Every finding on record at Hilltop Center

Based on observation, staff interview, and record review, the facility failed to ensure call systems were within the resident's reach. This failed practice had the potential to affect a limited number of residents. Resident Identifiers: #69 and #85. Facility Census: 117.Findings included:a) Resident #69On 05/11/26 at 12:30 PM, Resident #69's call light was attached to her nightstand. The resident was sitting in her wheelchair near the bottom of her bed. The resident stated, I want it close as I can. The resident's call light was not within reach.On 05/11/26, Activity Director #140 confirmed the call light was out of reach. The activity director attached the call light to the resident's blanket on the bed within the resident's reach.b) Resident #85 On 05/11/26 at 12:29 PM, Resident #85's call light was observed on the floor behind the resident's wheelchair. The resident was sitting in his wheelchair at the time. On 05/12/26, Activity Director #140 confirmed the resident's call light was in the floor and placed the call light within the resident's reach.c) Policy for Call LightsThe facility's policy and procedure for Call Lights stated, 4. Staff will ensure the call light is within reach of the patient and secured as needed.

Based on observation and staff interview, the facility failed to maintain an effective infection control program related to the placement of urinary catheter drainage bags for Resident #72 and #78, and storage of a granulated cylinder for Resident #54. These were random opportunities for discovery. Resident Identifiers: #72, #78 and #54. Facility Census: 117. Findings Included:a) Resident #72On 05/11/26 at 12:19 PM, an initial interview was held with Resident #72. The urinary catheter drainage bag was observed behind the wheelchair hanging and touching the floor. On 05/11/26 at 12:23 PM, the Activities Director #55 was asked to come to the resident's room. The Activities Director #55 confirmed the urinary catheter drainage bag should not be touching the floor. The Activities Director #55 raised the bag and the urinary catheter drainage bag was not touching the floor.On 05/11/26 at approximately 12:40 PM, the Administrator was notified and confirmed the urinary catheter drainage bag should not be touching the floor. The Administrator stated, We will talk to the staff.b) Resident #78On 05/11/26 at 12:35 PM, an initial interview was held with Resident #78. The urinary catheter drainage bag was observed laying in the floor. Nurse Aide (NA) #45 entered the room and moved the urinary catheter foley bag on the bed rail.On 05/11/26 at approximately 12:40 PM, the Administrator was notified and confirmed the urinary catheter drainage bag should not be touching the floor. The Administrator stated, We will talk to the staff.c) Resident #54On 05/11/26 at 12:44 PM, an initial interview was attempted with Resident #54. A granulated cylinder was observed sitting on the back of the commode. The granulated cylinder did not have any identifying information located on it, and was not properly stored in a storage bag.On 05/11/26 at 12:48 PM, Unit Manager (UM) #115 was asked to enter the resident's room. UM #115 confirmed the granulated cylinder did not have any identifying information and was not stored properly. The UM stated, I'll remove it.

Based on observation, resident interview, and staff interview, the facility failed to provide adequate hydration for Residents #55, #107, and #68. These were random opportunities for discovery. Resident Identifiers: #55, #107 and #68. Facility Census: 117.Findings Included:a) Resident #55On 05/11/26 at 12:25 PM, an initial interview was held with Resident #55. The resident stated, I would like some ice water. The resident was asked, Did you get any fresh ice water today? Resident #55 stated, No, I haven't. An observation was made at this time of a 12-ounce Styrofoam cup, which was undated, that had a small amount of water and no ice inside the cup.On 05/11/26 at 12:30 PM, Activities Director #55 was asked to come into the resident's room. The Activities Director confirmed the cup was not dated and there was a small amount of water and no ice inside the cup.b) Resident #107On 05/11/26 at 12:35, an initial interview was held with Resident #107. Resident #107 is roommates with Resident #68. The resident was asked, Did you receive fresh ice water today? The resident stated, No, we haven't been given any ice water today. An observation of a 12-ounce Styrofoam cup, undated, was sitting on the over-the-bed table with no water or ice inside of the cup. On 05/11/26 at 12:45 PM, Licensed Practical Nurse (LPN) #71 was asked to come into the room. LPN #71 confirmed no water or ice was inside of the Styrofoam cup.c) Resident #68On 05/11/26 at 12:35, an initial interview was held with Resident #68. Resident #68 is roommates with Resident #107. The resident was asked, Did you receive fresh ice water today? The resident stated, No, not today. An observation of a 12-ounce Styrofoam cup, undated, was sitting on the over-the-bed table with no water or ice inside of the cup. On 05/11/26 at 12:45 PM, LPN #71 was asked to come into the room. LPN #71 confirmed no water or ice was inside the Styrofoam cup.On 05/11/26 at approximately 1:20 PM, the Administrator was notified. The Administrator confirmed the staff should be passing ice and water to the residents. The Administrator stated, We will get education started immediately with staff.

Based on record review, staff interview, resident interview, and observation, the facility failed to ensure physician orders were followed for residents receiving oxygen therapy. This failed practice had the potential to affect a limited number of residents. Resident Identifiers: #54 and #87. Facility Census: 117. Findings included:a) Resident #54 On 05/11/26 at 12:45 PM, Resident #54's oxygen concentrator was set on 1.5 liters and the resident reported he felt he was short of breath. The resident reported he was supposed to be on two (2) liters of oxygen. Review of Resident #54's electronic medical record revealed:-The resident's physician order stated, Oxygen at 2L/min via Nasal Cannula continuously every day and night shift. -The resident's care plan stated, Oxygen per order. On 05/11/25 at 2:26 PM, the resident's care plan was updated following surveyor intervention to include: Resident is non-compliant with use of oxygen since admission on [DATE]. Resident will at times refuse to wear oxygen, throw tubing in the floor, self-adjust concentrator settings. Unit Manager Licensed Practical Nurse #115 observed the oxygen concentrator and stated, Let me check the order. The unit manager returned to the resident's room and reported the order was for two (2) liters and stated, It's slightly off. b) Resident #87 On 05/11/26 at 1:00 PM, Resident #87's concentrator was set on 3.5 liters. The concentrator was out of the resident's reach at the time of the observation. The resident reported he was supposed to be on four (4) liters of oxygen. Review of Resident #87's electronic medical record revealed:-The resident's care plan stated, Oxygen as ordered. -The resident's physician order stated, Oxygen at 4L via NC [nasal canula] every day and night shift. Unit Manager Licensed Practical Nurse #94 confirmed the oxygen concentrator was on 3.5 liters and stated, Let me go check. The unit manager returned and reported the concentrator was to be set on four (4) liters and that the resident was care planned to sometimes mess with it. c) Policy and Procedure for Oxygen Concentrator The facility's policy and procedure for Oxygen Concentrator stated, 10. Set liter flow per order.

Based on record review and staff interview, the facility failed to ensure the resident's care plans were comprehensive, patent-centered and individualized for transfers. This was found true for five(5) of 31 care plans reviewed during the Long Term Care Survey process. Resident Identifiers: #2, #9, #84, #85, and #105. Facility Census: 117.Findings included: a) The facility's policy and procedure stated, the Center must develop and implement a person-centered care plan for each patient/resident (hereinafter patient) consistent with patient rights measurable objectives and timeframes to meet a patient's medical, nursing and mental and psychosocial needs and all services that meet professional standards of quality. b) On 01/20/2026 at 3:53 PM , the following resident's records were reviewed: Residents #2, #9, #84, #85 and #105. All five (5) care plans reviewed listed the intervention for transfers as Lift per assessment. The care plans were not individualized for each resident. On 01/20/2026 at 04:36 PM, the Minimum Data Set (MDS) Coordinator confirmed the care plans were the same for transfers and reported they only update the actual assessment with changes, not the care plan. When asked by the state surveyor how they identify a resident's change in transfer status for staff, the MDS Coordinator reported, they follow the assessment and a sticker on the resident' door was used to identify how the resident transfer for staff. On 01/20/2025 at 04:40 PM, the Director of Nursing (DON) reported transfer changes are on the door by the resident's name and if there is a change in transfer they usually put a change in transfer/lift under a different section of the care plan. The DON stated, I understand. when discussing how the care plans were not individualized for each resident.

Based on record review, observation, staff interview and resident interview, the facility failed to ensure a resident's call light was adapted to a resident's individual physical needs. This failed practice was a random opportunity for discovery and had the potential to affect a limited number of residents. Resident identifier: #84. Facility census: 117. Findings included: a) Resident #84 On 01/19/2026 at 10:10 AM, Resident #84's call light was out of reach and attached to the bed. Registered Nurse (RN) #78 confirmed the call light was out of reach and stated, it was hooked around the bed. RN # 78 re-attached the call light in reach of the resident. The resident reported they could reach it and the resident stated, but no one answers it. RN #78 requested the resident to push the call light. The resident attempted to push the call light, but it did not come on. The resident was physically unable to activate the regular, standard call light button on the call light device. The state surveyor pushed the call light button, and it came on immediately. After surveyor intervention, an adaptive touch pad call light was placed, and the resident was able to activate the call system for assistance as needed. On 01/21/2026, the resident continued to be able to activate the call light system with the new touch pad call light upon request by the surveyor. b) The facility's policy and procedure for Activities of Daily Living (ADL's) stated, Assistive devices and adaptive equipment are provided, as needed. The facility's policy and procedure for Call Lights stated, Each resident will be evaluated for unique needs and preferences to determine any special accommodations that may be needed in order for the patient to use the call system.

Based on record review, staff interview, resident interview and observation, the facility failed to ensure call lights were operational and within the resident's reach. This failed practice had the potential to affect a limited number of residents. Resident identifiers: #9 and #84. Facility Census: 117.Findings included: a) Resident #9 On 01/18/2026, during the initial interview process, Resident #9 was observed requesting to lay down. The resident's call light was behind him on his bed. The resident was unable to reach his call light upon two observed attempts. Assistance was obtained by the state surveyors. Nursing Assistant (NA) #25 confirmed the call light was out of reach. The NA reported the resident was care planned to be out of bed for meals. The patient's call light did not turn on when activated by the surveyor. At 11:20 AM, NA # 25 confirmed the call light did not turn on and stated, Maybe it got unplugged a little bit. On 01/18/2026 at11:40 AM, the Administrator reported the broken call light was put into the TELS system to be repaired and maintenance was coming in to fix it. b) Resident #84 On 01/8/2026 at 01:20 PM, Resident #84 was unable to reach her call light while sitting in her wheelchair. Nursing Assistant (NA) #96 confirmed the call light was not in reach of the resident and stated, I moved stuff to put the tray down. On 01/19/2026 at 10:10 AM, Resident #84's call light was out of reach and attached to the bed. Registered Nurse (RN) #78 confirmed the call light was out of reach and stated, it was hooked around the bed. Registered Nurse (RN) #78 re-attached the call light in reach of the resident.

Based on records review and staff interviews, the facility failed to ensure a complete and accurate medical records. This failed practice was found true for one (1) out of (31) residents reviewed. Resident identifier: #61. Facility Census: 117 a) Resident #61 Documentation review of the medical record revealed a note by a medical provider reflected that resident has capacity and the assessment sheet scanned into the medical record demonstrated resident lacks capacity. Interview with the facility's Assistant Administrator on 01/18/26 at approximately 3:08 p.m., verified the inaccuracy of Resident #61's medical record.

Based on record review, observation and staff interview, the facility failed to ensure a resident was provided a physician ordered assistive device during mealtime in the dining room. This failed practice was a random opportunity for discovery, and had the potential to affect a limited number of residents residing in the long term care facility. Resident Identifier: #6. Facility Census: 117. Findings included:a) Resident #6The facility's policy and procedure for Activities of Daily Living (ADL's) stated, Assistive devices and adaptive equipment are provided, as needed. The facility's policy and procedure for Dining Service Standards 6.6 Assistance - adaptive devices are provided, as indicated on the resident plan of care. The resident 's diet order stated, Regular Liberalized diet Regular Texture, Standard Thin Liquids consistency, Scoop plate with meals, large portions, [NAME] Cup. The resident's care plan interventions stated, Scoop plate with all meals, large portions, Kennedy cup. The resident's tray card listed [NAME] Cup in bold print. On 01/19/2026 at 11:34 AM, Registered Nurse (RN) #78 confirmed the resident did not have a Kennedy cup and reported she would talk to Occupational Therapy (OT) about the cup. RN #78 stated, He does good. without the [NAME] Cup.The state surveyor reported the findings to the Assistant Administrator on 01/19/2026 at 12:36 PM.

Based on record review , observation, staff interview and resident interview, the facility failed to ensure a resident received food that accommodated the resident's intolerances and preferencesfor one (1) of two (2) residents reviewed for choices. Resident Identifier: #84. Facility Census: 17. Findings included: a) The facility's policy and procedure for Person-Centered Choices stated, Patients/Residents (hereinafter resident) are offered a choice of nourishing, palatable, well-balanced food and beverage options that meet their daily nutritional needs, taking into consideration the preferences of each resident. b) On 01/20/2026, Resident #84's tray card was reviewed by the state surveyor. The resident received the following items on her tray: Fish on a bun, Potato Wedges and Sliced Peaches. Resident #84 reported they had told staff they did not like fish. The DON asked the resident if she wanted the rice or an alternate from the always available menu. The resident declined the rice and alternates from the always available menu. According to Resident #84's food preference list, baked fish was listed as a dislike.

Based upon record review and staff interview, the facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) program when a new mental health diagnosis or change in condition is presented. This was found to be true for one (1) of six (6) residents during the long term care survey process. Resident identifier #87. Facility census: 117. Resident #87 a) On 01/20/26 reviewed Resident #87 PASARR dated 09/17/24. It was observed that the only diagnosis on the form was Delusional Disorder. According to the medical diagnosis listed for Resident #87 was diagnosed with conversion disorder with seizures or convulsions and anxiety disorder unspecified on 02/05/25. On 01/21/26 at approximately 9:00 a.m., interview with the facility's Social Worker verified the missed diagnosis and that a new PASARR should have been completed (Social Worker did submit a new PASARR on 01/21/26).

Based on record review and staff interview, the facility failed to ensure a comprehensive assessment of resident preferences for customary routine and activities was completed and documented in the annual Minimum Data Set (MDS) for one (1) of two (2) residents. This was true for Resident #15. Resident identifier: #15. Facility census: 117.Findings include:a) Resident #15On 01/20/25, a review of Resident #15's annual Minimum Data Set (MDS) completed on 07/06/25 revealed that Section F (Preferences for Customary Routine and Activities) was not completed. The MDS reflected Not assessed for all required items, including:F0300 - Should the resident be interviewed regarding daily and activity preferencesF0400 - Interview for daily preferencesF0500 - Interview for activity preferencesF0600 - Primary respondent for daily and activity preferencesF0700 - Should a staff assessment be conductedF0800 - Staff assessment of daily and activity preferencesThis demonstrated that the facility failed to conduct and document an assessment of Resident #15's customary routine and activity preferences as required for the annual MDS.On 01/20/25 at approximately 1:00 PM, an interview was conducted with the Activity Director, in the presence of the Assistant Administrator. During the interview, the Activity Director stated, I completed a recreation quarterly progress note and care plan evaluation assessment instead of the annual. This statement confirmed that Section F of the annual MDS for Resident #15 was not assessed or completed.Resident Assessment Instrument guidance indicates if information is unavailable use the appropriate non responsive or dashed code.

Based on record review and staff interview, the facility failed to provide an accurate and complete record for Resident #118's discharge and diagnosis for a medication. This was true for for one (1) of two (2) residents reviewed during the survey process. Resident Identifier: #118. Facility Census: 116.Findings Include: a1) Resident #118On 10/21/25 at 9:00 AM, a record review was completed for Resident #118. The review found the discharge plan documentation dated 07/09/25 was incorrect. Under section C entitled Recreation, a physician's order for treatment was listed as: Cleanse right 2nd toe amputation site with wound cleanser, pat dry, cover with betadine soaked gauze calcium alginate, wrap with kerlix. Upon further review, the resident did not have an amputation of the second toe.On 10/21/25 at 10:00 AM, the Administrator #22 confirmed this information listed on the discharge plan documentation was incorrect. a2) Resident #118On 10/21/25 at 9:00 AM, a record review was completed for Resident #118. The review found a physician's order for the medication Ropinirole (Requip) was listed with a diagnosis of Parkinson's disease. The resident did not have a diagnosis of Parkinson's disease. The correct diagnosis should have been listed as restless leg syndrome. On 10/21/25 at 11:45 AM, the Administrator #22 confirmed the diagnosis of Parkinson's disease was incorrect and the diagnosis of restless leg syndrome was correct.

Based on record review and staff interview, the facility failed to revise the care plan with a correct diagnosis for Resident #118. This was true for one (1) of 20 residents reviewed during the survey process. Resident Identifier: #118. Facility Census: 116.Findings Include: a) Resident #118On 10/21/25 at 10:00 AM, a record review was completed for Resident #118. The review found the care plan had not been revised with the correct diagnosis of restless leg syndrome. Under the focus area of Resident exhibits or is at risk for alterations in comfort related to chronic pain, neuropathy, left knee pain, bilateral calf pain, bladder spasms, Parkinsons disease, fibromyalgia, ganglion right wrist, spondylosis, osteroarthritis., the resident did not have a diagnosis of Parkinson's disease but did have a diagnosis of restless leg syndrome. On 10/21/25 at 11:45 AM, the Administrator #22 confirmed the care plan was incorrect. The Administrator #22 confirmed the diagnosis of Parkinson's disease was incorrect and should have been restless leg syndrome.

Based on record review and staff interview the facility failed to ensure one (1) of two (2) residents reivewed for pressure ulcers received the apprpirate care to treat a wound to the coccyx. Resident #1 entered the facility without a pressure ulcer to the coccyx . He was discharged to another facility (nursing home). An assessment completed within 40 minutes after his discharge from the facility revealed a deep foul smelling wound to the coccyx. Resident #1 sustained actual harm. Resident identifier: #1. Facility Census: 118 Findings Include: a) Resident #1 Resident #1 was admitted to the facility on [DATE] from a critical illness recovery hospital. He had been at that facility from 01/22/25 - 02/18/25. He had previously been at another acute care hospital from [DATE] - 01/22/25. He was sent to the acute care hospital on [DATE] after his percutaneous endoscopic gastrostomy tube malfunctioned. While hospitalized he had two (2) surgeries and left the hospital on [DATE] with a surgical wound to the left and right abdomen. Due to postoperative complications a wound vac was placed for healing purposes. Upon admission to Facility #1, there was an admission progress note, and skin check performed. Documentation shows the resident arrived on 02/18/25 at 10:30 PM. Observation of the skin assessment was documented as (absent of any related wounds to coccyx). New skin Issue. Location: Left Lower Quadrant Midline. Issue type: Surgical wound. Wound was present on admission. Length (cm): 3.5 Width (cm): 0.6 Depth (cm): 0.1#002: New skin Issue. Location: Right Lower Quadrant Midline. Issue type: Surgical wound. Wound was present on admission. Length (cm): 9.8 Width (cm): 4.8 Depth (cm): 0.2#003: New skin Issue. Location: Left heel. Issue type: Pressure ulcer / injury. Pressure ulcer staging: Unstagable pressure injuries presenting as deep tissue injury. Wound was present on admission. Length (cm): 5.6 Width (cm): 4.4 Depth (cm): 0#004: New skin Issue. Location: Right heel. Issue type: Pressure ulcer / injury. Pressure ulcer staging: Unstagable pressure injuries presenting as deep tissue injury. Wound was present on admission. Length (cm): 1.9 Width (cm): 1.3 Depth (cm): 0 Additional skin checks were performed weekly on 02/25/25, 03/05/25, 03/12/25, 03/19/25, 03/26/25, 04/02/25 and 04/09/25. Random dated copies were provided for review for the following dates: 02/18/25 (admission), 02/26/25, 03/19/25, 04/02/25, 04/09/25. (absent of any related wounds to coccyx). In addition, the facility provided the latest skin and wound evaluations. 04/02/25 documented surgical wound to left lower quadrant abdomen 04/02/25 documented surgical wound to right lower quadrant abdomen 04/02/25 documented surgical wound, dehiscence to right lower quadrant abdomen 04/02/25 documented pressure deep tissue injury to left heel 04/02/25 documented pressure deep tissue injury to left heel On 05/12/25 Residents #1s medical records were reviewed. A Braden scale for predicting pressure risk was completed on the following days resulting in the following scores: 02/29/25 - 10 which indicated the resident was at a high risk of developing pressure ulcers. 02/25/25 - 10 which indicated the resident was at a high risk of developing pressure ulcers 03/05/25 - 11 which indicated the resident was at a high risk of developing pressure ulcers 03/12/25 -11 which indicated the resident was at a high risk of developing pressure ulcers Resident #1's care plan was reviewed and showed a focus area for the resident being at risk for skin breakdown due to decreased activity, frail fragile skin, impaired condition, incontinence, limited mobility, recent surgery and pressure areas to the left and right heel, a surgical site to the left and right lower abdomen. The goal associated with this focus area was for the pressure areas and surgical sites to heal upon review and for the resident's wound/skin impairment to heal as evidenced by a decrease in size, absence of erythema and drainage and/or pressure ulcer: Interventions related to his goal included: - Enhanced Barrier Precautions - Heels up device while in bed as resident will allow - Low air loss mattress to bed, weekly hand checks to monitor settings - Negative pressure wound therapy to right lower ABD per orders - pro mattress to bed - Pad side rails/wheelchair or other equipment as necessary - Pat (do not rub) skin when drying - Provide patient and/healthcare decision maker education regarding risk factors and interventions - Provide preventative skin care i.e. lotions, barrier creams as ordered. - Observe skin for signs/symptoms of skin breakdown i.e. redness, cracking, blistering, decrease sensation, and skin that does not blanch easily. - Evaluate for any localized skin problems, i.e. dryness, redness, pustules, inflammation. - Observe skin condition daily with ADL care and report abnormalities. - Observe for verbal and nonverbal signs of pain related to wound or wound treatment and medication as ordered. - Obtain dietitian consult as needed/ordered - Obtain skilled PT/OT evaluation to improve functional mobility. - Provide wound treatment as ordered - Provide supplements as ordered. - Weekly skin check by license nurse - Weekly wound assessment to include measurements and description of wound status. The care plan also indicated the following related to Activities of Daily Living (ADL) assistance required by Resident #1. Resident requires assistance/is dependent for ADL care in bathing, grooming, personal hygiene, - dressing, eating, bed mobility, transfer, locomotion, toileting related to hx (history) of Cerebrovascular Accident (CVA) VA with paraplegia affecting both sides. Resident is incontinent of bladder and bowel and is unable to cognitively and physically participate in a retaining program due to total lift status, neurocognitive disorder. During an interview on 05/13/25 with the Director of Nursing, she stated Nurse Aides do not document each time they turn the residents, they only document if they turn the resident during that shift. Medical Record documentation on the following days showed the resident was not turned for each of the three (3) shifts. 03/11/25, 03/16/25, 03/18/25, 03/25/25, 03/30/25, 04/08/25. When asked why all three shifts were not documented, she could not provide an answer. A review of the physician's orders for Resident #1 from the time of admission until the time discharged found no orders related to pressure ulcer treatment and/or prevention for his coccyx. A review of Resident #1s discharge progress note completed by Licensed Practical Nurse #8 states a skin check was completed, however there is no skin check or skin, and wound evaluations documented for 04/10/25 (discharge date ). There was no written discharge skin and wound evaluation documentation noted. Treatment Administration Records (TAR) for February, March and April 2025 found no wound treatments were missing. (absent of any related wounds to coccyx) On 05/12/25 at 1 PM during an interview with Licensed Practical Nurse (LPN) #6 she states she does 99% of all wound care. She said she was responsible for weekly skin checks and skin and wound evaluations. LPN #6 said if there is a new wound identified by an LPN or Nurse Aid, she also assessed that wound if she was in the facility. If not, the LPN assesses it, and LPN #6 follows up when LPN #6 returned. When asked to identify wounds that Resident #1 had upon discharge, she stated He had two abdominal surgical wounds, one on each side, bilateral DTI's (deep tissue injuries) to his heels. She denied any knowledge of a wound to his coccyx. When asked if there was ever a time when a dressing would be in place without a physicians order, she stated no. On 05/13/25 at 12:55 PM during a telephone interview with the Medical Director for the facility, he said he did not perform skin checks on residents. He said he depended on documentation from the staff. On 05/12/25 at 4:20 PM the surveyor went to the facility where the resident was discharged to. LPN #3 took report from the facility on 04/10/25. She stated the report consisted of when his last bowel movement was, his vital signs, his tube feeding details. She states the only report obtained concerning skin status, was that there were no new issues. LPN #4 was the nurse on duty on 04/10/25 at 5:45 PM when the resident arrived at the facility. She stated Resident #1 arrived at 5:45 PM via stretcher by ambulance. She stated she performed a body audit at 6:00 PM and documented it at that time on paper. She described the wound on the coccyx as deep, maybe bone exposed, foul odor, dressing in tack dated 4/10/25, there were initials on the dressing, but she did not remember what they were. Once she removed the dressing, which was a Mepilex, was removed, there was a blue foam dressing in place, it was not packed in the wound, only laid across it. LPN #4 said, Our facility calls it hydrofera blue. It smelled terrible. The body audit drawing showed the following: dated 04/10/25 6:00 PM 160.8 weight, vital signs, BP (blood pressure) 106/74 P (pulse) 76, T (temperature) 97.7, R (respirations) 20, 02 Sat 99% on 2 liters of oxygen. Front view: Head: dry, flaky skin. Feet: dry, flaky skin. Right arm: scab. Bilateral lower extremities: dry, flaky skin. Right abdominal wound, left abdominal healing scar. lower left abdomen: feeding tube. Rear view: Back: redness. Bilateral heels: redness. Wound on coccyx. Note on the back of the body audit stated: Resident has dry skin on his head and face. Small scab on right upper arm. Large abdominal wound middle of upper abdomen cover by Allevyn. Healing scar on the left side of mid abdomen. Feeding tube site on left lower abdomen. Bilateral lower legs and feet are dry and flaky. Redness on middle of back towards right side. Wound on coccyx covered with a dressing. Both heels are red. LPN #4 also documented an electronical assessment once the resident was admitted , comfortable in bed and time allowed. The electronic documentation on 04/10/25 at 8:40 PM identifies vital signs as noted above. Integumentary assessment: Deficits noted: Color: normal flesh tone appropriate to complexion Moisture: Dry Temperature: Warm Turgor: Fair Skin intact: No Comments: Abdominal wound to middle of abdomen, wound on coccyx, feeding tube on left lower abdomen, redness on heels, dry skin, scab on right arm. On 04/11/25 at 9:40 AM a wound and ulcer assessment was completed and documented by the RN as follows: Wound #1 Wound type: Pressure Ulcer Wound location: Coccyx Dressing present: Yes Dressing intact: yes Dressing changed Yes Incision present: no Sutures/staples present: No Size length 2.5 width 1.5 depth: 05 Has wound be staged by Registered Nurse? Yes Unstagable, necrotic slough/eschar tissues obscure base of ulcer, unable to determine whether ulcer is III or IV. Odor: Yes extensive malodorous purulent smell to wound Drainage: Yes Drainage color: black. Drainage amount: moderate Signs of infection: Hot, reddened Additional comments: black drainage coming from wound tissue and soaking removed dressing, gray necrotic tissues surrounding wound bed with tunneling noted at the left upper side of wound measuring 0.5 cm Are there significant changes in would or signs of infection since last assessment? Yes. Physician notified. Photos taken of the wound: Yes Wound #2 Wound type: surgical wound Wound location: Abdomen Dressing present: Yes Dressing intact: yes Dressing changed: yes Incision present: no Sutures/staples present: no Size: length: 6/9 width 3.3 depth 0 cm Not staged, no odor, no drainage Signs of infection: reddened Additional comments: healing surgical wound to left abdomen with scab formation, no drainage Physician notified Wound #3 Wound type: pressure ulcer Wound location: right heel Dressing present: yes Dressing intact: yes Dressing changed: yes Incision present: no Sutures/staples present: no Size length 3 width 3 depth 0 cm No odor, no drainage, Signs of infection: swollen, hot and reddened Physician notified Wound #4 Wound type: pressure ulcer Wound location: left heel Dressing present: yes Dressing intact: yes Dressing changed: yes Incision present: no Sutures/staples present: no Size length 3 width 3 depth 0 cm No odor, no drainage, Signs of infection: reddened Additional comments: 2 small areas of dry flaking skin beginning to peel with new tissue. Physician notified A registered nursing note stated, Resident returned 4/10/25 in late evening, wounds present with dressings intact completed on 4/10/25 at (name of facility) Wounds reviewed today per this Registered Nurse (RN) and Unit Manager for staging. Resident noted to be 100.3 degrees temp., with pain noted to turning and touch of coccyx. Coccyx wound is infected, necrotic, unstagable and requires debridement and support not available in house. No treatment orders or notification received on this wound condition; Wound not included on PASR preadmission screening and resident review). Resident condition reported to Family Nurse Practitioner (FNP) and Medical Director with orders to send to ER for further treatment. Social Services informed of wound findings to coccyx. DON/Administrator informed. Health care surrogate (HCS) informed of findings per RN unit manager and gave preference of (local hospital name) for hospital. According to the discharge summary from the local hospital with admission date of 4/11/25, the resident was admitted with the following admitting diagnosis: Decubitus ulcer State 3 present on admission. Infected with osteomyelitis. Post obstructive pneumonia. Mucus plugging. General surgery and infectious disease was consulted for care. While inpatient a debridement of the wound on his coccyx was complete with discharge orders to pack wound daily with normal saline moistened kerlix gauze. Cover with 4 X 4 and ABD (abdominal pad). Clean wound daily with wound cleanser. Per the surgical team the resident was transferred to another local hospital for a course of intravenous antibiotics. On 4/22/25 the resident was transferred to another skilled nursing facility where he was admitted because of a decubitus ulcer, sacral region, State III. He received a ten (10) day course of Daptomycin in 0.9% sodium chloride 500mg/50 ml piggyback, give 400 mg daily per IV and Piperacillin-Tazobactam 3.375 gram reconstituted solution IV every 6 hours. On 05/12/25 at 2:10 PM the Resident #1's wound was observed by this surveyor accompanied by the floor nurse and unit manager. There was a dressing in place. The wound was clean and dressed. The necrotic tissue had been removed. The RN Unit Manager states he had an appointment on 05/13/25 with the wound center to see if he is a candidate for a wound vacuum to his coccyx. . During an interview on 05/13/25 at 9:00 AM the Administrator, wound nurse and DON, said they were aware of the DON from the facility he was discharged to coming into their facility however they did not accompany her to the resident's room and are unaware if she did a skin assessment. It was their understanding that she was only there to confirm that the wound vac had been removed prior to him being sent to her facility. During this interview the wound nurse was asked for a list of wound care supplies they typically use in their facility, the list consisted of blue classic foam. On 5/13/25 at 9:10 AM the Administrator, wound nurse and DON at Facility #1 were shown the body audit, skin assessment and pictures of Resident #1 upon returning to the facility. The discussion included that the resident left their facility at 5:20 PM and arrived at the other facility at 5:45 PM. They were informed Resident #1 had a dressing to his coccyx dated 4/10/25. They all agreed. When asked how they think the dressing got applied at their facility, they had no explanation. They expressed their shock and concern for Resident #1 but denied knowing anything about the Stage III pressure ulcer to Resident #1's coccyx.

Based on record review and staff interview the facility failed to ensure one (1) of two (2) residents reivewed for pressure ulcers were not neglected. Resident #1 entered the facility without a pressure ulcer. He was discharged to another facility (nursing home). An assessment completed within 40 minutes after his discharge from the facility revealed a deep foul smelling wound to the coccyx. Resident #1 sustained actual harm. Resident identifier: #1. Facility Census: 118 Findings Include: a) Resident #1 Resident #1 was admitted to the facility on [DATE] from a critical illness recovery hospital. He had been at that facility from 01/22/25 - 02/18/25. He had previously been at another acute care hospital from [DATE] - 01/22/25. He was sent to the acute care hospital on [DATE] after his percutaneous endoscopic gastrostomy tube malfunctioned. While hospitalized he had two (2) surgeries and left the hospital on [DATE] with a surgical wound to the left and right abdomen. Due to postoperative complications a wound vac was placed for healing purposes. Upon admission to Facility #1, there was an admission progress note, and skin check performed. Documentation shows the resident arrived on 02/18/25 at 10:30 PM. Observation of the skin assessment was documented as (absent of any related wounds to coccyx). New skin Issue. Location: Left Lower Quadrant Midline. Issue type: Surgical wound. Wound was present on admission. Length (cm): 3.5 Width (cm): 0.6 Depth (cm): 0.1#002: New skin Issue. Location: Right Lower Quadrant Midline. Issue type: Surgical wound. Wound was present on admission. Length (cm): 9.8 Width (cm): 4.8 Depth (cm): 0.2#003: New skin Issue. Location: Left heel. Issue type: Pressure ulcer / injury. Pressure ulcer staging: Unstagable pressure injuries presenting as deep tissue injury. Wound was present on admission. Length (cm): 5.6 Width (cm): 4.4 Depth (cm): 0#004: New skin Issue. Location: Right heel. Issue type: Pressure ulcer / injury. Pressure ulcer staging: Unstagable pressure injuries presenting as deep tissue injury. Wound was present on admission. Length (cm): 1.9 Width (cm): 1.3 Depth (cm): 0 Additional skin checks were performed weekly on 02/25/25, 03/05/25, 03/12/25, 03/19/25, 03/26/25, 04/02/25 and 04/09/25. Random dated copies were provided for review for the following dates: 02/18/25 (admission), 02/26/25, 03/19/25, 04/02/25, 04/09/25. (absent of any related wounds to coccyx). In addition, the facility provided the latest skin and wound evaluations. 04/02/25 documented surgical wound to left lower quadrant abdomen 04/02/25 documented surgical wound to right lower quadrant abdomen 04/02/25 documented surgical wound, dehiscence to right lower quadrant abdomen 04/02/25 documented pressure deep tissue injury to left heel 04/02/25 documented pressure deep tissue injury to left heel On 05/12/25 Residents #1s medical records were reviewed. A Braden scale for predicting pressure risk was completed on the following days resulting in the following scores: 02/29/25 - 10 which indicated the resident was at a high risk of developing pressure ulcers. 02/25/25 - 10 which indicated the resident was at a high risk of developing pressure ulcers 03/05/25 - 11 which indicated the resident was at a high risk of developing pressure ulcers 03/12/25 -11 which indicated the resident was at a high risk of developing pressure ulcers Resident #1's care plan was reviewed and showed a focus area for the resident being at risk for skin breakdown due to decreased activity, frail fragile skin, impaired condition, incontinence, limited mobility, recent surgery and pressure areas to the left and right heel, a surgical site to the left and right lower abdomen. The goal associated with this focus area was for the pressure areas and surgical sites to heal upon review and for the resident's wound/skin impairment to heal as evidenced by a decrease in size, absence of erythema and drainage and/or pressure ulcer: Interventions related to his goal included: - Enhanced Barrier Precautions - Heels up device while in bed as resident will allow - Low air loss mattress to bed, weekly hand checks to monitor settings - Negative pressure wound therapy to right lower ABD per orders - pro mattress to bed - Pad side rails/wheelchair or other equipment as necessary - Pat (do not rub) skin when drying - Provide patient and/healthcare decision maker education regarding risk factors and interventions - Provide preventative skin care i.e. lotions, barrier creams as ordered. - Observe skin for signs/symptoms of skin breakdown i.e. redness, cracking, blistering, decrease sensation, and skin that does not blanch easily. - Evaluate for any localized skin problems, i.e. dryness, redness, pustules, inflammation. - Observe skin condition daily with ADL care and report abnormalities. - Observe for verbal and nonverbal signs of pain related to wound or wound treatment and medication as ordered. - Obtain dietitian consult as needed/ordered - Obtain skilled PT/OT evaluation to improve functional mobility. - Provide wound treatment as ordered - Provide supplements as ordered. - Weekly skin check by license nurse - Weekly wound assessment to include measurements and description of wound status. The care plan also indicated the following related to Activities of Daily Living (ADL) assistance required by Resident #1. Resident requires assistance/is dependent for ADL care in bathing, grooming, personal hygiene, - dressing, eating, bed mobility, transfer, locomotion, toileting related to hx (history) of Cerebrovascular Accident (CVA) VA with paraplegia affecting both sides. Resident is incontinent of bladder and bowel and is unable to cognitively and physically participate in a retaining program due to total lift status, neurocognitive disorder. During an interview on 05/13/25 with the Director of Nursing, she stated Nurse Aides do not document each time they turn the residents, they only document if they turn the resident during that shift. Medical Record documentation on the following days showed the resident was not turned for each of the three (3) shifts. 03/11/25, 03/16/25, 03/18/25, 03/25/25, 03/30/25, 04/08/25. When asked why all three shifts were not documented, she could not provide an answer. A review of the physician's orders for Resident #1 from the time of admission until the time discharged found no orders related to pressure ulcer treatment and/or prevention for his coccyx. A review of Resident #1s discharge progress note completed by Licensed Practical Nurse #8 states a skin check was completed, however there is no skin check or skin, and wound evaluations documented for 04/10/25 (discharge date ). There was no written discharge skin and wound evaluation documentation noted. Treatment Administration Records (TAR) for February, March and April 2025 found no wound treatments were missing. (absent of any related wounds to coccyx) On 05/12/25 at 1 PM during an interview with Licensed Practical Nurse (LPN) #6 she states she does 99% of all wound care. She said she was responsible for weekly skin checks and skin and wound evaluations. LPN #6 said if there is a new wound identified by an LPN or Nurse Aid, she also assessed that wound if she was in the facility. If not, the LPN assesses it, and LPN #6 follows up when LPN #6 returned. When asked to identify wounds that Resident #1 had upon discharge, she stated He had two abdominal surgical wounds, one on each side, bilateral DTI's (deep tissue injuries) to his heels. She denied any knowledge of a wound to his coccyx. When asked if there was ever a time when a dressing would be in place without a physicians order, she stated no. On 05/13/25 at 12:55 PM during a telephone interview with the Medical Director for the facility, he said he did not perform skin checks on residents. He said he depended on documentation from the staff. On 05/12/25 at 4:20 PM the surveyor went to the facility where the resident was discharged to. LPN #3 took report from the facility on 04/10/25. She stated the report consisted of when his last bowel movement was, his vital signs, his tube feeding details. She states the only report obtained concerning skin status, was that there were no new issues. LPN #4 was the nurse on duty on 04/10/25 at 5:45 PM when the resident arrived at the facility. She stated Resident #1 arrived at 5:45 PM via stretcher by ambulance. She stated she performed a body audit at 6:00 PM and documented it at that time on paper. She described the wound on the coccyx as deep, maybe bone exposed, foul odor, dressing in tack dated 4/10/25, there were initials on the dressing, but she did not remember what they were. Once she removed the dressing, which was a Mepilex, was removed, there was a blue foam dressing in place, it was not packed in the wound, only laid across it. LPN #4 said, Our facility calls it hydrofera blue. It smelled terrible. The body audit drawing showed the following: dated 04/10/25 6:00 PM 160.8 weight, vital signs, BP (blood pressure) 106/74 P (pulse) 76, T (temperature) 97.7, R (respirations) 20, 02 Sat 99% on 2 liters of oxygen. Front view: Head: dry, flaky skin. Feet: dry, flaky skin. Right arm: scab. Bilateral lower extremities: dry, flaky skin. Right abdominal wound, left abdominal healing scar. lower left abdomen: feeding tube. Rear view: Back: redness. Bilateral heels: redness. Wound on coccyx. Note on the back of the body audit stated: Resident has dry skin on his head and face. Small scab on right upper arm. Large abdominal wound middle of upper abdomen cover by Allevyn. Healing scar on the left side of mid abdomen. Feeding tube site on left lower abdomen. Bilateral lower legs and feet are dry and flaky. Redness on middle of back towards right side. Wound on coccyx covered with a dressing. Both heels are red. LPN #4 also documented an electronical assessment once the resident was admitted , comfortable in bed and time allowed. The electronic documentation on 04/10/25 at 8:40 PM identifies vital signs as noted above. Integumentary assessment: Deficits noted: Color: normal flesh tone appropriate to complexion Moisture: Dry Temperature: Warm Turgor: Fair Skin intact: No Comments: Abdominal wound to middle of abdomen, wound on coccyx, feeding tube on left lower abdomen, redness on heels, dry skin, scab on right arm. On 04/11/25 at 9:40 AM a wound and ulcer assessment was completed and documented by the RN as follows: Wound #1 Wound type: Pressure Ulcer Wound location: Coccyx Dressing present: Yes Dressing intact: yes Dressing changed Yes Incision present: no Sutures/staples present: No Size length 2.5 width 1.5 depth: 05 Has wound be staged by Registered Nurse? Yes Unstagable, necrotic slough/eschar tissues obscure base of ulcer, unable to determine whether ulcer is III or IV. Odor: Yes extensive malodorous purulent smell to wound Drainage: Yes Drainage color: black. Drainage amount: moderate Signs of infection: Hot, reddened Additional comments: black drainage coming from wound tissue and soaking removed dressing, gray necrotic tissues surrounding wound bed with tunneling noted at the left upper side of wound measuring 0.5 cm Are there significant changes in would or signs of infection since last assessment? Yes. Physician notified. Photos taken of the wound: Yes Wound #2 Wound type: surgical wound Wound location: Abdomen Dressing present: Yes Dressing intact: yes Dressing changed: yes Incision present: no Sutures/staples present: no Size: length: 6/9 width 3.3 depth 0 cm Not staged, no odor, no drainage Signs of infection: reddened Additional comments: healing surgical wound to left abdomen with scab formation, no drainage Physician notified Wound #3 Wound type: pressure ulcer Wound location: right heel Dressing present: yes Dressing intact: yes Dressing changed: yes Incision present: no Sutures/staples present: no Size length 3 width 3 depth 0 cm No odor, no drainage, Signs of infection: swollen, hot and reddened Physician notified Wound #4 Wound type: pressure ulcer Wound location: left heel Dressing present: yes Dressing intact: yes Dressing changed: yes Incision present: no Sutures/staples present: no Size length 3 width 3 depth 0 cm No odor, no drainage, Signs of infection: reddened Additional comments: 2 small areas of dry flaking skin beginning to peel with new tissue. Physician notified A registered nursing note stated, Resident returned 4/10/25 in late evening, wounds present with dressings intact completed on 4/10/25 at (name of facility) Wounds reviewed today per this Registered Nurse (RN) and Unit Manager for staging. Resident noted to be 100.3 degrees temp., with pain noted to turning and touch of coccyx. Coccyx wound is infected, necrotic, unstagable and requires debridement and support not available in house. No treatment orders or notification received on this wound condition; Wound not included on PASR preadmission screening and resident review). Resident condition reported to Family Nurse Practitioner (FNP) and Medical Director with orders to send to ER for further treatment. Social Services informed of wound findings to coccyx. DON/Administrator informed. Health care surrogate (HCS) informed of findings per RN unit manager and gave preference of (local hospital name) for hospital. According to the discharge summary from the local hospital with admission date of 4/11/25, the resident was admitted with the following admitting diagnosis: Decubitus ulcer State 3 present on admission. Infected with osteomyelitis. Post obstructive pneumonia. Mucus plugging. General surgery and infectious disease was consulted for care. While inpatient a debridement of the wound on his coccyx was complete with discharge orders to pack wound daily with normal saline moistened kerlix gauze. Cover with 4 X 4 and ABD (abdominal pad). Clean wound daily with wound cleanser. Per the surgical team the resident was transferred to another local hospital for a course of intravenous antibiotics. On 4/22/25 the resident was transferred to another skilled nursing facility where he was admitted because of a decubitus ulcer, sacral region, State III. He received a ten (10) day course of Daptomycin in 0.9% sodium chloride 500mg/50 ml piggyback, give 400 mg daily per IV and Piperacillin-Tazobactam 3.375 gram reconstituted solution IV every 6 hours. On 05/12/25 at 2:10 PM the Resident #1's wound was observed by this surveyor accompanied by the floor nurse and unit manager. There was a dressing in place. The wound was clean and dressed. The necrotic tissue had been removed. The RN Unit Manager states he had an appointment on 05/13/25 with the wound center to see if he is a candidate for a wound vacuum to his coccyx. . During an interview on 05/13/25 at 9:00 AM the Administrator, wound nurse and DON, said they were aware of the DON from the facility he was discharged to coming into their facility however they did not accompany her to the resident's room and are unaware if she did a skin assessment. It was their understanding that she was only there to confirm that the wound vac had been removed prior to him being sent to her facility. During this interview the wound nurse was asked for a list of wound care supplies they typically use in their facility, the list consisted of blue classic foam. On 5/13/25 at 9:10 AM the Administrator, wound nurse and DON at Facility #1 were shown the body audit, skin assessment and pictures of Resident #1 upon returning to the facility. The discussion included that the resident left their facility at 5:20 PM and arrived at the other facility at 5:45 PM. They were informed Resident #1 had a dressing to his coccyx dated 4/10/25. They all agreed. When asked how they think the dressing got applied at their facility, they had no explanation. They expressed their shock and concern for Resident #1 but denied knowing anything about the Stage III pressure ulcer to Resident #1's coccyx.

Based on record review, and staff interview the facility failed to provide accurate information to the receiving facility regarding skin condition. This failed practice was found true for (1) one of (3) three residents reviewed for transfer/discharge during the complaint survey. Resident identifier #1. Facility census: 118. Findings Include: a) Resident #1 A record review on 05/12/25 at 9:55 AM, revealed that Resident #1 was transferred from this facility to a different nursing home on [DATE] at approximately 5:20 PM. Further record review revealed the following general note dated 04/10/25 at 5:20 PM, that read as follows: Resident discharging from the facility at this time via ambulance transport to (Local State Nursing Home Named). Vital signs obtained and within normal limits. Skin check completed and no new issues identified. All discharge paperwork reviewed with MPOA (via phone) and with the Nurse during the report called to (Local State Nursing Home Named). Medication list reviewed and sent with the resident as well. No questions or concerns. Further record review revealed a Skin and wound assessment dated [DATE] that indicates Resident #1 had the following skin/wound issues: Deep tissue injury to Right heal Deep tissue injury to left heal Surgical wound to abdomen A review of the Pre-admission Screening and Resident Review (PASRR'S) for admission and discharge from the facility dated 02/18/25 and 04/07/25 were marked no for decubitus. Further review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/10/25 was marked no for stage 2, 3, 4, and unstageable pressure ulcers. During an interview on 05/12/25 at 12:30 AM, Nursing Assistant (NA) #5 He had a place on his butt. It was a little one. I did not really see it after that because it was always covered with a bandage of some sort that was dated. During an interview on 05/12/25 at 4:00 PM, Licensed Practical Nurse (LPN) #4 stated, I was one of the admitting nurses. He came to us on April 10th. When he came in had a square bandage on a wound on his belly which we knew about. He also had a clean dressing on his coccyx that had the date of 04/10/24 and initials on it. I do not remember what the initials were. The dressing was blue foam like you use to pack a wound but it wasn't packed it was just laid on top, and then the covering to secure it. The wound on his coccyx looked like it was to the bone. It smelled awful. It was red and brown down there and was really deep. He would kind of groan when we rolled him to look at it. The discharge that they sent us did not say anything about the wound on his coccyx. A record review on 05/12/25 at 4:15 PM, of the admission Body Audit dated 04/10/25 reads as follows: Resident has dry skin and his head and face. Small scab on right upper arm. Large abdominal wound middle of upper abdomen covered by Allevyn. Healing scar on the left side of mid abdomen. Bilateral lower legs and feet are dry and flaky. Redness on middle of back towards right side. Wound on coccyx covered with a dressing. Both heels are red. On 5/13/25 at 9:10 AM the Administrator, wound nurse and DON at Facility #1 were shown the body audit, skin assessment and pictures of Resident #1 upon returning to the facility. The discussion included that the resident left their facility at 5:20 PM and arrived at the other facility at 5:45 PM. They were informed Resident #1 had a dressing to his coccyx dated 4/10/25. They all agreed. When asked how they think the dressing got applied at their facility, they had no explanation. They expressed their shock and concern for Resident #1 but denied knowing anything about the Stage III pressure ulcer to Resident #1's coccyx.

Based on observation, staff interview and record review, the facility failed to complete an accurate Minimum Data Set (MDS) related to dental status. This failed practice was found true for (1) one of (3) three residents reviewed for dental during the Long- Term Care Survey Process. Resident identifier #55. Facility Census: 112. Findings included: a) Resident #55 The initial observation on 12/02/24 at 12:02 PM, revealed that Resident #55 has no upper teeth. She has several teeth on the bottom that appeared to be broken off at the gums. A record review on 12/03/24 at 12:49 PM, revealed an MDS with an Assessment Reference Date (ARD) of 07/29/24, section L, question B, indicated Yes for being edentulous. Question D, indicated No for obvious broken natural teeth. During an interview and observation, on 12/03/24 at 12:49 PM, Licensed Practical Nurse (LPN) #37 confirmed that Resident #55 had bottom teeth that were broken off at the gums and black in color.

Based on record review, staff interview, observation and resident interview, the facility failed to develop and implement a comprehensive care plan for one (1) of two (2) resident's revieed for vision/hearing. Resident #62 had a hearing deficit/use of hearing aids. Resident identifier #62. Facility Census: 112. Findings included: a) Resident #62 During an interview with Resident #62 on 12/02/24 at 1:11 PM, Resident #62 reported that she was hard of hearing, that she wore hearing aids and asked that I speak loudly. She was observed to be wearing said hearing aids at this time. A review of resident's care plan showed no mention of resident's hearing aids or hearing deficit at the time of review in the chart on 12/02/24. A copy of resident's care plan was printed and given to the surveyor on 12/03/24 and was noted in the electronic chart to have hearing deficit and hearing aids added to the care plan on this date. During an interview, on 12/04/2024 9:00 AM, with the Director of Nursing (DON) the DON reported that when asked for information yesterday, she realized the hearing deficit was not care planned for Resident #62 and revised the care plan.

Based on record review and staff interview, the facility failed to provide an activity program to meet the needs and interest of the residents. This failed practice was found true for (1) one of (2) two residents reviewed for activities during the Long-Term Care Survey Process. Resident identifier: #52. Facility Census 112. Findings Included: a) Resident #52 During the initial interview on 12/02/24 at 11:59 AM, Resident #52 stated, I would go to activities if I knew what was going on. I have no idea. A record review on 12/04/24 at 1:06 PM, of Resident #52's activity participation for the months of 09/2024, 10/2024, and 11/2024 revealed that Resident #52 only participated in (2) two group activities for the (3) month period. During an interview on 12/04/24 at 1:07 PM, The Activity Director stated, We offer her to come but she refuses. No, I do not have the refusals documented. A record review on 12/04/24 at 1:30 PM, revealed a Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/06/24, Section F, Question E is marked to indicate that it is Somewhat important for Resident #52 to participate in group activities. Further record review of Resident #52's Recreation Quarterly Progress Note and Care Plan Evaluation dated 11/28/24, question E, indicated that Resident #52 needed large print. Residents assessment states that she needed large print An observation on 12/04/24 at 1:45 PM, revealed a December Activities Calendar in very small print placed on the bulletin board across the room from Resident # 52's bed. During an interview on 12/04/24 at 2:15 PM, the Assistant Administrator stated, Activities told me at one point they were told not to document refusals. She further stated, I just did education with the activity staff about documenting refusals. During an interview on 12/04/24 at 2:04 PM, the Activity Director confirmed that the calander in Resident #52's room was not large print.

Based on record review, resident interview, and staff interviews the facility failed to protect Resident #96 from verbal abuse during an ongoing investigation involving Resident #96 and LPN #83. LPN #83 was allowed into the facility, and she verbally abused Resident #96 in regard to allegations he had previously made against her which were still under investigation. The resident's demeanor and verbalization of being very upset by this incident constitutes immediate jeopardy with psychological harm for Resident #96. The facility was first notified of the Immediate Jeopardy (IJ) at 2:07 PM on 06/14/22. The state agency (SA) provided a revised IJ template at 06/14/22 at 2:49 PM which changed the tag from 600 to 610 which is a more appropriate tag for the situation. The SA received the Plan of Correction (POC) at 3:40 PM on 06/14/22. The SA accepted this POC at 3:40 PM. The following is the facility's POC typed as written: Abatement Plan F610 On 6/14/2022 the Nursing Home Administrator and the Director of Nursing implemented the following plan: 1. The Nursing Home Administrator(NHA) changed the code to the front door on 6/14/22 at 11:25 am and educated the front door screener that Licensed Practical Nurse (LPN) #83 was not permitted in the facility at any time. Nurse #83 was terminated via telephone by NHA on 6/14/22 at 1:34 PM. 2. All current residents of the facility have the potential to be affected. 3. The Nurse Practice Educator (NPE)will immediately initiate re-education with a posttest to validate understanding beginning 6/14/22 at 2:45 PM to all staff currently in the facility and all staff, prior to his/her next scheduled shift regarding no employee suspended/terminated for substantiated abuse is permitted to re-enter the facility and that door codes must be changed immediately when an employee is suspended pending investigation to prevent re-entry into the facility .A list of suspended employees or employees terminated for substantiated abuse will be posted at the front desk and all 3 nurses stations for staff awareness. This list will be updated as needed. In the event that a suspension occurs after hours/weekends/holidays, maintenance/designee will be contacted to come to the center to change codes, suspended employees name will be added to the front desk list and all 3 nurses stations. All staff not available during this timeframe will be provided reeducation including posttest prior to the next scheduled shift by the ADON/designee. New hires during orientation by the ADON/Designee will receive education and complete a posttest prior to completion of orientation. The Director of Nursing (DON)/Designee will monitor the screening log daily across all shifts x 2 weeks and then daily for 2 weeks and randomly thereafter to ensure that no suspended employee pending investigation or terminated employee for substantiated abuse has entered the facility with corrective action immediately upon discovery. DON/Designee will review findings with the Center Executive Director/Designee daily. 4. The NHA/designee will present results of audits or monitoring monthly to the Quality Improvement Committee for any additional follow up and/or inservicing until the issue is resolved and randomly thereafter as determined by the Quality Improvement Committee. The SA observed for the implementation of the POC and the IJ was abated on 06/15/22 on 10:20 am. Post abatement the deficiency was reduced to a scope and severity of G. Resident Identifier: #96. Facility Census: 116. Findings included: a) Resident #96 On 06/07/22 at 8:50 am Resident #96 reported to the state surveyor Licensed Practical Nurse (LPN) #83 takes her sweet time giving him his medicine and that she cussed him out twice for no reason. Resident #96 did not know the exact dates this occurred, but stated it was not too long ago. This allegation of abused was reported to the Nursing Home Administrator (NHA) on 06/07/22 at 9:00 am. The facility reported this allegation of abuse to appropriate state agencies on 06/07/22 at 10:22 am. The initial reporting indicated LPN #83 had been suspended pending the outcome of the investigation. On 06/14/22 at approximately 9:40 am a reportable incident involving Resident #96 and LPN #83 was reviewed. This incident occurred on 06/10/22 at 9:10 am. The brief description of the incident read as follows: Allegation of verbal abuse. Staff overheard LPN, (First and Last Name of LPN #83), state to Resident, I can't be your nurse anymore because I can't take care of someone who lies about me. LPN, (First and Last name of LPN #83), was in facility in front lobby to provide statements related to previous allegations, she would not provide statements by phone. The following statements were included in the investigation: Statement from Resident #96: I, (First Name Middle Initial and Last Name of the Director of Social Services (DSS)), Director of Social Services, interviewed resident (First and Last Name of Resident #96) on this date related to the incident with LPN (First and Last Name of LPN #83). Resident said Nurse (First Name of LPN #83) was up front in the building when he was at the nurse's station. He said that the Nurse called him a liar and asked him why he was telling lies on her. Resident said he told her that she deserves to be fired and then staff member came and took the nurse out of the facility. Statement from LPN #83, This nurse inquired to (first and last name of Resident #96) why he told things to the state that weren't true. Statement from the Director of Marketing and Admissions wrote the following statement: On June 10,2022, approximately around 9:10 am I heard (First and Last name of LPN #83), and off duty nurse - tell one of the residents (First and Last Name of Resident #96) that I can't be your nurse anymore, because I can't take care of someone who lies about me. In front of the front nursing station. (First and Last Name of LPN #83) stated that in a loud voice/rude manner to (First and Last Name of Resident #96) . Since I overheard this exchange from my office, which is located in the front part of the building - I proceeded to the front nursing station. Once at the front nursing station, (First and Last Name of LPN #83) was walking away, and at the same time, the resident stated you deserve to lose your license. (First ad Last name of LPN #83) did not reply to that comment, as continued to walk down the hall. Statement given by the Activities Director (AD) read as follows: While writing on the activity board (First and Last Name of LPN #83) came into the building as she walked by (First and Last name of Resident #96) she asked him if he was going to the tell the truth about her and to stop lying. He said that he was telling the truth. She said that she will not give him care anymore that he would have to work with someone else. She said this in a loud and hateful tone. Statement given by Ward Clerk #87 read as follows: I was sitting I the activities office and overheard (First and Last name of LPN #83) talking to the resident (First and Last Name of Resident #96) in a hateful tone in the middle of the hallway. She was being very loud. An interview with Resident #96 on 06/14/22 at 9:55 am, revealed he was sitting at the nurse's station on 06/10/22 and LPN #83 came up to him and told him she was not going to give him medicine anymore because he was lying on her. When asked how this made him feel, Resident #96 paused and thought about it, he lowered his head and wrung his hands then looked up at the surveyor and said, I was really upset by it. He then stated, She don't need no job here if she is going to cuss the residents. A review of Resident #96's medical record found he has diagnosis of Cerebral Palsy and unspecified intellectual disabilities. An interview with the Nursing Home Administrator (NHA) and the Social Service Director (SSD) on 06/14/22 at 10:23 am revealed the common practice of the facility is while the alleged perpetrator is suspended, they should have no contact with the residents. When asked why LPN #83 was allowed to have contact with Resident #96 they indicated she had refused to give a statement about the allegations made against her over the phone. They stated, she was supposed to come to the front porch of the facility and let them know she was here, but instead she barged in the front door and went straight to Resident #96 and that is when this incident occurred. An interview with The Marketing and Admissions director at 11:00 am on 06/14/22 found by the time he went from his office to the nurse's station, LPN #83 was observed by him walking down the long hall toward the back of the building. An interview with the AD on 06/14/22 at 11:23 am confirmed she did hear the nurse talking to Resident #96 in a hateful tone. She stated, I did not know who she was because she works night shift. She stated the NHA then escorted her off the unit. Review of the COVID - 19 screening kept by the facility for all visitors and staff found LPN #83 was screened for COVID-19 symptoms prior to entering the building on 06/10/22 at 8:49 am. This was 20 minutes prior to the altercation that occurred with Resident #96. An interview with the NHA at 11:42 am on 06/14/22 confirmed he was in the stand-up meeting when the incident occurred. He stated the Admission Director came to the stand-up meeting to get him. He stated that once he was alerted to the situation LPN #83 was all ready back at the front desk. When asked if Receptionist #56 was aware that LPN #83 should not be in the building he stated, I would think so. We attempted to call Receptionist #56 with the NHA and she did not answer. An interview with the SSD on 06/14/22 at 11:48 am confirmed she obtained written statements from LPN #83 on the front porch of the facility, but this happened after the altercation occurred with Resident #96. A telephone interview with Receptionist #56 at 11:51 am on 06/14/22 confirmed she did screen in LPN #83. She indicated that if she was on the log then she did screen her in. When asked if she was aware LPN #83 was not allowed to be in the building she stated, No Mam I did not know that. When asked if she had known that what would she have done, she stated, I would have told her to wait outside and I would have got one of the managers to go talk to her. When asked if she heard LPN #83 say anything to Resident #96 she stated, I heard her say something like she wanted to change his mind about what he said. And (First name of Resident #96) said no I was telling the truth about what you said. She indicated she did not hear everything that was said. Review of the Investigation found Receptionist #56 did not provide a written statement in regard to this incident. An interview in the afternoon of 06/14/22 the NHA and SSD both stated the SSD had told Receptionist #56 that LPN #83 was not allowed in the facility on the morning of 06/10/22. Please note LPN #83 had another active abuse investigation related to Resident #2 where the resident stated LPN #83 made her cry for her medication every night she worked, and she was hateful to her. These allegations were made on 06/06/22 at 9:04 PM to the survey team. LPN #83 was also still suspended for this allegation as well.

Based on record review, resident interview, and staff interviews the facility failed to ensure all residents were free from abuse and neglect for Resident #96, #2, and #212. Resident #96 was verbally abuse during an ongoing investigation involving Resident #96 and LPN #83. This verbal abuse occurred on 06/10/22 when LPN #83 as was supposed to be suspended from the facility. She entered the facility and verbally abused Resident #96 in regard to the allegations previously made against her by Resident #96. Based on Resident #96's interview it was determined he suffered psychological harm as a result of this incident of verbal abuse from LPN #83. Resident #2 indicated to the survey team they had been abused by LPN #83 on an ongoing basis by having to cry in order to receive her medications. For Resident #212 the facility failed to ensure she was free from neglect by failing to provide her medication in a timely manner. This was true for three (3) of Four (4) residents reviewed for the care area of abuse during the Long Term Care Survey. Resident Identifiers: #96, #2, and #212. Facility Census: 116. Findings included: a) Resident #96 On 06/07/22 at 8:50 am Resident #96 reported to the state surveyor that Licensed Practical Nurse (LPN) #83 takes her sweet time giving him his medicine and that she cussed him out twice for no reason. Resident #96 did not know the exact dates this occurred, but stated it was not too long ago. This allegation of abused was reported to the Nursing Home Administrator (NHA) on 06/07/22 at 9:00 am. The facility reported this allegation of abuse to appropriate state agencies on 06/07/22 at 10:22 am. The initial reporting indicated LPN #83 had been suspended pending the outcome of the investigation. On 06/14/22 at approximately 9:40 am a reportable incident involving Resident #96 and LPN #83 was reviewed. This incident occurred on 06/10/22 at 9:10 am. The brief description of the incident read as follows: Allegation of verbal abuse. Staff heard LPN, (First and Last Name of LPN #83), state to Resident, I can't be your nurse anymore because I can't take care of someone who lies about me. LPN, (First and Last name of LPN #83), was in facility in front lobby to provide statements related to previous allegations, she would not provide statements by phone. The following statements were included in the investigation: Statement from Resident #96: I, (First Name Middle Initial and Last Name of the Director of Social Services (DSS)), Director of Social Services, interviewed resident (First and Last Name of Resident #96) on this date related to the incident with LPN (First and Last Name of LPN #83). Resident said Nurse (First Name of LPN #83) was up front in the building when he was at the nurse's station. He said that the Nurse called him a liar and asked him why he was telling lies on her. Resident said he told her that she deserves to be fired and then staff member came and took the nurse out of the facility. Statement from LPN #83, This nurse inquired to (first and last name of Resident #96) why he told things to the state that weren't true. Statement from the Director of Marketing and Admissions wrote the following statement: On June 10,2022, approximately around 9:10 am I heard (First and Last name of LPN #83), and off duty nurse - tell one of the residents (First and Last Name of Resident #96) that I can't be your nurse anymore, because I can't take care of someone who lies about me. In front of the front nursing station. (First and Last Name of LPN #83) stated that in a loud voice/rude manner to (First and Last Name of Resident #96) . Since I overheard this exchange from my office, which is located in the front part of the building - I proceeded to the front nursing station. Once at the front nursing station, (First and Last Name of LPN #83) was walking away, and at the same time, the resident stated you deserve to lose your license. (First ad Last name of LPN #83) did not reply to that comment, as continued to walk down the hall. Statement given by the Activities Director (AD) read as follows: While writing on the activity board (First and Last Name of LPN #83) came into the building as she walked by (First and Last name of Resident #96) she asked him if he was going to the tell the truth about her and to stop lying. He said that he was telling the truth. She said that she will not give him care anymore that he would have to work with someone else. She said this in a loud and hateful tone. Statement given by Ward Clerk #87 read as follows: I was sitting I the activities office and overheard (First and Last name of LPN #83) talking to the resident (First and Last Name of Resident #96) in a hateful tone in the middle of the hallway. She was being very loud. An interview with Resident #96 on 06/14/22 at 9:55 am, revealed he was sitting at the nurse's station on 06/10/22 and LPN #83 came up to him and told him she was not going to give him medicine anymore because he was lying on her. When asked how this made him feel, Resident #96 paused and thought about it, he lowered his head and wrung his hands then looked up at the surveyor and said, I was really upset by it. He then stated, She don't need no job here if she is going to cuss the residents. Resident #96's demeanor when asked how it made him feel and his response that it really upset him was indicative of psychological harm. A review of Resident #96's medical record found he has diagnosis of Cerebral Palsy and unspecified intellectual disabilities. An interview with the Nursing Home Administrator (NHA) and the Social Service Director (SSD) on 06/14/22 at 10:23 am revealed the common practice of the facility is while the alleged perpetrator is suspended, they should have no contact with the residents. When asked why LPN #83 was allowed to have contact with Resident #96 they indicated she had refused to give a statement about the allegations made against her over the phone. They stated, she was supposed to come to the front porch of the facility and let them know she was here, but instead she barged in the front door and went straight to Resident #96 and that is when this incident occurred. An interview with The Marketing and Admissions director at 11:00 am on 06/14/22 found by the time he went from his office to the nurse's station, LPN #83 was observed by him walking down the long hall toward the back of the building. An interview with the AD on 06/14/22 at 11:23 am confirmed she did hear the nurse talking to Resident #96 in a hateful tone. She stated, I did not know who she was because she works night shift. She stated the NHA then escorted her off the unit. Review of the COVID - 19 screening kept by the facility for all visitors and staff found LPN #83 was screened for COVID-19 symptoms prior to entering the building on 06/10/22 at 8:49 am. This was 20 minutes prior to the altercation that occurred with Resident #96. An interview with the NHA at 11:42 am on 06/14/22 confirmed he was in the stand-up meeting when the incident occurred. He stated the Admission Director came to the stand-up meeting to get him. He stated that once he was alerted to the situation LPN #83 was all ready back at the front desk. When asked if Receptionist #56 was aware that LPN #83 should not be in the building he stated, I would think so. We attempted to call Receptionist #56 with the NHA and she did not answer. An interview with the SSD on 06/14/22 at 11:48 am confirmed she obtained written statements from LPN #83 on the front porch of the facility, but this happened after the altercation occurred with Resident #96. A telephone interview with Receptionist #56 at 11:51 am on 06/14/22 confirmed she did screen in LPN #83. She indicated that if she was on the log then she did screen her in. When asked if she was aware LPN #83 was not allowed to be in the building she stated, No Mam I did not know that. When asked if she had known that what would she have done, she stated, I would have told her to wait outside and I would have got one of the managers to go talk to her. When asked if she heard LPN #83 say anything to Resident #96 she stated, I heard her say something like she wanted to change his mind about what he said. And (First name of Resident #96) said no I was telling the truth about what you said. She indicated she did not hear everything that was said. Review of the Investigation found Receptionist #56 did not provide a written statement in regard to this incident. b) Resident #2 A review of the medical record revealed Resident #2 had the following diagnosis: -Parkinson's Disease -Dementia without behaviors -Osteoartritis to right knee and hip -Muscle weakness -Anxiety -Chronic pain -Effusion right knee -leg pain -Alzheimer's On 06/06/22 at 9:04 PM, Resident # 2 was in a wheelchair in the doorway to her room. Resident # 2 was tearful and stated her left knee was hurting. Resident #2 said, she (pointing at Licensed Practical Nurse (LPN) #83) makes me cry every night before she will give me my medicine. Resident #2 was asked if any of the staff have ever been rude to her. Resident #2 said, that nurse (pointing at LPN #83) is hateful not just to me but everyone, she doesn't care about us at all. Resident #2 was pointing at LPN #83 as LPN #83 was pacing back and forth from the medication cart to the supply room and medication storage room. LPN #83 was not answering any of the residents that were asking for medications. Resident #2 was asked if she has told anyone about having to cry to get her medications and being treated badly. Resident #2 said she told Tall (named Director of Guest Services (DGS) #33 by his first name), but nothing changed it still happens. Resident #2 said she told him sometime last week. On 06/06/22 at 9:30 PM the Administrator was informed about Resident #2 saying she has to cry to get her medications and LPN#83 being hateful to her. Administrator said he would get someone to take over that medication cart. He said he understands the facility has some customer service issues. On 06/06/22 at 9:35 PM, DGS #33 was asked if Resident # 2 had reported to him about getting her medication late every time LPN#83 works and having to cry before she gets her medications, and that LPN #83 was hateful? DGS #33 said, Yes, I believe she told me about that last Wednesday. DGS #33 was asked if he completed a report or any type of form to address this complaint? DGS #33 stated, No, he told the Unit nurse, and it was handled eternally. DGS #33 went on to explain that Resident # 2 is the kind of person that thinks if her medications are due at 8 than it should be in her hand at 8. On 06/06/22 at 9:45 PM, the Director of Nursing (DON) was asked if someone could please help Resident # 2 because she is in pain and needs her medications. The DON said, what are her 9 o'clock medications? The DON was told there was no way for this surveyor to know, but Resident # 2 has been asking LPN#83 for her medications since 8:50 PM. During a review of facility records it was revealed there was not any concern/grievance or reportable forms completed about the above issue. A review of the facility form titled, Medication Admin Audit Report, revealed the following dates and times when Resident #2's medications were administered by LPN #83: The following medications were scheduled to be administrated at 9:00 PM every night and were not Administrated within the parameters of one hour of the scheduled times. -Ropinirole HCL 0.5 mg by mouth three times a day for Parkinson's. -Tylenol extra strength 1000 mg three times a day for osteoarthritis pain. -Carbidopa-Levodopa 10-100 mg by mouth four times a day for Parkinson's. -Tizanidine HCL 2mg three times a day for muscle spasms. -Aricept 10 mg at bedtime for Dementia related to Parkinson's. -Clobetasol Propionate cream 0.05 % apply two times a day to affected areas for eczema -IBU-200 give two tablets three times a day for pain. -Bio-freeze Professional 5% gel apply three times a day for chronic knee pain. -Buspirone HCL 5mg two tablets three times a day for Anxiety The following are the days and times the above medications were given late by LPN #83. - 05/10/22 for 9:00 PM, not given until 05/10/22 at 11:20 PM. - 05/14/22 for 9:00 PM, not given until 05/14/22 at 11:52 PM. - 05/15/22 for 9:00 PM, not given until 05/15/22 at 11:09 PM. - 05/29/22 for 9:00 PM, not given until 05/29/22 at 11:35 PM. - 06/01/22 for 9:00 PM, not given until 06/02/22 at 12:21 AM On 06/08/22 at 7:45 AM, Administrator was again informed of the allegation of abuse that Resident #2 made against LPN #83. Administrator was also informed of the above medications, what the medications are for, how many times a day they are ordered, and how late all the medications were. Also discussed the DGS #33 having knowledge of the complaint concerning Resident #2 last Wednesday and no report was made. The Administrator stated he would educate the DGS #33 on the correct way to handle complaints, and have a social worker speak to Resident # 2 today. On 06/08/22 at 12:45 PM, the Administrator and Social Worker (SW) #68 approached this surveyor in the 300 hall while observing lunch, and said SW #68 spoke to Resident # 2. SW #68 was asked if she could provide a copy of the report. SW #68 stated she did not do any report. On 06/08/22 at 1:12 PM, SW #68 came in room and stated she did not do a reportable because Resident # 2 did not complain about LPN#83 at this time she had a complaint about someone else. SW #68 was informed of the allegations Resident # 2 had made on the night of 06/06/22 at 9:04 PM. She was told these allegations were told to the Administrator at 9:30 PM on the night of 06/06/22 and that Resident # 2 had also reported this to DGS #33 last week on a Wednesday and nothing was done. SW #68 was informed that today on 06/08/22 at 7:45 AM, once again the administrator was informed. SW #68 stated she was not told that this was an allegation of abuse and would report it right away. On 06/08/22 at 4:48 PM, the Administrator asked this surveyor to go with him to answer some questions the social workers have. As we were walking down the hall the Administrator stated he did not write it down in his notebook about Resident # 2 saying the nurse makes her cry before she gets her medication, on Monday night. This surveyor asked for another surveyor to join the meeting because the surveyor was also present at the time this surveyor reported the information to the administrator on 06/06/22 at 9:30 PM. Administrator stated he did not understand why he should complete a reportable when it would be out of compliance due to the time. Administrator said he did write it down on Monday night that Resident #2 said LPN #83 was hateful to her but felt like that was a customer service issue not a form of abuse. Administrator was asked if the DGS #33 should have reported the allegations from Resident #2 on 6/01/22 on the Wednesday when Resident # 2 first told him? The Administrator was the asked why was a report not started on the night of 06/06/22 when it was reported to him at 9:30 PM, and again when it was reported to him at 7:45 AM today on 06/08/22, then once again today on 06/08/22 when it was reported to SW #68 at 1:12 PM? Please note : By the time of this interview with the Administrator it was three (3) past the fourth time staff were made aware of Resident #2's allegations. The Administrator was then asked why LPN #83 was allowed to finish the shift on 06/06/22 even after he knew of the allegation. Once again, he said he felt like it was a customer service issue and could be handle as that, and sometimes people are just in a bad mood or personalities do not match. On 06/09/22 at 8:30 AM, a copy of the reportable for allegation of abuse for Resident #2 was provided. The following information was on the facility form titled, immediate fax reporting of Allegations-Nursing Home Program Facility Name: (Named the facility by name) Alleged Victim Name: (named Resident #2) Alleged Perpetrator Name: (Named LPN #83) Position: LPN Allegation information: Date of incident: 06/06/22 at 9:04 PM. Brief description of the incident: State Surveyor reported that she interviewed Resident #2 the night of 06/06/22 at 9:04 PM. Surveyor reported that the nurse makes her cry for her medications every night before she will give them to her. Surveyor also reports Resident said the nurse is hateful to her and hateful to everyone. State surveyor said that Resident pointed to (named LPN #83) during interview. Completed by: (named Social Worker #68) dated: 06/08/22 Time of fax was 5:40 PM on 06/08/22. A typed interview with Resident #2 by Director of Social Services (DSS) #76, dated: 06/08/22, no time was noted. The following is typed as it was on the paper. I, (named first and middle initial last name of DSS #76), interviewed resident (named Resident #2 by first and last name) on this date related to Medication Administration and staff approach. Resident stated, on the nights (named first name of LPN#83) works I don't get my medicine on time. Sometimes I cry until I get my medicine because it is late. Resident reports that she has no other issues with her medication being provided timely. Resident also reports that the Nurse named (used first name of LPN #83) is hateful to her. Resident unable to provide example of the how the Nurse is hateful with her. Signed by: DSS #76 On the five-day follow-up for Resident #2 and LPN #83, dated: 06/13/22. Outcome/Results of investigation: -After further investigation, allegation of verbal abuse and neglect has been substantiated based on Resident interviews and Medications Admin Audit, Residents disclosed the LPN (used first name of LPN #83) had been witnessed being hateful. Upon further review of Medication Admin Audit, there were a total of five occasions that Resident's medication was administered late in the last 30 days. Written statement on 06/10/22, by LPN #83 reads as written: Resident (named first and last name of Resident #2) cries incessantly related behaviors and medical dx of schizophrenia. Please Note: Resident #2 does not have a diagnosis of Schizophrenia. Typed statements from residents that reside on 100 unit on 06/10/22 related to allegation made on 06/06/22 that LPN (used first and last name of LPN #83) is hateful: Question: How are your interactions with LPN (used first and last name of LPN #83)? Have you observed LPN (used first and last name of LPN #83) being hateful with any residents? If so, can you provide details about this incident(s)? Resident: (used full name of Resident #13) She has never been hateful to me. She becomes flustered when she is antagonized over and over and will ask residents to go to their rooms and let her work. States, She just tells it like it is. (Used last name of Resident #13 unable to recall specific resident's names at this time and said if she felt someone was being abused or treated poorly she would report it. Resident: (used full name of Resident #96) She is rude and hateful. (Used the first name of Resident #96) unable to state specific residents, just said this nurse is not nice. (Used the first name of Resident #96) made an allegation of verbal abuse towards this Nurse 06/07/22 which was reported and investigated. Resident: (used first and last name of Resident #100) I have heard her get hateful and use a loud rude voice. I can hear her from my room. I don't know who she is talking to. I have had no problem with her. c) Resident #212 A review of medical reports for Resident # 212, revealed this resident missed 14 doses of Neurontin (used for neuropathy pain). Resident #212 has a diagnosis of Peripheral Vascular disease, and type II Diabetes. Which both could cause neuropathy pain. The surveyor was unable to interview Resident #212 due to her not feeling well. Resident # 212 was admitted on [DATE]. There was an order that read, May hold Neurontin until arrival from pharmacy. Dated: 05/31/2022 Review of the Medication Administration Record (MAR) for the dates of 05/26/22 through current found the following: Neurontin Capsule 100 mg by mouth two times a day for neuropathy. Below are the dates and times this medication was not administered: -05/26/22 at 9 PM -05/27/22 at 9 AM and 9 PM -05/28/22 at 9 AM and 9 PM -05/29/22 at 9 AM and 9 PM -05/30/22 at 9 AM and 9 PM -05/31/22 at 9 AM and 9 PM -06/01/22 at 9 AM and 9 PM -06/02/22 at 9 AM for a total of 14 missed doses. During an interview on 06/09/22 at 10:02 AM, the Director of Nursing (DON) was asked why Resident # 212 was not given her medication for six and half days. The DON stated the facility has a problem with the current Pharmacy the facility is using. She will look for documentation to support attempts to obtain the medication. On 06/09/22 at 1:00 PM, the DON provided nursing notes by Licensed Practical Nurse (LPN) #92. Dated and timed: 05/28/22 at 10:38 PM, Neurontin Capsule 100 mg by mouth two times a day for neuropathy. Not on hand, awaiting physician signature for script. Nursing Note by LPN #92, dated and timed: 05/28/22 at 11:00 PM. Called UHC and requested script for Neurontin 100 mg BID (two times a day); script received and faxed to pharmacy; resident and provider aware; resident has no signs/symptoms of pain; rates pain 0 out of 10; awaiting script to be sent from pharmacy. Nursing Note by Registered Nurse (RN) #52, dated and timed, 06/01/22 at 10:19 AM, Neurontin 100 mg give two times a day for neuropathy. Not available. pharmacy contacted. Nursing Note by LPN #40, dated and timed, 06/01/22 at 8:40 PM, Neurontin 100 mg give two times a day for neuropathy, Script obtained. awaiting from pharmacy. Faxed pharmacy to pull from Omnicell. no authorization code provided. No other information was provided by the end of the survey. 39571

Based on observations, staff interview, resident interview, review of facility policies, review of the facility's infection control monthly line listings, review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed prevent the spread of infection to the extent possible by implementing contact precautions for residents whose urinary tract infections [MEDICAL CONDITION] included multi-drug resistant organisms. Record review and review of the line listings found five (5) residents identified as having Extended Spectrum Beta lactamase in two (2) months - (MONTH) and (MONTH) (YEAR). (Beta lactamases are enzymes produced by many species of bacteria which destroy one or more antibiotics. It is one of the ways in which bacteria develop resistance.) Observations and staff interviews confirmed contact precautions, in addition to standard precautions, were not employed. Due to the potential for the exposure to other residents, staff, and visitors, an immediate jeopardy to the health and well-being of others was determined. The Administrator and the Director of Nursing were notified of the determination of the immediate jeopardy on 08/29/18 at 2:48 PM and a brief statement of the deficient practice provided. The facility provided an acceptable plan of correction (P[NAME]) at 5:18 PM at which time the immediate jeopardy was removed as implementation of the P[NAME] had occurred. Resident identifiers: #31, #12, #80, #104, #99. After removal of the immediate jeopardy, deficient practices remained at a scope and severity of E for failure to cohort residents in keeping with infection control. Resident #33, a debilitated resident with a suprapubic catheter was residing in the same room as Resident #31, who had a multi-drug resistant urinary tract infection. Additionally, items such as straws, cups, and plastic utensils were stored under the sink in the medication room where contamination was a potential. This had the potential to affect more than a limited number of residents. Findings include: a) Resident #31 Observation and interview with the resident at 9:05 AM on 08/27/18, found the resident said he was receiving an IV (intravenous) antibiotic for a urinary tract infection. Review of the medical record on 08/29/18 found the physician ordered a urinalysis with culture and sensitivity (UA C&S) on 08/21/18. The lab called the facility with the results of the culture and sensitivity, which identified the urine was positive for ESBL (Extended-Spectrum Beta-Lactamase), Escherichia coli (E-coli), and Proteus Vulgaris, on 08/24/18. At 12:35 PM on 08/29/18, the resident's Nursing Assistant (NA), NA #21, said she was aware the resident had a urinary tract infection. She said the resident was incontinent of urine and wore gloves when providing incontinence care and always washed her hands. At 12: 45 PM on 08/29/18, the resident's Licensed Practical Nurse (LPN). LPN #42 said she was aware the resident had ESBL and E-coli in his urine. She said, We follow standard precautions, which is wearing gloves and hand washing when providing incontinence care. At 12:50 p.m. on 08/29/18, the Director of Nursing (DON) said, We follow the CDC (Centers for Disease Control and Prevention) guidelines and the resident does not require isolation, only standard precautions. The ESBL is contained in the resident's brief. b) Resident #80 The laboratory report for a urine sample collected 08/23/18 with the final report dated 08/25/18, included, This is an ESBL positive organism, it is considered a multi-drug resistant organism. It also confers resistance to the beta-lactam antibiotics such as [MEDICATION NAME], cephalosporins, and aztreonam. According to the lab report, the final results were called to the facility. On 08/26/18, an order was written for, Ertapenem for ESBL in urine. (Ertapenem is a broad spectrum carbapenem antibiotic.) Random observations on 08/27/18, 08/28/18/, 08/29/18, and 08/30/18 did not find signage posted on the resident's door to alert those entering the room to check with the nurse and/or identify additional precautions were needed. c) Resident #104 Review of the Infection Control Monthly Line Listing on 08/29/18 found Resident #104's name listed as having a urinary tract infection [MEDICAL CONDITION]. According to the line listing, the resident was [MEDICATION NAME] 08/20/18. Review of the resident's medical record on 08/29/18 did not find the results of the culture and sensitivity (C&S). At approximately 10:30 AM, the Director of Nursing (DON) was asked for the report for the C&S. The results of the C&S were provided at 12:30 PM. According to the copy of the report provided, the report was faxed to the facility on [DATE] at 12:06 PM, however, the report was dated as final on 08/25/18. The report identified E. Coli ESBL. Random observations on 08/27/18, 08/28/18/, 08/29/18, and 08/30/18 did not find signage posted on the resident's door to alert those entering the room to check with the nurse and/or identify additional precautions were needed. d) Resident #99 Review of the facility's infection control line listing for (MONTH) (YEAR) found this resident also had ESBL in her urine. The resident was ordered Bactrim DS on 07/05/18. The line listing did not indicate the resident was place on contact precautions. The C&S report dated 07/05/18 confirmed the resident had ESBL in her urine. e) Resident #12 A review of Resident #12's medical record at 1:33 p.m. on 08/27/18 found an order for [REDACTED].#12 returned from the hospital. The stop date for this antibiotic was 08/28/18. The reason listed for this medication was ESBL E. coli UTI/Sepsis. Further review of Resident #12's medical record found an Antimicrobial Susceptibility and Organism Report for a local hospital dated 08/17/18 which was reported on 08/22/18. This report indicated Resident #12's blood culture was ESBL positive E. coli. The report indicated the laboratory notified Licensed Practical Nurse (LPN) #29 at the facility on 08/22/18 at 10:45 a.m. Observations of Resident #12 at 10:00 a.m. on 08/27/18 found the resident resting in his room. His IV pole and pump were at his bedside and his completed IV bag was still hanging on the pole, but was not running at the time of the observations. There was no signage on the door, nor was there any personal protective equipment (PPE) by the door. There was nothing observed to indicate the resident was on contact precautions on 08/27/18 or 08/28/18, while being actively treated for [REDACTED]. An interview with the Director of Nursing (DON) on 08/29/18 in the afternoon confirmed that Resident #12 was not placed in contact isolation because their infection control policy did not warrant contact isolation for residents with ESBL. Further review of Resident #12's medical record found that on 17 occasions during the seven (7) days Resident #12 was being actively treated for [REDACTED]. Observations of Resident #12's room found that Resident #12 shared a bathroom with Resident #75. A review of Resident #75's medical record on 08/29/18 at 3:00 p.m. found he had a wound vac to an open wound on his coccyx. A review of his activities of daily living (ADL) documentation found that he was continent of both bladder and bowel. A review of the ADL documentation for the time frame of 08/22/18 through 08/28/18 (the time Resident #12 was actively treated for [REDACTED].#75 was continent of urine in the toilet on 18 times and was continent of bowel on 11 occasions. On these occasions, Resident #75, who had an open area to his coccyx, was using a toilet that was shared with Resident #12 who was positive for ESBL in both his blood and his urine. f) Review of the minimum data sets (MDS) for Residents #31, #12, #80, #104, and #99 found only one resident, Resident #104, was admitted since (MONTH) (YEAR). The MDS records did not indicate the other residents had a discharge and/or reentry record identifying a hospital stay prior to having a urine culture identifying ESBL. However, record review identified Resident #12 had been hospitalized [DATE] to 08/21/18, where the ESBL was identified. g) CDC classifies ESBL as a serious threat The list of Serious Threats at https://www.cdc.gov/drugresistance/biggest_threats.html includes: Multidrug-resistant Acinetobacter Drug-resistant Campylobacter Fluconazole-resistant Candida Extended-spectrum Beta-lactamase producing [MEDICATION NAME] [MEDICATION NAME]-resistant [MEDICATION NAME] (VRE) CDC guidelines, Appendix A, includes recommendations for individuals with active ESBL infections be placed on contact precautions. h) The facility provided a copy of its infection control policy/procedure for multi-drug resistant organisms (MDROs). The procedure included to, 3. Clinically document the level of risk for transmission . Instruct staff, patient, and visitors regarding the level of Precautions needed and use of personal protective equipment. No evidence was found to support these elements were implemented. i) According to these findings, Residents #31, #104, #12, and #80 were all being treated with antibiotics for ESBL producing organisms in their urine. On 08/30/18 at 11:22 AM, an interview with a representative of the local health department found the facility had not reported an outbreak of ESBL. j) Due to the potential for the exposure to other residents, staff, and visitors, an immediate jeopardy to the health and well-being of others was determined. The Administrator and the Director of Nursing were notified of the determination of the immediate jeopardy on 08/29/18 at 2:48 PM and a brief statement of the deficient practice provided. The facility provided an acceptable plan of correction (P[NAME]) at 5:18 PM at which time the immediate jeopardy was removed as implementation of the P[NAME] had occurred. k) Facility's Plan of Correction (P[NAME]) Resident #31 and resident #80 was placed in contact isolation by the Director of Nurses/designee immediately upon discovery. Resident #99, resident #104, and resident #12 are no longer receiving treatment, are not symptomatic therefore require standard precautions. All residents of the facility have the potential to be affected. Director of Nurses/designee checked all residents for active cases of ESBL on 8/29/18 to ensure contact precautions were implemented for all residents with ESBL who are receiving active treatment. The Performance Development Specialist (PDS)/designee will provide reeducation regarding placing residents in contact isolation when a resident is actively being treated for [REDACTED]. Licensed nurses not available during this timeframe will be provided reeducation including posttest by the PDS/designee upon return to work. New licensed nurses will be provided education and complete posttest during orientation. The PDS/designee will audit residents upon admission, readmission, and residents with active symptoms of ESBL and randomly thereafter to ensure residents are placed in contact isolation. Trends identified will be reviewed by the PDS/designee monthly at the Quality Improvement Committee (QIC) for any additional follow up and/or inservicing until the issue is resolved and randomly thereafter as determined by the QIC committee. l) After removal of the immediate jeopardy, deficient practices remained at a scope and severity of E for failure to cohort residents in keeping with infection control. Resident #33, a debilitated resident with a suprapubic catheter was residing in the same room as Resident #31, who had a multi-drug resistant urinary tract infection. Additionally, items such as straws, cups, and plastic utensils were stored under the sink in the medication room where contamination was a potential. This had the potential to affect more than a limited number of residents. m) Resident #33 Resident record reviews and observations found Resident #33, who had a suprapubic catheter and was on comfort measures, was housed with a resident who was receiving IV antibiotics for an active ESBL producing E. Coli infection (an MDRO). The facility's policy/procedure regarding MDROs includes, 7. When cohorting patients with the same MDRO is not possible, place MDRO patients in rooms with patients who are at low risk for acquisition of MDROs and associated adverse outcomes from infection. The facility's policy indicated Resident #33 should not have been cohorted with Resident #31. n) Facility task On 08/28/18 at 9:17 AM, inspection of the 100 and 200 hallway medication room was conducted. The surveyor was accompanied by Licensed Practical Nurse (LPN) #90. The cabinet immediately below the sink was observed to contain straws, spoons, and plastic cups. The left side of the cabinet was inaccessible due to a screw that had been placed in the cabinet door. The right side of the cabinet had a hole where a screw had once been located. However, the screw was no longer in place and the cabinet door could be opened freely. LPN #90 stated items should not be stored under the sink due to potential contamination from the sink pipes. She stated she would have the items removed and discarded. On 08/28/18 at 9:20 AM, Nurse-Unit Manager LPN was notified about the items stored under the sink in the 100 and 200 hallway medication room. She stated she would have the items replaced and ensure the screw was replaced in the cabinet door to ensure the door could no longer be opened.

Based on record review, staff interview, and resident interview, the facility failed to ensure residents received needed care and services to meet each resident's physical, mental, and psychosocial needs. For Resident #64, the facility failed to promptly notify Resident #64's attending physician of chest x-ray results that indicated the resident had pneumonia. The resident was not started on intravenous (IV) antibiotics until almost a week later. The resident was upset by this and felt as if she was being neglected by the facility and felt she would never get better. Resident #64 voiced feelings of anxiousness and worry on 08/28/18 when there was a delay in starting her antibiotic once the physician had reviewed the results and ordered the antibiotics be started. The resident's feelings of neglect, anxiousness and worry resulted in Resident #64 suffering psychosocial harm. For Resident #101, staff failed follow a physician's orders [REDACTED]. These failures affected two (2) of twenty-six (26) sampled residents during the Long-Term Care Survey Process. Resident Identifiers: #64 and #101. Facility Census: 117. Findings Include: a) Resident #64 An interview with Resident #64 at 11:00 a.m. on 08/28/18 found the previous week, the physician had ordered a chest x-ray for the resident because she had wheezing in her lungs. She reported that a couple days ago (First name of Nurse Practitioner) told her that her chest x-ray was clear. She said that the night before last she woke up about 12:15 a.m. and was freezing like she had a fever and they had to put the heat on 85 degrees to get her warm. She stated early this morning they brought an IV pump into her room and told her that she was going to be started on an IV antibiotic because her chest x-ray she had done last week showed she had pneumonia. She stated they told her the attending physician reviewed the x-ray report last night and ordered the IV antibiotics. She stated, I am upset because it has been almost a week since they got the x-ray report and (First name of Nurse Practitioner) told me it was clear. She indicated that she felt she was being neglected and she was very worried about her health and wanted to get well. A review of Resident #64's medical record found a physician's orders [REDACTED]. A review of the record found the chest x-ray results for 08/22/18. The conclusion on the radiologist's report on 08/22/18 at 12:04 p.m. was, Slight right lower lobe infiltrate new since 08/15/18. Mild cardiomegaly. The results were signed by the attending physician on 08/27/18 and he wrote an order on the X-ray report, [MEDICATION NAME] 750 mg IV q day for 7 days. An interview with the Nurse Practitioner on 08/28/18 at 1:10 p.m. revealed she had not reviewed the resident's x-ray report because she was on vacation last week. She indicated she did not speak to the resident about her x-ray report and that perhaps the resident had her confused with someone else. An interview with the Director of Nursing (DON) at 1:21 p.m. on 08/28/18 confirmed the physician had not been notified of the x-ray report in a timely manner. She stated, I have no explanation for the delay in notification. An additional interview with Resident #64 at 1:31 p.m. on 08/28/18 revealed she did not feel well. She stated that she had no energy and she coughed, but could not get anything up. She indicated that she was very aggravated with the facility right now because she has a port which they could use to give her the antibiotics and she had been waiting since early that morning to get her antibiotic started. She stated, I don't know what is taking them so long, they can use my port. She indicated, she had anxiety about not getting her antibiotics started that morning and that the delay was adding more worry on top of the worry already caused by the delay in treatment. The resident's feeling of neglect, anxiety, and worry resulted in the resident suffering psychosocial harm. An interview with the DON at 1:53 p.m. on 08/28/18 found that Resident #64's antibiotic had arrived sometime in the early morning hours. She indicated that any Registered Nurse (RN) could start the antibiotic and she would have someone get it started. The DON indicated there were five (5) RNs working that morning and any of them could have started the antibiotic. Despite the antibiotic having arrived from the pharmacy early that morning and staff telling Resident #12 they were going to be starting it that morning, it was not started until 2:00 p.m. on 08/28/18. (The attending physician did order a repeat chest x ray on 08/28/18. The results of this x ray were reviewed and found the resident's pneumonia was clear. Based on these results the attending physician discontinued the residents IV antibiotics after only one dose.) b) Resident #101 Review of Resident #101's medical records revealed a Change in Condition Evaluation dated 08/21/18 at 3:06 AM reporting a red, bumpy, itchy rash on the resident's chest and shoulders. The rash was reported as starting on the morning of 08/19/18. The rash was reported to the physician on 08/21/2018 at 6:00 AM. A telephone order was obtained from the physician on 08/21/18 at 6:44 PM for [MEDICATION NAME] to affected area BID (twice a day) and PRN (as needed) d/t (due to) pruritis (itching). During an interview on 08/29/18 at 11:00 AM, the Center Nurse Executive (CNE) stated Change in Condition Evaluations were typically documented at the time the change in condition was discovered. She stated she would attempt to determine the reason Resident #101's rash was identified on 08/19/18, but not reported until 08/21/18. On 08/29/18 at 12:42 PM, the CNE reported Resident #101's rash was identified on 08/19/18 by a nurse who did not have computer access to Change in Condition Evaluations. The Change in Condition Evaluation was documented on 08/21/18 by another nurse who did have computer access to the form. The CNE stated she would look for information as to whether the physician was notified regarding Resident #101's rash before 08/21/18. On 08/29/18 at 2:25 PM, the CNE stated she had been unable to locate documentation that the physician was notified about Resident #101's rash before 08/21/18. Review of Resident #101's Treatment Administration Record (TAR) found the task to apply [MEDICATION NAME] twice a day and as needed to the resident's rash, as ordered by the physician on 08/21/18. The task was scheduled to be performed once a day on the 7:00 AM to 7:00 PM shift and once a day on the 7:00 PM to 7:00 AM shift. However, only the following dates and times were initialed by the nurse, indicating the medication had been applied: - 08/21/18 on the 7:00 PM to 7:00 AM shift - 08/22/18 on the 7:00 AM to 7:00 PM shift - 08/27/18 on the 7:00 AM to 7:00 PM shift - 08/28/18 on the 7:00 AM to 7:00 PM shift During an interview on 08/29/18 at 11:03 AM, the Nurse Unit Manager, Licensed Practical Nurse (LPN) #20, confirmed the TAR documented [MEDICATION NAME] ointment had only been applied four (4) times since ordered on [DATE]. She stated she thought the order for Resident #101's [MEDICATION NAME] ointment was only as needed, rather than twice a day and as needed. She stated other nurses may have also thought the [MEDICATION NAME] ointment order was for the medication only to be applied as needed, rather than twice a day and as needed. LPN #20 stated she would re-write the order on the TAR to clarify [MEDICATION NAME] ointment should be applied twice a day and as needed, as ordered by the physician. On 08/30/18 at 12:17 PM, the Administrator was notified about the facility's failure to document and report to the physician Resident #101's rash at the time the rash was identified on 08/19/18. The Administrator was also notified about the facility's failure to apply [MEDICATION NAME] ointment twice a day as ordered by the physician. The Administrator had no further information regarding these matters.

Based on medical record review, family interview, review of the facility's policies, and staff interview, the facility failed to ensure each resident was provided the necessary care and services to attain or maintain the highest practicable physical well-being. The facility did not ensure physician's orders [REDACTED]. Resident #198's [MEDICATION NAME] time/international ratio (PT/INR), a laboratory (lab) test, was not obtained as ordered resulting in actual harm. Resident #196's [MEDICATION NAME] test was not read seventy-two (72) hours after the administration. The facility failed to address Resident #139's [MEDICAL CONDITION] promptly, failed to assess her neurological status accurately, failed to complete neurological assessments after the resident experienced an unwitnessed fall, and failed to ensure the resident was transported to the right psychiatry office, therefore delaying the treatment of [REDACTED].#153 received adequate pain management by not assessing the effectiveness of an as needed pain medication. For [MEDICAL TREATMENT] Residents #149, #15, #111, #134, and #199, the facility failed to have blue clamps at the bedside as directed by the physician. Resident identifiers: #198, #196, #139, #153, #149, #15, #111, #134 and #199. Facility census: 100. Findings include: a) Resident #198 Review of the resident's medical record on [DATE] at 3:00 p.m., revealed a physician's orders [REDACTED]. Further record review found the PT/INR was obtained on [DATE] (Tuesday). On [DATE] the facility received the PT/INR results of 3.9, which was high. There was no evidence found in the resident's medical record indicating the physician was notified of the PT/INR results. The resident continued to receive [MEDICATION NAME] 5 milligrams (mg) on [DATE], [DATE], and [DATE], resulting in actual harm to the resident. Within 24 hours after discharge from the facility, the resident was admitted to the hospital for [MEDICATION NAME] toxicity. Interview with the director of nursing (DON) on [DATE] at 3:30 p.m., confirmed the PT/INR was not obtained on Monday ([DATE]) as the physician's orders [REDACTED]. b) Resident #196 Review of Resident #196's medical records on [DATE] at 9:00 a.m., found the resident was admitted to the facility on [DATE]. The admission orders [REDACTED]. Read seventy-two (72) hours after administration. Further record review of the medication administration record (MAR) on [DATE], found the PPD skin test was administered on ,[DATE] shift on [DATE]. On [DATE] the PPD skin test was not read as directed by the physician's orders [REDACTED].>During an interview on [DATE] at 9:40 a.m., the DON confirmed the PPD was not documented on the MAR as being read. She further confirmed the results/ and/or reading should be recorded on the MAR. c) Resident #139 1. [MEDICAL CONDITION] Review of Resident #139's medical record at 12:28 p.m. on [DATE] found she was admitted to the facility on [DATE] shortly after midnight from the hospital where she had the right upper lobe of her lung removed. She remained at the facility until she expired on [DATE]. Resident #139's admitting [DIAGNOSES REDACTED]. Resident #139's discharge instructions from the hospital included medications used to treat hypertension - [MEDICATION NAME] 25 milligrams (mg) every 12 hours and Amidarone 200 mg 2 tablets daily for seven (7) days then decrease to 200 mg daily there after. Review of the facility's admission orders [REDACTED]. On [DATE], eight (8) days after her lung surgery Resident #139 began to experience episodes of [MEDICAL CONDITION] (commonly defined as a blood pressure less than 90 systolic (top number of a blood pressure reading) or 60 diastolic (bottom number of a blood pressure reading)) as well as some confusion and [MEDICAL CONDITION]. It was found the resident [MEDICAL CONDITION] (an [MEDICAL CONDITION] response to infection throughout the body) and ischemic (deficient blood supply) bowel and had further surgery which resulted in Resident #139 having an [MEDICAL CONDITION] (an end of the lower small intestine is brought out the abdomen). Review of Resident #139's nursing admission assessment dated [DATE] at 12:45 a.m., found the resident's blood pressure on admission was ,[DATE] and she was orientated to person, place, and time. On [DATE] at 11:46 a.m., Resident #139's blood pressure was ,[DATE]. A change in condition nursing note written at 9:40 p.m. on [DATE], indicated Resident #139 had an unwitnessed fall in her room. At the time of her fall, the nurse obtained her vital signs. At 9:00 p.m., her blood pressure was ,[DATE]. The nurse also indicated the resident was confused. The resident's attending physician was notified of the fall, but there was no evidence to suggest that he was notified of Resident #139's [MEDICAL CONDITION]. ([MEDICAL CONDITION] can cause dizziness, which can contribute to falling.) The nurse indicated that neurological checks were initiated as a result of this fall. Review of the neurological checks found the following blood pressures recorded: - [DATE] at 9:30 p.m. ,[DATE] - [DATE] at 10:00 p.m. ,[DATE] - [DATE] at 10:30 p.m. ,[DATE] - [DATE] at 11:30 p.m. ,[DATE] - [DATE] at 12:30 a.m. ,[DATE] - [DATE] at 1:30 a.m. ,[DATE] - [DATE] at 2:30 a.m. ,[DATE] - [DATE] at 6:30 a.m. ,[DATE] Further review of the record found another change in condition nursing note dated 9:14 a.m. on [DATE]. This change in condition note indicated that Resident #139 had another fall in her room, which was unwitnessed. Her blood pressure at 8:00 a.m., which was the approximate time of the fall, was recorded as ,[DATE]. The note also indicated the resident continued to be confused. Again the physician was notified of this fall, but the record contained no evidence that he was made aware of the resident's multiple low blood pressure readings. The facility continued neurological checks on the resident and obtained the following blood pressure reading following this fall: - [DATE] 8:30 a.m. ,[DATE] - [DATE] at 9:30 a.m. ,[DATE] - [DATE] at 10:00 a.m. ,[DATE] - [DATE] at 11:00 a.m. ,[DATE] - [DATE] at 12:00 p.m. ,[DATE] - [DATE] at 1:00 p.m. ,[DATE]. - [DATE] at 5:00 p.m. ,[DATE] - [DATE] at 9:00 p.m. ,[DATE] - [DATE] at 1:00 a.m. ,[DATE] - [DATE] at 5:00 a.m. ,[DATE] - [DATE] at 9:00 a.m. ,[DATE] - [DATE] at 1:00 p.m. ,[DATE] - [DATE] at 4:00 p.m. ,[DATE] - [DATE] on the 7:00 a.m. to 3:00 p.m. shift (actual time not documented in the record) the resident's blood pressure was ,[DATE]. - [DATE] on the 3:00 p.m. to 11:00 p.m. shift (actual time not documented in the record) the resident's blood pressure was ,[DATE]. - [DATE] on the 11:00 p.m. to 7:00 a.m. shift (actual time not documented in the record the resident's blood pressure was ,[DATE]. There was no evidence to indicate Resident #139's attending physician was notified of any of her episodes of [MEDICAL CONDITION], which began on [DATE] and continued until [DATE] with the exception of 9:30 a.m. on [DATE] until 9:00 p.m. on [DATE], when the resident's blood pressures were not hypotensive. The facility continued to administer her prescribed medications, which lower blood pressure, until [DATE] at 11:00 a.m. It was at that time a change in condition note was completed and indicated the resident had episodes of dizziness and loss of balance and [MEDICAL CONDITION]. Her blood pressure at that time was recorded as ,[DATE]. When notified of this, the physician gave the following order (typed as written): Orthostatic (blood pressures) q (every shift) (laying, sitting, and standing) for three (3) days. (Orthostatic [MEDICAL CONDITION] is defined as a decrease in systolic blood pressure of 20 mm Hg or a decrease in diastolic blood pressure of 10 mm Hg within three minutes of standing when compared with blood pressure from the sitting or supine position.) The attending physician at this time also changed Resident #139's [MEDICATION NAME] (a medication used to treat anxiety) dose to 0.25 mg every 8 hours as needed. The prior dose was 2 mg as needed every 8 hours for anxiety. The 2 mg dose was not administered daily. She had only received this medication five (5) times since her admission to the facility. The following Orthstatic blood pressures were obtained: [DATE] Evening Shift (3:00 p.m. to 11:00 p.m.) Laying: ,[DATE] Sitting: ,[DATE] Standing: ,[DATE]. Night Shift (11:00 p.m. to 7:00 a.m.) Laying: ,[DATE] Sitting: ,[DATE] Standing: ,[DATE] [DATE] Day Shift (7:00 a.m. to 3:00 p.m.) Laying: ,[DATE] Sitting: ,[DATE]Standing: ,[DATE] Evening Shift (3:00 p.m. to 11:00 p.m.) Laying: ,[DATE] Sitting: ,[DATE] Standing: ,[DATE] Night Shift (11:00 p.m. to 7:00 a.m.) Laying: ,[DATE] Sitting: ,[DATE] Standing: ,[DATE] [DATE] Day Shift (7:00 a.m. to 3:00 p.m.) Only one blood pressure was entered in the MAR for this shift which was ,[DATE]. Evening Shift (3:00 p.m. to 11:00 p.m.) Laying: ,[DATE] Sitting: ,[DATE] Standing: ,[DATE]. Night Shift (11:00 p.m. to 7:00 a.m.) Laying: ,[DATE] Sitting: ,[DATE] Standing: ,[DATE]. The attending physician was contacted again on [DATE] regarding Resident #139's [MEDICAL CONDITION] at which time he gave orders to hold the resident's [MEDICATION NAME] at 9:00 p.m. and gave orders for the [MEDICATION NAME] to be held if the resident's systolic number was less than 100 or if her heart rate was less than 60 (some medications for high blood pressure also cause the heart rate to slow). The physician also ordered that the resident's blood pressure be obtained twice daily for three (3) days. Resident #139's Medication Administration Record (MAR) contained the following twice daily blood pressure readings: [DATE] at 9:00 p.m. ,[DATE] [DATE] at 9:00 a.m. ,[DATE] [DATE] at 9:00 p.m. ,[DATE] [DATE] at 9:00 a.m. ,[DATE] [DATE] at 9:00 p.m. ,[DATE] On [DATE], the physician gave an order to continue to hold Resident #139's [MEDICATION NAME]. Review of the MAR found that Resident #139 was administered [MEDICATION NAME] without physician ordered parameters from the day of her admission [DATE], twice daily until [DATE] despite multiple episodes of [MEDICAL CONDITION] and two (2) falls. The physician was not contacted concerning her [MEDICAL CONDITION] until [DATE], despite the fact it had been an ongoing problem since [DATE]. On [DATE], the attending physician gave orders for orthostatic blood pressures, which were obtained. On [DATE] the physician gave orders to hold the resident's 9:00 p.m. dose of [MEDICATION NAME], and added parameters to the order to hold the medication if the systolic number was less than 100 or pulse was less than 60. This order was followed on [DATE] at 9:00 a.m., when the medication was held for a blood pressure of ,[DATE]. On [DATE], the physician ordered to continue to hold the [MEDICATION NAME]. This order was not followed by facility staff and she was administered [MEDICATION NAME] on [DATE] at 9:00 a.m. and 9:00 p.m., and [DATE] at 9:00 a.m. even though the physician had ordered this medication to be held. Her blood pressure on [DATE] was ,[DATE] at 9:00 a.m. and ,[DATE] at 9:00 p.m. Her blood pressures on [DATE] were ,[DATE] at 9:00 a.m. and ,[DATE] at 9:00 p.m. An interview with Resident #139's family member at 3:10 p.m. on [DATE] revealed that Resident #139 never had any trouble with her blood pressure and she was not sure why she was receiving two (2) blood pressure medications. She indicated she had discussed this with staff but she does not think it was addressed. During and interview with the Director of Nursing (DON) at 9:31 a.m. on [DATE] evidence showing that the facility had notified the physician about Resident #139's [MEDICAL CONDITION] prior to [DATE] was requested. She indicated that the physician had seen her on three (3) occasions during her stay here. She stated that on [DATE] he saw her related to her falls. Review of the physician progress notes [REDACTED]. When the physician saw her on [DATE], he completed her history and physical, but did not note what her vital signs were, nor did he mention anything related to [MEDICAL CONDITION]. However, her episodes of [MEDICAL CONDITION] had not started on this date. The physician saw the resident on [DATE] and noted that she had two (2) unwitnessed falls, which was the reason for his visit. The vital signs section of his progress note was left blank. The physician indicated they would encourage the resident to use her call button and for her to have no unsupervised transfers. The physician's final visit with the resident was on [DATE], which was after he was contacted by staff and made changes to the resident's drug regimen regarding the management of her hyper/[MEDICAL CONDITION]. The physician's progress notes were reviewed with the DON and she stated that she would see if she could find any other information that would indicate the physician was notified of the resident's [MEDICAL CONDITION] prior to [DATE]. At 11:43 a.m. on [DATE], the DON reported she could find no evidence the physician was notified of Resident #139's [MEDICAL CONDITION] prior to [DATE]. 2. Neurological Assessments A review of Resident #139's medical record at 12:28 p.m. on [DATE], found the resident had a fall on [DATE] at 9:00 p.m. and on [DATE] at 8:00 a.m. Both falls were unwitnessed and facility staff, as directed by the facility's policy, initiated the Neurological Assessment Flow Sheet. Review of the Neurological assessment flow sheet initiated on [DATE] at 9:00 p.m., found the instructions at the top of the page included, . pupil response Check PERL (pupils equal and reactive to light) if applicable or enter the appropriate code for each eye. The flow sheet, which was to be completed for 72 hours following an unwitnessed fall, was blank for the section for pupil response. The flow sheet initiated on [DATE] at 9:00 p.m., indicated that when the nurse was completing the neurological assessment, she neglected to evaluate the resident's pupil response as directed. An interview with the DON at 9:31 a.m. on [DATE] confirmed the neurological assessments were not completed as directed by the facility's policy which was its accepted protocol when a resident had an unwitnessed fall. 3. Failure to complete accurate assessments. Review of Resident #139's medical record at 12:28 p.m. on [DATE], found the resident was admitted to the facility on [DATE] and remained at the facility until [DATE] when she expired. The resident was admitted from the hospital following a surgery to remove the right upper lobe of her lung and placement of an [MEDICAL CONDITION] following complications from the lung surgery. Further review of the record found two (2) nursing assessments, one (1) completed on [DATE] when the resident was admitted , and one (1) completed on [DATE]. Each assessment indicated that Resident #139's pupils were equal and briskly reactive to light. Further review of the record found that the resident's pupils were assessed as part of the Neurological Assessments that were completed on [DATE] through [DATE]. This flow sheet indicated the resident's pupils were assessed a total of 17 times and each time her pupils were described as being equal and reactive to light. Review of Resident #139's admission history and physical completed by the attending physician on [DATE], found the resident's right pupil was dilated and fixed and the left pupil was reactive to light. An interview with the DON on [DATE] at 2:21 p.m., confirmed the physician's findings. She stated she had spoken with the attending physician and he had indicated to her that the resident's right pupil had been dilated and fixed as a result of her having [MEDICAL CONDITION] in that eye several years ago. She stated that the attending physician had spoken with the daughter about her eye and the daughter explained to him that it had been that way for [AGE] years because she had shingles in that eye. An interview with Resident #139's daughter at 3:10 p.m. on [DATE] confirmed that Resident #139's right eye had been dilated and fixed because she had shingles [AGE] years ago in that eye and it had not been right since. The nurses' assessments of the resident's pupils were inaccurate and indicated they likely did not assess the resident's pupils when completing their nursing assessments and neurological assessment flow sheets completed on [DATE] through [DATE]. This was confirmed in an interview with the DON at 2:21 p.m. on [DATE]. 4. Psychiatry appointment An interview with Resident #139's daughter on [DATE] at 3:10 p.m. revealed, the facility asked her to meet her mother at the office of the resident's psychiatrist on [DATE] at 10:00 a.m. The daughter said she waited at the psychiatrist's office until 11:30 a.m., then called the facility two (2) times and was told they got a late start and the resident should arrive any minute. When her mother still had not arrived, the daughter called her mother's roommate who told her that her mother was back at the facility and was in her bed. The daughter said she then called the facility to see what happened and was told that they had sent her to the wrong psychiatrist, so they brought her back to the facility and would reschedule her appointment. Review of the medical record found a physician progress notes [REDACTED]. The record contained a nursing progress note dated [DATE] which indicated the nurse had made an appointment with Resident #139's psychiatrist for [DATE] at 10:00 a.m. Further review of the record found an order dated [DATE] at 2:00 p.m. for an appointment with the the resident's Psychiatrist for [DATE] at 2:00 p.m. An interview with the DON at 2:21 p.m. on [DATE] confirmed that the facility had sent the resident to the wrong psychiatry office on [DATE] and had to reschedule the appointment for [DATE], causing a delay in Resident #139's psychiatric treatment. d) Resident #153 A review of Resident #153's medical record at 10:17 a.m. on [DATE], found the following physician's orders [REDACTED]. This order had a start date of [DATE] and was a current order at the time of this review. Review of the facility's Pain Management Policy titled, Pain Management, with an effective date of [DATE], a review date of [DATE], and a revision date of [DATE], found it included under Practice Standards, 5. If PRN medications are given, document on the back of the MAR or on the PRN pain management flow sheet. 8. Patients receiving interventions for pain will be monitored for the effectiveness and side effects in providing pain relief. Document: 8.1 Effectiveness of PRN medications. 8.2 Ineffectiveness of routine or PRN medications including interventions, follow-up, and physician/mid level provider notification. Review of Resident #153's MAR beginning on [DATE] through present found the following dates in which the resident received a PRN pain medication and the effectiveness of the medication was not assessed: The following dates are dates in which the [MEDICATION NAME] ,[DATE] was signed out on the Controlled Substance Log for Resident #153, but was not documented on the MAR or the nurses' notes that this medication was administered and/or its effectiveness in treating Resident #153's pain: (The dates are the same, but the times are different. One set of dates and times include when the medication was signed out both on the MAR and the controlled substance log, the other set of dates and times are the times when the medication was just signed out on the controlled substance log and not recorded on the MAR. However, on all occasions the resident received a PRN pain medication and the staff did not assess its effectiveness.) - [DATE] at 9:30 a.m. - [DATE] at 2:00 a.m. and 6:00 p.m. - [DATE] at 2:00 p.m. and 8:00 p.m. - [DATE] at 2:00 p.m. - [DATE] at 1:00 p.m. and 6:00 p.m. - [DATE] at 8:00 p.m. - [DATE] at 12:00 a.m., 6:00 a.m., and 2:00 p.m. - [DATE] at 9:00 p.m. - [DATE] at 7:00 a.m., 12:00 p.m., and 9:00 p.m. - [DATE] at 2:00 a.m., 7:00 a.m., 1:00 p.m., and 9:00 p.m. - [DATE] at 5:00 a.m., 2:00 p.m., and 9:00 p.m. - [DATE] at 2:00 a.m., 6:00 a.m., and 9:00 p.m. - [DATE] at 4:00 a.m. - [DATE] at 8:00 a.m. and 10:30 p.m. - [DATE] at 8:00 a.m. and 1:00 p.m. - [DATE] at 12:00 a.m., 7:00 a.m., 1:00 p.m., 6:30 p.m., and 11:00 p.m. - [DATE] at 5:00 a.m., 2:00 p.m., and 9:00 p.m. - [DATE] at 9:00 a.m. and 6:00 p.m. - [DATE] at 5:00 a.m., 12:30 p.m., and 9:00 p.m. - [DATE] at 5:00 a.m., 9:00 a.m., and 9:00 p.m. - [DATE] at 9:00 a.m. and 9:00 p.m. - [DATE] at 5:00 a.m., 9:00 a.m., 2:00 p.m., and 10:00 p.m. - [DATE] at 9:00 a.m., 2:00 p.m., and 9:00 p.m. - [DATE] at 6:00 a.m. - [DATE] at 1:00 a.m., and 6:00 a.m. - [DATE] at 5:00 a.m. - [DATE] at 5:00 a.m., and 9:00 p.m. - [DATE] at 6:00 a.m., 2:00 p.m. and 6:00 p.m. - [DATE] at 5:00 a.m., 9:00 a.m., 2:00 p.m., and 9:00 p.m. - [DATE] at 6:00 a.m., and 9:00 p.m. - [DATE] at 9:30 p.m. - [DATE] at 8:00 p.m. - [DATE] at 2:00 p.m. - [DATE] at 10:00 a.m. - [DATE] at 9:00 a.m., 3:00 p.m., and 9:00 p.m. - [DATE] at 5:00 a.m. - [DATE] 2:00 p.m. and 9:00 p.m. - [DATE] at 2:00 p.m. - [DATE] at 2:00 (did not specify a.m. or p.m.) - [DATE] at 2:00 p.m. - [DATE] at 6:00 p.m. - [DATE] at 11:00 p.m. - [DATE] at 2:00 p.m. and 9:00 p.m. - [DATE] at 6:00 a.m. - [DATE] at 5:00 p.m. - [DATE] at 8:00 p.m. - [DATE] at 10:30 p.m. - [DATE] at 2:00 p.m. - [DATE] at 10:00 p.m. - [DATE] at 2:00 p.m. - [DATE] at 6:00 p.m. - [DATE] at 9:00 p.m. - [DATE] at 9:00 p.m. - [DATE] at 3:00 p.m. - [DATE] at 9:00 p.m. - [DATE] at 2:00 p.m. - [DATE] at 2:00 p.m. - [DATE] at 9:00 p.m. - [DATE] at 1:00 a.m. - [DATE] at 8:00 p.m. and - [DATE] at 12:30 p.m. The following are the dates where the medications were signed out of the controlled substance log and the MAR, but nursing staff still failed to determine if the PRN pain medication was effective in controlling Resident #153's pain: - [DATE] at 5:00 a.m., 11:00 a.m., and 6:00 p.m. - [DATE] at 8:00 a.m. and 1:00 p.m. - [DATE] at 7:00 a.m., 1:00 p.m. and 7:00 p.m. - [DATE] at 10:00 a.m. and 4:00 p.m. - [DATE] at 2:00 a.m., 8:00 a.m., and 11:00 p.m. - [DATE] at 5:00 a.m. and 11:00 p.m. - [DATE] at 5:00 a.m. - [DATE] at 5:00 a.m., and 9:00 a.m. - [DATE] at 1:00 a.m., 6:00 a.m., and 10:00 p.m. - [DATE] at 5:00 a.m. and 10:30 a.m. - [DATE] at 5:00 a.m. and 11:00 p.m. - [DATE] at 5:00 a.m. - [DATE] at 4:00 a.m., 1:00 p.m., and 11:00 p.m. - [DATE] at 1:00 a.m., 2:00 p.m., and 8:00 p.m. - [DATE] at 5:00 a.m., 12:00 p.m., and 9:00 p.m. - [DATE] at 7:00 a.m., 1:00 p.m., and 7:00 p.m. - [DATE] at 12:00 a.m. - [DATE] at 9:00 p.m. - [DATE] at 11:00 p.m. - [DATE] at 5:00 a.m. - [DATE] at 9:00 a.m. - [DATE] at 5:00 a.m., 9:00 a.m. and 9:00 p.m. - [DATE] at 5:00 a.m. and 8:00 p.m. - [DATE] at 5:00 a.m., 9:00 a.m., and 9:00 p.m. - [DATE] at 6:00 a.m. and 2:00 p.m. - [DATE] at 9:00 a.m. and 9:00 p.m. - [DATE] at 5:00 a.m. - [DATE] at 6:00 a.m. - [DATE] at 9:00 p.m. - [DATE] at 6:00 a.m., and 2:00 p.m. - [DATE] at 5:00 a.m., 2:00 p.m. and 9:00 p.m. - [DATE] at 12:00 a.m., and 6:00 a.m. - [DATE] at 6:00 a.m. and 2:00 p.m. - [DATE] at 5:00 a.m. and 11:00 a.m. - [DATE] at 5:00 a.m. and 9:00 p.m. - [DATE] at 1:00 p.m. and 7:00 p.m. - [DATE] at 6:00 a.m. and 11:00 a.m. - [DATE] at 5:00 a.m. and 11:00 a.m. - [DATE] at 6:00 p.m. - [DATE] at 5:00 a.m. - [DATE] at 5:00 a.m. and 8:30 a.m. - [DATE] at 5:00 a.m. and 9:00 a.m. - [DATE] at 9:00 a.m. and 9:00 p.m. - [DATE] at 9:00 a.m. and 9:00 p.m. - [DATE] at 9:00 a.m., 2:00 p.m., and 10:30 p.m. - [DATE] at 5:00 a.m. and 9:00 p.m. - [DATE] at 5:00 a.m. - [DATE] at 5:00 a.m., 10:00 a.m., and 8:00 p.m. - [DATE] at 5:00 a.m. and 8:00 p.m. - [DATE] at 5:00 a.m. and 10:00 p.m. - [DATE] at 9:00 a.m., 2:00 p.m. and 9:00 a.m. - [DATE] at 7:00 a.m. and 8:00 p.m. - [DATE] at 1:00 p.m. - [DATE] at 5:00 a.m., 2:00 p.m. and 9:00 p.m. - [DATE] at 5:00 a.m. and 8:00 p.m. - [DATE] at 6:00 a.m. - [DATE] at 9:00 p.m. - [DATE] at 9:00 p.m. - [DATE] at 6:00 a.m., 2:00 p.m. and 7:00 p.m. - [DATE] at 5:00 a.m. and 9:00 p.m. - [DATE] at 8:00 a.m., 10:00 a.m. and 9:00 p.m. - [DATE] at 5:00 a.m. and 9:00 p.m. - [DATE] AT 6:00 a.m. - [DATE] at 9:00 a.m. and 9:00 p.m. - [DATE] at 6:00 a.m., 2:00 p.m. and 9:00 p.m. - [DATE] at 6:00 a.m. and 1:00 a.m. - [DATE] 12:00 a.m. and 2:00 p.m. - [DATE] at 7:00 a.m. - [DATE] at 6:00 a.m., 10:00 a.m., 3:00 p.m., and 8:00 p.m. - [DATE] at 7:00 a.m., 2:00 p.m., and 8:00 p.m. - [DATE] at 9:00 a.m. - [DATE] at 1:30 a.m. - [DATE] at 7:30 a.m. - [DATE] at 8:00 p.m. - [DATE] at 3:00 p.m. - [DATE] at 1:00 p.m. - [DATE] at 5:00 a.m. and 9:00 p.m. - [DATE] at 6:00 a.m. - [DATE] at 8:15 a.m. - [DATE] at 6:00 a.m. - [DATE] at 2:00 a.m. - [DATE] at 9:00 p.m. - [DATE] at 8:00 p.m. - [DATE] at 8:00 p.m. - [DATE] at 9:00 p.m. - [DATE] at 7:00 p.m. - [DATE] at 8:30 a.m. - [DATE] at 9:00 p.m., and - [DATE] at 6:00 a.m. The nursing progress notes were reviewed from [DATE] through present and found no evidence the resident's pain was reevaluated after the administration of the PRN pain medication on the aforementioned dates. An interview with the DON at at 1:13 p.m. on [DATE] confirmed that the nurses who administer the PRN pain medication should evaluate its effectiveness on the MAR in the spaces provided to do so. She indicated they should mark a Y for Yes and an N for No, and if it was not completed on the MAR and not in the nurses' notes, then she would have to assume it was not done. She indicated that beginning in [DATE] they were implementing a new pain management flow sheet and that would hopefully remedy this problem. The instances in which the medication was signed out on the controlled substance log but not documented in the progress notes or on the MAR was reviewed with the DON on [DATE] at 6:30 p.m She stated that if she found anything in the record that showed where these were documented as administered, she would provide it. At the time of exit on [DATE] at 8:30 p.m. no additional information was provided. e) Resident #139 A medical record review on [DATE] at 2:22 p.m., had a physician's orders [REDACTED]. An observation on [DATE] at 5:10 p.m. with Licensed Practical Nurse (LPN) #11 verified the smooth clamps were not at the bedside of Resident #139. These clamps are used to apply pressure to stop bleeding at the [MEDICAL TREATMENT] access port. f) Resident #15 A medical record review on [DATE] at 4:10 p.m., had a physician's orders [REDACTED]. An observation on [DATE] at 5:30 p.m. with Registered Nurse (RN) #89 verified the smooth clamps were not at the bedside of Resident #15. g) Resident #111 A medical record review on [DATE] at 4:20 p.m., had a physician's orders [REDACTED]. An observation on [DATE] at 5:37 p.m. with Registered Nurse (RN) #56 verified the smooth blue clamps were not at the bedside of Resident #111. These clamps are used to apply pressure to stop bleeding at the [MEDICAL TREATMENT] access port. h) Resident #134 A medical record review on [DATE] at 4:30 p.m., had a physician's orders [REDACTED]. An observation on [DATE] at 5:45 p.m. with LPN #74 verified the blue clamps were not at the bedside of Resident #134. i) Resident #199 A medical record review on [DATE] at 4:45 p.m., had a physician's orders [REDACTED]. An observation on [DATE] at 5:40 p.m. with Registered Nurse (RN) #132, verified the smooth clamps were not at the bedside of Resident #199. These clamps are used to apply pressure to stop bleeding at the [MEDICAL TREATMENT] access port.

Based on medical record review, resident interview, staff interview and facility record review, the facility failed to ensure a resident was free of significant medication errors. A resident was administered the wrong antibiotic intravenously, requiring a hospital evaluation. Resident #48. Facility census: 112. Findings include: a) Resident #48 The risk management log, reviewed on 03/23/16 at 8:30 a.m., revealed an event dated, 03/19/16 at 1:15 p.m. The log noted the event as a medication error related to administration of the wrong medication. The risk management report description of the event indicated, Hung wrong IV (intravenous) antibiotic, resident became short of breath, cyanotic, 02 sat (oxygen saturation) of 69%. Immediately unhooked IV, elevated head of bed, encouraged resident to deep breathe. Pulse of 128. Respirations of 18. Was unable to obtain Blood Pressure, used 2 (two) different machines and checked manually. Contacted provider immediately and ambulance to send resident out to ER (emergency room ) . A late entry general progress note for 03/19/16 at 13:45 p.m., indicated, Resident out of facility via ambulance and stretcher with four (4) attendants. Resident going to Hospital emergency room due to adverse reaction to medication. Family, resident and physician notified. A change in condition note, dated 03/19/16 at 3:59 p.m. noted, Resident #48 had a change in condition - medical. Resident given wrong antibiotic and within (2) two minutes resident became short of breath .facial color is cyanotic. Level of consciousness is a change from previous state. Orientation person, place, time. Skin is diaphoretic .Cardiopulmonary: (SOB) shortness of breath, change in breathing pattern .Oxygen used at one percent (1%) via nasal cannula (nc) labored breathing, dyspnea with no activity . Facility interventions to prevent recurrence of errors included: any resident that received antibiotic therapy must have two (2) nurses signature on the IV flow sheet, to ensure the correct antibiotic was given to the right resident, and education related to general dose preparation and medication administration. A follow-up interview with the Director of Nursing (DON), on 03/24/16 at 9:45 a.m., revealed she entered the facility immediately upon being informed of the medication error. The DON related she was in the facility within an hour and related all of the nursing staff was educated. She indicated a plan was put into place for two (2) nurses to check off an antibiotic.

Based on random observation, medical record review, resident interview, staff interview, and policy review, the facility failed to appropriately and/or adequately control pain for two (2) residents. Resident #48 cried out in pain during wound care and Resident #40 expressed breakthrough pain with no intervention offered. Resident identifiers: Resident #48 and #40. Facility census: 112. Findings include: a) Resident #48 1. A random observation on 03/23/16 at 9:15 a.m., revealed Resident #48 being transported to the shower room. Another observation at approximately 9:40 a.m., revealed staff had assisted the resident back to bed and were adjusting her clothing and positioning. As the resident rolled to her left side she cried, Oh, and winced in pain. 2. An interview Nurse Aide (NA) #119 and NA #103, on 03/24/16 at 1:04 p.m., revealed Resident #48, Seemed to have more pain after coming back from the hospital. Both NA #119 and NA #103 confirmed Resident #48 grimaced with pain during wound treatments, and when she had to move her legs or change position. 3. A wound care observation on 03/23/16 at 11:12 a.m., revealed Resident #48 had multiple wounds on her thigh and calf areas, beneath the popliteal space (behind the knee). Resident #48 related they were very painful. Registed Nurse (RN) #71 first cleansed the wound on the right knee. As the nurse rubbed around and around the wound, Resident #48 winced in pain. The nurse then wiped the wound with gauze moistened with saline. The resident held tightly to NA #80's hand and winced with each stroke. Resident #48 had three (3) small wounds above the knee in a horizontal pattern. Each area was a separate wound. During the dressing change, Resident #48 winced and cried out, and drew her brows together. She again held tightly to NA #80's hand. RN #83 attempted to redirect the resident with conversation about family and friends, but the resident continued to cry out when wound care was being performed. RN #71 next provided wound care to the large wound on the anterior mid thigh area. The nurse scrubbed the wound with a back and forth motion, then placed saline moistened gauze over the wound bed. The resident cried out in pain, RN #71 hesitated, looked at the resident, and continued wound care. As the nurse cleaned the wound on the resident's left medial thigh, the resident winced in pain. RN #83 told the resident she was getting her, A bullet so you can bite it. Resident did not have a response, she was concentrating on the treatment. RN #71 then cleansed the right middle wound, which appeared as a deep cavity and contained granulation tissue and minimal slough. The RN cleansed the wound with a firm twisting motion, then packed it with saline gauze and applied an abdominal pad. Resident #48 cried out loudly, Oh, God, oh, please God, oh! RN #71 stopped, then asked the resident if she was ready. RN #83 said, You know we can stop if you want us to and the resident said, I just want to get it over with. Resident #48 related she had received pain medication about 30 minutes before the wound treatment was initiated, but it was not helping. The nurses did not offer Resident #48 pain intervention other than not performing the dressing change. After each wound treatment was completed, the nurse secured the abdominal pads with tape, then wrapped each leg with two (2) inch gauze roll dressings. The resident cried out in pain when staff elevated her leg to pass the gauze roll beneath it. RN #83 continued to talk to Resident #48 throughout the wound treatments, but the resident continued to express pain. Upon completion of wound care, RN #71 asked the resident how she was doing and Resident #48 related, Good now that we stopped. 4. During a discussion with the Director of Nursing (DON), on 03/23/16 at approximately 3:45 p.m. she related she had been made aware of the resident's expressions of pain during the wound care and indicated the expressions may have been enhanced due to the observation. 5. Licensed Practical Nurse (LPN) #17, interviewed on 03/23/16 at 4:00 p.m., related Resident #48 did not exhibit behaviors and would not exaggerate her level of pain. The nurse related if the resident expressed pain, she was having pain. 6. During an interview with Resident #48 and the Director of Nursing (DON), on 03/24/16 at 10:50 a.m., Resident #48 related her pain during wound care on 03/23/16 was very bad. Upon inquiry, the resident said she would like something more for pain if she was allowed to have it. The resident had expressed that she hurt whenever she moved, but as long as she laid quietly, she had no pain. The DON indicated the resident had a history of [REDACTED]. When exiting the room, the DON asked LPN #17 if the resident had received pain medication for breakthrough pain. The nurse related she had not, and indicated she would administer a dose of [MEDICATION NAME] 5-325 mg orally. physician's orders [REDACTED]. 7. During a second observation of wound care, on 03/24/16 at 1:45 p.m., the DON related Resident #71 had been medicated. The nurse related a once daily order for [MEDICATION NAME] 7.5 - 325 mg had been obtained to be administered prior to wound care. She indicated the medication had been administered. RN #71 first cleansed the posterior right calf. The resident watched in anticipation of pain. She whinced, but related the pain was bearable. The medial wound on the right leg was cleansed with a twisting back and forth motion and rinsed with the same motion. She patted the wound to dry it, applied a saline dressing, covered it with an abdominal pad. The resident related she was waiting on it to hurt. She flinched a couple of times, but related, it tolerable and was much better than yesterday. RN #71 related, I think the medication really did help, and the resident stated, Whatever you did, it worked. Remember to do it tomorrow. RN #71 cleansed the large wound on the right anterior thigh. Resident #48 again related, I think the medicine really did help, if you can remember to do tomorrow what you did today. 8. During a follow-up interview with LPN #17, review of the Medication Administration Record [REDACTED]. Additionally, she received a dose of [MEDICATION NAME] 7.5-325 mg orally at 1:05 p.m., prior to wound treatment. The order for [MEDICATION NAME] 7.5 mg po 30 minutes prior to the wound treatment was a new order. 9. The resident's care plan, reviewed on 03/24/16 at 9:00 a.m., revealed a focus related to activities of daily living (ADL) care. Interventions included staff would monitor for pain or discomfort and medicate as appropriate. The focus related to alterations in discomfort indicated staff would evaluate pain characteristics, including quality, severity, location, precipitating/relieving factors, monitor frequency of episodes of breakthrough pain to determine the need for pain med (medication) adjustment. A focus related to decision making indicated Resident #48 had capacity and staff would promote opportunities for resident/healthcare decision maker to participate in decisions regarding care. Another focus indicated the resident refused showers, turning and repositioning, and refused dressing changes. The interview with Resident #48, on 03/24/16 at 10:50 a.m., had revealed she had pain whenever she moved and related she would be more willing to move if her pain was more controlled. b) Resident #40 During a medication administration pass observation, on 03/23/16 at 8:54 a.m., Licensed Practical Nurse (LPN) #48 administered medication to Resident #90. Upon completion of administration. Resident #40 related he was experiencing pain. The LPN did not ask the resident the location, duration, or strength of his pain, and did not ask him to rate his pain. She informed the resident, I will be back with your medication in a few minutes. At 9:05 a.m., LPN #48 dispensed medication which included [MEDICATION NAME] 100 mg orally. The nurse returned to the room and the resident again related he was experiencing pain. The nurse responded, Your pain pill isn't (is not) due until twelve o'clock (12:00 p.m.) and it's (it is) just now nine o'clock (9:00 a.m.). The nurse did not offer any non-pharmacological interventions. She administered the medication, washed her hands and exited the room. The nurse continued her medication pass. An interview with the resident at 9:15 a.m., revealed he hurt all over, but especially in his legs and side. A follow-up interview at 10:20 a.m., revealed he continued to have pain, rated nine (9) on a zero to ten (0-10) scale, with ten (10) being the worst pain. Upon inquiry, the resident related staff had not offered medication or non-medication relief. Another interview at 12:40 p.m., revealed he had received pain medication which was effective. The medical record, reviewed on 03/23/16 at 12:45 p.m., revealed a physician's orders [REDACTED]. The care plan indicated a risk for alterations in comfort related to immobility, actual skin breakdown related to vascular disease, pneumonia, and [MEDICAL CONDITIONS]. The goal was to achieve an acceptable level of pain control. Interventions included evaluating pain characteristics of quality, severity, location, precipitating factors/relieving factors, utilization of the pain scale, medicate resident as ordered for pain and monitor for effectiveness and monitor for side effects, report to physician as indicated; monitor frequency of episodes of breakthrough pain to determine the need for pain med (medication) adjustment; complete pain assessment per protocol; assist resident to a position of comfort, utilizing pillows as appropriate positioning devices, monitor for nonverbal signs of pain such as increase in agitation, grimacing, and resistance to care. The pain evaluation, dated 01/28/16, indicated Resident #40 had bilateral lower leg pain, described as aching. Position made the pain worse and medication made the pain better. The resident had related he was satisfied with his current level of pain. The comments section indicated Physician #1, (doctor's name) was notified of continued pain with new orders for [MEDICATION NAME] 7/235 orally (PO) every six (6) hours. During an interview with the director of nursing (DON), on 03/23/16, at approximately 2:00 p.m., the DON confirmed the nurse should have evaluated the resident's pain, provided an intervention and evaluated its effectiveness. Another interview with Resident #40, on 03/24/16 at 10:30 a.m., revealed he experienced pain. Upon inquiry as to whether he informed anyone, the resident related, I can only have it every six (6) hours, and indicated it was not due. The resident related he hurt all over, but especially his legs. c) The pain management policy, with a revision date of 03//15/16 was reviewed on 03/23/16 at 4:45 p.m. The purpose was to maintain the highest possible level of comfort for patients by providing a system to identify, assess, treat and evaluate pain, and to achieve an optimal balance between pain relief and preservation of function, in accordance with patient directed goals. The policy indicated the care plan would be evaluated for effectiveness until satisfactory pain management was achieved.

Based on record review and staff interview, the facility failed to provide the necessary care and services to enable all residents to maintain and/or attain the highest practicable physical, mental, and psychosocial well-being. Residents #79, #73, #4, #85, and #110 had orders for [MEDICATION NAME]given after meals, depending on whether the resident ate more or less than 50% of the meal. [MEDICATION NAME] is an analog insulin that acts more quickly than regular human insulin. The manufacturer ' s instructions to patients includes, . Keep in mind, you will need to eat a meal within 5 to 10 minutes after taking [MEDICATION NAME] Record review found Resident #79 ' s [MEDICATION NAME]was discontinued on 06/19/15 without an order from the physician or family nurse practitioner. Additionally, when ordered, the resident did not receive [MEDICATION NAME] as ordered when the resident consumed more than 50% of a meal; received the medication when the resident ate less than 50% of a meal; and meal consumptions were not recorded, yet the insulin was given or held. This placed the resident at risk of developing [DIAGNOSES REDACTED] (low blood sugar) and/or [MEDICAL CONDITION] (high blood sugar), either which placed the resident ' s health and well-being at risk. The failure to administer the insulin in accordance with the physician ' s and/or family nurse practitioner ' s orders, and failure to document meal consumptions, also had the potential to affect the clinician ' s ability to determine whether the medication, at its ordered dosage, was resulting in the desired effect on controlling the resident ' s blood sugars. These findings were determined to pose an immediate jeopardy to the health and well-being of Resident #79. After identification of the immediate jeopardy for Resident #79, review of four (4) additional found Residents #73, #4, #85, and #110 all had orders for insulin administered after meals and to hold it if the resident consumed less than 50% of a meal. Review of each of these four (4) resident ' s medical records for June 2015, July 2015, and August 2015 found all four (4) resident's insulin was not consistently administered as directed by their physician's orders [REDACTED]. Therefore this practice affected five (5) of (5) sampled residents. The immediate jeopardy began on 06/19/15 when Resident #79's [MEDICATION NAME]was discontinued without a physician ' s or nurse practitioner ' s order. The facility was notified of the immediate jeopardy at ¿ 6:50 p.m. on 08/19/15. The facility provided a plan of correction at 10:20 p.m. on 08/19/15. The plan of correction was accepted by the State agency at 10:45 p.m. on 08/19/15. The facility was notified that the immediacy was removed at 5:30 p.m. on 08/20/15 after the plan of correction was implemented and confirmed as implemented by the State agency. No deficient practice remained. Resident Identifiers: #79, #73, #4, #85, and #110. Facility Census: 117. Findings Include: a) Resident #79 Review of Resident #79's medical record, at 12:00 p.m. on 08/19/15, found a physician's orders [REDACTED]. D/C [MEDICATION NAME] R 12 units q d (one time a day) monitor blood sugar ac (morning) and hs (night). ([MEDICATION NAME] R is a short-acting insulin.) This order was written by the Certified Family Nurse Practitioner (CFNP). A review of the Medication Administration Record [REDACTED] -- 06/05/15 - Resident #79's [MEDICATION NAME] was held after breakfast, but she consumed 75% (percent) of her meal. -- 06/10/15 to 06/12/15 - Resident #79's [MEDICATION NAME] was held after breakfast each day, but she consumed 100% of her breakfast each day. -- 06/17/15 - Resident #79's - [MEDICATION NAME] was held after breakfast, but she consumed 75% (percent) of her meal. Review of Resident #79's MAR for June 2015 found after the 6:00 p.m. dose on 06/18/15, the medication had been discontinued as indicated by a large DC (discontinue) written to the right of the order on the MAR. Review of the physician's orders [REDACTED]. On 07/17/15, the CFNP wrote an order, Order clarification [MEDICATION NAME] 9 units after (symbol for after) meals Hold if patient consumes less than 50 % of meal. Resident #79 was again started on this medication after her lunch meal on 07/17/15. From 06/19/15 through 07/16/15, this medication was not administered to Resident #79, nor was she evaluated for its need as the physician's orders [REDACTED]. Further review of the record found on 07/11/15, Resident #79 was given a one-time dosage of 5 units [MEDICATION NAME] R for a blood sugar level of 461. Additionally, on 07/15/15 Resident #79 was administered a one-time dose of [MEDICATION NAME] 10 units for a blood sugar of 454. A nursing progress note dated 07/11/15, read as follows (typed as written), Resident blood sugar obtained per ordered (sic). blood sugar level 461. no distress noted. Notified (Name of CFNP) received n/o (new order) for [MEDICATION NAME] R 5 units now. Insulin given per ordered (sic). Will continue to monitor resident. Further review of the record found a progress note dated 05/28/15, completed by the CFNP. This note identified the resident was seen due to elevated blood sugars. The progress note indicated the plan was to (typed as written), Change insulin to [MEDICATION NAME] 9 units after meals. Give 10 units of regular insulin now and repeat finger stick in one hour An additional progress note authored by the CFNP, dated 06/17/15, identified Resident #79 was seen for a follow up [MEDICAL CONDITION]([MEDICAL CONDITION] reflux disease). This note indicated the CFNP plan of care for Resident #79's diabetes was to continue the present medication regimen. A final progress note written by the CFNP, dated 07/17/15, indicated Resident #79 was being seen for a follow up to her blood sugars. The plan of care indicated she was going to change the resident's insulin to [MEDICATION NAME] 9 units after meals. Review of the MAR for July 2015 found from 07/17/15 to 07/21/15, this medication should have been held on seven (7) occasions, but the medication was administered. Additionally, on one (1) occasion Resident #79's medication was held when it should have been administered. Those occasions are as follows: -- 07/17/15 the resident ate 25% of her Breakfast, Lunch and Dinner, but administered this medication after all three (3) meals. -- 07/19/15 Resident #79 ate 25% of her breakfast and refused her lunch, but was administered this medication after both meals. -- 07/20/15 Resident #79 ate 25% of her breakfast and lunch meal, but was administered this medication after both meals. -- 07/21/15 Resident #79's insulin was held after breakfast, but she consumed 100% of her meal. Additional review of the medical record found a physician's orders [REDACTED]. Humalog 9 units after meals hold if patient consumes less than 50% (percent ) of meal. Review of the July 2015 MAR found the Humalog was begun on 07/22/15. From 07/22/15 through 7/31/15 found, this medication was administered five (5) times when it should have been held, and was held one (1) time when it should have been administered. The following are the dates in which these errors were made: -- 07/24/15 Resident #79's insulin was administered after breakfast when she only consumed 25% of her meal. -- 07/25/15 Resident #79's insulin was held after dinner when she had consumed 75% of her meal. -- 07/29/15 Resident #79's insulin was administered after all three meals, but she refused her breakfast meal and only ate 25% of her lunch and dinner. -- 07/30/15 Resident #79's insulin was administered after breakfast, but she only ate 25% of her meal. A review of the August 2015 MAR found the medication was held on one (1) occasion when it should have been administered, and was administered on eight (8) occasions when it should have been held. The dates of those errors are as follows: -- 08/06/15 Resident #79's insulin was administered after dinner, but she only ate 25% of her meal. -- 08/09/15 Resident #79's insulin was administered after all three meals, but but she only ate 25% of all three meals. -- 08/10/15 Resident #79's insulin was administered after breakfast and lunch, but she only ate 25% of her breakfast and lunch. -- 08/11/15 Resident #79's insulin was administered after breakfast, but she only ate 25% of her meal. -- 08/15/15 Resident #79's insulin was held after lunch, but she consumed 100% of her meal. -- 08/18/15 Resident #79's insulin was administered after lunch, but she only ate 25% of her lunch. Review of the ADL flow sheets from 06/01/15 through 06/18/15 found no meal percentage documentation for the following days and meals: -- 06/02/15 for dinner. The MAR indicated [REDACTED]. -- 06/06/15 for Breakfast, Lunch and Dinner. The medication was held for breakfast and dinner and was administered after lunch. -- 06/07/15 for Dinner. The medication was administered. -- 06/09/15 for Dinner. The MAR indicated [REDACTED]. -- 06/10/15 for Dinner. The medication was administered. -- 06/13/15- 06/15/15 for Dinner. The medication was administered on 06/13/15 and 06/15/15. The MAR for 06/14/15 was blank therefore it could not be determined if the medication was administered or not. Review of the ADL flow sheets for 07/17/15 through 07/31/15 found no meal percentage documentation for the following days and meals: -- 07/20/15 for dinner. The medication was held after the dinner meal. -- 07/21/15 for dinner. The medication was administered after the dinner meal. -- 07/23/15 for breakfast and lunch. The medication was held after breakfast and was administered after lunch. -- 07/26/15 for breakfast and lunch. The medication was administered after breakfast and lunch. -- 07/27/15 for all three meals. The medication was administered after all three meals. -- 07/31/15 for all three meals. The medication was administered after all three meals. Review of the ADL flow sheets for 08/01/15 through 08/18/15 found no meal percentages documented for the following days and meals: -- 08/02/15 for breakfast and lunch. The medication was administered after both meals. -- 08/04/15 for all three meals. The medication was held after breakfast and was administered after lunch and dinner. -- 08/05/15 for all three meals. The medication was held after breakfast and was administered after lunch and dinner. -- 08/07/15 for all three meals. The medication was administered after breakfast and lunch, but was held after dinner. -- 08/08/15 for breakfast and lunch. The medication was administered after each meal. -- 08/12/15 - 08/14/15 for all three meals each day. The medication was administered after each meal with the exception of the dinner meal on 08/12/15. The medication was held after that meal. -- 08/16/15 for all three meals. The medication was administered after breakfast and dinner. There was no documentation on the MAR indicated [REDACTED]. An interview with Licensed Practical Nurse (LPN) #29 at 4:40 p.m. on 08/19/15 confirmed she administered Resident #79's [MEDICATION NAME]on 08/04/15. She indicated she had administered all three (3) doses of the medication. When asked how she determined if Resident #79 should receive her insulin or if it should be held she stated, I actually go and visualize the residents plate after she is done eating and if she eats more than 50% of her food then I will give the insulin. She further added she does not take the nurse aides word for it she likes to actually look at the plate herself. An interview with LPN #65 at 4:52 p.m. on 08/19/15 confirmed she had administered Resident #79's insulin on 08/13/15 for all threes dosages and for 08/18/15 for the breakfast and lunch dosage. When asked how she determined if Resident #79 should receive her insulin or if it should be held. She stated, I go by what her blood sugar is because she just picks at her food. She then asked, Is that not right? A telephone interview with LPN #1 at 5:05 p.m. on 08/19/15, revealed when she was Resident #79's nurse, she would determine if the resident needed her insulin or not by asking the nurse aides or by reviewing the meal ticket on which the nurse aides wrote how much the resident ate at each meal. She stated, If I don't have a meal ticket, I will just ask the aide how much she ate. When asked if she ever visualizes the resident's plate herself she stated, No I just go by what the aide says. According to the MAR for August 2015, LPN #1 administered and/or held Resident #79's [MEDICATION NAME]after meals on 08/08/15 for all three doses, 08/09/15 for breakfast and lunch, and 08/14/15 for breakfast and lunch. Of these seven (7) occasions, LPN #1 administered Resident #79's insulin on 08/09/15 after breakfast and lunch when she should have held the medication. An interview with the Director of Nursing (DON) at 2:15 p.m. on 08/19/15 confirmed the order for Resident #79's [MEDICATION NAME] insulin, which was written on 06/01/15, was discontinued without a physician's orders [REDACTED]. She stated, There are not even any progress notes to indicate why the medication was discontinued. She indicated the staff must have forgotten to write the order. The identified dates on which the insulin was incorrectly administered and/or held were reviewed with the DON. She agreed that according to the documentation, the nurses had incorrectly administered and/or held Resident #79's insulin on the above dates. The missing documentation on the ADL flow sheet was also reviewed with the DON at this time. She confirmed there was no documentation on the flow sheets to indicate how much Resident #79 ate for the dates and times identified. When asked if this information was documented anywhere else in the medical record, she stated that it was not. b) Resident #110 A review of Resident #110's medical record at 2:45 p.m. on 08/19/15, found a physician's order [REDACTED]. [MEDICATION NAME] 4u (units) sc (subcutaneously) after (symbol for after) each meal - hold if pt (patient) eats < (less than) 50 % of meal. Review of Resident #110's June 2015 MAR found the following occurrences when Resident #110 did not receive her insulin as ordered by the physician's: -- 06/06/15 - Resident #110's [MEDICATION NAME] was administered after lunch and dinner, but she only consumed 25% if her lunch and dinner meal. -- 06/10/15 - Resident #110's [MEDICATION NAME] was administered after dinner, but she refused her dinner meal. -- 06/22/15 - Resident #110's [MEDICATION NAME] was administered after dinner, but she only ate 25% of her meal. -- 06/24/15 - Resident #110's lunch time dose of [MEDICATION NAME] was held, but she consumed 75% of her meal. Review of the June 2015 ADL Flow sheets found the following dates and meals in which no meal percentages were documented: -- 06/01/15, 06/03/15, 06/13/15, and 06/28/15 - for breakfast and lunch each day. Resident #110's [MEDICATION NAME] was administered on all of these occurrences with no supporting meal documentation. -- 06/02/15 and 06/12/15 - for breakfast, lunch, and dinner each day. Resident #110's [MEDICATION NAME] was administered on these occasions with no supporting meal documentation. -- 06/04/15, 06/07/15, 06/15/15, and 06/17/15 through 06/21/15 - for dinner each day . Resident #110's [MEDICATION NAME] was administered on all of these occasions with no supporting meal documentation. Review of July 2015 ADL flow sheets found the following dates and meals in which no meal percentages were documented: -- 07/04/15, 07/05/15, 07/07/15, and 07/14/15 - for breakfast and lunch each day. Resident #110's [MEDICATION NAME] was administered on all of these occurrences with no supporting meal documentation. -- 07/08/15 - for breakfast and dinner. Resident #110's [MEDICATION NAME] was administered on these occurrences with no supporting meal documentation. --07/01/15, 07/02/15, 07/21/15, and 07/26/15 - for breakfast, lunch, and dinner each day. Resident #110's [MEDICATION NAME] was administered on these occasions with no supporting meal documentation. --07/03/15, 07/15/15, 07/16/15, 07/17/15, 07/23/15, 07/27/15 and 07/29/15 for dinner each day . Resident #110's [MEDICATION NAME] was administered on all of these occasions with the exception of 07/16/15 and 07/24/15 which were left blank on the MAR for the dinner dosage with no supporting meal documentation. Review of Resident #110's August 2015 MAR found the following occurrences when Resident #110 did not receive her insulin as ordered by the physician: -- 08/04/15 - Resident #110 received her dose of [MEDICATION NAME] after dinner, but she only consumed 25% of her meal. -- 08/12/15 - Resident #110 received her dose of [MEDICATION NAME] after breakfast, but she only at 25% of her meal. -- 08/15/15 - Resident #110 received her dose of [MEDICATION NAME] after breakfast and lunch, but she only ate 25% of each meal. Review of August 2015 ADL flow sheets found the following dates and meals had no meal percentage documentation: -- 08/06/15, 08/10/15, 08/13/15, and 08/14/15 - for breakfast and lunch each day. Resident #110's [MEDICATION NAME] was administered on all of these occasions with no supporting meal documentation. -- 08/01/15, 08/02/15, 08/08/15, and 08/09/15 - for breakfast, lunch, and dinner each day. Resident #110's [MEDICATION NAME] was administered on these occasions with no supporting meal documentation. -- 08/05/15, 08/16/15, and 08/18/15 - for dinner each day . Resident #110's [MEDICATION NAME] was administered on all of these occasions with no supporting meal documentation. c) Resident #4 A review of Resident #4's medical record at 3:00 p.m. on 08/20/15, found a physician's orders [REDACTED]. Give after meals hold if patient consumes less than 50% of meals. Review of Resident #4's MAR from 06/27/15 through 06/30/15 found the following occurrences when Resident #4 did not receive her insulin as ordered by the physician: -- 06/27/15 - Resident #4's [MEDICATION NAME] was held after breakfast, but she ate 100 % of her breakfast. -- 06/30/15 - Resident #4's [MEDICATION NAME] was held after breakfast and lunch, but she 100 % of her breakfast and 75 % of her lunch. Review of Resident #4's ADL flow sheets for 06/27/15 through 06/30/15 found Resident #4's meal percentages were not documented for the dinner meal on 06/26/15, and 06/28/15 through 06/30/15. However, the MAR for these dates and times was also left blank. It could not be determined whether Resident #4 needed her [MEDICATION NAME]on these dates or not, and whether or not it was given. A review of Resident #4's MAR for the month of July 2015 found the following occurrences when Resident #4 did not receive her insulin as ordered by the attending physician: -- 07/01/15 - Resident #4's [MEDICATION NAME] was held after breakfast and lunch, but she ate 100% of both meals. -- 07/03/15 - Resident #4's [MEDICATION NAME] was held after breakfast and lunch, but she ate 100% of both meals. -- 07/08/15 - Resident #4's [MEDICATION NAME] was held after breakfast and lunch, but she ate 100% of both meals. -- 07/22/15 - Resident #4's [MEDICATION NAME] was held after breakfast, but she ate 100 % of her meal. -- 07/23/15 - Resident 34's [MEDICATION NAME] was administered after breakfast, but she only ate 25% of her meal. -- 07/30/15 - Resident #4's [MEDICATION NAME] was held after dinner, but she ate 100% of her meal. Resident #4's ADL flow sheets for the month of July 2015 were reviewed and found no meal percentages documented for the following dates and meals: -- 07/02/15 - for breakfast, lunch and dinner. Resident #4 received her insulin on this date after breakfast and dinner. However, it was held after the lunch meal. -- 07/03/15 - for dinner. Resident #4's MAR indicated [REDACTED]. -- 07/04/15 - for breakfast, lunch, and dinner. Resident #4's MAR indicated [REDACTED]. -- 07/05/15 - after breakfast and lunch. The MAR for this date was left blank therefore it could not be determined if Resident #4 received her [MEDICATION NAME]after breakfast and lunch. -- 07/06/15 - for dinner. The MAR indicated [REDACTED]. -- 07/07/15 - for breakfast and dinner. Resident #4's [MEDICATION NAME]was held on this date after both breakfast and dinner. -- 07/08/15 - for dinner. The MAR indicated [REDACTED]. -- 07/12/15 through 07/17/15 for dinner each day. Resident #4 received her [MEDICATION NAME]after dinner each day on 07/12/15, 07/13/15, 07/14/15, and 07/15/15. The MAR indicated [REDACTED]. -- 07/19/15 - for dinner. Resident #4 received her [MEDICATION NAME]after dinner on this date. -- 07/20/15 - for dinner. Resident #4 received her [MEDICATION NAME]after dinner on this date. -- 07/21/15 - for breakfast. Resident #4 received her dose of [MEDICATION NAME] after breakfast on this date. -- 07/23/15 through 07/25/15 - for dinner each day. Resident #4 received her [MEDICATION NAME]after dinner on each of these dates. -- 07/26/15 - for breakfast, lunch, and dinner. Resident #4 refused her breakfast dose of [MEDICATION NAME], but received her lunch and dinner dose on this date. -- 07/27/15 - for dinner. Resident #4 received her dinner dose of [MEDICATION NAME] on this date. -- 07/30/15 - for breakfast and lunch. Resident #4 received her breakfast and lunch dose of [MEDICATION NAME] on this date. -- 07/31/15 - for breakfast, lunch and dinner. All three (3) doses of Resident #4's [MEDICATION NAME] was held on this date. A review of Resident #4's August 2015 MAR found the following occurrences when Resident #4's [MEDICATION NAME] was not given as a directed in the physician's orders [REDACTED].>-- 08/06/15 - Resident #4's [MEDICATION NAME] was held, but she ate 100% of her meal. A review of Resident #4's ADL flow sheets for the Month of August 2015 found the following dates and meals which no meal percentages were documented in the medical record: -- 08/08/15 - for dinner. Resident #4's insulin was administered after dinner on this date. -- 08/09/15 - for breakfast and dinner. Resident #4's [MEDICATION NAME] was administered after breakfast and dinner on this date. -- 08/12/15 - for breakfast and lunch. Resident #4's [MEDICATION NAME] was administered after breakfast and lunch on this date. d) Resident # 85 A review of Resident #85's medical record at 3:30 p.m. on 08/20/15 found a physician's order [REDACTED].< (less than) 50%. Review of Resident #85's ADL flow sheets for the month of June 2015 found the following dates and meals had no meal percentage documentation. -- 06/01/15 - for dinner. Resident #85's [MEDICATION NAME] was administered on this occasion with no supporting meal documentation. -- 06/03/15 - for breakfast, lunch and dinner. Resident #85's [MEDICATION NAME] was administered on these occasions with no supporting meal documentation. -- 06/04/15 - for dinner. Resident #85's [MEDICATION NAME] was administered on this occasion with no supporting meal documentation. -- 06/04/15 - 6/07/15 - for breakfast, lunch and dinner daily. Resident #85's [MEDICATION NAME] was administered on these occasions daily with no supporting meal documentation. -- 06/08/15 - for dinner. Resident #85's [MEDICATION NAME] was administered on this occasion with no supporting meal documentation. -- 06/10/15 - for lunch and dinner. Resident #85's [MEDICATION NAME] was administered on these occasions with no supporting meal documentation. -- 06/12/15 - for breakfast, lunch and dinner. Resident #85's [MEDICATION NAME] was administered on these occasions with no supporting meal documentation. -- 06/14/15 - 06/16/15 - for dinner daily. Resident #85's [MEDICATION NAME] was administered on these occasions daily with no supporting meal documentation. -- 06/23/15 - for breakfast and lunch. Resident #85's [MEDICATION NAME] was administered on these occasions with no supporting meal documentation. -- 06/24/15- for dinner. Resident #85's [MEDICATION NAME] was administered on this occasion with no supporting meal documentation. -- 06/26/15 - for dinner. Resident #85's [MEDICATION NAME] was administered on this occasion with no supporting meal documentation. -- 06/27/15 - for dinner. Resident #85's [MEDICATION NAME] was administered on this occasion with no supporting meal documentation. -- 06/28/15 - for dinner. Resident #85's [MEDICATION NAME] was administered on this occasion with no supporting meal documentation. -- 06/29/15 - for dinner. Resident #85's [MEDICATION NAME] was administered on this occasion with no supporting meal documentation. -- 06/30/15 - for breakfast and dinner. Resident #85's [MEDICATION NAME] was administered on these occasions with no supporting meal documentation. Review of Resident #85's MAR for July 2015 found the following occasions when Resident #85's [MEDICATION NAME]was administered and/or held incorrectly. -- 07/08/15 - for breakfast. Residents [MEDICATION NAME]was held, but he consumed 100% of her breakfast. -- 07/09/15 - for lunch. Resident #85's [MEDICATION NAME] was held, but he consumed 100% of his lunch. Review of Resident #85's ADL flow sheets for the month of July 2015 found the following dates and meals had no meal percentage documentation. -- 07/01/15 through 07/02/15 - for dinner. Resident #85's [MEDICATION NAME] was administered on these occasions with no supporting meal documentation. -- 07/03/15 - for breakfast, lunch, and dinner. Resident #85's [MEDICATION NAME] was administered on these occasions with no supporting meal documentation. -- 07/08/15 - for dinner. Resident #85's [MEDICATION NAME] was administered on this occasion with no supporting meal documentation. -- 07/09/15 - for dinner. Resident #85's [MEDICATION NAME] was administered on this occasion with no supporting meal documentation. -- 07/10/15 - for breakfast, lunch and dinner. Resident #85's [MEDICATION NAME] was administered on these occasions with no supporting meal documentation. -- 07/11/15 - for dinner. Resident #85's [MEDICATION NAME] was administered on this occasion with no supporting meal documentation. -- 07/16/15 through 07/18/15 - for dinner. Resident #85's [MEDICATION NAME] was administered on these occasions with no supporting meal documentation. -- 07/22/15 - for dinner. Resident #85's [MEDICATION NAME] was administered on this occasion with no supporting meal documentation. -- 07/23/15 - for breakfast and lunch. Resident #85's [MEDICATION NAME] was administered on these occasions with no supporting meal documentation. -- 07/24/15 - for breakfast and lunch. Resident #85's [MEDICATION NAME] was administered on these occasions with no supporting meal documentation. -- 07/27/15 - for dinner. Resident #85's [MEDICATION NAME] was administered on this occasion with no supporting meal documentation. -- 07/28/15 - for breakfast and lunch. Resident #85's [MEDICATION NAME] was administered on these occasions with no supporting meal documentation. -- 07/29/15 - for breakfast, lunch and dinner. Resident #85's [MEDICATION NAME] was administered on these occasions with no supporting meal documentation. -- 07/30/15 - for dinner. Resident #85's [MEDICATION NAME] was administered on this occasion with no supporting meal documentation. e) Resident #73 A review of Resident #73's medical record at 2:30 p.m. on 08/20/15, found a physician's orders [REDACTED]. Review of Resident #73's June 2015 MAR found the following occasions when Resident #73's [MEDICATION NAME] was not administered as directed by the physician's orders [REDACTED].>-- 06/03/15 - for dinner. Resident #73's [MEDICATION NAME] was administered, but he only ate 25% of his meal. -- 06/11/15 - for lunch. Resident #73's [MEDICATION NAME] was administered but he only ate 25% of his meal. -- 06/29/15 - for breakfast and lunch. Resident #73's [MEDICATION NAME] was administered, but he refused to eat both breakfast and lunch. Review of Resident #73's ADL flow sheet for June 2015 found the following dates and meals in which no meal percentages were documented for Resident #73. -- 06/01/15 - for breakfast and lunch. Resident #73's [MEDICATION NAME] was administered on these occasions with no supporting meal documentation. -- 06/07/15 - for breakfast and lunch. Resident #73's [MEDICATION NAME] was administered on these occasions with no supporting meal documentation. -- 06/08/15 - for breakfast and lunch. Resident #73's [MEDICATION NAME] was administered on these occasions with no supporting meal documentation. -- 06/16/15 - for dinner. Resident #73's [MEDICATION NAME] was administered on this occasion with no supporting meal documentation. -- 06/21/15 - for dinner. Resident #73's [MEDICATION NAME] was administered on this occasion with no supporting meal documentation. -- 06/22/15 - for dinner. Resident #73's [MEDICATION NAME] was administered on this occasion with no supporting meal documentation. -- 06/28/15 - for dinner. Resident #73's [MEDICATION NAME] was administered on this occasion with no supporting meal documentation. Review of Resident #73 July 2015 MAR found on 07/14/15 for dinner Resident #73 received his [MEDICATION NAME], but only ate 25% of his meal. Review of Resident #73's August 2015 MAR, found on 08/06/15, for lunch Resident #73 received his [MEDICATION NAME], but refused his meal. f) Interview with the Director of Nursing (DON) After review of the findings for Resident #110, #4, #85, and #73, beginning at 3:45 p.m. on 08/20/15, the DON confirmed the findings. She agreed all four (4) residents received and/or did not receive their [MEDICATION NAME]as directed in the physician's orders [REDACTED]. The DON also confirmed the meal percentages for the aforementioned dates and meals were not documented in the medical record for each resident. The facility provided a plan of correction at 10:20 p.m. on 08/19/15. The plan of correction was accepted by the State agency at 10:45 p.m. on 08/19/15. The facility ' s immediate plan of correction read as follows: Hilltop Center provides this Plan of Correction without admitting or denying the validity or existence of the alleged deficiencies. The Plan of Correction is prepared and executed solely because it required by federal and state law. Resident #79 was assessed by Licensed Nurse on 8-19-15 and insulin was held due to resident consuming less than 50% of her meal. Medical Director currently in facility to assess resident #79 and will review insulin order containing dos

Based on medical record review, staff interview, and direct observation, the facility failed to ensure each resident received the necessary care and services to attain or maintain the highest practicable physical well-being in accordance with the comprehensive assessment and plan of care. One (1) resident did not receive adequate nutrition to prevent weight loss, ensure adequate hydration, and to prevent potentially avoidable pressure ulcers from developing. The resident, who received his nutrition and fluids via gastrostomy tube, had a significant weight loss in the first eighteen (18) days of admission. On the eighteenth day of admission, he was found to have three (3) small Stage II pressure ulcers. Also on the eighteenth day of admission, the resident was transferred to the hospital where he was diagnosed with [REDACTED]." A second resident had physician's orders [REDACTED]. For a third resident, a lap buddy was not removed during meals in accordance with the resident's care plan. Three (3) of nineteen (19) current residents on the sample were affected. Resident identifiers: #30, #33, and #18. Facility census: 106. Findings include: a) Resident #30 This [AGE] year old man was admitted to the facility on [DATE]. His admitting [DIAGNOSES REDACTED]. The following demonstrates the resident, who was maintained on feedings and fluids via gastrostomy tube, lost at least 9.3 pounds between his admission on 08/11/09 and his hospitalization on [DATE]. The registered dietitian (RD) had assessed the resident's tube feeding regimen as not being sufficient and had made recommendations on 08/17/09, but there was no evidence this was communicated to the physician in a timely manner. Also during this period, the resident developed Stage II pressure ulcers, and his laboratory studies, during his hospitalization [DATE] to 08/31/09, demonstrated he was significantly dehydrated. -- 1. His weight, on 8/11/09, was recorded as 131.2 pounds. This was later determined by the facility staff to be inaccurate. His weight, on 08/13/09, was recorded as 176.6 pounds. Subsequent weights were: 08/17/09 - 173.4 pounds 08/20/09 - 174.0 pounds 08/27/09 - 167.3 pounds (hospitalized from [DATE] to 08/31/09) 09/01/09 - 166.0 pounds 09/11/09 - 170.0 pounds 09/17/09 - 168.8 pounds 09/24/09 - 164.8 pounds 10/01/09 - 166.8 pounds 10/08/09 - 164.8 pounds 10/15/09 - 164.2 pounds 10/29/09 - 160.8 pounds 11/04/09 - 161.8 pounds 11/12/09 - 161.0 pounds 11/19/09 - 160.2 pounds 12/03/09 - 157.6 pounds 12/10/09 - 157.8 pounds 12/17/09 - 155.8 pounds 12/23/09 - 155.2 pounds 12/31/09 - 157.4 pounds 01/06/10 - 154.8 pounds -- 2. During this span of time, the resident's nutrition and hydration were maintained via gastrostomy tube. At the time of admission on 08/11/09, an "Enteral Protocol" sheet indicated the resident was to receive a [MEDICATION NAME] via pump of 240 ml at a rate of 240 ml per hour. The form identified the total nutrition would be 960 ml/hr. The total calories were not listed, nor was the tube feeding formula identified. The form noted the resident was to receive 200 ml of water every six (6) hours for a total of 800 ml of flush. The total volume of nutrient and flush was written as 1760 ml/24 hours. The amount of free water was not identified. Depending on the Glucerna formula used, the free water content would vary. Glucerna 1.0 has approximately 85.3% water; Glucerna 1.2 has approximately 80.5% water; and Glucerna 1.5 has 75.9% water. The higher the caloric density, the less water in the formula. -- 3. A computer generated admission order sheet had an order for [REDACTED]. -- 4. The RD completed an assessment on 08/14/09. Under diet order, she entered "Glucerna 240 cc via GT [MEDICATION NAME] over 1 hr q (every) 6 hours, flush 200 ml each feeding. Provides ~ (approximately) 948 kcals, 40 g protein, 808 ml fluid. Flushes provide an additional 800 ml." The RD's assessment listed the resident's height as 66 inches, his weight as 178, and his ideal body weight as 142 pounds. She calculated his caloric requirement based on actual body weight as 2131 and his fluid at 30 ml/kg as 2430 cc. In Section N of the assessment, in response to the question "Are nutritional needs met via current intake", the assessor entered "No". Under "Additional assessment data and identification of nutrition problem(s)", the RD noted "... Wt (weight) upon admission to center 8/11/09 noted as 131# however question the reliability given wt above on 08/13/09, and wt per WVDHHR records as 190#. Braden score indicates at high risk for developing pressure sores. No intolerance noted per nursing to current tube feeding. Glucose noted elevated as above, [MEDICATION NAME] WNL (within normal limits). Current tube feeding provides only 12 kcals/kg, 0.5 g/kg protein, 20 ml/kg fluid (including flushes) per most recent wt . ..." This section continued with "... [MEDICATION NAME] 1.2 @ goal rate of 105 ml/hr x 16 hours would provide ~2016 kcals, 94 g protein, 284 g CHO (carbohydrate), 1271 ml fluid. Flushes as ordered 200 ml q 6 hrs provide an additional 800 ml fluid. Supplies ~25 kcals/kg, 1.2 g/kg protein, 26 ml/kg fluid per most recent wt. ..." -- 5. A form entitled "RD Recommendations" (in large bold print) was found in the section for physician's orders [REDACTED]. The resident's name was listed under "Resident". In the column for "Recommendations", the RD had entered, "Question reliability of wts - recommend rewt (reweigh) (8/11/09 131#, 8/13/09 178#. ... Current tube feeding provides only 12 kcals/kg, 0.5 g/kg protein, 20 ml/kg fluid (including flushes) per most recent wt. ... Recommend [MEDICATION NAME] 1.2 @ goal rate of 105 ml/hr x 16 hours would provide ~2016 kcals, 94 g protein, 284 g CHO (carbohydrate), 1271 ml fluid. Flushes as ordered 200 ml q 6 hrs provide an additional 800 ml fluid. Supplies ~25 kcals/kg, 1.2 g/kg protein, 26 ml/kg fluid per most recent wt. ... Notify RD when po (by mouth) diet introduced for adjustments to tube feeding." In the last column of the form entitled "Responsible Party" was noted, "Nursing to MD order. ST (speech therapy) to notify if po diet introduced." There was no evidence this recommendation, which would have more than doubled the resident's calorie and fluid intake, was communicated to the physician in a timely manner. -- 6. There was no evidence the resident's enteral feedings and fluids were increased prior to 08/29/09, when he was found to have pressure ulcers. -- 7. A nursing entry, at 10:00 a.m. on 08/29/09, noted, "CNA (certified nursing assistant) reported to this nurse that resident had an open area to coccyx. This Nurse went into room and found 3 stage two's (sic) to coccyx. (1) 2.6 long x .5 (2) 3.2 long x 1.3 wide, (3) 2 cm long x .6 wide. Tx (treatment) written and applied." The admission nursing entry, written on 08/11/09, had not noted any reddened or open areas on the coccyx. None of the nursing entries indicated the resident had refused to be turned and repositioned. There were no entries indicating the resident had any precursors of impending skin breakdown. Prior to the resident developing pressure ulcers, the "Braden Scale - For Predicting Pressure Sore Risk" form had been completed on 08/11/09 and 08/18/09. On both dates, the resident was scored as 12. The form noted, "Total score of 12 or less represents HIGH RISK." On 09/28/09 at 1:00 p.m., a nurse wrote, "Area to coccyx closed. Buttocks red excoriated. New orders for Greer's Goo. Exuderm dcd (discontinued)." On 10/14/09 at 0700 (7:00 a.m.), a nurse noted, "Area to coccyx reopened .1 cm x 0.3 cm x 0.1 cm deep. ..." (It was noted to have healed again on 11/01/09.) On 01/14/10 at approximately 10:00 a.m., the resident's pressure ulcer development was briefly discussed with Employee #10. She was asked to find any documentation that would demonstrate the resident's pressure ulcers had been unavoidable. At 10:45 a.m., Employee #10 provided a copy of the Braden Scales that had been completed - showing the resident was at high risk for pressure sore development - and a copy of the RD's assessment from 08/14/09. She stated the resident was incontinent also. It was pointed out that many of the residents were incontinent (sixty-one (61) of one hundred-six (106) residents in the facility were identified as incontinent on the CMS-802 - Roster / Sample Matrix) and at high risk of pressure sore development. No additional information was provided. -- 8. On 08/29/09 at 3:30 p.m., the resident was found to have a decrease in his responsiveness. His blood sugar was checked and a reading of 'high' was obtained. Insulin (15 units) was given per sliding scale coverage. His blood pressure was 138/82, respirations 20, his heart rate was 135, and his oxygen saturation was 93%. The physician was notified. At 4:20 p.m., the resident's blood sugar was down to 485, and at 5:00 p.m. it was 458. At 5:20 p.m., the resident's blood sugar was again read as 'high'. The nurse noted he was "Still [MEDICAL CONDITION]." The resident's wife requested he be sent to the hospital. He left the facility by ambulance at 5:40 p.m. and was admitted to the hospital. -- 9. The RD noted, in her assessment on 08/14/09, the resident's BUN (blood urea nitrogen) had been 22 and his creatinine 1.4, according to labs from the hospital (prior to his admission on 08/11/09). (The normal range for BUN is 7 to 20 milligrams per deciliter (mg/dL). The normal range may vary slightly from lab to lab.) The hospital discharge summary, for 08/31/09, listed one (1) of his [DIAGNOSES REDACTED]. In the history portion of discharge summary, it was noted, "... He came to the ER with a glucose over 500, and an altered mental status. He was quite dehydrated... His BUN was 71 and his creatinine." Under "Hospital Course" was noted, "... His blood sugar came down nicely. His BUN also improved over the 36 hour hospital stay, to the point that on the morning of discharge his BUN was only 34, creatinine 1.1. ..." -- 10. Errors in calculations were found in "Enteral Protocol" forms that were included in the medical record section for physician's orders [REDACTED]. a. A second type of "Enteral Protocol" form was used to record the times when tube feedings and flushes were given. The physician's orders [REDACTED].@ 4 p.m. off at 10:00 a.m. Flush tube /c 200 ml water 5 times a day," yet there were only four (4) times a day marked on the record where nurses initialed to indicate the flushes had been given. The flushes as ordered by the physician should have equaled 1000 cc in 24 hours, but the form had "Total Vol: 1200 ML/24 hours." b. The first type of "Enteral Protocol" form (with the physician's orders [REDACTED]. For example, the form dated 12/29/09 indicated the resident was to receive Glucerna 1.5 at 75 cc 18 hours a day. The total nutrient was listed as 1271 ml/24 hours, but should have been 1350 ml/24 hours. The total calories was listed as 2016, but should have been 2025 calories/24 hours. The form indicated the resident was to receive 200 ml of flush every 6 hours. The space for total flush in twenty-four (24) hours was blank. Then, in the space for "Total volume of nutrient + flush", a nurse had written "2471" ml/24 hours. However, using her numbers of 1271 ml/24 hours + 800 cc flush, the total should have been "2071", or 400 cc/24 hours less than the nurse had calculated. The total of the flush and nutrient should have been 2150 ml/24 hours. c. Another "Enteral Protocol" form found with the physician's orders [REDACTED]. The nurse entered "1200" in the space for total flush. It should have been 800 cc/24 hours. d. Intake and output records were often incomplete, so the correlation between what was ordered and what was given could not be ascertained. --- b) Resident #33 1. On 01/13/10 at approximately 2:00 p.m., the resident's medical record, when reviewed, revealed the physician had ordered a regular advanced mechanical soft diet. The orders also included "Fluid Consistency: Thick liquids - Nectar Special Instructions: No straws." The start date for these orders was listed as 12/08/09. 2. Observation of the resident's room, on 01/13/09 at approximately 2:30 p.m., found the resident's insulated water pitcher contained unthickened ice water, and a straw had been inserted in the opening in the top of the pitcher and bent as though used to provide a drink to the resident. A second straw was lying on the resident's overbed table. There were also two (2) sippy cups on the over-bed table. Both cups also contained unthickened water. A packet of thickener was also noted on the overbed table. It had not been opened. A box of nectar-thick water sat on the resident's chest of drawers, partially obscured by other items on the chest. The viscosity of this product was checked and used to confirm that the water in the pitcher and the two (2) sippy cups was plain, unthickened water. 3. On 01/14/10 at 9:05 a.m., the resident's room was again observed. Again, there was unthickened water in the water pitcher and the two (2) sippy cups. The packet of thickener remained unopened. A bent straw was in the pitcher. At approximately 9:10 a.m. on 01/14/10, Employee #43 was asked to go to the resident's room. He agreed the resident was not to have straws and should have thickened fluids. --- c) Resident #18 Observations of the noon meal, in the restorative dining room on 01/12/10, found Resident #18 seated at the table with a lap buddy in place while a staff member was feeding her. The surveyor, at that time, questioned the staff regarding the use of the lap buddy, and Employee #28 stated the resident was supposed to be without the lap buddy at meals and activities. Employee #28 stated, "I just forgot to take it off." A review of the resident's most recent care plan in the medical record found the resident was "dependent on staff to assist with ADL's (activity of daily living) d/t (due to) cognitive deficits" and that a lap buddy was to be used "when up in w/c (wheelchair), release with meals and supervised activities." This intervention had not been followed. .