loss and 2-cal - [DATE] Resident #1 is listed with A&B (antibiotics), [MEDICAL CONDITION]. - [DATE]Resident #1 is listed with [MEDICATION NAME] restarted WAR meetings are designed to discuss residents at risk of triggered concerns to allow facility identify concerns and intervene for resident's quality of care. DON was not able to produce WAR meeting notes detailing what area of care of was discussed for each resident identified on the weekly list. WAR records revealed that the facility did not discuss interventions, weight loss, change in condition, dehydration, or reassess interventions for triggered residents identified on the WAR meeting list. Record Review of the facility Meal Intake Records on [DATE] for Resident #1 revealed a decrease in resident's meal intake starting from [DATE] through [DATE]. Records due not include fluid intake. A review of resident intake is listed below; - From [DATE] through [DATE] there was an opportunity for 19 meals. The percent eaten can be documented as ,[DATE]%- she ate this percent on 1 meal, ,[DATE]%-2 meals, ,[DATE]%-9 meals, ,[DATE]%-5 meals. Two refusals were documented. - From [DATE] through [DATE]-21 meals were documented. ,[DATE]%- 1 meal, ,[DATE]%-6 meals, ,[DATE]%-9 meals, ,[DATE]%-2 meals. Three refusals were documented. - From [DATE] through [DATE]-21 meals were documented. ,[DATE]%- 5 meals, ,[DATE]%-7 meals, ,[DATE]%-7 meals, ,[DATE]%-1 meal. One refusal was documented. - From [DATE] through [DATE]-22 meals were documented. ,[DATE]%- 8 meals, ,[DATE]%-8 meals, ,[DATE]%-3 meals, ,[DATE]%-none. Three refusals were documented. - From [DATE] through [DATE]-21 meals were documented. ,[DATE]%- 7 meals, ,[DATE]%-7 meals, ,[DATE]%-5 meals, ,[DATE]%-1 meal. One refusal was documented. - From [DATE] through [DATE]-21 meals were documented. ,[DATE]%- 7 meal, ,[DATE]%-5 meals, ,[DATE]%-4 meals, ,[DATE]%-1 meal. Four refusals were documented. - From [DATE] through [DATE]- 18 out of 21 meals were documented. ,[DATE]%- 7 meals, ,[DATE]%-5 meals, ,[DATE]%-3 meals, ,[DATE]%-none. Three refusals were documented. - From [DATE] through [DATE]-20 out of 21 meals were documented. ,[DATE]%- 5 meals, ,[DATE]%-0 meals, ,[DATE]%-3 meals, ,[DATE]%-0 meals. Twelve refusals were documented. - From [DATE] through [DATE]- 19 of 21 meals were documented. ,[DATE]%- 2 meals, ,[DATE]%-3 meals, ,[DATE]%-7 meals, ,[DATE]%-1 meal. Four refusals were documented. - From [DATE] through [DATE]- 9 of 18 meals were documented. ,[DATE]%- none, ,[DATE]%-3 meals, ,[DATE]%-3 meals, ,[DATE]%-none. Three refusals were documented. Review of the facility Policy titled Weight Program, revised ,[DATE], and revealed the following; Residents are weighed at admission, readmission, and per physician orders. Weekly weights are completed for an additional 3 weeks (or longer if not stable) on the following: Admit, Readmit, significant weight loss of 5% or more in 1 month or less, Physician's orders, on a [MEDICATION NAME] feeding And. Weekly weights- residents with a significant weight loss x30 days or less (5% or more) will be placed on weekly weights x4 weeks or until weights are stable and no weight concerns are noted. If weight concerns are noted/weights are not stable, notify your RD and continue the weekly weights until stable. Process DON or Designee will review monthly and weekly weights prior to WAR (Weekly At Risk) Meeting. WAR (Weekly At Risk) Meeting Weekly War meeting-discuss residents with greater than a 3 pound change in a week. Continue to discuss resident in weekly WAR meeting until concern is resolved. In an interview on [DATE] at 4:34 p.m., Resident #1's son stated that his mother used to be 215 pounds and is now down to 138. Stated that Resident #1 has not opened her eyes or talked since she has been here. Resident #1's son stated that the facility transferred her to the hospital because her kidneys were shutting down. In an interview on [DATE] at 12:34 p.m., the POA stated that the resident started refusing medications, food, and liquids after change in medication administration of [MEDICATION NAME]. POA stated that she showed the facility staff how to trick her mom into taking the medications. Stated that she told the facility to not take resident off the medication because DR took her off once and she began to refuse her medication and became fearful with anxiety. Stated that the resident is now going to be put on hospice. Stated that the hospital staff told her to call the state due to Resident #1's condition at admission from the facility. In an interview on [DATE] 12:55 p.m. TD stated that Resident #1 was receiving therapy for all three specialty services (PT, OT, ST). Stated that she worked with resident a couple of times, but she was definitely in the therapy room. Stated that the resident was not very active but alert, she was not able to express whether she was in pain, so it was hard to communicate with her. Stated that the resident seemed to decline and had thr

Based on observation, interview, and record review, the facility failed to apply fundamental principle to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility failed ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of three residents reviewed for MDS assessment, nutrition and hydration, and physician notification of - change in condition, and severe weight loss. 1. The facility failed to monitor Resident #1 fluid intake from [DATE] through [DATE] to ensure she was adequately hydrated. Resident #1 entered the facility at risk for dehydration. 2. The facility failed to consult with the Attending Physician when Resident #1 had a change of condition and was not taking in fluids. The facility failed to reassess interventions for resident #1 regarding weight loss. 3. The facility failed to ensure abnormal lab results received on [DATE] and [DATE] were promptly reported to the physician. Resident #1 was hospitalized on [DATE] with [DIAGNOSES REDACTED]. Resident #1 expired in the hospital on [DATE]. These failures resulted in an identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was lowered on [DATE], the facility remained out of compliance at a level of actual harm with a scope identified as a pattern. This failure affected one resident and placed 2 residents reviewed at risk receiving insufficient nutrition and hydrtion resulting in a change in condition, dehydration, decline in health, and/or death. Findings Include: In an interview on [DATE] at 9:37 a.m., the POA called to inform the state that the resident had passed away. Record review of Resident #1's face sheet on [DATE] revealed the resident to be an [AGE] year-old woman admitted on [DATE] with a [DIAGNOSES REDACTED]. The facility did not include the [DIAGNOSES REDACTED]. Record review of Resident #1's MDS resident assessment and care screening on [DATE] revealed that the MDS did not list [MEDICAL CONDITION] as a diagnosis. MDS care area assessment revealed that the resident did not exhibit behavioral symptoms, signs of [MEDICAL CONDITION], acute onset mental status change, and had a mood severity score of zero with no potential indicators of [MEDICAL CONDITION]. Resident had an MDS BIMS score of 5. Review of MDS history revealed that the facility did not conduct an MDS assessment for a change in condition for Resident #1. Further review of MDS revealed that the MDS did not list [MEDICAL CONDITION] as a diagnosis. MDS care area assessment revealed that the resident did not exhibit behavioral symptoms, signs of [MEDICAL CONDITION], acute onset mental status change, and had a mood severity score of zero with no potential indicators of [MEDICAL CONDITION]. Resident had an MDS BIMS score of 5. Review of MDS history revealed that the facility did not conduct an MDS assessment for a change in condition for Resident #1. Record review of care plan for Resident #1 (Start dated: [DATE], Completion Date: [DATE]) created by MDSN, revealed that the facility was to monitor/document change in behavior, change in eating patterns. Monitor/document/report to PRN Change on Mental status, emaciation, weight loss. Alert dietician if consumption is poor for more than 48 hours, weight decline persists, contact physician and dietician immediately. Resident was not care planned for a GDR, [MEDICAL CONDITION], or dehydration. Review of the care plan does not have signatures from the facility staff, resident, resident POA, or resident physician. Record review on [DATE] of History and Physical electronically signed by DR on [DATE] revealed that Resident #1 had a history of [REDACTED]. Resident was admitted to the hospital on ,[DATE] for acute [MEDICAL CONDITION] related to dehydration from inadequate intake and hospitalized again on ,[DATE] for acute on [MEDICAL CONDITION] and acute UTI. Resident was seen in office on ,[DATE], the renal status was noted to be stable. Review of facility Care Area Assessments (CAA) policy (Dated: 2001) states: CAAs will be used to help analyze data to obtain from the MDS and to develop individualized care plans. CAAs are linked between assessment and care planning. Triggered Care Areas will be evaluated by the Interdisciplinary Team to determine the underlying causes, potential consequences and relationship to other trigger areas. Observation on [DATE] at 4:15 p.m., revealed Resident #1 in hospital bed on the 5th floor. Resident was not responsive to verbal prompts. Resident #1 had loose skin sagging off her face, no teeth/dentures, inside of mouth was red, eyes sockets were sunken, cracked lips, labored breathing, mouth wide open, tongue resting at the bottom of mouth, white spots on resident's tongue, gaunt, eyes closed, not moving. In an interview on [DATE] at 4:47 p.m., POA stated that Resident #1's condition got so bad that she was severally dehydrated and that her kidneys are dried out and shutting down, her mouth was bloody, blistered and raw. Stated that the urine in the catheter showed a brown orange color when she was admitted because she was so dry. Stated that Resident #1 was not able to be completely revived so they have taken her off everything and are preparing for Hospice care. Stated that the resident is on [MEDICATION NAME] and IV for hydration. Stated that the DR told her that the facility never notified him about the resident's condition. POA stated that the facility never had a treatment plan meeting for Resident #1 and did not have any meetings about the resident's care. Stated the facility never called to inform her about the resident's infection. In an interview on [DATE] at 5:47 p.m. Hospital Nurse Manager stated that she was told patient was covered in feces and bruises. Stated that there was an APS referral and DR was the admitting physician. Stated that she was told Resident #1 had while yellow plaque, moaning and did not respond to any questions, severally dehydrated. Stated that the nursing home sent resident to the hospital because she was unresponsive. Stated that hospital staff stated that she came for dehydration. Stated that she worked at a nursing home and that she knows you can't make people drink but they should have done some kind of intervention. In an interview on [DATE] at 3:45 p.m. MDSN stated that she completes the MDS resident assessment and care screening for admitting residents. Stated that she put in active and pertinent [DIAGNOSES REDACTED]. Stated that a history of [MEDICAL CONDITION] and dehydration would be significant to a resident's care if they were on a medication like [MEDICATION NAME] or on a diuretic like [MEDICATION NAME]. MDSN stated that a resident's care plan would address the active and pertinent [DIAGNOSES REDACTED]. Stated that she was unaware of Resident #1's history of [MEDICAL CONDITION] caused by dehydration and that she may have overlooked it. MDSN stated that the she would do an MDS resident assessment and care screening for residents with a change in condition. Stated that nurses should be seeing the change in behaviors and do a change of condition and let the doctor know. Stated that the nurse notes would be under resident name and under assessments tab in point click care system. MDSN stated that she can conduct an MDS assessment for a change in condition if she feels it is needed. MDSN stated that she does not sign off on the MDS resident assessments because she is only an LVN and that the DON is the person that signs off on the MDS assessments. MDSN stated that she looked back at Resident #1's H&P and saw the acute chronic [MEDICAL CONDITION]. MDSN stated that the [MEDICAL CONDITION] should have been put on the resident's chart as a diagnosis. Stated that she looked over it and did not put it on the resident's chart. Stated that if she would have put the [DIAGNOSES REDACTED].#1's chart the facility could have care planned for it. In an interview on [DATE] at 9:40 a.m. RD stated there was no indication of that in Resident #1 had a [DIAGNOSES REDACTED]. In an interview on [DATE] at 11:13 a.m. DON stated she did not know about Resident #1's renal [DIAGNOSES REDACTED]. DON stated that the [MEDICAL CONDITION] caused by dehydration should have been triggered onto resident's diagnosis. DON stated that yes knowing the history of the resident would have triggered the facility to be aware of the resident's condition. DON stated that the [DIAGNOSES REDACTED]. DON stated that she did not review Resident #1's MDS assessment before signing off on it. Record Review of Facility Lab results for Resident #1's revealed she has labs conducted twice while at the facility, on [DATE] there is a critical Value of Glucose at 47, normal range (70 to 110), no indication of physician notification, no initials or progress notes indicating this was reported to the physician. On [DATE] there are Critical labs values of CO2 at 15, normal range (,[DATE]) and BUN 75, normal range (,[DATE]). The received date on the [DATE]. Labs are noted to be [DATE] at 2:21am, Reported date is [DATE] at 6:39am. And the report notes that the DON reviewed the results online on [DATE] at 12:47am. Record review of hospital admission records for Resident #1 on [DATE] revealed that the resident was transported by EMS on [DATE]. ER assessment shows resident was restless, crying, moaning, with slight dyspnea, acutely inflamed [MEDICATION NAME] mucosa, nonresponsive, distended neck veins at supine, scattered rhonchi, 1+ [MEDICAL CONDITION] both legs and ankle. Resident's ER lab results show her white blood count was 13.1 w/left shift, Sodium level at 137, Potassium in urine at 4.4, carbon [MEDICATION NAME] level at 19, blood urea nitrogen level at 82, creatinine level at 2.2, glomerular filtration rate at 20.2. [DIAGNOSES REDACTED]. [DATE] Resident Lab results showed Resident #1's Sodium level at 134, Potassium in urine at 3.6, blood urea nitrogen level at 71, creatinine level at 1.7, glomerular filtration rate at 27.7, white blood count at 11 with left shift. [DATE] Hospital Assessment: Acute on [MEDICAL CONDITION] due to inadequate oral intake superimposed on chronic [MEDICAL CONDITIONS] with combination of acute UTI and left lower lobe of lung pneumonia with exacerbation of [MEDICAL CONDITIONS] with status [REDACTED]. [DATE] Resident Lab results showed Resident #1's Sodium level at 146, Potassium in urine at 3.2, anion-gap at 12, blood urea nitrogen level at 35, creatinine at 1.3, glomerular filtration rate at 38.6, whit blood count at 9400. [DATE] Hospital Assessment: Acute on [MEDICAL CONDITION] due to inadequate oral intake, superimposed on [MEDICAL CONDITIONS], combination of acute UTI and left lower lobe of lung pneumonia, Hypertension with hypertensive cardiovascular disease with impending [MEDICAL CONDITION], History of multiple [MEDICAL CONDITION]. [DATE] Hospital note revealed Resident was conscious but responds only to painful stimuli. Review of link Medical News Today website accessed at https://www.medicalnewstoday.com/articles/ 7.php on [DATE] revealed, A BUN, or Blood Urea Nitrogen test, measures the level of urea nitrogen in the blood using a standard blood sample. Urea nitrogen is the natural byproduct of the breakdown of protein. According to the American Association for Clinical Chemistry, BUN tests are mainly used to assess kidney health .A rise or fall in blood urea nitrogen levels may indicate a wide range of health problems. This is because the kidneys and liver are involved in a wide range of body functions . A result higher than 50 milligrams per deciliter is likely to signal an underlying health problem . Elevated BUN levels can result from: - Kidney damage, failure, or disease - Dehydration - Shock . Typical BUN levels by age and gender . -Adult women: 6 to 20 milligrams per deciliter . In an interview on [DATE] at 5:47 p.m. Hospital Nurse Manager stated that Resident #1 had abnormal lab values. Stated that resident's mucus membranes were cracked, skin turgor not good, mouth was inflamed, nutrition not adequate, BUN was 82 and [MEDICATION NAME] was 2.2 meaning resident was in kidney failure. Interview on [DATE] at 2:38pm with RN 1 stated that ADON, or MDSN keep track of labs drawn. Stated that she will call the doctor and or the DON if she saw critical lab results, would document and would be in the progress notes. Stated that she did not know the results of Resident #1's lab results. In an interview on [DATE] at 11:13 a.m. DON stated DON stated that she looks at all the lab work. Not sure if there is a way that the DR or NP looked at the labs. DON stated that DR does not have a medical director to call if he is not available to receive critical labs. DON stated that she has the power to call the facility to ask them to have the resident sent to a hospital if she feels a resident is not doing well. DON stated that she did not call DR on Sunday at midnight because he was not going to answer his phone at that hour. DON stated that Resident #1 was dehydrated and was worried about her BUN. DON stated that she wanted to do an IV but Resident #1 would have pulled it out. In an interview on [DATE] at 1:00 p.m., LVN 1, when asked about critical lab values and procedure she stated that the lab would call when there is a critical lab value. She stated it was usually that same day via morning report. She stated that usually it is the ADON and/or DON that take care of labs that come in via the fax. LVN 1 stated she was not aware of Resident #1's critical lab values. LVN 1 stated she does not know about a policy but knows that you are supposed to notify the physician immediately. Record Review of a physician's order initiated [DATE] for Med Pass 2.0 supplement to be given three times a day. Record Review of Resident #1's (MONTH) (YEAR) MAR's revealed Supplement 2.0 (supplemental shake) given 3x a day starting [DATE]. Out of 72 opportunities during the month Resident #1 refused 36 times (50%). The amount of the supplement consumed on the dates Resident #1 accepted the 2.0 is not included in the documentation. Record Review of Resident #1 (MONTH) (YEAR) MAR ([DATE]st thru (MONTH) 09) revealed 26 opportunities and Resident #1 refused medication 20 times. The amount of the 2.0 supplement consumed on the dates Resident #1 accepted the 2.0 is not included in the documentation. Record Review of Resident #1's weights in total taken at facility during her 67 day stay revealed the following; On ,[DATE], her day of admission, she weighed 189 pounds. On [DATE], 186 pounds (which is a 1.5%, 3 pound weight loss in one week). On ,[DATE], 179 pounds (5.2% or 10 pounds lost since admission). On ,[DATE], 169 pounds (10.6% or 20 pounds lost since admission). On ,[DATE], 166 pounds (12% or 23 pounds in one month). The next available weight was taken on ,[DATE] as weights were taken once a month after the first month, Resident #1 weighed 149 pounds (21 % over the 2 months or 40 pound weight loss). Record Review of Review of Resident #1's Nutritional History Form dated [DATE] has that Resident #1 feeds herself and has a good meal intake. Information regarding her likes and dislikes obtained from the resident and her family. Record Review of Resident #1's Nutritional Risk Assessment Form, dated [DATE], revealed that her weight is listed as 207 pounds. Resident #1's diet is listed as regular. The form notes No recent wt (weight) changes noted. The goal for Resident #1 is noted to be gradual wt loss, ,[DATE] #/ a month, to about 175, nutr (nutritional) labs wnl (within normal limits) over the next 90 days. Review of the facility policy #6.13 regarding 2.0 Calorie Med Pass, the purpose of the supplement is noted to be; To provide a high calorie, high protein supplement in small volume for adding nutrients when other interventions are not appropriate. And . The amount of the supplement taken is documented on the MAR and signed out by the designated person passing the medication. Record review of Resident #1's Electronic Medical Chart to include MAR, Progress Notes, Weights, Daily Intakes, Physician Orders, Dietary Orders, Care Plan, MDS assessment revealed that the resident had a change in condition after the facility initiated a GDR for [MEDICATION NAME] on [DATE]. Resident medical records reveal that the resident had severe weight loss, refused medications, refused nutrition intake, refused fluids. Review of Resident #1's hospital records revealed her weight at the time of her hospital admission on [DATE] was 143 pounds. Review of the physician progress notes [REDACTED]. On [DATE] notes the reason for the visit is follow-up to post hospital care. Resident #1's weight is noted to be 207 pounds. The Physician noted Resident #1 is to be maintained on the same medications and physical therapy. On [DATE] the Physician note again includes the resident's weight as 207. The reason for the visit is noted to be a follow-up, sleepy lethargic. The Physician noted Resident #1 is to be maintained on the same medications and supportive therapy. On [DATE] there is no weight listed. The reason for the visit is noted to be a follow-up, (an illegible word), participating in PT but remains in bed most of the time, afebrile. Record Review of the facility WAR meeting notes on [DATE] revealed that the DON did not take notes on Resident #1's weights, reassessment of interventions, or change in condition. The following is a review of the WAR meetings from [DATE] through [DATE]; - [DATE], Follow up summary notes revealed 10 residents were reviewed. There is no indication on the document indicating decisions made. Each name of a resident has one or two words beside the resident name, such as new admit - [DATE] Resident #1's name appears on the summary notes for the first time with new admit beside her name. - [DATE] Resident #1 is not listed on the summary. - [DATE] Resident #1 is listed with med options, illegible med name and [MEDICATION NAME] are listed. - [DATE] Resident #1 is not listed. - [DATE] Resident #1 is listed with weight loss beside her name. - [DATE] Resident #1 is listed with weight loss and 2-cal - [DATE] Resident #1 is listed with A&B (antibiotics), [MEDICAL CONDITION]. - [DATE]Resident #1 is listed with [MEDICATION NAME] restarted WAR meetings are designed to discuss residents at risk of triggered concerns to allow facility identify concerns and intervene for resident's quality of care. DON was not able to produce WAR meeting notes detailing what area of care of was discussed for each resident identified on the weekly list. WAR records revealed that the facility did not discuss interventions, weight loss, change in condition, dehydration, or reassess interventions for triggered residents identified on the WAR meeting list. Record Review of the facility Meal Intake Records on [DATE] for Resident #1 revealed a decrease in resident's meal intake starting from [DATE] through [DATE]. Records due not include fluid intake. A review of resident intake is listed below; - From [DATE] through [DATE] there was an opportunity for 19 meals. The percent eaten can be documented as ,[DATE]%- she ate this percent on 1 meal, ,[DATE]%-2 meals, ,[DATE]%-9 meals, ,[DATE]%-5 meals. Two refusals were documented. - From [DATE] through [DATE]-21 meals were documented. ,[DATE]%- 1 meal, ,[DATE]%-6 meals, ,[DATE]%-9 meals, ,[DATE]%-2 meals. Three refusals were documented. - From [DATE] through [DATE]-21 meals were documented. ,[DATE]%- 5 meals, ,[DATE]%-7 meals, ,[DATE]%-7 meals, ,[DATE]%-1 meal. One refusal was documented. - From [DATE] through [DATE]-22 meals were documented. ,[DATE]%- 8 meals, ,[DATE]%-8 meals, ,[DATE]%-3 meals, ,[DATE]%-none. Three refusals were documented. - From [DATE] through [DATE]-21 meals were documented. ,[DATE]%- 7 meals, ,[DATE]%-7 meals, ,[DATE]%-5 meals, ,[DATE]%-1 meal. One refusal was documented. - From [DATE] through [DATE]-21 meals were documented. ,[DATE]%- 7 meal, ,[DATE]%-5 meals, ,[DATE]%-4 meals, ,[DATE]%-1 meal. Four refusals were documented. - From [DATE] through [DATE]- 18 out of 21 meals were documented. ,[DATE]%- 7 meals, ,[DATE]%-5 meals, ,[DATE]%-3 meals, ,[DATE]%-none. Three refusals were documented. - From [DATE] through [DATE]-20 out of 21 meals were documented. ,[DATE]%- 5 meals, ,[DATE]%-0 meals, ,[DATE]%-3 meals, ,[DATE]%-0 meals. Twelve refusals were documented. - From [DATE] through [DATE]- 19 of 21 meals were documented. ,[DATE]%- 2 meals, ,[DATE]%-3 meals, ,[DATE]%-7 meals, ,[DATE]%-1 meal. Four refusals were documented. - From [DATE] through [DATE]- 9 of 18 meals were documented. ,[DATE]%- none, ,[DATE]%-3 meals, ,[DATE]%-3 meals, ,[DATE]%-none. Three refusals were documented. Review of the facility Policy titled Weight Program, revised ,[DATE], and revealed the following; Residents are weighed at admission, readmission, and per physician orders. Weekly weights are completed for an additional 3 weeks (or longer if not stable) on the following: Admit, Readmit, significant weight loss of 5% or more in 1 month or less, Physician's orders, on a [MEDICATION NAME] feeding And. Weekly weights- residents with a significant weight loss x30 days or less (5% or more) will be placed on weekly weights x4 weeks or until weights are stable and no weight concerns are noted. If weight concerns are noted/weights are not stable, notify your RD and continue the weekly weights until stable. Process DON or Designee will review monthly and weekly weights prior to WAR (Weekly At Risk) Meeting. WAR (Weekly At Risk) Meeting Weekly War meeting-discuss residents with greater than a 3 pound change in a week. Continue to discuss resident in weekly WAR meeting until concern is resolved. In an interview on [DATE] at 4:34 p.m., Resident #1's son stated that his mother used to be 215 pounds and is now down to 138. Stated that Resident #1 has not opened her eyes or talked since she has been here. Resident #1's son stated that the facility transferred her to the hospital because her kidneys were shutting down. In an interview on [DATE] at 12:34 p.m., the POA stated that the resident started refusing medications, food, and liquids after change in medication administration of [MEDICATION NAME]. POA stated that she showed the facility staff how to trick her mom into taking the medications. Stated that she told the facility to not take resident off the medication because DR took her off once and she began to refuse her medication and became fearful with anxiety. Stated that the resident is now going to be put on hospice. Stated that the hospital staff told her to call the state due to Resident #1's condition at admission from the facility. In an interview on [DATE] 12:55 p.m. TD stated that Resident #1 was receiving therapy for all three specialty services (PT, OT, ST). Stated that she worked with resident a couple of times, but she was definitely in the therapy room. Stated that the resident was not very active but alert, she was not able to express whether she was in pain, so it was hard to communicate with her. Stated that the resident seemed to decline and had thrush in her mouth before she left. Stated that the ST was trying to address swallowing and on her last daily notes she was trying to do her treatment during meals and trying to address feeding. Stated that on [DATE] there was a decline in oral intake, that is when the ST tried to address swallowing, on [DATE] resident refused all intake from therapist, then on [DATE] attempted again to assess resident intake but resident declined. The oral decline was not on the resident's goals but ST started addressing the issue. Stated that she believes the resident did not have her dentures at this time. Stated that she is not aware of any other residents that had thrush. Stated that the speech therapist is on vacation and cannot be reached at this time. In an interview on [DATE] at 2:54 p.m. DM stated she gets resident weights and looks for the 5% weight loss. Stated that she did notice Resident #1's loss. Stated that the resident was taking a 2.0 supplement and she does not get feedback about whether or not the resident is taking the supplement. Stated that she does not recall doing a care plan meeting for Resident #1. Stated that she knows they need to get fluids to residents that have swallowing problems. Stated that she did not know about the thrush and ST did not notify me about any problems Resident #1 had. Stated that resident weights are done by restorative aids they give them to me and I calculate loss. Stated that she thinks the facility talked about resident this month and discussed fortified/high calorie food. Stated that the dietician is notified if resident is refusing to eat, then the physician is notified if he/she is here when we have the meeting. Stated that if she has any concerns about a resident she will inform the DON. In an interview on [DATE] at 3:45 p.m. MDSN stated that weight loss and change in condition is discussed in morning meetings. In an interview on [DATE] at 9:20 a.m. MDSN stated that she was not aware of the weight change that was posted on [DATE] and [DATE]. Stated that the weight change should have been brought to her attention and that the CNAs should have done a stop and watch for Resident #1 and a change in condition should have been done. Stated that the weekly weight reports are given to the DON and the kitchen. In an interview on [DATE] at 10:15 a.m. RA stated that she does the weights weekly and gives a copy of them to the DON, Dietary, and she keeps a copy for herself, so they can review them and let the nurse know of any significant weight changes. Stated that if there is a significant weigh change they will notify the DON. RA stated that she did do weights for Resident #1 and that the weights would be on the list she gives to the DON on a weekly basis. In an interview on [DATE] at 11:13 a.m. the DON stated that she does not do weights, the restorative aide does all the weights and the dietary manager puts them in the computer. Stated that they discuss weights on weekly WAR (Weekly At Risk) meeting. Stated that the SW, Activity Director, Dietary Manager, DON, ADMIN meet every Tuesday for WAR meetings to discuss new admissions, fall, antibiotics, weight loss, skin issues. Stated that for weight loss they notify the doctor in a note, then they are notified when the doctor signs the note. DON stated that she does not have any documentations of communication between the facility and the doctor for Resident #1. The DON stated that Resident was discussed on [DATE] because she was a new admit and on [DATE] for Multi vitamin and weight loss. DON stated that they did not talk about her weight on [DATE]. In an interview on [DATE] at 1:00 p.m., LVN1 stated she noticed Resident #1's weight loss because she had gone on vacation for a couple of weeks and when she saw her face she realized she had lost quite a bit of weight. LVN 1 stated she asked the DON to ask the physician to put Resident #1 on 2.0 supplement. She stated that weights are on the computer, but she didn't look the weights up just knew she was losing weight. LVN started that when she came back form vacation on [DATE] there was noticeable weight loss just by looking at resident's face. In an interview on [DATE] at 9:40 a.m. with the facility RD revealed she is at the facility ,[DATE] days a month. The RD stated she did Resident #1's initial assessment on [DATE]. She stated the weight 207 pounds was from the facility records when they did the admission. Stated that something definitely changed for Resident #1 and she had not gotten in to do monthly weights and review so she would not have seen Resident #1 prior to her hospitalization . Stated that her last review for Resident #1 was on [DATE]. Stated that if she had been notified of (MONTH) 1st weight of 149 pounds for Resident #1 she would have looked into it and talked to family to see what we could do. The RD stated that on [DATE] she went back to facility, she looked up weights, would expect some loss due to fluid issues due to [MEDICAL CONDITION]. The RD stated that if oral intake is that low (25%) the facility staff are going to let her know. She was not aware of Resident #1's meal intake amounts. The RD stated that on [DATE] she went back to facility, she looked up weights, would expect some loss due to fluid issues due to [MEDICAL CONDITION]. Interview on [DATE] at 3:50 p.m., DR stated he was not aware of Resident #1's severe weight prior to his visit on [DATE]. Stated that the POA requested that he see the resident that morning of [DATE] and did not receive a call from the DON until the afternoon of [DATE]. Interview on [DATE] at 5:14 p.m. ADMIN stated that the expectation is that the physician or the registered dietician and family are informed of changes in resident condition. Stated that he was not aware of the weight loss but was aware of the behaviors for Resident #1. Stated that the expectation is that the administrator be made aware of significant changes in conditions, WAR meetings should be utilized to review interventions. Stated that when DR has the on-call number and if he is unavailable then we default to the medical director. Stated that if the DON is not available the ADON will take charge of operations then the MDS nurse. Stated that the expectation is that the DON inform the ADON of significant resident information. Interview on [DATE] at 3:50 p.m., DR stated that Resident #1's POA called him early in the morning to request that he check on her condition. DR stated that he was not aware of Resident #1's severe weight loss or change in resident #1's condition prior to his visit on [DATE]. DR stated that the POA called him on the morning of [DATE] requesting that he check up on Resident #1. DR stated that he received a call later the same day in the afternoon from the DON asking to check on Resident #1. Record review of facility Change in a Resident's Condition or Status Policy (Dated: 2001) states - 1. The nurse will notify the resident's attending physician or physician on call when there has been a(an): d. significant change in the resident's physical/emotional/mental condition f. refusal of treatment or medication tow (2) or more consecutive times g. need to transfer to a hospital/treatment center 2. A significant change of condition is a major decline or improvement in the resident's status that: b. Impact more than one area of the resident's health status c. Requires multidisciplinary review and/or revision to the careplan 3. Prior to notifying

Based on observation, interview, and record review, the facility nursing staff failed to provide care that includes but is not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident's needs for one (Resident #1) of three residents reviewed. 1. The facility nursing staff failed to monitor Resident #1's fluid intake from [DATE] through [DATE] to ensure she was adequately hydrated. Resident #1 entered the facility with a history of [MEDICAL CONDITION] due to dehydration. 2. The facility nursing staff failed to consult with the Attending Physician when Resident #1 had a change of condition and was not taking in fluids, her medications or meals. The facility failed to reassess and/or monitor interventions for resident #1 regarding weight loss. 3. The facility nursing staff failed to ensure abnormal lab results received on [DATE] and [DATE] were promptly reported to the physician. This failure potentially placed 82 residents at risk for inadequate assessments, evaluations, planning and implementing resident care plans, respond to resident's needs. Findings Include: In an interview on [DATE] at 9:37 a.m., the POA called to inform the state that the resident had passed away. Record review of Resident #1's face sheet on [DATE] revealed the resident to be an [AGE] year-old woman admitted on [DATE] with a [DIAGNOSES REDACTED]. The facility did not include the [DIAGNOSES REDACTED]. Record review of Resident #1's MDS resident assessment and care screening on [DATE] revealed that the MDS did not list [MEDICAL CONDITION] as a diagnosis. MDS care area assessment revealed that the resident did not exhibit behavioral symptoms, signs of [MEDICAL CONDITION], acute onset mental status change, and had a mood severity score of zero with no potential indicators of [MEDICAL CONDITION]. Resident had an MDS BIMS score of 5. Review of MDS history revealed that the facility did not conduct an MDS assessment for a change in condition for Resident #1. Further review of MDS revealed that the MDS did not list [MEDICAL CONDITION] as a diagnosis. MDS care area assessment revealed that the resident did not exhibit behavioral symptoms, signs of [MEDICAL CONDITION], acute onset mental status change, and had a mood severity score of zero with no potential indicators of [MEDICAL CONDITION]. Resident had an MDS BIMS score of 5. Review of MDS history revealed that the facility did not conduct an MDS assessment for a change in condition for Resident #1. Record review of care plan for Resident #1 (Start dated: [DATE], Completion Date: [DATE]) created by MDSN, revealed that the facility was to monitor/document change in behavior, change in eating patterns. Monitor/document/report to PRN Change on Mental status, emaciation, weight loss. Alert dietician if consumption is poor for more than 48 hours, weight decline persists, contact physician and dietician immediately. Resident was not care planned for a GDR, [MEDICAL CONDITION], or dehydration. Review of the care plan does not have signatures from the facility staff, resident, resident POA, or resident physician. Record review on [DATE] of History and Physical electronically signed by DR on [DATE] revealed that Resident #1 had a history of [REDACTED]. Resident was admitted to the hospital on ,[DATE] for acute [MEDICAL CONDITION] related to dehydration from inadequate intake and hospitalized again on ,[DATE] for acute on [MEDICAL CONDITION] and acute UTI. Resident was seen in office on ,[DATE], the renal status was noted to be stable. Review of facility Care Area Assessments (CAA) policy (Dated: 2001) states: CAAs will be used to help analyze data to obtain from the MDS and to develop individualized care plans. CAAs are linked between assessment and care planning. Triggered Care Areas will be evaluated by the Interdisciplinary Team to determine the underlying causes, potential consequences and relationship to other trigger areas. In an interview on [DATE] at 4:47 p.m., POA stated that Resident #1's condition got so bad that she was severally dehydrated and that her kidneys are dried out and shutting down, her mouth was bloody, blistered and raw. Stated that the urine in the catheter showed a brown orange color when she was admitted because she was so dry. Stated that Resident #1 was not able to be completely revived so they have taken her off everything and are preparing for Hospice care. Stated that the resident is on [MEDICATION NAME] and IV for hydration. Stated that the DR told her that the facility never notified him about the resident's condition. POA stated that the facility never had a treatment plan meeting for Resident #1 and did not have any meetings about the resident's care. Stated the facility never called to inform her about the resident's infection. In an interview on [DATE] at 5:47 p.m. Hospital Nurse Manager stated that she was told patient was covered in feces and bruises. Stated that there was an APS referral and DR was the admitting physician. Stated that she was told Resident #1 had while yellow plaque, moaning and did not respond to any questions, severally dehydrated. Stated that the nursing home sent resident to the hospital because she was unresponsive. Stated that hospital staff stated that she came for dehydration. Stated that she worked at a nursing home and that she knows you can't make people drink but they should have done some kind of intervention. In an interview on [DATE] at 3:45 p.m. MDSN stated that she completes the MDS resident assessment and care screening for admitting residents. Stated that she put in active and pertinent [DIAGNOSES REDACTED]. Stated that a history of [MEDICAL CONDITION] and dehydration would be significant to a resident's care if they were on a medication like [MEDICATION NAME] or on a diuretic like [MEDICATION NAME]. MDSN stated that a resident's care plan would address the active and pertinent [DIAGNOSES REDACTED]. Stated that she was unaware of Resident #1's history of [MEDICAL CONDITION] caused by dehydration and that she may have overlooked it. MDSN stated that the she would do an MDS resident assessment and care screening for residents with a change in condition. Stated that nurses should be seeing the change in behaviors and do a change of condition and let the doctor know. Stated that the nurse notes would be under resident name and under assessments tab in point click care system. MDSN stated that she can conduct an MDS assessment for a change in condition if she feels it is needed. MDSN stated that she does not sign off on the MDS resident assessments because she is only an LVN and that the DON is the person that signs off on the MDS assessments. MDSN stated that she looked back at Resident #1's H&P and saw the acute chronic [MEDICAL CONDITION]. MDSN stated that the [MEDICAL CONDITION] should have been put on the resident's chart as a diagnosis. Stated that she looked over it and did not put it on the resident's chart. Stated that if she would have put the [DIAGNOSES REDACTED].#1's chart the facility could have care planned for it. In an interview on [DATE] at 9:40 a.m. RD stated there was no indication of that in Resident #1 had a [DIAGNOSES REDACTED]. In an interview on [DATE] at 11:13 a.m. DON stated she did not know about Resident #1's renal [DIAGNOSES REDACTED]. DON stated that the [MEDICAL CONDITION] caused by dehydration should have been triggered onto resident's diagnosis. DON stated that yes knowing the history of the resident would have triggered the facility to be aware of the resident's condition. DON stated that the [DIAGNOSES REDACTED]. DON stated that she did not review Resident #1's MDS assessment before signing off on it. In an interview on [DATE] at 1:00 p.m., LVN 1 stated that she did not know about Resident #1's history of [MEDICAL CONDITION] due to dehydration. Record Review of Facility Lab results for Resident #1's revealed she has labs conducted twice while at the facility, on [DATE] there is a critical Value of Glucose at 47, normal range (70 to 110), no indication of physician notification, no initials or progress notes indicating this was reported to the physician. On [DATE] there are Critical labs values of CO2 at 15, normal range (,[DATE]) and BUN 75, normal range (,[DATE]). The received date on the [DATE]. Labs are noted to be [DATE] at 2:21am, Reported date is [DATE] at 6:39am. And the report notes that the DON reviewed the results online on [DATE] at 12:47am. Record review of hospital admission records for Resident #1 on [DATE] revealed that the resident was transported by EMS on [DATE]. ER assessment shows resident was restless, crying, moaning, with slight dyspnea, acutely inflamed [MEDICATION NAME] mucosa, nonresponsive, distended neck veins at supine, scattered rhonchi, 1+ [MEDICAL CONDITION] both legs and ankle. Resident's ER lab results show her white blood count was 13.1 w/left shift, Sodium level at 137, Potassium in urine at 4.4, carbon [MEDICATION NAME] level at 19, blood urea nitrogen level at 82, creatinine level at 2.2, glomerular filtration rate at 20.2. [DIAGNOSES REDACTED]. [DATE] Resident Lab results showed Resident #1's Sodium level at 134, Potassium in urine at 3.6, blood urea nitrogen level at 71, creatinine level at 1.7, glomerular filtration rate at 27.7, white blood count at 11 with left shift. [DATE] Hospital Assessment: Acute on [MEDICAL CONDITION] due to inadequate oral intake superimposed on chronic [MEDICAL CONDITIONS] with combination of acute UTI and left lower lobe of lung pneumonia with exacerbation of [MEDICAL CONDITIONS] with status [REDACTED]. [DATE] Resident Lab results showed Resident #1's Sodium level at 146, Potassium in urine at 3.2, anion-gap at 12, blood urea nitrogen level at 35, creatinine at 1.3, glomerular filtration rate at 38.6, whit blood count at 9400. [DATE] Hospital Assessment: Acute on [MEDICAL CONDITION] due to inadequate oral intake, superimposed on [MEDICAL CONDITIONS], combination of acute UTI and left lower lobe of lung pneumonia, Hypertension with hypertensive cardiovascular disease with impending [MEDICAL CONDITION], History of multiple [MEDICAL CONDITION]. [DATE] Hospital note revealed Resident was conscious but responds only to painful stimuli. Review of link Medical News Today website accessed at https://www.medicalnewstoday.com/articles/ 7.php on [DATE] revealed, A BUN, or Blood Urea Nitrogen test, measures the level of urea nitrogen in the blood using a standard blood sample. Urea nitrogen is the natural byproduct of the breakdown of protein. According to the American Association for Clinical Chemistry, BUN tests are mainly used to assess kidney health .A rise or fall in blood urea nitrogen levels may indicate a wide range of health problems. This is because the kidneys and liver are involved in a wide range of body functions . A result higher than 50 milligrams per deciliter is likely to signal an underlying health problem . Elevated BUN levels can result from: - Kidney damage, failure, or disease - Dehydration - Shock . Typical BUN levels by age and gender . -Adult women: 6 to 20 milligrams per deciliter . In an interview on [DATE] at 5:47 p.m. Hospital Nurse Manager stated that Resident #1 had abnormal lab values. Stated that resident's mucus membranes were cracked, skin turgor not good, mouth was inflamed, nutrition not adequate, BUN was 82 and [MEDICATION NAME] was 2.2 meaning resident was in kidney failure. Interview on [DATE] at 2:38pm with RN 1 stated that ADON, or MDSN keep track of labs drawn. Stated that she will call the doctor and or the DON if she saw critical lab results, would document and would be in the progress notes. Stated that she did not know the results of Resident #1's lab results. In an interview on [DATE] at 11:13 a.m. DON stated DON stated that she looks at all the lab work. Not sure if there is a way that the DR or NP looked at the labs. DON stated that DR does not have a medical director to call if he is not available to receive critical labs. DON stated that she has the power to call the facility to ask them to have the resident sent to a hospital if she feels a resident is not doing well. DON stated that she did not call DR on Sunday at midnight because he was not going to answer his phone at that hour. DON stated that Resident #1 was dehydrated and was worried about her BUN. DON stated that she wanted to do an IV but Resident #1 would have pulled it out. In an interview on [DATE] at 1:00 p.m., LVN 1, when asked about critical lab values and procedure she stated that the lab would call when there is a critical lab value. She stated it was usually that same day via morning report. She stated that usually it is the ADON and/or DON that take care of labs that come in via the fax. LVN 1 stated she was not aware of Resident #1's critical lab values. LVN 1 stated she does not know about a policy but knows that you are supposed to notify the physician immediately. Record Review of a physician's order initiated [DATE] for Med Pass 2.0 supplement to be given three times a day. Orders revealed an active ordered for [MEDICATION NAME] 25mg a tab by mouth with a start date of [DATE] and a revision date of [DATE]. Record Review of Resident MAR revealed that Resident #1 was admitted on 50 mg BID of [MEDICATION NAME] on [DATE]. Dose for [MEDICATION NAME] reduced to 25 mg BID on [DATE] through [DATE] and then down to 25 mg QD on [DATE] and then discontinued after 7 seven days. The order was created by DON on [DATE] and revised by MDSN on [DATE]. Record review of Facility Pharmacy Consultation revealed Resident #1 was prescribed [MEDICATION NAME] by DR on [DATE] for Major [MEDICAL CONDITION]. The pharmacy consult revealed that the medication was a routine order. Record review revealed that the resident had an GDR eval for [MEDICATION NAME] on [DATE]. Resident #1 was taking trazadone for depression on routine order starting [DATE]. Resident #1 had a GDR evaluation scheduled for [DATE]. Record Review of Resident #1's Medication Administration Records (MARs) on [DATE] revealed an increase in medication administration refusals from (MONTH) (YEAR) through (MONTH) (YEAR). The amount of refusals is listed below; May (YEAR) - [MEDICATION NAME] 5mg- refused one time during the month. - Calcium 20mg- refused one time during the month. - [MEDICATION NAME] Bisulfate 75mg- refused one time during the month. - [MEDICATION NAME] Sodium 100mg- refused one time during the month. - [MEDICATION NAME] 325mg- refused one time during the month. - [MEDICATION NAME] 20mg- refused one time during the month. - Losartan Potassium 100mg- refused one time during the month. - [MEDICATION NAME] Powder 17 Gm- refused one time during the month. - [MEDICATION NAME] 20mg- refused five times during the month. - [MEDICATION NAME] 100mg- refused one time during the month. - [MEDICATION NAME] 25mg- refused one time during the month. - [MEDICATION NAME] 10mg- refused one time during the month. - [MEDICATION NAME] 50mg then 25mg- refused one time during the month. - [MEDICATION NAME] 25mg- refused one time during the month. - [MEDICATION NAME] 50mg- refused one time during the month. June (YEAR) - [MEDICATION NAME] 5mg- refused seventeen times during the month. - Calcium 20mg- refused seventeen times during the month. - [MEDICATION NAME] Bisulfate 75mg- refused seventeen times during the month. - [MEDICATION NAME] Sodium 100mg- refused seventeen times during the month. - [MEDICATION NAME] 325mg- refused seventeen times during the month. - [MEDICATION NAME] 20mg- refused seventeen times during the month. - Losartan Potassium 100mg- refused seventeen times during the month. - [MEDICATION NAME] Powder 17 Gm- refused seventeen times during the month. - [MEDICATION NAME] 20mg- refused nine times during the month. - [MEDICATION NAME] 100mg- refused seventeen times during the month. - [MEDICATION NAME] 25mg- refused seventeen times during the month. - [MEDICATION NAME] 10mg- refused seventeen times during the month. - [MEDICATION NAME] 50mg then 25mg- refused five times out of the seven times ordered during the middle of the month and refused 5 times out of the eight doses ordered at the end of the month. - [MEDICATION NAME] 25mg- refused seventeen times during the month. - [MEDICATION NAME] 50mg- refused seventeen times during the month. July (YEAR) (in the facility 9 days) - [MEDICATION NAME] 5mg- refused eight times during the month. - Calcium 20mg- refused eight times during the month. - [MEDICATION NAME] Bisulfate 75mg- refused eight times during the month. - [MEDICATION NAME] Sodium 100mg- refused eight times during the month. - [MEDICATION NAME] 325mg- refused seven times during the month. - [MEDICATION NAME] 20mg- refused eight times during the month. - Losartan Potassium 100mg- refused seven times during the month. - [MEDICATION NAME] Powder 17 Gm- refused seven times during the month. - [MEDICATION NAME] 20mg- refused seven times during the month. - [MEDICATION NAME] 100mg- refused seven times during the month. - [MEDICATION NAME] 25mg- refused seven times during the month. - [MEDICATION NAME] 10mg- refused seven times during the month. - [MEDICATION NAME] 50mg then 25mg- refused seven times during the month. - [MEDICATION NAME] 25mg- refused seven times during the month. - [MEDICATION NAME] 50mg- refused seven times during the month. In an interview on [DATE] at 12:34 p.m., the POA stated that the resident is currently at the hospital and unresponsive. The POA stated that admitting nurse at the emergency room stated that Resident #1's condition was something that took time to develop. Stated the resident started to decline after the change in medication. POA stated the facility did not call the her to inform her of the change in medications treatment. Stated that Resident #1 was taken off the medication for a week before the daughter came to visit. POA stated that the behaviors started because the facility stopped the [MEDICATION NAME] without her permission. Stated that the DON stopped her in the hallway during a visit and told her that they are going to stop giving Resident #1 the [MEDICATION NAME]. POA stated that she told the DON to not stop the [MEDICATION NAME] because Resident #1 will not respond well. Stated that her mom would become paranoid and start refusing care. Stated that she told the DON that her mom would not put dentures in and would not swallow. In an interview on [DATE] at 4:34 p.m., Resident #1's son stated that his mom was on a medication that kept her stable, but the nursing home stopped giving it to her without letting the family know. Stated that the care giver and the POA have found the resident with feces on her and disoriented and that she did not have thrush before she went to the nursing home. Stated that the facility was not cleaning her dentures and is why she did not put them back in. Resident #1's son stated that Resident #1 was supposedly taking her clothes off, and that when she talked it would be incoherent which is out of character for her. Stated that not too long ago she was driving around and taking care of herself for the most part. Interview on [DATE] at 2:38pm with RN 1 stated that she knew Resident #1 was not taking medications and that they tried to put it in her mouth or crush it but she still wouldn't take. Stated that with refusals we try again and try again, the first refusal we don't notify anybody but if it continues a 2nd day we will notify the doctor, also would document in the progress notes. Stated that she did not call the doctor and doesn't remember if Resident #1 refused medications when she worked with her or not. Stated that for meals the CNAs chart on kiosk if we offer substitutes. If resident refuses food the ST will get involved, CNA's will let nurses know. Stated that the facility does try to monitor fluids for residents with a history of [MEDICAL CONDITION]. In an interview on [DATE] at 11:13 a.m. DON stated there was an increase in behaviors for Resident #1. Stated that the DR knew she was having behaviors and apparently what he was seeing was nothing abnormal for her. Stated that she did not know if these behaviors were because of GDR. Stated that the daughter told her she was going to regret taking Resident #1 off of [MEDICATION NAME]. In an interview on [DATE] at 1:00 p.m., LVN 1 stated that Resident #1 had some behaviors when she first came in and they increased right away when she stopped taking her medications. LVN 1 stated she discussed Resident #1's medications with the resident's daughter-in-law/medical POA and she said that is what happens when they take her off the [MEDICATION NAME]. LVN 1 stated that the POA wanted Resident #1 back on the medication. LVN 1 reported she spoke to the DON, who spoke to the physician and the [MEDICAL CONDITION] was restarted around ,[DATE] before she went on vacation. LVN 1 stated that if there is ever any change of condition she would let the DON know. Record Review of Resident #1's (MONTH) (YEAR) MAR's revealed Supplement 2.0 (supplemental shake) given 3x a day starting [DATE]. Out of 72 opportunities during the month Resident #1 refused 36 times (50%). The amount of the supplement consumed on the dates Resident #1 accepted the 2.0 is not included in the documentation. Record Review of Resident #1 (MONTH) (YEAR) MAR ([DATE]st thru (MONTH) 09) revealed 26 opportunities and Resident #1 refused medication 20 times. The amount of the 2.0 supplement consumed on the dates Resident #1 accepted the 2.0 is not included in the documentation. Record Review of Resident #1's weights in total taken at facility during her 67 day stay revealed the following; On ,[DATE], her day of admission, she weighed 189 pounds. On [DATE], 186 pounds (which is a 1.5%, 3 pound weight loss in one week). On ,[DATE], 179 pounds (5.2% or 10 pounds lost since admission). On ,[DATE], 169 pounds (10.6% or 20 pounds lost since admission). On ,[DATE], 166 pounds (12% or 23 pounds in one month). The next available weight was taken on ,[DATE] as weights were taken once a month after the first month, Resident #1 weighed 149 pounds (21 % over the 2 months or 40 pound weight loss). Record Review of Review of Resident #1's Nutritional History Form dated [DATE] has that Resident #1 feeds herself and has a good meal intake. Information regarding her likes and dislikes obtained from the resident and her family. Record Review of Resident #1's Nutritional Risk Assessment Form, dated [DATE], revealed that her weight is listed as 207 pounds. Resident #1's diet is listed as regular. The form notes No recent wt (weight) changes noted. The goal for Resident #1 is noted to be gradual wt loss, ,[DATE] #/ a month, to about 175, nutr (nutritional) labs wnl (within normal limits) over the next 90 days. Review of the facility policy #6.13 regarding 2.0 Calorie Med Pass, the purpose of the supplement is noted to be; To provide a high calorie, high protein supplement in small volume for adding nutrients when other interventions are not appropriate. And . The amount of the supplement taken is documented on the MAR and signed out by the designated person passing the medication. Record review of Resident #1's Electronic Medical Chart to include MAR, Progress Notes, Weights, Daily Intakes, Physician Orders, Dietary Orders, Care Plan, MDS assessment revealed that the resident had a change in condition after the facility initiated a GDR for [MEDICATION NAME] on [DATE]. Resident medical records reveal that the resident had severe weight loss, refused medications, refused nutrition intake, refused fluids. Review of Resident #1's hospital records revealed her weight at the time of her hospital admission on [DATE] was 143 pounds. Review of the physician progress notes [REDACTED]. On [DATE] notes the reason for the visit is follow-up to post hospital care. Resident #1's weight is noted to be 207 pounds. The Physician noted Resident #1 is to be maintained on the same medications and physical therapy. On [DATE] the Physician note again includes the resident's weight as 207. The reason for the visit is noted to be a follow-up, sleepy lethargic. The Physician noted Resident #1 is to be maintained on the same medications and supportive therapy. On [DATE] there is no weight listed. The reason for the visit is noted to be a follow-up, (an illegible word), participating in PT but remains in bed most of the time, afebrile. Record Review of the facility WAR meeting notes on [DATE] revealed that the DON did not take notes on Resident #1's weights, reassessment of interventions, or change in condition. The following is a review of the WAR meetings from [DATE] through [DATE]; - [DATE], Follow up summary notes revealed 10 residents were reviewed. There is no indication on the document indicating decisions made. Each name of a resident has one or two words beside the resident name, such as new admit - [DATE] Resident #1's name appears on the summary notes for the first time with new admit beside her name. - [DATE] Resident #1 is not listed on the summary. - [DATE] Resident #1 is listed with med options, illegible med name and [MEDICATION NAME] are listed. - [DATE] Resident #1 is not listed. - [DATE] Resident #1 is listed with weight loss beside her name. - [DATE] Resident #1 is listed with weight loss and 2-cal - [DATE] Resident #1 is listed with A&B (antibiotics), [MEDICAL CONDITION]. - [DATE]Resident #1 is listed with [MEDICATION NAME] restarted DON was not able to produce WAR meeting notes detailing what area of care of was discussed for each resident identified on the weekly list. WAR records revealed that the facility did not discuss interventions, weight loss, change in condition, dehydration, or reassess interventions for triggered residents identified on the WAR meeting list. Record Review of the facility Meal Intake Records on [DATE] for Resident #1 revealed a decrease in resident's meal intake starting from [DATE] through [DATE]. Records due not include fluid intake. A review of resident intake is listed below; - From [DATE] through [DATE] there was an opportunity for 19 meals. The percent eaten can be documented as ,[DATE]%- she ate this percent on 1 meal, ,[DATE]%-2 meals, ,[DATE]%-9 meals, ,[DATE]%-5 meals. Two refusals were documented. - From [DATE] through [DATE]-21 meals were documented. ,[DATE]%- 1 meal, ,[DATE]%-6 meals, ,[DATE]%-9 meals, ,[DATE]%-2 meals. Three refusals were documented. - From [DATE] through [DATE]-21 meals were documented. ,[DATE]%- 5 meals, ,[DATE]%-7 meals, ,[DATE]%-7 meals, ,[DATE]%-1 meal. One refusal was documented. - From [DATE] through [DATE]-22 meals were documented. ,[DATE]%- 8 meals, ,[DATE]%-8 meals, ,[DATE]%-3 meals, ,[DATE]%-none. Three refusals were documented. - From [DATE] through [DATE]-21 meals were documented. ,[DATE]%- 7 meals, ,[DATE]%-7 meals, ,[DATE]%-5 meals, ,[DATE]%-1 meal. One refusal was documented. - From [DATE] through [DATE]-21 meals were documented. ,[DATE]%- 7 meal, ,[DATE]%-5 meals, ,[DATE]%-4 meals, ,[DATE]%-1 meal. Four refusals were documented. - From [DATE] through [DATE]- 18 out of 21 meals were documented. ,[DATE]%- 7 meals, ,[DATE]%-5 meals, ,[DATE]%-3 meals, ,[DATE]%-none. Three refusals were documented. - From [DATE] through [DATE]-20 out of 21 meals were documented. ,[DATE]%- 5 meals, ,[DATE]%-0 meals, ,[DATE]%-3 meals, ,[DATE]%-0 meals. Twelve refusals were documented. - From [DATE] through [DATE]- 19 of 21 meals were documented. ,[DATE]%- 2 meals, ,[DATE]%-3 meals, ,[DATE]%-7 meals, ,[DATE]%-1 meal. Four refusals were documented. - From [DATE] through [DATE]- 9 of 18 meals were documented. ,[DATE]%- none, ,[DATE]%-3 meals, ,[DATE]%-3 meals, ,[DATE]%-none. Three refusals were documented. Review of the facility Policy titled Weight Program, revised ,[DATE], and revealed the following; Residents are weighed at admission, readmission, and per physician orders. Weekly weights are completed for an additional 3 weeks (or longer if not stable) on the following: Admit, Readmit, significant weight loss of 5% or more in 1 month or less, Physician's orders, on a [MEDICATION NAME] feeding And. Weekly weights- residents with a significant weight loss x30 days or less (5% or more) will be placed on weekly weights x4 weeks or until weights are stable and no weight concerns are noted. If weight concerns are noted/weights are not stable, notify your RD and continue the weekly weights until stable. Process DON or Designee will review monthly and weekly weights prior to WAR (Weekly At Risk) Meeting. WAR (Weekly At Risk) Meeting Weekly War meeting-discuss residents with greater than a 3 pound change in a week. Continue to discuss resident in weekly WAR meeting until concern is resolved. In an interview on [DATE] at 4:34 p.m., Resident #1's son stated that his mother used to be 215 pounds and is now down to 138. Stated that Resident #1 has not opened her eyes or talked since she has been here. Resident #1's son stated that the facility transferred her to the hospital because her kidneys were shutting down. In an interview on [DATE] at 12:34 p.m., the POA stated that the resident started refusing medications, food, and liquids after change in medication administration of [MEDICATION NAME]. POA stated that she showed the facility staff how to trick her mom into taking the medications. Stated that she told the facility to not take resident off the medication because DR took her off once and she began to refuse her medication and became fearful with anxiety. Stated that the resident is now going to be put on hospice. Stated that the hospital staff told her to call the state due to Resident #1's condition at admission from the facility. In an interview on [DATE] 12:55 p.m. TD stated that Resident #1 was receiving therapy for all three specialty services (PT, OT, ST). Stated that she worked with resident a couple of times, but she was definitely in the therapy room. Stated that the resident was not very active but alert, she was not able to express whether she was in pain, so it was hard to communicate with her. Stated that the resident seemed to decline and had thrush in her mouth before she left. Stated that the ST was trying to address swallowing and on her last daily notes she was trying to do her treatment during meals and trying to address feeding. Stated that on [DATE] there was a decline in oral intake, that is when the ST tried to address swallowing, on [DATE] resident refused all intake from therapist, then on [DATE] attempted again to assess resident intake but resident declined. The oral decline was not on the resident's goals but ST started addressing the issue. Stated that she believes the resident did not have her dentures at this time. Stated that she is not aware of any other residents that had thrush. Stated that the speech therapist is on vacation and cannot be reached at this time. In an interview on [DATE] at 2:54 p.m. DM stated she gets resident weights and looks for the 5% weight loss. Stated that she did notice Resident #1's loss. Stated that the resident was taking a 2.0 supplement and she does not get

Based on observation, interview, and record review, the facility failed to promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of results that fall outside of clinical reference ranges for one (Resident #1) of three residents reviewed. The facility nursing staff failed to ensure abnormal lab results received on [DATE] and [DATE] were promptly reported to the physician. Resident #1 was hospitalized on [DATE] with [DIAGNOSES REDACTED]. Resident #1 expired in the hospital on [DATE]. These failures resulted in an identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was lowered on [DATE], the facility remained out of compliance at a level of actual harm with a scope identified as a pattern. This failure affected one resident and placed an additional 82 at risk for critical labs not being reported to the physician. Findings Include: Record review of Resident #1's face sheet on [DATE] revealed the resident to be an [AGE] year-old woman admitted on [DATE] with a [DIAGNOSES REDACTED]. The facility did not include the [DIAGNOSES REDACTED]. Record review on [DATE] of History and Physical electronically signed by DR on [DATE] revealed that Resident #1 had a history of [REDACTED]. Resident was admitted to the hospital on ,[DATE] for acute [MEDICAL CONDITION] related to dehydration from inadequate intake and hospitalized again on ,[DATE] for acute on [MEDICAL CONDITION] and acute UTI. Resident was seen in office on ,[DATE], the renal status was noted to be stable. Record review of hospital admission records for Resident #1 on [DATE] revealed that the resident was transported by EMS on [DATE]. ER assessment shows resident was restless, crying, moaning, with slight dyspnea, acutely inflamed [MEDICATION NAME] mucosa, nonresponsive, distended neck veins at supine, scattered rhonchi, 1+ [MEDICAL CONDITION] both legs and ankle. Resident's ER lab results show her white blood count was 13.1 w/left shift, Sodium level at 137, Potassium in urine at 4.4, carbon [MEDICATION NAME] level at 19, blood urea nitrogen level at 82, creatinine level at 2.2, glomerular filtration rate at 20.2. [DIAGNOSES REDACTED]. [DATE] Resident Lab results showed Resident #1's Sodium level at 134, Potassium in urine at 3.6, blood urea nitrogen level at 71, creatinine level at 1.7, glomerular filtration rate at 27.7, white blood count at 11 with left shift. [DATE] Hospital Assessment: Acute on [MEDICAL CONDITION] due to inadequate oral intake superimposed on chronic [MEDICAL CONDITIONS] with combination of acute UTI and left lower lobe of lung pneumonia with exacerbation of [MEDICAL CONDITIONS] with status [REDACTED]. [DATE] Resident Lab results showed Resident #1's Sodium level at 146, Potassium in urine at 3.2, anion-gap at 12, blood urea nitrogen level at 35, creatinine at 1.3, glomerular filtration rate at 38.6, whit blood count at 9400. [DATE] Hospital Assessment: Acute on [MEDICAL CONDITION] due to inadequate oral intake, superimposed on [MEDICAL CONDITIONS], combination of acute UTI and left lower lobe of lung pneumonia, Hypertension with hypertensive cardiovascular disease with impending [MEDICAL CONDITION], History of multiple [MEDICAL CONDITION]. [DATE] Hospital note revealed Resident was conscious but responds only to painful stimuli. Record Review of Facility Lab results for Resident #1's revealed she has labs conducted twice while at the facility, on [DATE] there is a critical Value of Glucose at 47, normal range (70 to 110), no indication of physician notification, no initials or progress notes indicating this was reported to the physician. On [DATE] there are Critical labs values of CO2 at 15, normal range (,[DATE]) and BUN 75, normal range (,[DATE]). The received date on the [DATE]. Labs are noted to be [DATE] at 2:21am, Reported date is [DATE] at 6:39am. And the report notes that the DON reviewed the results online on [DATE] at 12:47am. Record Review of Resident #1's electronic medical record in Point Click Care System on [DATE] revealed that there is was no notification to the DR of resident #1's critical lab results on [DATE] or [DATE]. Facility was not able to produce documentation of communication informing DR of Resident #1's condition. Review of link Medical News Today website accessed at https://www.medicalnewstoday.com/articles/ 7.php on [DATE] revealed, A BUN, or Blood Urea Nitrogen test, measures the level of urea nitrogen in the blood using a standard blood sample. Urea nitrogen is the natural byproduct of the breakdown of protein. According to the American Association for Clinical Chemistry, BUN tests are mainly used to assess kidney health .A rise or fall in blood urea nitrogen levels may indicate a wide range of health problems. This is because the kidneys and liver are involved in a wide range of body functions . A result higher than 50 milligrams per deciliter is likely to signal an underlying health problem . Elevated BUN levels can result from: - Kidney damage, failure, or disease - Dehydration - Shock . Typical BUN levels by age and gender . -Adult women: 6 to 20 milligrams per deciliter . In an interview on [DATE] at 5:47 p.m. Hospital Nurse Manager (HNM) stated that she was told patient was severally dehydrated. Stated that the nursing home sent resident to the hospital because she was unresponsive. Stated that hospital staff stated that she came for dehydration. The HNM stated she worked at a nursing home and that she knows you can't make people drink but they should have done some kind of intervention. She stated that Resident #1 had abnormal lab values. Stated that resident's mucus membranes were cracked, skin turgor not good, mouth was inflamed, nutrition not adequate, BUN was 82 and creatinine was 2.2 meaning resident was in kidney failure. In an interview on [DATE] at 11:41 a.m. DR's Secretary stated that the DR is not able to be reached at this time and he will be back on next Monday. Stated that the DR is on a boat. Secretary stated that the facility will call the medical director if DR cannot be reached. Interview on [DATE] at 3:50 p.m., DR stated that Resident #1's POA called him early in the morning to request that he check on her condition. DR stated that he was not aware of Resident #1's severe weight loss or change in resident #1's condition prior to his visit on [DATE]. Interview on [DATE] at 2:38pm with RN 1 stated that ADON, or MDSN keep track of labs drawn. She stated that she will call the doctor and or the DON if she saw critical lab results, would document and would be in the progress notes. RN 1 stated that she did not know the results of Resident #1's lab results. In an interview on [DATE] at 9:40 a.m. with the facility RD revealed she is at the facility ,[DATE] days a month. The RD stated that she did not see the [DATE] critical lab results for Resident #1 with the critical glucose value. She stated that the DR should have been notified of that critical lab value. In an interview on [DATE] at 11:41 a.m. ADMIN, the administrator was asked if there were any other documents that reflected communication between the physician and the facility regarding residents health concerns. ADMIN stated that there is a communication book that the facility and physician maybe using to communicate. ADMIN stated that the DON may have notes obtained from the communication book in her office. In an interview on [DATE] at 11:14am with the facility DON revealed that she does not have any documentation of communication between the facility and the doctor for Resident #1. When asked about lab report drawn on [DATE], she stated she saw the labs on [DATE] at 12:47am. The DON stated that at times the lab will have the results online before they fax them to the facility. She saw the online results before they were faxed to the facility. She reported the results were faxed to the facility on [DATE] at 6:39am an LVN would have been the nurse working but the fax machine at the nursing station is broke so the results go to a fax machine they are not used to checking. When asked about immediate physician notification, the DON stated that the physician was not going to answer the phone at one o'clock in the morning on a Sunday, so she waited until Monday morning. When she notified the physician on Monday morning he stated to send her to the hospital because she was dehydrated. When asked why Resident #1 wasn't sent until Monday late afternoon, the DON stated she wasn't sent until the late afternoon? When asked about the ,[DATE] critical blood sugar lab for Resident #1 she stated she did see the results but we get a lot of low glucose levels because they take the draw in the afternoon. Physician was not notified because we can explain why her glucose was low. Didn't do finger sticks to check. We would know if her blood sugar went down to 25 (the amount on the critical lab was 47). When asked if she would have notified the physician sooner of the lab values on [DATE] if she had known then that Resident #1 had a history of [REDACTED]. In an interview on [DATE] at 1:00pm with LVN 1/Charge Nurse revealed when asked about critical lab values and procedure she stated that the lab would call when there is a critical lab value. She stated it was usually that same day via morning report. LVN 1 stated she does not know about a policy but knows that you are supposed to notify the physician immediately. She stated that usually it is the ADON and/or DON that take care of labs that come in via the fax. LVN 1 stated she was not aware of Resident #1's critical lab values. Record review of Laboratory Policy (Dated: (MONTH) 2012) states; Record review of Facility Laboratory Policy (Dated: August, 2012) states: Lab results will be reported to the physician Abnormal lab tests will be sent to the physician Panic/Critical value labs will be called immediately to the physician upon receipt of the panic/critical value lab DON provided census of 82 resident in the facility at the time of entry.

Based on observation, interview and record review the facility failed to ensure one (1) of 5 Residents reviewed for pressure sores received necessary treatment and services to promote healing, accurately assess and stage, and once developed, failed to ensure necessary treatment and services to promote healing (Resident #6). Resident #6 was admitted with surgical sutures to her right and left stumps a Stage II decubitus to her coccyx and a blister to her right inner thigh. Resident #6 developed two new Stage II decubitus within three days of admission. The facility did not assess the surgical incisions, measure the pressure sore or blister, implement preventative measures, or obtain physician orders [REDACTED]. This deficient practice affected one (1) resident and placed her at risk for developing new or worsening pressure sores, [MEDICAL CONDITION] (skin infection), [DIAGNOSES REDACTED] (infection of the bone),[MEDICAL CONDITION] (infection of the blood), severe pain and death. Findings Include: Review of Resident #6' s MICU physician ' s progress notes from the discharging hospital dated 12/26/14 reflected Bilateral ischemic (insufficient blood flow), which resulted in the amputation of both legs above the knee. Resident #6 was discharged six days post- operatively to the nursing facility. Review of Resident # 6 ' s Admission Nursing Evaluation form dated 12/26/14 revealed she was admitted on [DATE] with Inferior [MEDICAL CONDITION] infarction, Cardiac [MEDICAL CONDITIONS] infarction, and Diabetes. Review of Resident #6 ' s BRADEN Scale for predicting pressure sore risk dated 12/26/14 reflected: Skin is often, but not always moist. Linen must be changed at least once a shift. Confined to bed. Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently. Moves feebly or requires minimum assistance. During a move skin probably slides to some extent against sheet, chair, restraints or other devices. Maintains relatively good position in chair or bed most of the time but occasionally slides down. Review of Resident#6 ' s admission records reflected there was no completed MDS due to Resident #6 being discharged from the facility on 12/31/14. Review of Resident #6 ' s Interim Plan of Care dated 12/26/14 reflected Pressure Sores; treat according to physician orders [REDACTED]. Pressure Ulcer Risk reflected turn and reposition; it did not detail how often. It did not reflect the need for a pressure device. The plan of care did not reflect the need for linens to be changed every shift. The plan of care reflected Promote Healing to sutures; it did not detail what the treatment was. Review of Resident #6 ' s Immediate Needs Care Plan Pressure Ulcers dated 12/29/14 reflected the measurement and treatment of [REDACTED]. The Care Plan did not reflect a target/review date. Review of #6 ' s first Daily Skilled Nurse ' s Note dated 12/26/14 at 2:50 pm reflected: Skin condition, Pressure ulcer, surgical wound, and bruise were checked off as being present. The nurse wrote; Skin with bruises on both arms and a stage II pressure ulcer on the coccyx, blister on the right thigh. Patient needs help in reposition due to imbalance. Review of Resident # 6 ' s Consolidated physician's orders [REDACTED]. Review of Resident #6 ' s Physician telephone orders dated 12/26/14 and 12/29/14 did not reflect treatment orders for surgical incisions the blister or the two new decubitus. Review of Resident #6 ' s Daily Skilled Progress notes dated 12/26/14 through 12/28/14 did not reflect wound care or treatment to the decubitus or surgical wounds. The Skilled Progress notes did not describe condition or treatment to the blister, decubitus or surgical wounds. Review of Resident #6 ' s Nurse ' s notes dated 12/29/14 at 10:30 am reflected a skin assessment done. Stage II to buttocks and coccyx times 3 areas. Areas cleansed and skin barrier cream applied. Resident to be repositioned every 2 hours and overlay placed to bed. During an interview on 1/21/15 at 3:30 pm the facility wound care nurse stated when she first assessed the resident on 12/29/14, she found three wounds. There was the original wound on her bottom from admission and two additional ones. She stated at that time, she placed Resident #6 on an overlay mattress and in-serviced the CNAs on care needs. During an interview on 1/21/15 at 3:00 pm the DON stated the admitting nurse should have called the physician to get orders concerning how to clean the wounds. She stated she would have expected Resident #6 to have an overlay mattress placed on the bed on the first day of admission. Review of Resident #6' s Physician telephone orders dated 12/31/14 reflected an order/referral for wound care management. There were no additional orders indicating wound care. During an interview on 1/21/15 at 3:30 pm the facility wound care nurse stated she does weekly skin checks. She is responsible for notifying the physician if a wound requires a treatment; she will call the physician. If a wound gets worse she will call the physician. The facility wound care nurse stated she did not call the physician to consult on the wound care or treatment; she followed the facility protocol sheet. The facility wound care nurse informed the DON of Resident #6's wounds and was asked if she had been placed on an overlay. The wound care nurse stated she had checked Resident #6' s skin on 12/31/14 at around 9:00 am; the family had wanted to have a dressing applied to her bottom, since she was going out to a Dr. ' s appointment. The wound care nurse stated she did not place a dressing on the wound because of the barrier cream that was present. The wound did not look any worse than it had before. During further interviewing with the wound care nurse she was asked about the lack of documentation concerning the right inner thigh wound, she stated she did not see any wound to the right inner thigh. The facility wound care nurse did not explain the lack of documenting the surgical incisions on her wound sheets. During an interview on 1/21/15 at 3:00 pm the DON stated the admission nurse must have missed documenting the other two decubitus. The DON stated she works with the wound care nurse to determine treatments and wound care. The DON stated she did not see Resident #6 ' s wounds. During an interview on 1/21/15 at 3:10 pm CNA F stated she worked with Resident #6 on 12/29/14 and 12/30/14. CNA F stated she had observed the sores on Resident #6's back. She stated Resident #6 had 3 sores. The last time she changed her they looked like they were getting better, she had only changed her once. CNA F stated she was not given a turning schedule; she stated the family turned her or she would ask the resident if she had been turned. CNA F stated the nurse told her to put the cream on Resident #6 ' s sores. During an interview on 1/21/15 at 3:00 pm CNA G stated she did not usually work with Resident #6, but had been placed on the hall on 12/29/14. CNA G stated she had not been given a turn schedule. She did not record when Resident #6 had been turned. When asked how she knew when to turn a resident, CNA G stated she just remembers when she has to turn them. Review of Resident #6 ' s emergency room Progress notes dated 12/31/14 at 1:00 pm reflected Resident #6 arrived for a Doctor ' s appointment at the hospital. The notes reflected at 1:45 pm Resident #6 arrived at the emergency room . Resident #6 was reporting pain at a 10/10. Family reported increase in pain, right inner thigh skin breakdown along with lower back and gluteal breakdown. Resident #6 was given [MEDICATION NAME] 1 mg at 2:00 pm and [MEDICATION NAME] 2mg at 7:10 pm for the pain. Review of Resident #6 ' s emergency room Physician note dated 12/31/14 at 2:51 pm reflected interview with step daughter reports she was in special bed/ mattress at the previous hospital, no bed sores, but she noted right thigh blister/bleb 12/26/14 after getting to nursing home and following day noticed open [MEDICAL CONDITION]/ Also [MEDICAL CONDITION] on back/sacrum coccyx area since 12/26 are getting larger/ with more pain/ bilateral stumps covered with severe pain. Physician review of systems reflected: Back: multiple bluish black discolored areas, with surrounding blanching, large superficial skin erosions over sacral area/ Stage I bed sores. Extremities: bilateral AKA/ with [MEDICAL CONDITION] right upper thigh/ruptured. Review of Resident #6 ' s Hospital Inpatient Progress note dated 12/31/14 at 7:23 pm reflected Patient has 6 with two more developing Stage I and Stage II bed sores on buttocks/coccyx upon arrival on the unit. Incontinence Associated [MEDICAL CONDITION] (IAD): Comment: to include a 10 cm x 10 cm reddened area in Sacrum/Coccyx/Glut region Comment: There are 8-9 wound related IAD - two of which are Stage II (coccyx 1.5 cm in circumference and just to right of coccyx approximately 2 cm x 1 cm). Observation on 1/21/15 at 9:50 am at the local hospital revealed Resident #6 receiving wound care; Resident #6 had a large wound with blackened eschar (the body's natural biological cover) to her right thigh with reddened areas surrounding the wound. The wound extended from the entire top of the right thigh and continued under her thigh to half the circumference of her thigh. The wound was 6 cm at its widest point. The lower inner thigh had a black and red unstageable (full thickness tissue loss in which the base of the ulcer is covered by black eschar) wound. Continued observation revealed Resident #6 ' s left stump had a blackened dry wound that was 4 cm x 1 cm. The surgical incisions on both stumps contained intact sutures with blackened and reddened skin surrounding both stumps. Continued observation revealed Resident #6 ' s buttocks a 7 cm x 10 cm wound with black and brown eschar. Resident #6 ' s left and right buttock was observed to have multiple decubitus that areas were in the process of being debrided, (the medical removal of dead, damaged or infected tissue to improve the healing of the remaining tissue). There was a 6.5 cm x 4 cm stage II pressure sore on the left buttocks and a 5 cm x 2 cm, 1.5 cm x 1 cm, 3 cm x 1 cm stage II pressure sore on the left buttock. During an interview on 1/21/15 at 9:00 am the hospital wound care nurse, stated Resident #6 was admitted to the hospital through the emergency roiagnom on [DATE]. He stated Resident #6 had the pressure sores prior to being admitted to the hospital. The hospital wound care nurse stated he took a photograph of the wounds on the day of admission. The hospital wound care nurse stated the wounds were from pressure. During an interview on 1/21/15 at 10:00 am at the second hospital, Resident #6 stated she developed blisters near the bandaging from the tape. The blisters opened while she was at the facility and they became infected. She stated the bandaging was not being changed and the incisions were becoming infected. Resident #6 stated she had developed bed sores due to not being repositioned every two hours. Resident #6 stated she was only turned once while at the facility. During a telephone interview on 1/16/15 at 1:10 pm with Resident #6 ' s daughter, she stated her mother was a diabetic and had surgery at a local hospital. Her mother was admitted to the facility with a blister on her thigh. The blister was busted sometime between the 26th and the 31st, and became infected. She stated the orders from the hospital included the need for an air mattress. The facility brought an air mattress into her mother ' s room on 12/27/14, but never put it on the bed, it sat on the side chair for three days. During an interview on 1/20/15 at 3:50 pm the medical director and Resident #6 ' s physician stated he did not recall the resident or issues regarding her admission into the facility. He stated he would have to go to his office and get more information. No additional information was provided. During an interview on 1/21/15 at 4:50 pm with the Corporate Consulting Nurse and the Administrator they stated the wound care nurse is very thorough. They were not able to explain why the blister to the right thigh and the bi-lateral surgical incisions were not on the skin sheets. They stated the wound care nurse follows the Skin Management Protocol. Review of facility provided, Skin Management System (undated) 1. A head to toe body assessment will be completed on every resident upon admission or readmission. A. Pressure Ulcers, Venous Ulcers and Arterial Ulcers, and surgical sites will be documented on SCC-005. Use one form per wound. Wound progress is to be documented each week with measurements and would descriptions. Daily treatments are also documented on the same form. B. Bruises, rashes, and other non-pressure areas are to be documented on the Weekly Skin Integrity Form (SCC-012). Treatments for such areas will be documented on the TAR. 2. Routine weekly checks will be completed on every resident; if skin is intact it will be noted as such. If a new pressure sore is noted a progress record will be started. 3. Assignments for skin assessments will be posted on a monthly calendar at the station and initialed when completed. Assignment should be by room number. These assignments are to be saved by the DON. 3. CNA ' s will note any alteration in skin integrity during care on the (MP 5460) and turn in to the Charge Nurse. 4. Braden scales will be completed on all new residents upon admission or readmission and interventions noted on the Interim Plan of Care. 5. Braden Scale will be completed every quarter on either hard copy of in LTC. 6. Refer to SCC/AMT would algorithms for suggested protocols. 7. Follow Recover Care ' s specialty bed algorithm should a specialty mattress be needed 8. A weekly skin report will be completed and reviewed in the weekly Standard of Care meeting. 9. Keep open lines of communication with physicians, families, and residents regarding status of wounds. 10. Assess all residents for pain and act accordingly during treatments. 11. All dressings are to be dated and initialed upon completion. The facility provided a census of 77 residents. There were no residents with pressure sores currently in the facility.