Every finding on record at La Vida Serena Nursing and Rehabilitation

Based on interview and record review, the facility failed to consider the views of the resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility or to demonstrate their response and rationale for such response for 1 of 1 Resident Council group reviewed. The facility failed to follow up on concerns and requests expressed in Resident Council meetings June 2025 through November 2025. The facility failed to provide the Resident Council group with a response, actions, and rationale taken regarding their concerns. This failure placed residents at risk of not having their grievances followed up and addressed. Findings included: Review of the Resident Advisory Council minutes from June 2025 to December 2025 reflected there was no documentation of the facility's responses to the following grievances: Review of document titled, Grievance Report Form dated 6/24/2025, reflected: Resident Council group communicated concerns with meals. The grievance report form was assigned to the Dietary Department. The grievance report form documents concerns were reported to AD. There was no investigation conducted, no results or resolution reported to the Resident Council group. Review of document titled, Grievance Report Form dated 6/24/2025, reflected: Resident Council group communicated concerns with water pass/hydration, rounding during the day (noon or so), night shift staff - make more rounds more often - 2x only during the night 11 pm and 5 am - need to answer call light and not just turn it off, and CNAs complaining and talking about being tired, pulling doubles, cussing in hallway. The grievance report form documents concerns were reported to AD. The grievance report form was assigned to the Nursing Department. There was no investigation conducted, no results or resolution reported to the Resident Council group. Review of document titled, Grievance Report Form dated 7/15/2025, reflected: Resident Council group communicated concerns with dining room requests of leaving out one napkin dispenser on countertop throughout the day, [NAME] letters/font on menus for easy reading, and posting of alternative menus. The grievance report form documents concerns were reported to Dietary/Admin/AD. The grievance report does not list it was assigned to a department or person. There was no investigation conducted, no results or resolution reported to the Resident Council group. Review of document titled, Grievance Report Form dated 8/18/2025, reflected: Resident Council group communicated concerns with call lights: need to be placed within reach, most times, it is wrapped on nightstand drawer or curtain, showers sometimes 1x(once) a week, and residents requesting specific shower times. The grievance report form documents concerns were reported to Nursing. The grievance report does not list it was assigned to a department or person. There was no investigation conducted, no results or resolution reported to the Resident Council group. Review of document titled, Resident Advisory Council Minutes 9/23/2025, reflected: Resident Council group communicated concerns with 500/600 hall showers,, no hot water, aids need to check water before shower; 100 hall - last rooms are getting colder in the evenings, check thermostat or provide extra blankets; 600 hall aids to check on residents more often during morning. Review of document titled, Grievance Report Form dated 11/18/2025, reflected Resident Council group communicated concerns with call lights down 100/600 hall, 2-10 shift lights get turned off, staff stating they are busy and will come back, and light has to be turned on again. The grievance report form documents concerns were reported to DON. There was no investigation conducted, no results or resolution reported to the Resident Council group. In an interview on 12/10/2025 at 2:00 PM, the Resident Council group stated the AD submits group grievances mentioned during monthly meetings to the management staff. The group stated they do not get information on the outcome of the grievances and would like this to change. In an interview on 12/10/2025 at 2:40 PM, the AD stated she was responsible for taking the minutes of the group meeting as the residents invite her monthly. She stated she will write down any group grievances, enter information on a grievance report, and give to department heads to address and return once resolved. She stated that if grievances are not investigated and communicated with the residents it would have a negative impact in that they may not feel as if they are being heard and feel discouraged. She stated the SW position has been vacant since the former SW transitioned to the ADM over 2 months back and the SW position was just filled today, 12/10/2025. She stated the SW was responsible for grievances and following up on them and stated the ADM has been present, but not in the SW capacity. She stated when residents have an immediate grievance, she tells them it was best to notify the DON or ADM if it needs to be addressed quickly and not to wait. She stated she does address resident rights during meetings and how to file grievances. She stated once grievance was resolved she would communicate resolution to the group. She stated she was unsure as to why this information was not documented in Resident Council group minutes or on the Grievance Report Form, but moving forward she will ensure if a grievance resolution was addressed during group meetings, she will ensure it was documented in the minutes. In an interview on 12/12/2025 at 12:32 PM, the DON stated an individual or the Resident Council group has a complaint staff will assist with completing a grievance form. She stated this grievance form will be submitted to self or ADM, if it pertains to a specific department, it will be assigned to the department head. She stated the department head is expected to address the concern, find a resolution, educate the nursing staff with an in-service, and return to the SW who tracks the grievance, notify the complainant and file. She stated the SW position has been vacant for some time, and the ADM is currently responsible for grievances as she transitioned from the SW to ADM position two months back. She stated if the grievance is not addressed and no resolution is provided to the individual or group filing the grievance it would cause the resident to become upset with the overall process. She stated she is unsure why the group grievances do not have findings, documented corrective actions taken by the facility, or if communicated to the resident as this is the responsibility of the ADM at this time. In an interview on 12/12/2025 at 12:40 PM, the ADM stated she was the former SW of the facility and transitioned over to the ADM position after becoming certified on 10/28/2025. She stated anyone can file a grievance or remain anonymous. She stated that any resident can file a grievance, the grievance was assigned to the department head relating to the grievance. She stated the grievance should be addressed within less than a week, it was returned to the SW to communicate the resolution to the person who filed the complaint, track it, and file. She stated this process was the same for both individual and group grievances. She stated for group grievances the AD will provide resolution details at the next Resident Council meeting. She stated if grievance was not investigated and a resolution was not provided to the individual or group it could affect them negatively as they are not being heard and they would feel ignored. She stated she was the former SW of the facility and transitioned over to ADM when she became certified on 10/28/2025. She stated the SW was responsible for tracking grievances, following up on the investigation and providing a resolution to the individual who filed the grievance. She stated the new SW was hired during recertification on 12/10/2025 and she was responsible for grievances until this recent hire. She stated she was sure the grievances the Resident Council group submitted were investigated by department heads, in-service training addressing the concern was provided to the nursing staff, and the group was notified of the outcome. She stated she was not sure why the grievance was not fully completed with the findings/conclusions regarding the residents' concern, whether the grievance was confirmed or not confirmed, any corrective action taken by the facility. She stated this process will improve with the hiring of a new SW. Review of the facility policy dated 11/28/2016, titled Resident Rights reflected the following: Respect and dignity - The resident has a right to be treated with respect and dignity. Grievances. The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have. Review of the facility policy dated 11/02/2016, titled Grievances reflected the following: The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents; and other concerns regarding their LTC facility stay. The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have. Procedure3. The grievance official will: Oversee the grievance process Receive and track grievances to their conclusion Lead any necessary investigations by the facility Issue written grievance decisions to the resident 6. All written grievances decisions will include: The date the grievance was received A summary statement of the residents grievance The steps taken to investigate the grievance A summary of the pertinent findings or conclusions regarding the resident's concern(s) A statement as to whether the grievance was confirmed or not confirmed Any corrective action taken or to be taken by the facility as a result of the grievance The date the written decision was issued

Based on interview and record review, the facility failed to implement and maintain a comprehensive Quality Assurance & Performance Improvement Program (QAPI) Plan, disclose records upon request, and have governance and leadership for 1 of 1 QAPI Program Plan reviewed. The facility failed to maintain an effective, comprehensive QAPI program and plan that addresses the full range of services the facility provides. The facility failed to ensure the QAPI Program uses performance indicator data, resident and staff input, and other information to identify and prioritize problems and opportunities. The facility failed to identify and prioritize quality deficiencies and utilize Resident and Family Council minutes, Grievance Review process, and Daily QA meetings (Morning QA stand up meeting) for improving resident outcomes. This failure has the potential to impact residents' quality of life and resident rights. Findings included:Review of the Resident Advisory Council minutes reflected the following with no documentation of the facility's responses to the grievances: 6/24/2025 reflected: Resident Council notes included specific details of concerns about direct care and nutrition services. 7/15/2025 reflected: Resident Council notes included specific details of concerns about direct care and nutrition services. 8/18/2025 reflected: Resident Council notes included specific details of concerns about direct care, nutrition services, maintenance, and activities. 9/23/2025 reflected: Resident Council notes included specific details of concerns about direct care, nutrition services, maintenance, activities, and medication administration. 10/28/2025 reflected: Resident Council notes included specific details of concerns about direct care and nutrition services. 11/28/2025 reflected: Resident Council notes included specific details of concerns about direct care and nutrition services. In an interview on 12/10/2025 at 2:00 PM, the Resident Council group stated the AD submits group grievances mentioned during monthly meetings to the management staff. The group stated they do not get information on the outcome of the grievances and would like this to change. In an interview on 12/10/2025 at 2:40 PM, the AD stated she was responsible for taking the minutes of the group meeting as the residents invite her monthly. She stated she will write down any group grievances, enter information on a grievance report, and give to department heads to address and return once resolved. She stated that if grievances are not investigated and communicated with the residents it would have a negative impact in that they may not feel as if they are being heard and feel discouraged. She stated she was unsure as to why resolution information was not documented in Resident Council group minutes or on the Grievance Report Form, but moving forward she will ensure if a grievance resolution was addressed during group meetings, she will ensure it is documented in the minutes. In an interview on 12/12/2025 at 12:32 PM, the DON stated if an individual or the Resident Council group has a complaint staff will assist with completing a grievance form. She stated this grievance form will be submitted to self or ADM, if it pertains to a specific department, it will be assigned to the department head. She stated the department head was expected to address the concern, find a resolution, educate the nursing staff with an in-service, and return to the SW who tracks the grievance, notify the complainant and file. She stated if the grievance was not addressed and no resolution was provided to the individual or group filing the grievance it would cause the residents to become upset with the overall process. She stated she was unsure why the group grievances do not have findings, documented corrective actions taken by the facility, or if communicated to the residents as this was the responsibility of the ADM at this time. In an interview on 12/12/2025 at 12:40 PM, the ADM stated anyone can file a grievance or remain anonymous. She stated that any resident can file a grievance, the grievance was assigned to the department head the grievance was related to. She stated the grievance should be addressed within less than a week, it is returned to the SW to communicate the resolution to the person who filed the complaint, track it, and file. She stated this process was the same for both individual and group grievances. She stated grievances are discussed during the morning daily meetings. ADM stated for group grievances the AD will provide resolution details at the next Resident Council meeting. She stated if grievance was not investigated and a resolution was not provided to the individual or group it could affect them negatively as they are not being heard and they would feel ignored. She stated she was the former SW of the facility and transitioned over to ADM when she became certified on 10/28/2025. She stated the SW was responsible for tracking grievances, following up on the investigation and providing a resolution to the individual who filed the grievance. She stated the new SW was hired during recertification on 12/10/2025 and she was responsible for grievances until this recent hire. She stated she was sure the grievances the Resident Council group submitted were investigated by department heads, in-service training addressing the concern was provided to the nursing staff, and the group was notified of the outcome. She stated she was not sure why the grievance was not fully completed with the findings/conclusions regarding the residents' concern, whether the grievance was confirmed or not confirmed, any corrective action taken by the facility. She stated this process will improve with the hiring of a new SW. ADM stated during morning meetings the nursing staff address any deviations from expected performance or a negative trend. She stated the Champion Team Program also helps to implement a proactive approach to resolving resident and environmental issues before they escalate and the nursing staff report quality concerns directly to the ADM. ADM stated anything related to residents' life or safety was priority and would be worked on first. She stated HR, DON, and she act immediately upon facility concerns and implemented corrective actions of corporate in-services and staff writeups, which she follows up on. She stated the QAA Committee was not aware of the issues concerning the resident family group and response and resident records, which were identified during the survey this week and thus did not undergo good faith attempts to correct quality deficiencies. Review of document titled, Grievance Report Form dated 6/24/2025, reflected: Resident Council group communicated concerns with meals. The grievance report form was assigned to the Dietary Department. The grievance report form documents concerns were reported to AD. There was no investigation conducted, no results or resolution reported to the Resident Council group. Review of document titled, Grievance Report Form dated 6/24/2025, reflected: Resident Council group communicated concerns with water pass/hydration, rounding during the day (noon or so), night shift staff - make more rounds more often - 2x only during the night 11 pm and 5 am - need to answer call light and not just turn it off, and CNAs complaining and talking about being tired, pulling doubles, cussing in hallway. The grievance report form documents concerns were reported to AD. The grievance report form was assigned to the Nursing Department. There was no investigation conducted, no results or resolution reported to the Resident Council group. Review of document titled, Grievance Report Form dated 7/15/2025, reflected: Resident Council group communicated concerns with dining room requests of leaving out one napkin dispenser on countertop throughout the day, [NAME] letters/font on menus for easy reading, and posting of alternative menus. The grievance report form documents concerns were reported to Dietary/Admin/AD. The grievance report does not list it was assigned to a department or person. There was no investigation conducted, no results or resolution reported to the Resident Council group. Review of document titled, Grievance Report Form dated 8/18/2025, reflected: Resident Council group communicated concerns with call lights: need to be placed within reach, most times, it is wrapped on nightstand drawer or curtain, showers sometimes 1x(once) a week, and residents requesting specific shower times. The grievance report form documents concerns were reported to Nursing. The grievance report does not list it was assigned to a department or person. There was no investigation conducted, no results or resolution reported to the Resident Council group. Review of document titled, Resident Advisory Council Minutes 9/23/2025, reflected: Resident Council group communicated concerns with 500/600 hall showers,, no hot water, aids need to check water before shower; 100 hall - last rooms are getting colder in the evenings, check thermostat or provide extra blankets; 600 hall aids to check on residents more often during morning. Review of document titled, Grievance Report Form dated 11/18/2025, reflected Resident Council group communicated concerns with call lights down 100/600 hall, 2-10 shift lights get turned off, staff stating they are busy and will come back, and light has to be turned on again. The grievance report form documents concerns were reported to DON. There was no investigation conducted, no results or resolution reported to the Resident Council group. Review of the facility policy dated 11/28/2016, titled Resident Rights reflected the following: Respect and dignity - The resident has a right to be treated with respect and dignity. Grievances. The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have. Review of the facility document undated, titled Quality Assurance Performance Improvement Program (QAPI) Plan reflected the following: The main purpose for the facility QAPI plan is to ensure all opportunities for improvement are identified and corrected using various methods to include action plans, root cause, PDSA methodology and various benchmarks as goals. This process will be done through a team approach involving all staff members and residents' representatives. The primary goal is to identify, correct and prevent reoccurrence of identified problems that arise within the facility. This plan will assist the facility to ensure that care and services delivered meet accepted standards of quality, identify problems and opportunities for improvement and ensure progress toward correction or improvement is achieved and sustained. 2. Governance and Leadership This involves leadership working with input from facility staff, as well as from residents and their families and/or representatives. 3. Feedback, Data Systems and Monitoring The facility will identify and prioritize quality deficiencies and will utilize all opportunities to identify areas with the potential for improving resident outcomes to include but not limited to: Resident interview, family interview and staff interview, observations and reviews Standards of Care Meeting Champion Round Program Resident and Family Council minutes Grievance Review process Daily QA meetings (Morning QA stand up meeting) Review of the facility policy dated 11/02/2016, titled Grievances reflected the following: The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents; and other concerns regarding their LTC facility stay. The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have. Procedure 3. The grievance official will: Oversee the grievance process Receive and track grievances to their conclusion Lead any necessary investigations by the facility Issue written grievance decisions to the resident 6. All written grievances decisions will include: The date the grievance was received A summary statement of the residents grievance The steps taken to investigate the grievance A summary of the pertinent findings or conclusions regarding the resident's concern(s) A statement as to whether the grievance was confirmed or not confirmed Any corrective action taken or to be taken by the facility as a result of the grievance The date the written decision was issued Review of the facility document undated, titled Champion Team Program reflected the following: STANDARD: The Champion Team Program is designed to foster open communication and collaboration among residents, staff, and families. By removing departmental barriers and promoting shared responsibility, the program aims to proactively address concerns and enhance the quality of care. Program Goals: Implement a proactive approach to resolving resident and environmental issues before they escalate.

Based on observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public on 3 of 13 resident rooms (rooms 205, 206, 213) and 1of 1 hydration room and 1 of 1 laundry room reviewed for environmental concerns in that: 1-The facility failed to repair a bathroom ceiling vent that was dirty/rusty, replace a bathroom light bulb, repair a bedroom's broken window shade, repair a hydration room's ceiling, repair a laundry rooms ceiling vent and ceiling area, repair a laundry room's corner wall panel, clean a laundry room's corner wall area that had a film resembling mold, and replace laundry room floor tiles. These failures could place residents at risk of a diminished quality of life due to exposure to an environment that is unpleasant, unsanitary, and unsafe.The findings included: Observation on 12/11/25 from 1100am-1115am with the Administrator and Maintenance Director revealed the following:a-There was a bathroom ceiling vent that had dirt and rust on the vents in room # 205.b-There was an overhead light over the bathroom sink that did not turn on in room # 206.c-There was a broken window shade next to bed-B in room # 213.d-There was a ceiling area with peeling paint and water embarkation spots in the hydration room.e-There was a circular ceiling vent which measured approximately 2x3 ft in diameter that had dirt and rust on the vent in the laundry room.f-There was a ceiling area which measured approximately 1x1 ft in size that had peeling paint in the laundry room.g-There was a corner wall area that had a side panel which measured approximately 1.5 ft in length that was dislodged from the side- wall in the laundry room.h-There was a corner of the wall behind the washing machine which measured approximately 1.5x1.5 ft that contained a black-dotted film on the wall surface that resembled mold in the laundry room.i-There were 12 floor tiles which each measured 1x1 ft that were dirty and stained in the laundry room. During an interview on 12/11/25 at 11:20am with the Administrator and Maintenance Director the Maintenance Director stated that staff notify him of pending work order needs and he had been aware of the observed areas which needed repair. The Administrator stated the completed repairs would create a safer environment for the Residents and staff. Record review of the facility policy titled Preventative Maintenance in the Environment of Care Policy and Procedure Manual dated 2003 revealed Preventative maintenance will be completed routinely and according to protocol by the Maintenance Supervisor or qualified designee.

Based on observations, interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment [TT1] for 2 of 24 residents (Residents #28 and #44) reviewed for care plan. 1. The facility failed to develop and implement a care plan with a focus, goals, and interventions for Resident #28's needs for dialysis (a life-sustaining medical treatment that filters waste products and excess fluid from the blood when the kidneys fail.) 2. The facility failed to develop and implement a care plan with a focus, goals, and interventions for Resident #44's needs for an intravenous catheter (a thin, flexible tube inserted into a vein to deliver fluids, medications, blood, or nutrition, and to draw blood, commonly placed in the hand or arm.) These failures could place residents at risk for harm by not having their nursing interventions planned. The findings included: Resident #28A record review of Resident #28's admission record dated 12/12/2025 revealed an admission date of 10/29/2025 with a diagnosis of end stage renal disease (ESRD - when the kidneys permanently fail and can no longer function well enough to keep a person alive, requiring life-sustaining treatments like dialysis or a kidney transplant.) A record review of Resident #28's admission MDS dated [DATE] revealed Resident #28 was a [AGE] year-old male admitted for LTC Resident #28 was assessed with a BIMS score of 13 out of a possible 15, which indicated no cognitive impairment. review of section o Special Treatments, Procedures, and Programs revealed Resident #28 received dialysis treatments. A record review of Resident #28's physicians orders dated 12/10/2025 revealed the physician prescribed the following:- To receive dialysis therapy 3 times a week on Tuesdays, Thursdays, and Saturdays. - For nursing to assess Resident #28's dialysis device for a positive bruit and thrill every shift (a whooshing sound heard with a stethoscope over a dialysis port, while a thrill is the palpable vibration or buzzing sensation felt over that same dialysis port. - Nursing may withhold medications prior to Resident #28's dialysis appointments. A record review of Resident #28's care plan dated 12/10/2025 revealed the following:- To receive dialysis therapy 3 times a week on Tuesdays, Thursdays, and Saturdays. - For nursing to assess Resident #28's dialysis device for a positive bruit and thrill every shift (a whooshing sound heard with a stethoscope over a dialysis port, while a thrill is the palpable vibration or buzzing sensation felt over that same dialysis port. - Nursing may withhold medications prior to Resident #28's dialysis appointments. Further review revealed there were no focus care areas, goals, nor interventions. Resident #44A record review of Resident #44's admission record revealed an admission date of 10/17/2025 with diagnoses which included hemiparesis (weakness on one side of the body) and urinary tract infection. A record review of Resident #44's MDS assessment dated [DATE] revealed Resident #44 was an [AGE] year-old female admitted for LTC with a urinary tract infection. Resident #44 was assessed with a BIMS score of 15 which indicated no cognitive impairment. Resident #44 was assessed with adequate vision with glasses, and hearing without aides. Resident #44 was assessed with the ability to usually make herself understood and could usually understand others. Resident was assessed with the need for antibiotics via a peripherally inserted central catheter (PICC) intravenous access. A record review of Resident #44's nursing progress note dated 10/17/2025 revealed LVN F documented Resident #44 was admitted from the hospital with a PICC intravenous access (IV); . readmission Note readmitted / returned from the hospital. Has IV access via PICC Line,. Location of PICC line: RIGHT UPPER ARM. A record review of Resident #44's physician's orders dated 10/31/2025 revealed Resident #44 was prescribed antibiotics to treat a urinary tract infection (UTI) intravenously and orders to maintain her PICC IV line; Admit to Medicare Part A effective 10/17/2025 due to status post hospitalization requiring skilled nursing care for management of diagnosis of urinary tract infection. change dressing to double lumen PICC line to right upper extremity. Flush PICC line to right upper extremity with 10 milliliters of normal saline before and after medication . No blood pressure or vein puncture to right arm . levofloxacin in d5w intravenous solution 250mg / 50mg, use 50ml intravenously one time a day related to UTI. A record review of Resident #44's care plan dated 12/10/2025 revealed no focus, Goals, nor interventions for: UTI, PICC line, nor Antibiotic use. During an interview on 12/12/2025 at 8:30 AM the RN G stated she was the facility's MDS nurse. RN G stated Resident #44 was discharged to the hospital for evaluation and treatment for a diagnosed UTI. RN G stated Resident #44 was admitted to the facility with an intravenous line developed and maintained at the hospital. RN G stated Resident #44 returned with orders for antibiotic treatments through the intravenous line. RN G stated she assessed Resident #44 upon her admission and developed and implemented Resident #44's MDS and initiated Resident #44's care plan by introducing care plan templates. RN G stated she reviewed Resident #44 care plan and recognized she had failed to introduce nursing care plans with focuses, goals and interventions for Resident #44's UTI, antibiotic use, and PICC line. RN G stated she was responsible for bringing this information into the care plan and had not, I overlooked it due to human error. RN G stated the Administrator was her supervisor and was responsible for reviewing and ensuring the accuracy of the MDS and care plan. RN G stated residents who were admitted to the facility were reviewed in the IDT daily morning meetings and IV lines with antibiotic therapies would also be reviewed to ensure transcription to the care plan. RN G stated the potential negative outcome could be no care plan focuses, goals, and interventions for residents admitted with needs for PICC lines with antibiotic administration. During an interview on 12/12/2025 at 12:18 PM the DON and LVN H stated Resident #28 had a need for dialysis 3 times a week related to his kidney failure and diagnosis of ESRD. The DON and LVN H stated they had reviewed Resident #44's care plan and recognized Resident #44 did not have focuses, goals, and nursing interventions for Resident #28's dialysis, which could have included his chair days and times of service, how to handle Resident #28's shunt, e.g. no blood draws to shunt arm, no blood pressure to arm etc. The DON and LVN H stated this failure could have potential negative outcomes related to poor continuity of care. During an interview on 12/12/2025 at 11:40 AM the DON and the Administrator stated residents with care needs like dialysis and intravenous antibiotics should be assessed by nursing and care plans should be developed and implemented with focuses, goals, and interventions to promote a residents highest practical health status. The DON and the Administrator stated they were responsible to overview and ensure residents care plans were developed and implemented and in regard to the lack of care plan interventions for Residents #28 and #44 there was room for improvement, and the failure could have potential negative outcomes for care plans. A record review of the facility's undated Comprehensive Care Planning policy revealed, The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.The comprehensive care plan will describe the following - The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; . The facility will establish, document and implement the care and services to be provided to each resident to assist in attaining or maintaining his or her highest practicable quality of life. Care planning drives the type of care and services that a resident receives. When developing the comprehensive care plan, facility staff will, at a minimum, use the Minimum Data Set (MDS) to assess the resident's clinical condition, cognitive and functional status, and use of services.

Based on observations, interviews, and record reviews the facility failed to ensure that residents' environments remained as free of accident hazards as possible and each resident received adequate supervision and assistance devices to prevent accidents, for 1 of 8 residents reviewed for anti-slip mats. Resident #9 was assessed as a fall risk with a history of falls from her wheelchair. Resident #9 was prescribed an anti-slip mat on the seat of her wheelchair and had gone missing for days. This failure could place residents at risk of falls and injuries. The findings included: A record review of Resident #9's admission record dated 12/10/2025 revealed an admission date of 3/21/2025 with diagnoses which included a history of falling, syncope and collapse (fainting), and difficulty walking. A record review of Resident #9's annual MDS assessment dated [DATE] revealed Resident #9 was a [AGE] year-old female admitted for LTC and assistance with safety assistance and supervision related to her being assessed as a fall risk and history of falling. Resident #9 was assessed with a BIMS score of 12 out of a possible 15 which indicated moderate cognitive impairment. Resident #9 was assessed with adequate hearing and poor vision and used glasses. Resident #9 was assessed with the ability to usually understand others and could usually make herself understood. Resident #9 was assessed with the need to use a wheelchair. A record review of Resident #9's care plan dated 12/10/2025 revealed, Focus: Resident #9 has a potential for falls related to history of falls. Goal: Resident #9 will suffer no major injury related to falls through the review date. Interventions: . therapy referral; sic[brand name anti-slip mat] mat. A record review of Resident #9's nursing progress notes revealed LVN A documented on 3/4/2025 that Resident #9 had fallen out of her wheelchair; . Resident Statement: I was sitting in my wc sic[wheelchair] and I was undoing the blankets on my bed and since I was wearing my socks only I slipped and fell out of my wc . During an observation and interview on 12/9/2025 at 11:30 AM revealed Resident #9 in her bedroom seated in her wheelchair. Resident #9 stated she would like her red anti-slip mat back onto her wheelchair. Resident #9 stated she had her wheelchair washed last week and it was returned without her red mat. Resident #9 stated the mat helped her to not slip out of her wheelchair which, in the past, she had fallen out of her wheelchair. Resident #9 leaned over slightly to demonstrate there was no red mat on the wheelchair seat. During an observation and interview on 12/10/2025 at 8:00 AM revealed Resident #9 in her bed with her wheelchair at the bedside. Observation of the wheelchair seat revealed no anti-slip mat. Resident #9 stated she had been asking staff for her red mat and pointed out the mat was still missing from her wheelchair seat. During an interview on 12/11/2025 at 5:30 AM CNA B and CNA C stated they were CNAs during the daily 10:00 PM to 6:00 AM shift. CNAs B and C stated they would provide care for Resident #9 to include assistance in transferring Resident #9 from her bed to her wheelchair. CNA B and C stated they were aware Resident #9 was a fall risk but were unaware Resident #9 needed an anti-slip mat on her wheelchair. During an observation, interview, and record review on 12/11/2025 at 5:45 AM LVN D and LVN E stated they were nurses for Residents from 10:00 pm to 6:00 AM. LVN D stated she was the charge nurse for Resident #9 and was aware Resident #9 was a fall risk but was unaware Resident #9 needed an anti-lip mat for her wheelchair seat. LVN E stated she was aware Resident #9 was a fall risk and needed an anti-slip mat on her wheelchair seat but was unaware the mat was missing. LVN D reviewed Resident #9's care plan and revealed Resident needed an anti-slip mat for her wheelchair seat. LVN D was observed to go to Resident #9's room and assessed Resident #9 in bed with her wheelchair nearby. Resident #9 awoke and reported to LVN D that her anti-slip mat was missing since the wheelchair was washed last week. LVN D checked the wheelchair and stated the ant-slip mat was missing. LVN D stated she would replace the mat prior to Resident #9's use of the wheelchair. LVN D stated without the anti-slip mat Resident #9 was at risk for slipping out of her wheelchair. During an interview on 12/11/2025 at 2:04 PM the Administrator and the DON stated they had received a report from LVN D that Resident #9 did not have her anti-slip mat on her wheelchair seat; however, LVN D replaced the anti-slip mat immediately prior to Resident #9 using the wheelchair. The DON stated Resident #9 was at risk for falls and was prescribed to use an anti-slip mat to her wheelchair to mitigate any potential fall out of the wheelchair. The DON stated the lack of a wheelchair anti-slip mat could have potential to contribute to a slip out of the wheelchair. The DON and the administrator stated the nurses and CNAs had the responsibility to ensure residents received care according to their care plans and had the responsibility to report any discrepancies in the care provided. A policy for the failure to have an anti-slip mat on a wheelchair was requested on 12/12/2025 at 1:27 PM and as of 12/20/2025 was not received.

Based on interviews and record reviews the facility failed to ensure medical records were maintained completely, accurately documented, readily accessible, and systematically organized per professional standards for 2 of 8 residents (Residents #9 and #76) reviewed for accurate medical records. Resident #76's hospital discharge documents were stored in Resident #9's medical record. This failure could place residents at risk of harm by keeping inaccurate records. The findings included:Resident #9A record review of Resident #9's admission record dated 12/10/2025 revealed an admission date of 3/21/2025 with diagnoses which included a history of falling, syncope and collapse (fainting), and difficulty walking. A record review of Resident #9's annual MDS assessment dated [DATE] revealed Resident #9 was a [AGE] year-old female admitted for LTC and assistance with safety assistance and supervision related to her being assessed as a fall risk and history of falling. Resident #9 was assessed with a BIMS score of 12 out of a possible 15 which indicated moderate cognitive impairment. Resident #9 was assessed with adequate hearing and poor vision and used glasses. Resident #9 was assessed with the ability to usually understand others and could usually make herself understood. Resident #9 was assessed with the need to use a wheelchair. Resident #76A record review of Resident #76's admission record revealed an admission date of 10/3/2025 with a discharge date of 10/20/2025 with diagnoses which included chronic obstructive pulmonary disease and anxiety disorder. A record review of Resident #76's discharge MDS assessment dated [DATE] revealed Resident #76 was a [AGE] year-old female admitted for rehabilitation care and after 17 days was discharged to her home with home healthcare. A record review of Resident #9's scanned medical records revealed a 13 page hospital discharge document for Resident #76, dated 10/3/2025. During an interview on 12/12/2025 at 7:30 AM Medical Records I (MR I) stated she was the was the staff member assigned to electronically scan Residents' documents into MR I stated she was given many boxes of documents to scan and felt overwhelmed and has been scanning records every day since and has currently caught up with the demand for scanning records as they are developed. MR I stated she had recognized she made mistakes in scanning the wrong records into the wrong residents' medical records. MR I stated her supervisors were DON and the Administrator and they were responsible for ensuring her training and supervision for accurate records. During an interview on 12/12/2025 at 11:40 AM the DON and the Administrator stated they were the supervisors for MR I and had recognized MR I had made some mistakes in scanning medical records. The administrator stated the facility would develop and implement an audit tool to ensure accurate medical records were scanned. The DON and the Administrator stated the failure to have accurate medical records could be potentially inaccurate records. A record review of the facility's undated Documentation policy revealed, Documentation is the recording of all information, both objective and subjective, in the clinical record of an individual resident and or soft resident file. It may include observations, investigations, and communications of the resident involving care and treatments. It has legal requirements regarding accuracy and completeness, legibility and timing. Special forms in the clinical record are utilized in nursing documentation, such as assessment, care plan, nursing progress notes, flow sheets, medication sheets, incident reports, and summary sheets (daily, weekly, monthly, discharge). Documentation also occurs in the clinical software sic[name brand of medical record]. All documentation and clinical records are confidential and can be released only with signed permission of the resident or legal representative.Goal1. The facility will maintain complete and accurate documentation for each resident on all appropriate clinical record sheets.

Based on the interviews and record review, the facility failed to review and revise Resident Care Plans after each assessment for 1 of 3 Residents (Resident # 1) whose records were reviewed for care plan revision/timing, The kardex of Resident # 1 was not updated to reflect the required extensive assistance with 2 persons for transfers via mechanical lift . These deficient practices could affect any resident and contribute to the Residents not receiving the care and services they need. The findings included: Record review of Resident # 1's face sheet dated 5/6/25 revealed an [AGE] year-old female admitted to the facility on [DATE], readmitted [DATE] with the diagnosis that included: anxiety disorder (mental illness characterized by feelings of uneasiness, worry, and fear), Communication deficit (impairment in the ability to receive, send, process, and comprehend concepts of verbal, nonverbal communication), and dementia (loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities). Record review of the quarterly MDS assessment, 1/29/25, revealed a BIMS score of 3, which indicated severe cognitive impairment. Section G revealed Resident #1 required extensive assistance with 2 persons for transfers. Record review of the Kardex for resident # 1, dated 3/08/25, revealed a care plan with focus area [ resident's name is at risk for falls] interventions: staff X 2 to assist with transfers via mechanical lift. Interview with CNA ( A ) on 5/5/25 at 11:15 AM revealed that on 3/7/25, when she transferred Resident # 1 from the wheelchair to bed, Resident #1's transfer status was X1 on the Kardex. Interview on 5/07/2025 at 2:30 PM, the MDS nurse stated she had not updated the Kardex for Resident #1 regarding transfer status, staff X 2 to assist with transfers via mechinical lift lift until 3/8/25, as it was missed during audits. She emphasized failing to update these care plans/kardex might prevent staff from being aware of Resident #1's transfer status, potentially injuring Resident #1. The MDS nurse stated it was her responsibility to update the Kardex to reflect the transfer status. Interview on 5/7/2025 at 11:00 a.m., the DON stated the MDS nurse should have updated Resident #1's Kardex to reflect extensive assistance with 2 persons for transfers via mechinical lift as soon as the Quarterly MDS assessment was completed 1/29/25. She added her ADON was responsible for overseeing care plans, and she audited them at random as failure to update Kardex timley could negatively affect Residents. Record review of the facility policy, titled Comprehensive Care Planning, undated, revealed . The resident care plan will be reviewed after each admission, quarterly, annually, and/or a significant change in MDS assessment, and revised based on the changing goals, preferences, and needs of the resident and in response to current interventions.

Based on observations, interviews, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 2 residents (Resident #1) reviewed for accident hazards and supervision, On 03/07/2025, Resident #1 was transferred by CNA (A) using a standing pivot transfer x 1 staff instead of a mechanical lift. During transfer, Resident #1 was injured, resulting in a laceration to the left lower calf requiring 13 stitches. The non-compliance was identified as past non-compliance. The PNC began on 3/7/25 and ended on 3/09/25. The facility had corrected the non-compliance before the survey began. This failure could lead to injury or death to residents. Findings included: Record review of Resident # 1's face sheet dated 5/6/25 revealed an [AGE] year-old female admitted to the facility on [DATE], readmitted [DATE] with the diagnoses that included: anxiety disorder (mental illness characterized by feelings of uneasiness, worry, and fear. Communication deficit (impairment in the ability to receive, send, process, and comprehend concepts of verbal, nonverbal communication), and dementia (loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities). Record review of the quarterly MDS assessment, 1/29/25, revealed a BIMS score of 3, which indicated severe cognitive impairment. Section G revealed Resident #1 required extensive assistance with 2 persons for transfers. Record review of the Care plan for resident # 1, dated 3/08/25, revealed a care plan with focus area [ resident's name is at risk for falls] interventions: staff X 2 to assist with transfers via mechinical lift . Record review of the progress note for Resident # 1, dated 03/07/2025, revealed on 03/07/2025 at 12:45 PM, [CNA A] transferred [Resident #1] from the chair to the bed and left leg rubbed against bed frame. [Resident #1] voiced that her leg hurt. Further review revealed Resident #1 was noted to have an abnormality in the left lower leg, and the resident was transferred to the local hospital for treatment. Record review confirmed that [Resident #1's] MDS assessment , dated 3/7/2025 was a staff X 2 to assist with transfers via mechinical lift. Record review of a progress note, dated 03/07/2025 at 12:45 PM, revealed, This nurse was called into the residents' room by CNA (A), left lower extremity assessed, and [Resident #1] was able to state where the pain was, and 911 was called. Record review of Resident #1's hospital discharge records dated 3/7/25 revealed that Resident # 1 received 13 stitches to the left lower leg. During an Interview with the DON on 05/07/2025 at 1:25 PM, the DON stated CNA (A) should have transferred Resident #1 using two staff members with a mechanical lift as per Resident #1's MDS assessment. The DON also stated residents may be injured if CNAs do not follow the MDS assessment. Interview with CNA (A) on 5/7/2025 at 9:58 AM revealed she transferred Resident #1 without using a mechanical lift, opting for a single-person pivot transfer. She had previously used the lift but was unaware it was indicated in the MDS assessment. As a result of the incident, she was suspended for one day and retrained on locating the Kardex /Care plan. During a follow-up interview on 5/8/2025 at 8:02 AM , CNA (A) reported that Resident #1 complained of pain in her left lower leg after the transfer, and blood was observed on the left lower calf. Record review of the facility's policy titled, Hydraulic Lift, undated, revealed, The Resident will achieve safe transfer to bed or chair via mechanical lift device. The Administrator was notified on 05/08/2025 at 1:00 PM that a past non-compliance was identified due to the above failure. The facility implemented the following interventions before the survey entrance on 05/05/2025. During an interview with the DON on 5/06/25 at 2:18 PM, the DON stated the facility implemented a system for PRN (as needed) staff to review forms before their shift to identify each resident's care needs. Record review of in-service training titled, How to use Kardex in EMAR /Report change of condition to charge nurse, dated 03/7/2025 to 03/09/2025, showed that 36 of 36 staff members, and 2 of 2 PRN staff (as needed) completed the in-service training. Further, review revealed the in-service training addressed: CNAs look at Kardex, mechinical lift's to be used if indicated for two-person assist, where to find POC (Plan of Care), competencies, and demonstration of mechanical lift transfers. Interviews with 12 staff members on 05/6/25 from 11:00 a.m. to 1:00 p.m. the following staff [CNA (B), CNA (C), CNA (D), CNA (E), CNA (F), CNA (G), CNA (H), MA (I), CNA (J), CNA (K), CNA (L), CNA (M)] confirmed completion of in services/training: Always Follow the POC (Plan of Care), the CNA's look at the Kardex, mechanical lifts to be used if it is indicated 2 people assist,and where to find the POC (Plan of Care. The Staff were able to verbalize understanding and information provided in the in-service/training. Observation on 05/6/25 at 10:30 AM confirmed MA (N) and LVN (O) transferred Resident #2 using a two-staff mechanical lift transfer. Observation on 5/6/25 at 7:10 AM confirmed CNA (P) and LVN (Q) transferred Resident #3 using a two-staff mechanical lift transfer. The non-compliance was identified as past non-compliance. The PNC began on 3/7/25 and ended on 3/09/25. The facility had corrected the non-compliance before the survey began.

Based on interviews and record reviews the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown sources were reported immediately to the administrator of the facility and to other officials, including to the State Survey Agency in accordance with State law through established procedures, for 1 of 3 Residents (Resident #1) reviewed for Neglect, The facility did not report an allegation of neglect per facility policy to the State Survey Agency (HHSC) when Resident # 1 received an injury to the left lateral calf occurred. This deficient practice could affect any resident and could contribute to further neglect. The findings were: Record review of Texas Unified Licensure Information Portal (TULIP) on 5/6/25 at 1:50 P.M. revealed no self-reported incidents regarding allegations of Neglect were reported for Resident # 1 . Record review of Resident # 1's face sheet dated 5/6/25 revealed an [AGE] year-old female admitted to the facility on [DATE], readmitted [DATE] with the diagnosis that included: anxiety disorder (mental illness characterized by feelings of uneasiness, worry, and fear) , Communication deficit (impairment in the ability to receive, send, process, and comprehend concepts of verbal, nonverbal communication), and dementia (loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities). Record review of the quarterly MDS assessment, 1/29/25, revealed a BIMS score of 3, which indicated severe cognitive impairment. Section G revealed Resident #1 required extensive assistance with 2 persons for transfers. Record review of Resident #1's progress note, dated 3/7/25, revealed injury to left lower calf 10 cm X 1 cm X 0.5 cm, sent to [local hospital] for evaluation and treatment. Record review of Resident #1's care plan dated 3/7/25, revealed [Resident's name has a laceration to left lateral calf] interventions: perform wound care as ordered. Record review of resident #1's hospital discharge instructions, reviewed 5/5/25 at 10:30 AM, dated 3/7/25, revealed that resident #1 received 13 stitches on the left lower calf. Interview with CNA (A) on 5/6/25 at 10:20 AM revealed she transferred Resident # 1 from the wheelchair to the bed with X 1 assist when the resident's left leg caught on the bed rail. She did not notice the injury to Resident #1's left leg until Resident #1 was in bed, and this was when she notified LVN (B) . Interview with LVN (R) on 5/6/25 at 10:52 AM revealed she was the nurse on duty on 3/7/25 when CNA (A) notified her of the injury to Resident #1's left lower leg. She notified MD, who ordered Resident # 1 to be sent to the local ER. Interview with the MD on 5/6/25 at 1:34 PM revealed he was notified by LVN(R) on 3/7/24 regarding the injury to the left lower leg of Resident # 1, and he ordered for Resident # 1 to be sent to the local ER for an evaluation. During an interview with the DON on May 6, 2025, at 11:15 AM, she shared LVN (R) had reached out to her on March 14, 2025, about an injury to Resident #1's left lower leg. The DON also noted she promptly informed the Administrator about this incident. In a follow-up interview with the DON on the same day at 11:30 AM, she emphasized it was the Administrator's role to report any neglect allegations to HHSC, which was why she did not take the step to report the leg injury for Resident #1. Nonetheless, she conveyed she felt strongly that any allegations of neglect should indeed be reported , to help those responsible accountable for their actions if required. Interview with the Administrator on 5/06/25 at 12:45 P.M. revealed he did not report the injury involving Resident #1, as the incident was witnessed. However, upon reviewing the neglect guidelines from HHSC, he acknowledged he should have reported the incident. Record review of facility policy titled, Abuse, Neglect: , dated 9/9/24, , reflected, The Facility will report and cooperate with any investigations concerning reports of abuse, neglect, exploitation, mistreatment of residents, misappropriation of residents property and injuries of unknown source by the company's employees as outlined in state law ( including to the state survey and certification agency ) .

Based on interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 4 residents (Resident #64) reviewed for assessments, in that: The facility failed to ensure Resident #64's Quarterly MDS assessment incorrectly documented the resident as not receiving hospice care. This failure could place residents at risk for inadequate care due to inaccurate assessments. The findings were: Record review of Resident #64's face sheet, dated 09/18/2023, revealed the resident was [AGE] years old with an admitted [DATE] and a readmitted [DATE], Resident #64's with diagnoses that included: Osteomyelitis(a serious infection of the bone that can be acute or chronic) , unspecified, Type II diabetes Mellitus with unspecified complications, End Stage Renal Disease. Record review of THHS Texas Medicaid Hospice Program Individual Election/Cancellation/Update Form 3071 revealed Resident #64 elected hospice services effective 05/14/2024. Record review of Resident #64's Quarterly MDS dated [DATE] revealed a BIMS score of 10 indicating moderate cognitive impairment, and resident was not receiving hospice services. During an interview with the MDS nurse on 09/18/2024 at 11:58 AM, the MDS nurse stated she had completed the MDS. The MDS nurse stated Resident #64's Quarterly MDS was coded as the resident not receiving hospice services and confirmed Resident #64 readmitted to the facility on [DATE] under Hospice. MDS nurse confirmed that MDS should have been completed as a Significant Change MDS and reflected hospice election. The MDS nurse revealed that the RAI was used as reference for the MDS and she had access electronically to the RAI on her computer. During an interview with the DON on 09/19/24 at 12:18 PM, the DON stated Resident #64 was receiving hospice services and should have been coded as receiving hospice services on a Significant Change MDS. The DON confirmed the RAI is used as reference for the MDS and expected MDS Nurse follow the RAI reference. The MDS Nurse was responsible for ensuring accurate coding and the DON was responsible to review for accuracy. Record review of, Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.19.1, September 2024, revealed, An SCSA is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains resident at the nursing home.

Based on observations, interviews, and record reviews the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 9 residents (Resident #34) reviewed for treatments and care related to enteral access devices. The facility failed to ensure medications were administered according to acceptable standards and practices related to enteral access devices when Resident #34's medications were not dissolved in water for administration with a flush between each medication administered. These failures could place residents with enteral access devices at risk of not receiving the intended therapeutic effects of medications, having medical complications, or complications related to utilization of enteral access devices, potentially leading to a decline in health and well-being. Findings included: Record review of the Admission Record revealed Resident #34 was a [AGE] year-old male, originally admitted on [DATE] . Record review of the quarterly MDS assessment dated [DATE] revealed Resident #34 had a BIMS summary score of 9, indicative of moderately impaired cognition. Resident #34's primary reason for admission was cerebral infarction, unspecified [a type of stroke caused by blood clot or hemorrhage in the brain]. Other active diagnoses included seizure disorder and malnutrition. Nutritional approaches included feeding tube, with more than 51% of calories and 501 ml or more fluid intake received thru the feeding tube per day. Record review of the Order Summary Report printed on 09/18/2024 revealed: flush enteral tube with 30 ml of water between each medication; flush enteral tube with 60 ml of water before and after medication and feedings; with a start date of 02/25/2021 Medications included: metoprolol [for high blood pressure] the a start date of 07/08/2021, aspirin [for stroke] with a start date of 01/20/2023, Keppra [for seizures] with a start date of 11/04/2022, folic acid [for supplement] with a start date of 09/08/2024, Celexa [for depression] with a start date of 04/27/2022, losartan [for high blood pressure] with a start date of 02/26/2021, multivitamin [for malnutrition], and thiamine [for supplement] ] with a start date of 02/26/2021. Record review of the Care Plan revealed Resident #34 had the following focus areas: seizure disorder, high blood pressure, potential for pressure injury, potential fluid deficit, on psychotropic medication related to depression, seasonal allergies, muscle spasms, and polyneuropathy [nerve damage at multiple sites can result in chronic and acute pain]; with the following associated interventions: give medications as ordered with a date initiated of 02/25/2021. In an observation on 09/18/2024 at 7:45 AM, LVN A prepared medications for Resident #34 by individually crushing each tablet or pill and pouring liquids in separate souffle cups for administration via the enteral access device. The medications were not mixed with water to dissolve. The [NAME] tions included metoprolol tartrate 25 mg, give 0.5 tablet [given for high blood pressure]; aspirin 81 mg [given for history of stroke]; Keppra 7.5 ml solution [given for seizures]; folic acid [for supplement]; Celexa 10 mg, give 0.5 tablet [given for depression]; Losartan 25 mg [given for high blood pressure]; fexofenadine 180 mg [given for seasonal allergies]; multivitamin, and thiamine [given for supplemental nutrition. In an observation on 09/18/2024 beginning at 7:55 AM, LVN A assessed the placement of the enteral access device for Resident #34 by aspiration with no fluids returned. LVN A flushed the enteral access device with 60 ml of water. When the water level got to near the bottom of the syringe, approximately 1 to 3 ml of water, LVN A then added the powder of the first crushed medication to the syringe, then added the 30 ml of water flush to the syringe. As the water and medication mixture then drained into the enteral access device, LVN A then added the powder from the next crushed medication to the last 1 to 3 ml mixture of water and previous medications to the syringe, adding the 30 ml flush of water after. Powder residue could be observed at the top of the 60 ml syringe, and at one point a brownish-beige frothy particulate could be seen coating the walls of the barrel of the syringe. LVN A swirled the syringe while attached to the enteral access device to have all the solid matter trapped by water and drain down the syringe into the enteral access device. After each medication was added to the dregs of the liquid in the barrel, LVN A added 30 ml water, including when she administered the liquid Keppra solution. After the last medication was administered LVN A flushed the syringe with 60 ml of water, clamped the enteral access device, capped the distal end of the enteral access device, and replaced the tube under Resident #34's shirt. In an interview on 9/18/2024 at 8:00 AM, Resident #34 stated he did not want breakfast and declined the supplement. Resident #34 stated he would see what was on the breakfast tray when it arrived, and he would decide then if he was hungry enough to eat. In an interview on 9/18/2024 at 8:03 AM, LVN A stated that either method, mixing the powder of a crushed medication in a few ml of water to dissolve or adding it directly to the syringe, would be correct. LVN A stated that adding the powder of a crushed medication directly to the syringe is how she almost always administered medication to an enteral access device, unless there were specific orders to do it differently. In an interview on 9/18/2024 at 8:40 AM, the DON stated she believed an enteral medication could be added directly to the syringe once crushed as long as there was still some liquid at the bottom of the syringe, and then immediately added the flush as per MD orders. In an interview on 9/18/2024 at 11:35 AM, R.Ph. stated that the order of operations for an enteral tube medication administration should be: 1.) check tube placement first [aspiration of fluids from the enteral access device to visually inspect color and character]; 2.) ensure patency [being unclogged, allowing flow] with a flush in the amount of water as ordered by the MD; 3.) crush each suitable tablet or pill into its own souffle cup with 10 to 15 ml of water; 4.) allow each medication to flow by gravity; 5.) after each medication flush in the amount of water as ordered by the MD; 6.) repeat as necessary and after the last medication flush in the amount of water as ordered by the MD. R.Ph. stated the initial and final flushes at the beginning and end of a medication administration were usually slightly larger, but depended on the amount the MD determined was appropriate. R.Ph. stated the frothy brownish beige particulate was most likely not a reaction between medications, but more likely the inert ingredients coming in contact with air, water and turbulence. R.Ph. stated she would have to review the resident's profile to give more specific details. R.Ph. stated she would call me back in about an hour as she was driving and en route to another facility at the time of the interview. In an interview on 9/18/2024 at 12:26 PM, the MD stated Resident #34 had originally been admitted for stroke some time back, but recently exhibited stroke like symptoms. The MD stated Resident #34's diagnostics came back as negative for a stroke; however, he had more difficulty with speech and swallowing after the stroke like symptoms were noted; which was why Resident #34 had an enteral access device placed. The MD stated he was not sure if the resident was quite at the point where he could take his medications by mouth, crushed in a puree at this point, but that was something therapy was working towards with him. The MD stated he did not believe there was much of a risk in the small amount of medications being mixed in the syringe as described in the observation above. The MD stated there would be some expectation of medication residual in the souffle cup if the medication had been dissolved in water that would approximate the amount of medication observed at the top of the syringe as described in the observation above. The MD stated his expectation was that the crushed medications be dissolved in a small amount of water and flushed as per orders. MD stated that he would consult with the pharmacist for best practice on this issue in regard to Resident #34. In an interview on 9/18/2024 at 2:37 PM, R.Ph. stated that she had reviewed the medication profile for Resident #34, and she did not see any medications that would have an adverse reaction if administered in the fashion as described in the observation above. R.Ph. stated that the best practice would be to place a medication in pill or tablet form in a syringe with 15 to 30 ml of water and allow it to become a slurry [semiliquid mixture of denser solids suspended in liquid] over approximately 20 minutes. Alternatively, medications could be dissolved in a small amount of water for administration via an enteral access device and followed with a prescribed amount of water to ensure the medication reaches the resident and does not interfere with the patency of the enteral access device. Record review of the facility's policy entitled Enteral Medication Administration, revised 1/25/2013, reflected the following procedure: flush the tube with 30 ml or according to physician order; administer one medication at a time, with a flush of 5-10 ml water or the amount ordered by the physician, between each medication and after the medication is administered; verify that the medication cups are clear of any remnants of crushed pills or liquid medication; once all medications have been administered flush the tube with 30 ml of water or according to the physician order. Review of website Nursing 2024, article titled Administering medication through a gastrostomy tube, dated December 2022, accessed from Nursing202https://journals.lww.com/nursing/fulltext/2002/12000/administering_medication_through_a_gastrostomy.14.aspx4 (lww.com), accessed on 09/20/2024, revealed: .Release the GT [enteral access device] clamp. To verify tube placement and patency, aspirate for gastric contents, note the residual volume, and follow your facility's policy for re-instilling it . let the water flow by gravity to flush it .Pour the diluted medication into the syringe and release the tubing to administer it. If you're giving more than one drug, flush between each dose with 15 to 30 ml of water. When finished, flush with 30 ml of water, clamp the GT, and replace the plug . Review of ASPEN Safe Practices for Enteral Nutrition Therapy, accessed from https://aspenjournals.onlinelibrary.[NAME].com/doi/10.1177/0148607116673053, accessed on 09/2024, In Step 11 of Practice Recommendations, under the subheading for Medication Delivery via Enteral Access Devices [feeding tubes], it states Prepare approved immediate-release solid dosage forms of medication for enteral administration according to pharmacist instructions. Techniques may include: a. Crush simple compressed tablets to a fine powder and mix with purified water. b. Open hard gelatin capsules and mix powder containing the immediate release medication with purified water. Further, recommendations are to avoid mixing together different medications intended for administration through the feeding tube [enteral access device]; Inappropriate utilization of the feeding tube can result in complications include impairing the patency of the feeding tube, reducing therapeutic effect of the medication, or increasing drug toxicity; Complications include impairing the patency of the feeding tube, reducing therapeutic effect of the medication, or increasing drug toxicity.

Based on observation, interview, and record review the facility failed to ensure the assessment accurately reflected the resident's status for 2 (Resident #1 and #2) of 5 residents reviewed for accuracy of assessments. 1. The facility failed to ensure Resident #1 was coded on his Quarterly MDS, dated [DATE] for a fall with major injury that occurred on 01/18/2024. 2. The facility failed to ensure Resident #2 was coded on her Quarterly MDS, dated [DATE] for a fall with major injury that occurred on 05/21/2024. This failure could place residents at risk of improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being. The findings included: 1. Record review of Resident #1's Admission Record, dated 07/11/2024, reflected Resident #1 was admitted on [DATE] and was [AGE] years old. Resident #1 discharged on [DATE] to another nursing home. Resident #1 had diagnoses of cerebral infarction (a disruption in the brain's blood flow), dementia (a general term for impaired ability to remember, think, or make decisions), and heart failure (heart muscle is weakened and cannot pump enough blood to meet the body's needs). A diagnosis of fracture of right pubis (break in the right bone of the pelvis) was noted with onset date of 01/18/2024 and classified as during stay. Record review of Resident #1's Event Nurses' Note, dated 01/18/2024, reflected Resident #1 had an unwitnessed fall in his room on 01/18/2024 at 07:15 a.m. Under Resident statement, Resident #1 was noted as stating that he fell when walking back to bed after toileting himself. Resident #1 stated he got himself up and back into the bed. The event note reflected Resident #1 was assessed and found to have had a 1.0 cm by 05 cm abrasion on his right elbow and complained of pain to his right buttocks and right leg. Resident #1 was noted to have been sent to the local hospital for evaluation and treatment. Record review of Resident #1's local hospital discharge paperwork, dated 01/18/2024, reflected a CT (an imaging procedure using x-rays to create detailed images of bones and soft tissues) Scan Report, noted date of service 01/18/2024, reflected a CT of the pelvis bone was performed on 01/18/2024 due to history of a fall. The impression revealed a nondisplaced fracture (bone cracked but did not move or change alignment) of the right inferior pubic ramus. Record review of Resident #1's Quarterly MDS, dated [DATE] reflected Resident #1 had a BIMS (Brief Interview of Mental Status) score of 7 indicating he was moderately impaired, he required partial/moderate assistance for transferring from lying to sitting on the side of the bed or sitting to standing; and he had no falls since admission/entry or reentry or the prior assessment. Record review of Resident #1's Quarterly MDS, dated [DATE] reflected Resident #1 had a BIMS (Brief Interview of Mental Status) score of 5 indicating he was moderately impaired, he required partial/moderate assistance for transferring from lying to sitting on the side of the bed or sitting to standing; and he had no falls since admission/entry or reentry or the prior assessment. Record review of Resident #1's comprehensive care plan, dated as closed 04/22/2024, reflected: - Resident #1 had an abrasion to his right elbow. The focus was initiated 01/18/2024. - Resident #1 had a right inferior pubic ramus (right lower section of the pelvis bone) fracture. The focus was initiated 01/18/2024. 2. Record review of Resident #2's Admission Record, dated 07/11/2024, reflected Resident #2 was initially admitted on [DATE], readmitted on [DATE], and was [AGE] years old. Resident #2 had diagnoses of systolic (congestive) heart failure (heart failure in which the left side of the heart cannot pump blood efficiently), muscle wasting and atrophy (shrinking of muscle or nerve tissue), lack of coordination, unsteadiness on feet, and mild cognitive impairment of uncertain or unknown etiology (mild difficulty with language, memory, and thinking with an unknown case). A diagnosis of fracture of unspecified part of right clavicle for closed fracture (a break in part of the right collarbone where the broken bone did not penetrate the skin) was noted with onset date of 05/21/2024, classification was blank. Record review of Resident #2's Event Nurses' Note- Bruise, dated 05/21/2024, reflected Resident #2 had a noted bruise on the right side of her neck/collar bone during a routine shower on 05/21/2024. Resident #2 was noted at the time of the event as cognitively impaired, required cueing, and combative. The event note reflected Resident #2 was assessed, the bruise was noted as purple discoloration with swelling and the resident verbalized pain with touch on site. Resident #2 was noted to have been sent to the local hospital for evaluation and treatment. Record review of Resident #2's local hospital discharge paperwork, dated 05/24/2024, reflected a CT Scan Report, noted date of service 05/21/2024, reflected a CT of the chest was performed on 05/21/2024 due to history of right clavicle trauma. The impression reflected a comminuted and mildly displaced right medial clavicular fracture with extension into the sternoclavicular joint (a break in at least two places on the right part of the collarbone, in the part of the bone close to the breastbone, and the breaks resulted in the bones only slightly not lining up straight). Record review of Resident #2's Quarterly MDS, dated [DATE] reflected Resident #2 had a BIMS score of 5 indicating she was moderately impaired, she required set-up or clean-up assistance with walking, substantial/maximal assistance for showers/baths, supervision or touching assistance for transferring from lying to sitting on the side of the bed, sitting to standing, chair/bed-to-chair transfers, and toilet transfers; and she had no falls since admission/entry or reentry or the prior assessment. Record review of Resident #2's Quarterly MDS, dated [DATE] reflected Resident #2 had a BIMS score of 3 indicating she was moderately impaired, she required substantial/maximal assistance for showers/baths, transferring from lying to sitting on the side of the bed, chair/bed-to-chair transfers, and toilet transfers; and she had two or more falls since admission/entry or reentry or the prior assessment but without injury. Resident #2's mobility for as sitting to standing and walking was coded as not attempted due to medical condition or safety concerns. Record review of Resident #2's comprehensive care plan, accessed 07/11/2024, reflected: - Resident #2 had a bruise to right side of neck/collar bone area with closed clavicle fracture. The focus was initiated 05/21/2024. An observation and attempted interview with Resident #2 on 07/11/2024 at 03:44 p.m., revealed Resident #2 was in her bed laying down, well dressed, and groomed. Resident #2's bed was in low position, against the wall on her left side, a fall mat was placed on the floor to the right side of the bed, and Resident #2's call light was pinched to mattress sheet and within reach, and side table was within reach. Resident #2 refused interview upon request. During an interview on 07/11/2024 at 04:36 p.m., the MDS Nurse stated that she was responsible for updating and reviewing the resident care plans and MDS Assessments. The MDS Nurse stated that after a resident fall, the resident would be screened by the therapy department and if the therapy department determined the resident's need for therapy services, she would complete an assessment and update the resident's care plan. The MDS Nurse stated that if a fall occurred within the lookback period or period of time designated to review between assessments, she would code the fall. The MDS Nurse stated that if Resident #1's fall occurred within that lookback period and if he was sent out to the local hospital for assessment and treatment, his fall should have been coded. The MDS Nurse stated Resident #1's fall should have been coded under the J section on the MDS Assessment for falls and that it would have been considered a major injury. She stated Resident #2's injury should have been coded on her last quarterly assessment. The MDS Nurse stated that because Resident #1 and Resident #2's injuries were care planned the impact of the MDS assessment having not been coded accurately would not have been a big deal, stated it would only have been a documentation issue. During an interview on 07/11/2024 at 05:59 p.m., the MDS Nurse stated she inaccurately coded Resident #2's fall. She stated she coded that Resident #2 had two (2) or more falls but not that Resident #2 had a major injury. She stated for Resident #1, she did not document the Resident #1's fall with fracture, which was a major injury. She stated that she would usually review resident orders and events, where the nurses document a resident fall but had missed Resident #1's fall with injury when completing his quarterly assessment in March 2024. During an interview on 07/11/2024 at 06:38 p.m., the DON stated the nursing staff do not refer to the MDS assessments for interventions, only the care plan. She stated that she did not think the MDS having been coded inappropriately would have impacted the residents' (Resident #1 and Resident #2) care provided by the direct care nursing staff, as long as the care plan was updated with the appropriate interventions. She stated that she believed the inaccurate MDS coding would only impact the communication with the state on how much assistance both the residents (Resident #1 and Resident #2) would have required. During an interview on 07/11/2024 at 07:35 p.m., the ADMIN stated his understanding was that the MDS Assessment coding impacted financial reimbursement to the facility for resident care services, so as long as the care plan was updated appropriately, the care provided to the residents (Resident #1 and Resident #2) would not have been impacted. The ADMIN stated the impact would have been that the facility would have received less compensation for services. Record review of facility policy, 4. Minimum Data Set (MDS) Policy for MDS assessment Data Accuracy 2.2021 revealed The purpose of the MDS policy is to ensure each resident receives and accurate assessment by qualified staff to address the needs of the resident who are familiar with his/her physical, mental, and psychosocial well-being .Federal regulations at 42 CFR 483.20 (b) (1)(xviii), (g), and (h) require that: 1. The assessment accurately reflects the resident's status.

Based on observation, interview, and record review the facility failed to post daily information that included the facility name, current date, total number and actual hours worked by registered nurses, licensed practical or licensed vocational nurses, certified nurse aides directly responsible for resident care per shift and the resident census. The facility did not post the required current nurse staffing information from 07/05/2024 to 07/11/2024. This failure could place all residents, their families, and facility visitors at risk of not having access to information regarding staffing data and the facility census. Findings included: Observation on 07/11/2024 at 10:30 a.m., revealed a document labeled [facility name] Direct Care Posting dated 07/04/2024, was posted on a wall across from the nurses' station. During an interview on 07/11/2024 at 10:31 a.m., the ADMIN confirmed the posted nurse staffing document was dated 07/04/2024. The ADMIN stated he believed the staffing document was supposed to be posted every morning around 10:00 a.m. The ADMIN stated the document had not been posted for several days. During an interview on 07/11/2024 at 10:56 a.m., the ADMIN stated he had misspoken earlier and that the night shift charge nurse was responsible for posting the daily census and staffing document. The ADMIN confirmed the night shift charge nurse had not posted the document for several days. During an interview on 07/11/2024 at 06:38 p.m., the DON stated that the night shift was responsible for posting the daily census and nurse staffing document. The DON stated the night shift charge nurse was new and had been putting the document in the ADON's box, who had been out for vacation and therefore did not know the document was there. The DON stated that the failure to post the census and nurse posting information daily would impact the facility's communication with residents, who are cognitively aware, and visiting resident families or guests who would look for that information when visiting the facility. During an interview on 07/11/2024 at 07:35 p.m., the ADMIN stated he was unsure on what the impact of not posting the facility's daily census and nurse staffing would be. The ADMIN stated he reached out to the facility's corporate office for a policy regarding the posting of daily census and nurse staffing and was told that the facility did not have a specific policy, just that the facility was to follow the federal and state regulations.

Based on observations, interviews, and record reviews, the facility failed to ensure residents are free of any significant medication errors, for 2 of 3 residents (Residents #20 and #48) reviewed for medication administration, in that: 1. MA D attempted to administer to Resident #20, midodrine [a medication designed to raise a person's blood pressure] while Resident #20 was assessed with high blood pressure. Also, during the same attempt MA D attempted to concurrently administer midodrine [a drug to raise blood pressure] and antihypertensive medications [drugs designed to lower blood pressure]. 2. Resident #20 was administered midodrine incorrectly 6 times during the period from 08/01/2023 to 08/12/2023 by MA D and LVN F. 3. Resident #48 was administered midodrine incorrectly 23 times during the period from 08/01/2023 to 08/15/2023 by MA D, MA E, and LVN F. This deficient practice placed residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions. The findings included : 1. A record review of Resident #20's admission record dated 08/14/2023 revealed an admitted [DATE] and diagnoses which included hypertensive [high blood pressure] heart and chronic kidney disease. A record review of Resident #20's annual MDS dated [DATE] revealed Resident #20 was an [AGE] year-old female admitted for long term care who was able to understand others and make her needs known. Resident #20 was assessed without mental cognition impairment as evidence by a BIMS score of 13 out of 15. Further review revealed Resident #20 received dialysis therapy. A record review of Resident #20's care plan dated 08/14/2023 revealed, [Resident #20] needs dialysis 3x a week r/t end stage renal disease .[Resident #20] will have no s/sx of complications from dialysis through the review date . Obtain vital signs and weight per protocol. Report significant changes in pulse, respirations and BP immediately A record review of Resident #20's August 2023 physician's orders revealed the physician ordered for Resident #20 to receive midodrine 10mg three times a week, 1 hr. prior to dialysis if her blood pressure was lower than 110 systolic [the first number in a blood pressure reading; systolic/diastolic], Give 1 tablet by mouth one time a day every Tue, Thu, Sat related to end stage renal disease, administer medication one hour prior to dialysis if systolic BP is <110. During an observation and interview on 08/15/2023 at 09:00 AM revealed MA D prepared medications to administer to r esident #20. MA D assessed resident #20's blood pressure as 156/58 with a pulse of 57 and alerted LVN G to reassess Resident #20. LVN G assessed Resident #20 with a blood pressure of 137/62 and a pulse of 70. MA D proceeded to dispense Resident #20's morning medications which included midodrine with an order if the blood pressure was greater than 110 do not give the midodrine. MA D also had dispensed 3 medications prescribed for high blood pressure concurrently MA D dispensed all the medications into a pill cup and gathered a cup of water and attempted to administer the medications when the surveyor actively interrupted the attempt to administer the medications and asked MA D if she intended to administer the medications. MA D stated yes. The surveyor again interrupted the medication administration and asked for MA D to please review the order for midodrine. MA D reviewed the order and removed the midodrine and placed the midodrine in another pill cup and stated she would administer the midodrine later; approximately 1 hour prior to Resident #20's dialysis appointment. MA D then administered the remaining medications to Resident #20 . During an interview on 08/15/2023 at 09:20 AM LVN G stated she was the charge nurse for Resident #20. The surveyor gave LVN G a report of the medication error where MA D tried to administer midodrine concurrently with blood pressure medications prescribed to lower high blood pressure. LVN G stated MA D should not have attempted to administer the midodrine due to the blood pressure assessment for Resident #20 was too high for the midodrine to be administered. LVN G stated she would address MA D . During an interview on 08/15/2023 at 09:34 AM the DON received a report from the surveyor of the medication error where MA D tried to administer midodrine concurrently with blood pressure medications prescribed to lower high blood pressure. The DON stated MA D should not have attempted to administer the midodrine due to the blood pressure assessment for Resident #20 was too high for the midodrine to be administered. The DON stated she would address MA D. The DON stated the risk for harm to Resident #20 was possible heart injury. 2. A record review of Resident #20's August 2023 medication administration record and blood pressure records revealed Resident #20 was administered midodrine outside of physicians ordered parameter, give .if blood pressure is less than 110, 4 times. MA D administered the midodrine outside of physicians ordered parameter as follows: - On 08/01/2023 Resident #20 was assessed in the morning, with a blood pressure of 128/63 and was administered the midodrine. - On 08/03/2023 Resident #20 was assessed in the morning, with a blood pressure of 134/64 and was administered the midodrine. - On 08/08/2023 Resident #20 was assessed in the morning, with a blood pressure of 132/64 and was administered the midodrine. - On 08/10/2023 Resident #20 was assessed in the morning, with a blood pressure of 129/64 and was administered the midodrine. A record review of Resident #20's August 2023 medication administration record and blood pressure records revealed Resident #20 was administered midodrine outside of physicians ordered parameter, give .if blood pressure is less than 110, 1 time. LVN F administered the midodrine outside of physicians ordered parameter as follows: - On 08/12/2023 Resident #20 was assessed in the morning, with a blood pressure of 148/70 and was administered the midodrine. 3. A record review of Resident #48's admission record dated 08/15/2023 revealed an admitted [DATE] with diagnosis which included hypotension [low blood pressure]. A record review of Resident #48's quarterly MDS dated [DATE] revealed Resident #48 was a [AGE] year-old male admitted for long term care. A record review of Resident #48's care plan dated 08/14/2023 revealed, [Resident #48] has potential fluid deficit .[Resident #48] will be free of symptoms of dehydration and maintain moist mucous membranes, good skin turgor . Administer medications as ordered. Monitor/document for side effects and effectiveness. Encourage the resident to drink fluids of choice. A record review of Resident #48's August 2023 physician's orders revealed the physician ordered for Resident #48 to receive midodrine 5mg three times a week, midodrine .Oral Tablet 5mg Give 1 tablet by mouth three times a day for Hypotension Administer if SBP <100 [less than 100]; Hold medication if SBP >100 [is greater than 100; the first number in a blood pressure]. A record review of Resident #48's August 2023 medication administration record and blood pressure records revealed Resident #48 was administered midodrine outside of physician's ordered parameters, give .if blood pressure is less than 100, 4 times. MA D administered the midodrine outside of physician's ordered parameter as follows: -On 08/01/2023 Resident #48 was assessed with a blood pressure of 122/70 and was administered the midodrine at 01:00 PM. -On 08/08/2023 Resident #48 was assessed with a blood pressure of 124/68 and was administered the midodrine at 01:00 PM. -On 08/11/2023 Resident #48 was assessed with a blood pressure of 112/77 and was administered the midodrine at 01:00 PM. - On 08/14/2023 Resident #48 was assessed with a blood pressure of 111/67 and was administered the midodrine at 01:00 PM. A record review of Resident #48's August 2023 medication administration record and blood pressure records revealed Resident #48 was administered midodrine outside of physician's ordered parameters, give .if blood pressure is less than 100, 13 times. MA E administered the midodrine outside of physician's ordered parameter as follows: -On 08/01/2023 Resident #48 was assessed with a blood pressure of 128/70 and was administered the midodrine at 08:00 PM. -On 08/02/2023 Resident #48 was assessed with a blood pressure of 138/68 and was administered the midodrine at 08:00 PM. -On 08/03/2023 Resident #48 was assessed with a blood pressure of 130/68 and was administered the midodrine at 08:00 PM. -On 08/04/2023 Resident #48 was assessed with a blood pressure of 138/68 and was administered the midodrine at 08:00 PM. -On 08/05/2023 Resident #48 was assessed with a blood pressure of 118/60 and was administered the midodrine at 08:00 PM. -On 08/06/2023 Resident #48 was assessed with a blood pressure of 108/62 and was administered the midodrine at 08:00 PM. -On 08/07/2023 Resident #48 was assessed with a blood pressure of 132/70 and was administered the midodrine at 08:00 PM. -On 08/08/2023 Resident #48 was assessed with a blood pressure of 128/66 and was administered the midodrine at 08:00 PM. -On 08/09/2023 Resident #48 was assessed with a blood pressure of 110/66 and was administered the midodrine at 08:00 PM. -On 08/10/2023 Resident #48 was assessed with a blood pressure of 128/70 and was administered the midodrine at 08:00 PM. - On 08/11/2023 Resident #48 was assessed with a blood pressure of 128/70 and was administered the midodrine at 08:00 PM. -On 08/12/2023 Resident #48 was assessed with a blood pressure of 119/70 and was administered the midodrine at 08:00 PM. -On 08/13/2023 Resident #48 was assessed with a blood pressure of 133/78 and was administered the midodrine at 08:00 PM. A record review of Resident #48's August 2023 medication administration record and blood pressure records revealed Resident #48 was administered midodrine outside of physicians ordered parameter, give .if blood pressure is less than 100, 6 times. LVN F administered the midodrine outside of physicians ordered parameter as follows: -On 08/05/2023 Resident #48 was assessed with a blood pressure of 112/70 and was administered the midodrine at 08:00 AM. -On 08/05/2023 Resident #48 was assessed with a blood pressure of 126/64 and was administered the midodrine at 01:00 PM. -On 08/05/2023 Resident #48 was assessed with a blood pressure of 118/60 and was administered the midodrine at 08:00 PM. -On 08/06/2023 Resident #48 was assessed with a blood pressure of 104/62 and was administered the midodrine at 08:00 AM. -On 08/06/2023 Resident #48 was assessed with a blood pressure of 110/64 and was administered the midodrine at 01:00 PM. -On 08/06/2023 Resident #48 was assessed with a blood pressure of 108/62 and was administered the midodrine at 08:00 PM. During an interview on 08/16/2023 at 03:02 PM MA E stated he had been in-serviced by the DON on the drug midodrine to include proper administration. MA E stated the less than symbol and the greater than symbol confused him and would now be written out and not used. MA E stated he had been administering the midodrine to residents in error and was regretful he did not seek out clarification on the less than greater than symbols. During an interview on 08/15/2023 at 05:01 PM the Medical Director stated he had not received reports that Residents #20 and #48 had received their midodrine outside of parameters for the month August 2023. The Medical Director received a report from the surveyor that Resident #20 had been receiving antihypertensive and hypotensive medications concurrently. The Medical Director stated Resident #20 should not have been administered the antihypertensive and hypotensive medications concurrently. The Medical Director stated he was not aware Resident #48 was also administered midodrine out of parameters multiple times in August 2023. The Medical Director stated he should have received reports from nursing staff that the midodrine was given while the residents were hypertensive. The Medical Director stated the risk to residents receiving concurrent hypertensive medications with hypotensive medications and receiving hypotensive medications while having hypertension could potentially at worst cause a resident a neurological event such as a stroke. A record review of the facility's Adverse Consequences and Medication Errors dated February 2023, revealed, Policy Heading: The interdisciplinary team monitors medication usage in order to prevent and detect medication-related problems such as adverse drug reactions and side effects. Policy Interpretation and Implementation .Medications Errors 1. A medication error is defined as the preparation or administration of drugs or biologicals which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services.

Based on observations, interview and record review the facility failed to provide a safe, functional, and comfortable environment for residents, staff and the public for 3 of 13 (201,202, 205) rooms in the 200 hall in that: Resident rooms 201, 202, 205 had broken window blinds. This could affect residents on the 200 hall and could result in low self-esteem and a lack of privacy. The findings were: 1.Observation on 8/15/2023 at 4:10 PM in resident room [ROOM NUMBER] revealed his window blinds had 5 slats that were broken and could see outside while the window blinds were closed. Interview on 8/15/2023 at 4:11 PM the resident in room [ROOM NUMBER] stated the window blinds had been broken for a while and he did report to Maintenance Supervisor. Observation on 08/16/2023 at 2:20 PM in resident room [ROOM NUMBER] revealed his window blinds had 5 slats that were broken and could see outside while the window blinds were closed. 2. Observation on 8/15/2023 at 4:12 PM in resident room [ROOM NUMBER] revealed the window blinds had 2 slats that were broken . Interview on 8/15/2023 at 4:13 PM the resident in room [ROOM NUMBER] stated he did report the window blinds were broken to staff (unknown). 3. Observation on 8/15/2023 at 4:41PM in resident room [ROOM NUMBER] revealed the window slates were broken. The resident not interviewable. Interview in 8/15/2023 at 4:45 PM with the ADM stated she was not aware the window blinds were broken. A policy was requested. Interview on 8/16/2023 at 1:57 PM the Maintenance Supervisor stated rooms 201,202, 205 had broken window blind slats. The Maintenance Supervisor stated the broken window blinds were not reported to him . Interview on 08/16/23 at 2:16PM the ADM stated the broken window slates on the blinds were not reported to her and would check on TELLS .(communication for environmental concerns in the facility) A policy was requested but was not provided.

Based on interviews and record reviews the facility failed to develop, within 7 days after completion of the comprehensive assessment, a comprehensive care plan, prepared by an interdisciplinary team for 1 of 8 residents (Resident #18) reviewed for care plans, in that: The facility failed to complete a comprehensive care plan for Resident #18 needs for durable medical equipment, a prosthetic leg. This failure could place residents at risk for harm by not supporting their needs. The findings included: A record review of Resident #18's admission record dated 08/14/2023, revealed an admitted [DATE] with diagnoses which included encounter for orthopedic aftercare following surgical amputation. A record review of Resident #18's admission MDS dated [DATE] revealed Resident #18 was a [AGE] year-old male admitted for post-surgical rehabilitation care to include physical and occupational therapies. Further review revealed Resident #18 had a prosthesis, Section G Functional Status . 2. Limited assistance - resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance . G. Dressing - how resident puts on, fastens and takes off all items of clothing, including donning/removing a prosthesis or TED hose A record review of Resident #18's nursing progress notes revealed LVN A documented Resident #18 had a prosthetic right leg; Nursing progress note .06/19/2023 . [LVN A] .nurse has answered light, and Resident needed help with prosthetic, leg was put on properly A record review of Resident #18's dated 08/02/2023, revealed, Assessment & Plan Global Assessment/Plan .PRECAUTIONS: fall risk, .BKA amputation, has prosthetic A record review of Resident #18's care plan dated 08/05/2023 revealed it did not have evidence of any care instructions for Resident #18's need to walk with a prosthesis related to his below the knee amputated leg . Observation on 8/16/2023 at 10:55 AM with Resident #18 revealed he had his right leg amputated below the knee and was supported to walk with a prosthetic leg. During an interview on 08/16/2023 at 11:00 AM the DON stated Resident #18 had his right leg amputated below the knee and was supported to walk with a prosthetic leg which was applied daily and as needed by nursing staff. The DON was informed that Resident #18's care plan did not address Resident #18's need for a prosthetic leg. The DON reviewed Resident #18's care plan and agreed there was no care instructions for staff to follow for care related to applying Resident #18's prosthesis. The DON stated the care plan should have had care instructions for staff to follow for care related to applying Resident #18's prosthesis. The DON stated she and her nurses were culpable for the lack of care support instructions and should have been reviewing the care plans for accuracy. During a joint interview on 08/16/2023 at 01:37 PM with MDS RN B and RN C, they were informed that Resident #18's care plan did not address Resident #18's need for a prosthetic leg. RN B and RN C reviewed Resident #18's care plan and agreed there were no care instructions for staff to follow for care related to applying Resident #18's prosthesis. RN B and RN C stated the care plan should have had care instructions for staff to follow for care related to applying Resident #18's prosthesis. RN B stated, It's my fault. I overlooked it and RN C stated she was also culpable for the lack of care instructions . Record review of the policy Comprehensive care Planning (no date), The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the residents' rights that includes measurable objective and timeframes to meet a resident's [NAME], nursing, and mental and psychological needs that are identified int eh comprehensive assessment. The services that are to be finished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the resident's medical, physical, mental and psychosocial needs

Based on observation, interview and record review the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition for 1 of 8 (Resident #2) residents reviewed in that: Resident #2 did not receive assistance while eating when he was served his meal. This failure could place residents who require feeding assistance at risk of not receiving the necessary services to maintain good nutrition and decline in health. The findings were: Record review of Resident #2's Admission Record dated 8/16/2023 revealed he was admitted to the facility on [DATE], readmitted on [DATE] and his diagnoses included pain in left in right/left knee, muscle weakness, lack of coordination, peripheral vascular disease heart failure and diabetes (a metabolic disease, involving inappropriately elevated blood glucose levels) and cerebral palsy. Record review of Resident #2's Quarterly MDS dated [DATE] revealed Section C Cognition BIMs was 5/15 (severely impaired) and Section G Functional Status bed mobility revealed the resident required extensive assistance with two-person assistance; for transfers the resident was total dependence with two-person assistance and with eating the resident required extensive assistance with one-person physical assistance. Record review of Resident #2's care plan dated 8/17/2023 revealed for Resident #2 in position due to cerebral palsy her Resident #2 request, encourage good nutrition and hydration, and Resident #2 was a risk for hygiene deficit, required extensive -total assist x2 with ADL's, showers, transfers due to neuromuscular impairment related to cerebral palsy interventions to assist with feeding as needed. Observation on 8/15/2023 at 10:06 AM in Resident # 2's room revealed he was served lunch and he was trying to open the butter container. He tried with his fingers and with his teeth with no success. There was no staff helping Resident #2 with eating his lunch. Observation of Resident #2 revealed he was one of the first residents to be served since his room was at the beginning of the hall . Interview on 8/15/2023 at 10:09 AM LVN H stated Resident # 2 required assistance with feeding at times and stated Resident #2 had a recent change. LVN H stated Resident #2 was one of the first residents to be served on the hall. Interview on 8/15/2023 at 10:11AM CNA I stated Resident #2 required assistance with meals. CNA I stated he had the serve the hall, then was going to come back and assist Resident #2 with feeding . Interview on at 8/16/2023 at 10:57 AM the DON stated she was not aware that Resident #2 did not receive help during meals. Interview on 8/16/2023 at 4 PM the ADM discussed occurrences with Resident #2, with no response. The Surveyor asked for a policy for residents receiving assistance during meal from staff. The ADM stated she had no policy for staff assisting residents during meals.

Based on observation, interview, and record review the facility failed to assure that residents received a therapeutic diet as prescribed by the physician for 1 of 8 residents (Resident #20) reviewed in that: Resident #20 was prescribed a low sodium diet and was provided a regular diet which did not meet her dietary needs. This failure could affect residents who are prescribed a low sodium diet and could result in complications with high blood pressure and kidney disease. The findings include: Record review of Resident #20's Face Sheet dated 8/14/2023 reflected an [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses including: pulmonary hypertension (high blood pressure), end stage renal disease (final stage of kidney disease where kidneys cannot function on their own), and fluid overload (condition where the liquid portion of the blood is too high ). Record review of Resident #20's MDS dated [DATE] reflected a BIMS of 13, indicating the resident was cognitively intact. The residents MDS did not reflect a Therapeutic diet for the resident. Record review of Resident #20's Dialysis Physician's Order dated 8/1/2023 reflected an order for Low Salt Diet. Record review of Nursing Progress Notes dated 8/1/2023 reflected a note reflecting the resident Returned from dialysis with orders for low salt diet. Record review of Nursing - Dietary Communication Form dated 8/1/2023 reflected a new order for a low sodium diet. Record review of Resident #20's tray ticket dated 8/14/2023 reflected no indication of a low salt diet. Record review of Resident #20's Care Plan dated 7/26/2023 did not reflect a therapeutic diet. Observation and interview on 8/14/2023 at 12:50 PM of the lunch service revealed a meal tray intended for Resident #20 containing a packet of salt on the tray for the resident to use on her food as needed. Resident #20 stated she did not know why she was provided salt, as her ankles were swollen due to water retention and her doctor at the dialysis clinic had informed her that she should maintain a low sodium diet. The resident stated her ankles felt tight at times when they were swollen and made her uncomfortable. Interview on 8/16/2023 at 9:34 AM, the DM stated that if a resident received new dietary orders, a nurse would create a communications slip and provide it to the DM either by physically handing it to her or putting it in her mailbox outside of her office. The DM stated she was able to review orders in the resident's EMR and that any changes would be reviewed in meetings. Interview on 8/16/2023 at 10:57 AM, the DON stated that her expectations for nursing staff was to review orders, create Nursing - Dietary Communication Forms, and provide them to the DM, informing the kitchen of the new dietary order. The DON stated that nursing staff was instructed to double check meals and compare the meals to orders and meal slips. Interview on 8/16/2023 at 3:12 PM, LVN G stated if a resident had an order for a change in their diet, LVN G would turn in a Nursing - Dietary Communication Form to the Dietary Manager to ensure the residents' ordered diet was followed by the kitchen. LVN G stated she had provided the Dietary department with the low sodium diet order the day the order was received. Interview on 8/16/2023 at 3:35 PM, the Administrator stated her expectations were for dietary staff to make any changes based on physicians' orders communicated to them by nursing. Record review of the facility policy, undated, titled Diet Orders/Diet Manual reflected The Dietary Service Department is to be informed of any of the changes listed below in a timely manner: . Change of Diet.

Based on interview and record review the facility failed to maintain clinical records that were complete and/or accurate for 3 of 6 (Resident #2, Resident #3, and Resident #4) residents reviewed for clinical records in that: Resident #2, Resident #3 & Resident #4 did not have a discharge summary sheet signed by their physician. This deficient practice could place residents at risk for not getting the required documentation to facilitate a proper discharge. The findings were: 1. Review of Resident #2's face sheet, dated 8/3/23, revealed he was admitted to the facility on [DATE] with diagnosis including unspecified fracture of right femur (breakage of a thigh bone). Further review revealed Resident #2 was discharged on [DATE]. Review of Resident #2's electronic record revealed a discharge summary, dated 6/5/23, revealed Resident #2 was discharged to the hospital. Further review revealed the physician did not sign the discharge summary. Interview on 8/3/23 at 2:30 PM with Medical Records revealed she stated the MD did not sign Resident #2's discharge summary. She stated she did not know when the MD should sign it after discharge. Interview on 8/3/23 at 2:45 PM with the ADM revealed she thought the physician should sign the discharge summary within 30 days after resident discharge. She reviewed Resident #2's discharge summary and stated the physician did not date it and she would not know when he signed it. The ADM stated Medical Records was responsible for ensuring the physician signed the residents discharge summary. 2. Review of Resident #3's face sheet, dated 8/3/23, revealed she was admitted to the facility on [DATE] with diagnosis including COVID-19. Further review revealed Resident #3 was discharged on [DATE]. Review of Resident #3's electronic record revealed a discharge summary, dated 6/5/23, revealed the resident was discharged to another facility. Further review revealed the physician did not sign the discharge summary. Interview on 8/3/23 at 2:30 PM with Medical Records revealed she stated the MD did not sign Resident #3's discharge summary. She stated she did not know when the MD should sign it after discharge. Interview on 8/3/23 at 2:45 PM with the ADM revealed she thought the physician should sign the discharge summary within 30 days after resident discharge. She reviewed Resident #3's discharge summary and stated the physician did not sign it. The ADM stated Medical Records was responsible for ensuring the physician signed the residents discharge summary. 3. Review of Resident #4's face sheet, dated 8/3/23, revealed he was admitted to the facility on [DATE] with diagnosis including unspecified Dementia, unspecified severity with behavioral disturbance. Further review revealed Resident #4 was discharged on [DATE]. Review of Resident #4's electronic record revealed a discharge summary, dated 12/15/22, revealed Resident #4 was discharged to the hospital on 12/6/22. Further review revealed the physician did not sign the discharge summary. Interview on 8/3/23 at 2:30 PM with Medical Records revealed she would complete the discharge form and then the physician would sign it while making rounds at the facility. She stated she did not know when he should sign it after discharge. Interview on 8/3/23 at 2:45 PM with the ADM revealed she thought the physician should sign the discharge summary within 30 days after resident discharge. She reviewed Resident #4's discharge summary and stated the physician did not sign it. The ADM stated Medical Records was responsible for ensuring the physician signed the residents discharge summary. Review of facility policy titled, Discharge Summary/Discharge Plan, dated December 2015, read: The entire discharge summary will be completed with each resident that discharges regardless of where they discharge to, or if they expire in house. For electronic discharge summaries, once completed, the DC summary will be printed on blue paper, a white copy made to be placed in the medical record and the original will be sent out for physician's signature. The white copy will remain in place until the signed original returns.

Based on observation, interview and record review the facility failed to implement written policies and procedures that Prohibit and prevent abuse for 1 of 5 Residents (Resident #1) whose record were revived for abuse. The facility failed to report an allegation of abuse involving Resident #1 within 2 hours per HHSC regulation. This deficient practice could affect any resident and contribute to further abuse. The findings were: Review of Resident #1's admission, dated [DATE], revealed he was admitted to the facility on [DATE] with diagnoses including UTI (A urinary tract infection is an infection that affects part of the urinary tract.), Major Depressive Disorder (clinical depression, it affects how you feel, think and behave and can lead to a variety of emotional and physical problems) and Anxiety Disorder (the mind and body's reaction to stressful, dangerous, or unfamiliar situations. It's the sense of uneasiness, distress, or dread you feel before a significant event). Review of Resident #1's quarterly MDS assessment dated , [DATE], revealed his BIMS was 6 out of 15 indicative of severe cognitive impairment. Review of incident report, dated [DATE], documented at 04:03 AM by RN A revealed Resident #1 was noted with 2 large bumps to right side of his forehead. Resident #1 reported he was hit on the head by an English speaking male and it happened earlier in the day at4 PM per RN A. Review of Provider Investigation Report, dated [DATE] and written by the ADM, revealed the allegation of abuse involving Resident #1 was reported to the ADM on [DATE] at 8 AM. Observation and attempted interview on [DATE] at 1:45 PM revealed Resident #1 was lying down in bed fully dressed. Attempted interview revealed Resident #1 was confused and in-coherent. He was not interviewable. Interview on [DATE] at 3:20 PM with the ADM revealed she was the abuse coordinator and she reported all allegations of abuse/neglect. She stated Resident #1 was very confused and his story changed about how he got the red marks/bumps on his forehead. She stated she was not sure who exactly told her about Resident #1's injuries but thought it was the morning nurse who told her at about 8 AM. She stated she reported it to HHSC soon afterwards. The ADM reviewed RN A's statement, dated [DATE], documented at 04:03 AM by RN A, which stated she noted the 2 bumps and red marks on Resident #1 during her last round. The ADM stated the allegation was not reportable right away because she had to determine whether or not abuse happened. After discussing the federal regulation and after reading the facility policy it clearly stated an allegation of abuse should be reported within 2 hours. The ADM read RN A's statement again and stated yes it was an allegation of abuse and it should have been reported within 2 hours. Telephone interview on [DATE] at 3:51 PM with RN A revealed she had worked the night shift as of [DATE]. Her statement, dated [DATE] was read to RN A and she stated she remembered the injuries on Resident #1. RN A stated Resident #1 first said he did not know what happened but then stated a big white man hit him. RN A believed she told the previous DON, and remembered taking a picture of Resident #1 and sending it to the DON. RN A stated she did not tell the ADM. RN A stated she was uncertain how soon she should have reported the incident to her immediate supervisor who was the DON. She stated she did not know the time frame the facility had to report the allegation of abuse to HHSC. However, commented she thought it was probably immediately. RN A stated she did not report Resident #1's allegation of abuse to the DON right away. RN A further stated she completed abuse training when she was first hired but did not remember anything afterwards. Interview on [DATE] at 4:50 PM with the DON revealed RN A called her about Resident #1 injuries after 6 AM as RN A was ending her shift. The DON stated she called the ADM right after and told the ADM about the injuries. The DON stated RN A should have reported the allegation of abuse immediately to her and or the ADM. The DON stated an allegation of abuse should be reported immediately per facility policy. She stated she did not in-service RN A about the timeframe for reporting an allegation of abuse. The DON stated she provided abuse/neglect training before assuming her current position. Review of facility policy, Abuse/Neglect, revised [DATE], read: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. 1. Abuse: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. E. Reporting 3. Facility employees must report all allegations of abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report the allegation to HHSC. a. If the allegations involve abuse or result in serious bodily injury, the report is to be made within 2 hours of the allegation.

Based on observation, interview, and record review the facility failed to ensure that residents who are fed by a gastrostomy tube (a tube inserted through the abdomen into the stomach for the purpose of administering liquid nutrition and medications) received the appropriate treatment and services to prevent metabolic abnormalities for six of 10 residents (Residents # 9, #2, # 4, #1 # 8 and # 11) reviewed for feeding tubes in that: 1. Resident # 9's did not receive tube feedings for 22 hours a day, as ordered by the physician, and suffered a severe weight loss of 8.33% between October and November. 2. Resident # 2 had a severe weight loss of 6.4% between September and October 2012 and the facility did not provide interventions to the weight loss for 20 days and then Resident # 2 had an additional 2 pound weight loss from October to November 2012 and the facility failed to re-assess and address her weight. 3. Resident # 4 had a severe weight loss of 5.9% from October to November 2012 and did not receive tube feedings as ordered by the physician. 4. Resident # 1 had a gradual weight loss of 2.44% from September to October 2012 and 1.25% from October to November 2012, and the facility did not adjust the tube feeding to prevent further weight loss over the three month period. 5. Resident # 8 had a weight loss of 2.42% from October to November 2012 and the facility did not adjust the tube feeding to prevent further weight loss. 6. Resident # 11's tube feeding was not administered per physician's orders [REDACTED]. This deficient practice affected three residents and could affect 13 residents who receive gastrostomy tube feedings and could result in weight loss, compromised nutritional status and decreased protein stores. Findings Include: 1. Resident # 9 was admitted to the facility 10/24/09 with a readmission date of [DATE] according to the Face Sheet, dated 8/31/12. Admitting [DIAGNOSES REDACTED]. Review of the annual MDS (Minimum Data Set), dated 4/12/12, revealed Resident # 9 was coded in the Active [DIAGNOSES REDACTED]. Percent of calorie intake was coded as 51% or more and fluid intake was coded as 501 ml/day or more. Review of the consolidated physician's orders [REDACTED]. An order was also noted for [MEDICATION NAME] suspension (medication used to treat and prevent ulcers in the intestines) 1 gram per PEG (gastrostomy) three times a day on an empty stomach 1 hour before tube feeding. Review of the Care Plan for Resident # 9, dated as reviewed 8/29/12, revealed a problem: "Resident #9 receives all nourishment via PEG (gastrostomy) tube inserted 6/14/11 due to [MEDICAL CONDITION] and dehydration". The goal was "Resident # 9 will receive nutrients to meet or exceed base needs and have no signs/symptoms of dehydration, weight loss and malnourishment for the next 90 days". Interventions listed were the ordered feedings and water flushes. A review of the facility's weight report revealed Resident # 9's September 2012 weight was 183, October 2012 weight was 180 and the November 2012 weight was 165 (8.33% loss in one month). During an interview on 11/15/12 at 12:30 p.m., RA (Restorative Aide) E stated all monthly weights were completed by the fifth of each month. During an interview on 11/16/12 at 8:00 a.m. the DON stated she notified the physician of the weight loss of Resident # 9 but did not notify the dietician. A review of laboratory results for Resident # 9, dated 11/5/12 revealed a Total Protein (total amount of Protein in blood) of 6.2 (normal 6.4-6.9) with a drop from 6.5 on 8/11/12. [MEDICATION NAME] (amount of liquid protein in blood) test was 3.2 (normal 3.5-6.7). A Hemoglobin (proteins in red blood cells that carry oxygen) was 9.6 (normal 12 -15.5) and revealed a drop from 10.6 on 8/11/12. Hematocrit (percentage of volume of whole blood made up of red blood cells) was 28.4 (normal 34.9-44.5) and revealed a drop from 30.7 on 8/11/12. Observations of Resident # 9, during entrance rounds on 11/13/12 at 11:55 a.m. with RN C revealed Glucerna 1.2 running at 57 ml/hr. per pump. The date hung, written on the bottle, read 11/12/12 at 23:00 (11:00 pm). All 1500 ml. of formula remained in the 1500 ml bottle. (According to the hang time on the bottle 684 ml. of formula should have been administered from the formula hanging). During an interview, at the time of the above observation, RN C confirmed with the charge nurse (LVN D) on duty that the current feeding was hanging when the charge nurse came on duty at 7:00 a.m.. Observation of Resident # 9 on 11/13/12 at 4:18 p.m., revealed Glucerna 1.2 hanging to run at 57 ml/hr. The hang date written on the bottle read 11/12/12 at 23:00 (11:00 pm). All 1500 ml of formula remained in the 1500 ml. bottle. (According to the hang time on the bottle 855 ml. of formula should have been administered from the formula hanging). This figure included the two hour down time for the feeding. During an interview, 11/13/12 at 4:30 p.m. LVN A verified the pump had been off 30 minutes prior (at 4:00pm). During an interview on 11/13/12 at 4:30 p.m. LVN B stated Resident # 9's pump was turned off for medication three times a day. LVN B stated at 9:00 am, 1:00 pm and 5:00 pm Resident #9 received [MEDICATION NAME] and the tube feedings were held one hour before and one hour after the medication for total of 6 hours per day (physician's orders [REDACTED]. Observation of Resident # 9 on 11/14/12 at 6:40 am, revealed Glucerna 1.2 hanging to run at 57 ml/hr. The date hung, written on the bottle, read 11/13/12 at 17:50 (5:50 p.m.). Eleven hundred (1100) ml. of formula remained in the 1500 ml. bottle (indicating 400ml. had been received during the time the bottle was hung until the current time). According to the label the bottle had been hanging for 13 hours and Resident # 9 should have received 741 ml. of formula. Observation of Resident # 9 on 11/15/12 at 7:15 a.m., revealed Glucerna 1.2 hanging to run at 57 ml/hr. The date hung, written on the bottle, read 11/15/12 at 0400 (4:00 am). One-hundred seventy one (171) ml. should have been received at the time of the observation but all 1500 ml of formula remained in the 1500 ml. bottle. Observation of Resident # 9 on 11/15/12 at 2:25 p.m. revealed the above bottle had been removed and a new bottle of Glucerna 1.2 had been hung on 11/15/12 at 1408 (2:08 p.m.). During an interview, at the time of the above observation, LVN D stated the pumps were cleared at the beginning of each shift. At the end of the shift LVN D stated she recorded the intake from the pump and not from the bottle hanging. LVN D stated the bottle hanging previously had been thrown away, even though it had formula remaining. On 11/15/12 at 5:00 pm the DON presented a list of requested reweights of residents. Resident #9's weight was listed as 167.4 pounds (a 12.6 pound weight loss from the October 2012 weight of 180 pounds or 7 %). 2. Resident # 2 was admitted to the facility on [DATE] and re-admitted to the facility on [DATE] per the face sheet dated 8/31/12. The [DIAGNOSES REDACTED]. Observation on 11/14/12 at 7:05 a.m. revealed Resident # 2 had a gastrostomy tube and LVN O administered medications and formula through the tube at that time. Review of the clinical record revealed the following weights for 2012: July 120.6, August 118.6, September 116.4, and October 109.0. There was a significant weight loss between September and October of 6.36 % for 1 month and 9.32 % in 3 months. Review of the Dietary Notes dated 10/25/12 (20 days after the last weekly weight was obtained) revealed October weight was 109, down 7.4 pounds (6.4 %) for 1 month, down 11.2 pounds (9.3 %) for 3 months. The dietitian then noted the diet Resident # 2 was on orally and the supplements the resident was on. The dietician recommended 1 can of [MEDICATION NAME] 1.2 QID, per gastrostomy tube, for 1140 KCal, 53 grams of protein, and l764 ml of fluid. The recommendation was written as a physician's telephone order on 10/26/12. Review of the consolidated November Physician order [REDACTED]. Review of the Resident # 2's weight for November 2012 revealed a weight of 107.0 pounds. This indicated an additional 2 pound weight loss or a loss of weight of 1.83 % for 1 month and 9.78 % in 3 months. During an interview on 11/16/12 at 10:00 a.m. with the DON, she stated that the residents were put on weekly weights and some residents were re-weighed when there was a change in the residents' weights. She stated that Resident # 2 was on weekly weights. No documentation of weekly weights for the month of October 2012 was found in the restorative aide's weight notebook that she documents weekly weights for Resident # 2. 3. Review of Resident # 4's face sheet dated 8/31/12 revealed she was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Resident Weight report dated 12/1/11 to 11/30/12 revealed in October resident # 4 was at 156.60 pounds and review of the reweight from the facility for November 15, 2012 was 147.2, thus a 5.9% weight loss. Review of Resident #4's Consolidated physician's orders [REDACTED]. Continued review of Resident # 4's enteral feeding sheet dated November 2012 revealed the pump was to be turned off from 8 a.m. to 10 a.m. Review of Resident # 4's enteral feeding record dated November 2012 revealed 11/13/12 on the 11-7 shift she received 327 ml., on the 7-3 p.m. shift she received 352 ml. and on the 3-11 p.m. shift she received 336 ml of formula (a total of 1015 for the 24 hours). Review of a T.O. (telephone order) dated 11/13/12 at 8 p.m. for Resident # 4 revealed the tube feeding was not working properly, didn't receive the correct amount of formula feeding. Staff notified physician and he gave an order of continuous feeding to be replaced to bolus feeding of [MEDICATION NAME] 1.2 via peg tube at 8 p.m. and 11:30 p.m. today. This order change was after the surveyor intervention. Review of Resident # 4's care plan dated 1/9/12 revealed the resident was unable to take food or regular fluids orally due to inability to swallow and received 100% of nourishment via peg tube inserted on 12/15/07. The goal revealed Resident # 4 will receive nutrients to meet or exceed base needs and have to signs/symptoms of ... significant weight loss r/t the use of feeding tube for the next 90 days. The interventions for Resident #4 revealed staff were to monitor her weight every month and monitor her I&O (in and out) every shift. Review of Resident # 4's MDS (minimum data sheet) dated 7/10/2012 revealed she was confused, nonverbal, semi-comatose, needed total assistance with her ADL ' s (activity of daily living), and was incontinent of bowel and bladder. Observation of Resident # 4 on 11/13/12 at 12:30 p.m. during initial rounds, with the ADON revealed [MEDICATION NAME] 1.2 formula bottle at a rate of 42 ml/hr. was hung on 11/13/12 at 4:35 a.m. This bottle was at 1500 ml and should have been at 1080 ml. Observation on 11/13/12 at 4:35 p.m. with Resident # 4 revealed the [MEDICATION NAME] 1.2 bottle at a rate of 42 ml/hr. was hung on 11/13/12 at 4:35 a.m. This bottle 1500 ml bottle was at 1400 ml (504 ml of formula should have been received). Interview on 11/14/12 at 10:35 a.m. with LVN Q, regarding Resident # 4, revealed she hung the bottle of [MEDICATION NAME] 1.2 at 42 ml/hr on 11/13/12 at 4:35 a.m. Further interview she revealed the tube feeding pumps sometimes beeped and you had to shake the formula or see where the clog was in the tube to stop the pump from beeping. Observation on 11/13/12 from 4:35 p.m. to 5:04 p.m. in front of Resident #4's room revealed her tube feeding pump was alarming and the alarm was able to be heard in the hallway. The alarm to Resident # 4's tube feeding pump was ignored by LVN O, CNA S, CNA X and CNA Y. The tube feeding pump showed it was clogged and LVN O later came in to answer after the surveyor intervention. Interview on 11/13/12 at 4:59 p.m. with LVN B revealed staff were to check the call lights and the feeding pump alarms when they were buzzing. Interview on 11/17/12 at 8:47 a.m. with LVN O regarding Resident # 4 revealed the feeding pump was turned off from 8-10 a.m. 4. Resident # 1 was admitted to the facility 3/09/12 with a readmission date of [DATE] according to the Face Sheet (no date obtained). [DIAGNOSES REDACTED]. Review of the quarterly MDS (Minimum Data Set), dated 8/14/12, for Resident # 1 revealed in the Active [DIAGNOSES REDACTED]. Percent of calorie intake was 51% or more and fluid intake was 501 ml/day or more. Review of the consolidated physician's orders [REDACTED]. Review of the Care Plan for Resident # 1, dated as reviewed 8/22/12, revealed the problem "Resident # 1 receives all nourishment via PEG (gastrostomy) tube inserted 2/24/12 due to dysphagia and [MEDICAL CONDITION]". The goal was " Resident #1 will receive nutrients to meet or exceed base needs and have no signs/symptoms of dehydration, weight loss and malnourishment for the next 90 days". Interventions listed were the ordered feedings and water flushes. A review of laboratory results for Resident # 1, dated 9/17/12 revealed an [MEDICATION NAME] (amount of liquid protein in blood) test was 3.3 (normal 3.5-6.7). A Hemoglobin (proteins in red blood cells that carry oxygen) was 10.1 (normal 12 -15.5) and a Hematocrit (percentage of volume of whole blood made up of red blood cells) of 30.8 (normal 34.9-44.5). A review of the facility's weight report revealed Resident # 1's September 2012 weight was 131 pounds, October 2012 weight was 127.8 (2.44 % loss in one month) and the November 2012 weight was 126.2 (1.25% loss in one month). During an interview on 11/15/12 at 8:40 a.m. the DON stated gradual weight loss was monitored by the Dietician during the monthly visit. The DON stated the dietician reviewed the weights of all residents to include tube fed residents and residents with wounds. Record review revealed Resident # 1, had a culture of a right hip wound collected 11/05/12 that was positive for Staphlococcus Aureus (a bacteria). Observations of Resident # 1, during entrance rounds on 11/13/12 at 12:05 p.m., with RN C revealed [MEDICATION NAME] 1.5 running at 48 ml/hr. The date hung, written on the bottle, read 11/13/12 at 0100(1:00 am). All 1500 ml. of formula remained in the 1500 ml. bottle. (According to the time hung 528 ml. of formula should have been administered from the formula hanging). Observation on 11/13/12 at 4:20 p.m. revealed [MEDICATION NAME] 1.5 running at 48 ml/hr. The date hung, written on the bottle, read 11/13/12 at 0100(1:00 a.m.). Thirteen hundred (1300) ml. of formula remained in the 1500 ml. bottle. (According to the time hung 720 ml. of formula should have been administered from the formula hanging). Observation of Resident # 1 on 11/14/12 at 6:55 a.m. revealed [MEDICATION NAME] 1.5 running at 48 ml/hr. The date hung, written on the bottle, read 11/13/12 at 1745 (5:45 p.m.), twelve hundred (1200) ml. of formula remained in the 1500 ml. bottle. (According to the time hung 624 ml. of formula should have been administered from the formula hanging). Observation of Resident # 1 on 11/14/12 at 9:15 a.m. revealed [MEDICATION NAME] 1.5 running at 48 ml/hr. The date hung, written on the bottle, read 11/13/12 at 1745 (5:45 pm). twelve hundred (1200) ml. of formula still remained in the 1500 ml. bottle. (According to the time hung, 768 ml. of formula should have been administered from the formula hanging). Observation of Resident # 1 on 11/14/12 at 12:45 pm revealed the resident was not in the room and the pump with formula was hanging at the bedside. 5. Review of Resident # 8' s face sheet dated 8/31/12 revealed he was admitted to the facility on [DATE], re-admitted on [DATE], readmitted on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident #8's Quarterly MDS dated [DATE] revealed he was severely impaired, confused, forgetful, needed total assistance with his ADL's, and he was tube feed for nutrition Review of Resident # 8's consolidated physician's order [REDACTED]. Review of Resident # 8's nurse's notes revealed on 11/15/12 at 12 p.m. the nurse spoke to the dietician and discussed his weight loss and the dietician recommended to increase his tube feeding formula to [MEDICATION NAME] 1.2 at 70 ml/hr. Observation on 11/14/12 at 8:12 a.m. revealed Resident # 8's tube feeding pump was on and the [MEDICATION NAME] 1.2 formula was hung at 11/14/12 at 2:20 a.m. at a rate of 60 ml/hr. The formula bottle was at 1400 ml. The formula bottle should have read 1260 ml. Observation on 11/15/12 at 7:49 a.m. revealed Resident # 8's [MEDICATION NAME] 1.2 tube feeding formula was hung on 11/15/12 at 4:05 a.m. at a rate of 60 ml/hr and the marker on the tube feeding bottle read 1500ml. The formula bottle should have read 1380 ml. Observation on 11/15/12 at 3:55 p.m. revealed Resident # 8's tube feeding formula bottle was hung on 11/15/12 at 4:05 a.m. and the formula bottle read 1500ml. The formula bottle should have read 900 ml. Interview on 11/15/12 at 4:37 p.m. with LVN O revealed Resident # 8 had a 2 hour downtime for her tube feedings (random, not scheduled down time).. Interview on 11/15/12 at 3:55 p.m. with Resident # 8's spouse revealed the tube feeding pump was off since 2 p.m. during a shower. The tube feeding formula was hung at 11/15/12 at 4:05 a.m. with a rate of 60 ml/hr and the formula bottle marker was at 1200 ml. The bottle formula should have been at 900 ml. Review of Resident # 8's enteral feeding record dated November 2012 revealed on 11/14/12 was recorded as having used 493 ml of formula. The formula bottle should of read 1007 ml. Review of Resident # 8's facility Enteral Feeding Sheet MAR indicated [REDACTED]. This order was discontinued on 11/14/12 and a new 2 hour (did not specify exact times) p.m. time was ordered to provide for showers and care started on 11/14/12. 6. Review of Resident # 11' s consolidated physician' s orders revealed the order for [MEDICATION NAME] at 38 cc/hr (hour) for 22 hours with a [DIAGNOSES REDACTED]. Review of Resident #11's MAR (medication administration record) dated November revealed she was on [MEDICATION NAME] at 38 ml/hour for 22 hours. Continued review of the MAR indicated [REDACTED]. Review of the November 2012 MAR for Resident # 11 revealed to turn the tube feeding pump off for 2 hours in the p.m. ( no exact time was indicated) start date 11/15/12. Observation on 11/13/12 at 12:26 p.m. with Resident # 11 revealed [MEDICATION NAME] tube feeding formula was on and hung on 11/13/12 at 4:30 a.m. at a rate of 38 ml/hr and the formula bottle read 800 ml/hr. The formula bottle should been at 1272 ml. Observation on 11/14/12 at 9:30 a.m. revealed Resident # 11's tube feeding formula bottle was hung on 11/14/12 at 5:05 a.m. at a rate of 38ml/hr, the formula bottle was at 700 ml/hr. Observation on Resident # 11 on 11/15/12 at 7:47 a.m. revealed her [MEDICATION NAME] tube feeding formula was hung at 11/15/12 at 4:20 a.m. at a rate of 38 ml/hr, the formula bottle read 900 ml. The formula bottle should have read 1006 ml. Observation on 11/16/12 at 9:37 a.m. revealed Resident # 11 had a [MEDICATION NAME] tube feeding formula the bottle of formula was started on 11/16/12 at 4:00 a.m. at a rate of 38 ml/hr, the formula bottle read 900 ml. The formula bottle should have been at 1291 ml. Review of the facility Nursing Policy and Procedural Manual dated 2003, under the subject Gastrostomy Tube Care revealed the goal was the resident will maintain nutritional status optimal parameters via gastrostomy feeding. During an interview on 11/14/12 at 7:10 am, the DON presented a document, dated 11/14/12, stating the feeding pumps (currently used by the facility) had been in use since 5/15/12. One In-service Training Attendance Roster, dated 5/15/12, revealed Feeding Pump training had been conducted from 10:00 am to 10:45 am. Nine nursing staff signed in as attending. According to the staff roster, presented to surveyors on 11/13/12, Five Registered Nurses and eleven Licensed Vocational Nurses (total of 16 licensed staff) were employed by the facility (leaving 7 nurses responsible for operating the feeding pumps untrained). During an interview on 11/15/12 at 5:55 pm the DON presented a letter from the company supplying the tube feeding formula verifying the accuracy of the ready to hang containers was no greater than 101% (assuring that bottle measurement are accurate as labeled). During an interview on 11/15/12 at 12:30 p.m. Restorative Aide E stated residents on Tube feedings were weighed on the Hoyer scale but the Hoyer scale was not working at the beginning of November and the chair scale was used to weigh the tube feeding residents. Review of a form from the American Scale Company, dated 10/10/12, (who provide scale calibration services for the facility) revealed the digital wheelchair and the Hoyer Manuel slide scale were calibrated (on the above date) and in working order. On 11/16/12 at 4:00 pm the facility presented the following weights for residents that had been reweighed with the Hoyer manual slide scale on 11/17/12: Resident #9 180 pounds (a 1 pound loss from October 2012 to November 2012) Resident #4 153.5 pounds (a 3 pound weight loss from October 2012 to November 2012) Resident #1 130 pounds (a 2.2 pound weight gain from October 2012 to November 2012) Resident #8 175 pounds (a 1.2 pound from October 2012 to November 2012) Resident #11 134.5 pounds (a 2.5 pound weight gain from October 2012 to November 2012) Resident #2 Not included on list of resident reweighed Review of the facility's Policies and Procedures, signed and dated as reviewed 11/1/12, revealed a policy/procedure titled Resident Weight. Under the section Procedure the following was noted: 1. ....Factors indicating the need for more frequent weights include significant weight loss..... 8. The facility will hold a weight meeting during the first interdisciplinary care plan meeting after monthly weights are obtained, to discuss residents with significant weight changes. A significant weight change will be defined as greater than 5 % in one month, greater than 7.5 % in three months, or greater than 10 % in six months. ... 8. All significant weight changes will be referred to the Regional Dietician on the next visit. ... The Dietary Service Manager and Regional Dietician will complete an assessment on all significant weight lossess..... A review of the facility's Policies and Procedures, signed and dated as reviewed 11/1/12, revealed in the section Enteral Nutrition: "We will provide nutritional complete enteral feedings as ordered by the physician for the nourishment of residents who are unable to eat. Problems with the administration of the tube feeding are monitored and corrected by nursing. The Regional Dietician is notified by nursing of problems such as nausea, diarrhea, vomiting, abdominal distention, weight changes, pressure ulcers, electrolyte imbalances and abnormal Laboratory results". According to CMS form 672, signed and dated 11/13/12, there were 16 residents receiving tube feedings.

Based on observation, interview, and record review the facility failed to ensure that residents who are fed by a gastrostomy tube (a tube inserted through the abdomen into the stomach for the purpose of administering liquid nutrition and medications) received the appropriate treatment and services to prevent metabolic abnormalities for one of 15 residents (Resident # 2) reviewed for feeding tubes in that: Resident # 2 was receiving [MEDICATION NAME] 1.2 at 60 ml/hr per [DEVICE] instead of [MEDICATION NAME] 1.2 at 75 ml/hr as ordered by the physician on two of two survey days. This deficient practice could affect 15 residents in the facility with gastrostomy tubes, and could cause a decrease in the nutritional status. The findings were: Record review of Resident # 2's face sheet dated 12/28/12, revealed he was admitted on [DATE], with [DIAGNOSES REDACTED]. Record review of the Consolidated physician's orders [REDACTED]. Review of the Telephone Orders revealed an order dated 11/19/12 for [MEDICATION NAME] 1.2 at 75 ml/hr for 20 hours. Review of the MAR for December 2012 revealed the nurse was to verify that [MEDICATION NAME] 1.2 at 75 ml/hr was administered every shift. Observation on 12/27/12 at 1:50 p.m. revealed the feeding pump was infusing at 60 ml/hr. The bottle of formula was dated 12/27/12 and timed at 4:40 a.m. and listed the formula rate at 60 ml/hr. Observation on 12/28/12 at 9:10 a.m. revealed the feeding pump was infusing at 60 ml/hr. The bottle of formula was dated 12/28/12 and listed the formula rate at 60 ml/hr. In an interview on 12/28/12 at 9:10 a.m. LVN A confirmed the feeding pump was infusing at 60 ml/hr. and the bottle of formula was dated 12/28/12 and listed the formula rate at 60 ml/hr. She stated she did not know what happened, but that she could assure that the formula was at 75 ml/hr last week. In an interview with LVN B on 12/28/12 at 5:45 p.m. she stated she knew Resident # 2's feeding was infusing at 60 ml/hr the previous night. LVN B said she hung the bottle of formula, and stated that was her first night working the night shift. In an interview with LVN C on 12/28/12 at 5:50 p.m. he stated he previously worked the night shift, and that he hung the bottle of formula for Resident # 2. He said he did not remember what rate of infusion he wrote for Resident # 2. A review of the facility's Policies and Procedures, signed and dated as reviewed 11/01/12, revealed in the section Enteral Nutrition: "We will provide nutritional complete enteral feedings as ordered by the physician for the nourishment of residents who are unable to eat. Problems with the administration of the tube feeding are monitored and corrected by nursing. The Regional Dietician is notified by nursing of problems such as nausea, diarrhea, vomiting, abdominal distention, weight changes, pressure ulcers, electrolyte imbalances and abnormal Laboratory results". The facility's completed form Resident Census and Conditions of Residents dated 12/27/12 revealed there were 15 residents with tube feedings. .

Based on observation, interview, and record review the facility failed to ensure that residents received the appropriate treatment and services to maintain acceptable parameters of nutritional status, such as body weight and protein levels for five of 10 residents (Residents # 9, # 2, #4, # 1, # 8) reviewed for tube feedings in that: 1. Resident # 9's had a severe weight loss of 8.33% between October and November and the facility did not respond to the weight loss for 10 days. 2. Resident # 2 had a severe weight loss of 6.36 % from September to October 2012 and it was not addressed for 20 days. Resident # 2 did not receive the Magic Cup on her breakfast tray as ordered. 3. Resident # 4 had a severe weight loss of 5.9% from October to November 2012 and did not receive tube feedings as ordered by the physician. 4. Resident # 1 had a gradual weight loss of 2.44% from September to October 2012 and 1.25% from October to November 2012. and the facility did not adjust the tube feeding to prevent further weight loss over the three month period. 5. Resident # 8 had a weight loss of 2.42% from October to November 2012 and the facility did not adjust the tube feeding to prevent further weight loss. This deficient practice affected three residents and could affect 13 residents who receive gastrostomy tube feedings and could result in weight loss, compromised nutritional status and decreased protein stores. Findings Include: 1. Resident # 9 was admitted to the facility 10/24/09 with a readmission date of [DATE] according to the Face Sheet, dated 8/31/12. Admitting [DIAGNOSES REDACTED]. A review of the facility's weight report revealed Resident # 9's September 2012 weight was 183, October 2012 weight was 180 and the November 2012 weight was 165 (8.33% loss in one month). During an interview on 11/15/12 at 12:30 p.m., RA E stated all monthly weights were completed by the fifth of each month. During an interview on 11/16/12 at 8:00 a.m. the DON stated she notified the physician of the weight loss of Resident # 9 but did not notify the dietician. A review of laboratory results for Resident # 9, dated 11/5/12 revealed a Total Protein (total amount of Protein in blood) of 6.2 (normal 6.4-6.9) with a drop from 6.5 on 8/11/12. [MEDICATION NAME] (amount of liquid protein in blood) test was 3.2 (normal 3.5-6.7). A Hemoglobin (proteins in red blood cells that carry oxygen) was 9.6 (normal 12 -15.5) and revealed a drop from 10.6 on 8/11/12. Hematocrit (precentage of volumn of whole blood made up of red blood cells) was 28.4 (normal 34.9-44.5) and revealed a drop from 30.7 on 8/11/12. Review of the annual MDS (Minimum Data Set), dated 4/12/12, Resident # 9 was coded in the Active [DIAGNOSES REDACTED]. Percent of calorie intake was coded as 51% or more and fluid intake was coded as 501 ml/day or more. Review of Resident # 9's consolidated physician's orders [REDACTED]. A review of the MAR (Medication Administration Record) revealed an order (origination date 7/24/12: "[MEDICATION NAME] suspension 1 gram per peg tube three times a day. Give on an empty stomach 1 hour before tube feeding and one hour after" (a total of 6 hours the feeding would be held). Review of the Physician's Telephone Orders, 11/15/12 revealed: "Discontinue feeding pump. Chang to Glucerna 1.2 one can every four hours to provide 1422 cc, 1706 calories" (10 days after the signifigant weight loss was detected). Review of the Care Plan for Resident # 9, dated as reviewed 8/29/12, revealed a problem"Resident # 9 receives all nourishment via PEG (gastrostomy) tube inserted 6/14/11 due to [MEDICAL CONDITION] and dehydration". The goal was " Resident # 9 will receive nutrients to meet or exceed base needs and have no signs/symptoms of dehydration, weight loss and malnourishment for the next 90 days". Intervetions listed were the ordered feedings and water flushes. Review of a Dietary Progress Note, dated 10/25/12, revealed Resident # 9 should receive Glucerna 1.2 at 57ml/hr for 22 hours to provide 1504 calories, 69 grams of protein, and 1011 ml of free water. Observation of Resident # 9, during entrance rounds on 11/13/12 at 11:55 a.m. with RN C revealed Glucerna 1.2 running at 57 ml/hr. The date hung, written on the bottle, read 11/12/12 at 23:00 (11:00 pm). All 1500 ml of formula remained in the 1500 ml bottle. (According to the hang time on the bottle 684 ml of formula should have been administered from the formula hanging). During an interview, at the time of the above observation, RN C confirmed with the charge nurse (LVN D) on duty that the current feeding was hanging when the charge nurse came on duty at 7:00 a.m.. Observation of Resident # 9 on 11/13/12 at 4:18 pm, revealed Glucerna 1.2 hanging to run at 57 ml/hr. The feeding pump was turned off and no formula was being given. The hang date written on the bottle read 11/12/12 at 23:00 (11:00 pm). All 1500 ml of formula remained in the 1500 ml bottle. (According to the hang time on the bottle 855 ml of formula should have been administered from the formula hanging). This figure includes the 2 hour down time for the feeding. During an interview, 11/13/12 at 4:30 pm LVN A verified the pump had been off 30 minutes ago. During an interview LVN B stated Resident # 9's pump was turned off for medication three times a day. LVN B stated at 9:00 am, 1:00 pm and 5:00 pm Resident # 9 received [MEDICATION NAME] (medication used to treat and prevent ulcers in the intestines) and the tube feedings were held one hour before and one hour after the medication. Observation of Resident # 9 on 11/14/12 at 6:40 am, revealed Glucerna 1.2 hanging to run at 57 ml/hr. The date hung, written on the bottle, read 11/13/12 at 17:50 (5:50 pm). Eleven hundred (1100) ml of formula remained in the 1500 ml bottle (indicating 400 ml had been administred during the time the bottle was hung until the current time. According to the label the bottle had been hanging for 13 hours and the Resident # 9 should have received 741 ml of formula. Observation of Resident # 9 on 11/15/12 at 7:15 am, revealed Glucerna 1.2 hanging to run at 57 ml/hr. The date hung, written on the bottle, read 11/15/12 at 0400 (4:00 am). One-hundred seventy one (171) ml should have been received at the time of the observation but all 1500 ml of formula remained in the 1500 ml bottle. Observation of Resident # 9 on 11/15/12 at 2:25 pm revealed the above bottle had been removed and a new bottle of Glucerna 1.2 had been hung 11/15/12 at 1408 (2:08 pm). During an interview, at the time of the above observation, LVN D stated the pumps were cleared at the beginning of each shift. At the end of the shift LVN D stated she recorded the intake from the pump and not from the bottle hanging. LVN D stated the bottle hanging previously had been thrown away, even though it had formula remaining. 2. Resident # 2 was admitted to the facility on [DATE] and re-admitted to the facility on [DATE] per the face sheet dated 8/31/12. The [DIAGNOSES REDACTED]. Review of the clinical record revealed the following 2012 weights: April 115.6, May 116.0, June 124.6, July 120.2, August 118.6, September 116.4, and October 109.0. The weight loss between September and October revealed the following significant weight loss of 6.36 % for one month. Review of the weekly weights notebook provided by Restorative Aide E revealed no weekly weights were documented for Resident # 2 during the month of October. Review of the Resident # 2's weight for November 2012 revealed a weight of 107.0 pounds. This indicated an additional 2 pound weight loss or a loss of weight of 1.83 % for 1 month and 9.78 % in 3 months. Review of the weekly weights notebook revealed Resident # 2 was weighed during the week of November 5-9, 2012 and weighed 108.6 pounds and during the week of November 12-16 107.4 pounds. Review of the Dietary Notes revealed a note dated 10/25/12, 20 days after the monthly weights were completed by the restorative aide and had shown a significant weight loss. The dietician noted the October weight of 109 pounds and that the resident had a 6.4 % loss in one month and 9.3 % loss in 3 months. The dietician noted that the resident was on the following dietary/medications: a mechanical soft diet with no salt on the tray, 8 ounces of cranberry juice two times a day, [MEDICATION NAME] (antidepressant that had the side effects to be an appetite stimulant) and [MEDICATION NAME] (used to treat appetite loss and weight loss), Prosource (used to treat weight loss) three times a day, and the formula of [MEDICATION NAME] 1.2 one can three times a day. The dietician recommended to increase the number of cans of the formula [MEDICATION NAME] 1.2 to four a day per gastrostomy tube. Review of the consolidated November Physician order [REDACTED]. Observation on 11/14/12 at 7:05 a.m. revealed Resident # 2 had a gastrostomy tube and LVN O administered medications and formula through the tube at that time. Review of the Dietary Communication Form dated 11/03/12 revealed the kitchen was to add a Magic Cup to the tray at every meal. Observation of the breakfast tray on 11/16/12 at 7:40 a.m. revealed the resident had not eaten any of the food that was on the tray. There was no Magic Cup (a nutritional supplement that boosts calories, protein, and other nutrients) on the tray. Review of the breakfast tray slip on 11/16/12 at 7:40 a.m. revealed "Magic Cup at meals". Interview on 11/16/12 at 7:40 a.m. with LVN O revealed Resident # 2 did not want to eat breakfast so the tray was removed. She also confirmed there was no Magic Cup on the tray. She instructed CNA G to go to the kitchen and obtain a Magic Cup and then offer it to the resident. Interview with CNA G on 11/16/12 at 7:50 a.m. revealed Resident # 2 refused the Magic Cup also. During an interview on 11/16/12 at 10:00 a.m. with the DON, she stated that the residents were put on weekly weights and some residents were re-weighed when there when a weight issue was identified in the residents' weights. She stated that Resident # 2 was on weekly weights. No documentation of weekly weights for the month of October 2012 was found in the restorative aide's weight notebook that she documents weekly weights for Resident # 2. Review of the lab results revealeed the following: the total protein was 6.2 (low - normal range 6.4 - 6.9), and the [MEDICATION NAME] was 2.2 (low - normal range 3.5-6.7). Review of the physician order [REDACTED]. Review of the Significant Change in Status MDS assessment dated [DATE] and the Quarterly MDS assessment dated [DATE] revealed percent of calorie intake was coded as 51% or more and fluid intake was coded as 501 ml/day or more. Both of the MDSs revealed long term and short term memory problems with moderately impaired decision making on the the MDS dated [DATE] and a BIMS score of 2 on the MDS dated [DATE] indicating severe cognitive impairment. Review of the Care Plans dated 2/15/12 for Resident #2 revealed a care plan for "Unable to take foods or regular fluids orally. Receives nourishment via PEG tube. PEG tube inserted 2/3/12 due to inability to swallow." One of the interventions listed was: Monitor/record weight Q week for 4 weeks then q month if stable. Notify physician if weight loss 5 % in one month, 10 % in 180 days or below identified target weight. Review of the Care Plans dated 2/15/12 for Resident # 2 also revealed a care plan for: "Requires therapeutic diet - NSOT (no salt on tray) DX Hypertension, Mechanical Soft Diet". One of the interventions listed was the same as the one listed above. Review of Resident # 2's care plans revealed a care plan for Requires Therapuetic Diet. There was a hand written note - "11/03/12 Magic Cup to tray q meal" added to the problems area of the care plan. During an interview on 11/15/12 at 8:40 a.m. the DON stated gradual weight loss was monitored by the Dietician during the monthly visit. The DON stated the dietician reviewed the weights of all residents to include tube fed residents and residents with wounds. During an interview on 11/16/12 at 10:00 a.m. with the DON she stated that the residents are put on weekly weights and some residents are re-weighed when there was a change in the residents' weights. She stated that Resident # 2 was on weekly weights. No documentation of weekly weights for the month of October 2012 were found the restorative aide's weight notebook that she documents weekly weights. 3. Review of Resident # 4's face sheet dated 8/31/12 revealed she was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Resident Weight report dated 12/1/11 to 11/30/12 revealed in October resident # 4 was at 156.60 pounds and review of the reweight from the facility for November 15, 2012 was 147.2, thus a 5.9% weight loss. Review of Resident # 4's Consolidated physician's orders [REDACTED]. Continued review of Resident # 4's enteral feeding sheet dated November 2012 revealed the pump was to be turned off from 8 a.m. to 10 a.m. Review of Resident # 4's enteral feeding record dated November 2012 revealed 11/13/12 on the 11-7 shift she received 327 ml., on the 7-3 p.m. shift she received 352 ml. and on the 3-11 p.m. shift she received 336 ml of formula (a total of 1015 for the 24 hours). Review of a T.O. (telephone order) dated 11/13/12 at 8 p.m. for Resident # 4 revealed the tube feeding was not working properly, didn't receive the correct amount of formula feeding. Staff notified physician and he gave an order of continuous feeding to be replaced to [MEDICATION NAME] feeding of [MEDICATION NAME] 1.2 via peg tube at 8 p.m. and 11:30 p.m. today. This order change was after the surveyor intervention. Review of Resident # 4's care plan dated 1/9/12 revealed the resident was unable to take food or regular fluids orally due to inability to swallow and received 100% of nourishment via peg tube inserted on 12/15/07. The goal revealed Resident # 4 will receive nutrients to meet or exceed base needs and have to signs/symptoms of ... significant weight loss r/t the use of feeding tube for the next 90 days. The interventions for Resident #4 revealed staff were to monitor her weight every month and monitor her I&O (in and out) every shift. Review of Resident # 4's MDS (minimum data sheet) dated 7/10/2012 revealed she was confused, nonverbal, semi-comatose, needed total assistance with her ADL ' s (activity of daily living), and was incontinent of bowel and bladder. Observation of Resident # 4 on 11/13/12 at 12:30 p.m. during initial rounds, with the ADON revealed [MEDICATION NAME] 1.2 formula bottle at a rate of 42 ml/hr. was hung on 11/13/12 at 4:35 a.m. This bottle was at 1500 ml and should have been at 1080 ml. Observation on 11/13/12 at 4:35 p.m. with Resident # 4 revealed the [MEDICATION NAME] 1.2 bottle at a rate of 42 ml/hr. was hung on 11/13/12 at 4:35 a.m. This bottle 1500 ml bottle was at 1400 ml (504 ml of formula should have been received). Interview on 11/14/12 at 10:35 a.m. with LVN Q, regarding Resident # 4, revealed she hung the bottle of [MEDICATION NAME] 1.2 at 42 ml/hr on 11/13/12 at 4:35 a.m. Further interview she revealed the tube feeding pumps sometimes beeped and you had to shake the formula or see where the clog was in the tube to stop the pump from beeping. Observation on 11/13/12 from 4:35 p.m. to 5:04 p.m. in front of Resident #4's room revealed her tube feeding pump was alarming and the alarm was able to be heard in the hallway. The alarm to Resident # 4's tube feeding pump was ignored by LVN O, CNA S, CNA X and CNA Y. The tube feeding pump showed it was clogged and LVN O later came in to answer after the surveyor intervention. Interview on 11/13/12 at 4:59 p.m. with LVN B revealed staff were to check the call lights and the feeding pump alarms when they were buzzing. Interview on 11/17/12 at 8:47 a.m. with LVN O regarding Resident # 4 revealed the feeding pump was turned off from 8-10 a.m. Review of the facility Nursing Policy and Procedural Manual dated 2003, under the subject Gastrostomy Tube Care revealed the goals was the resident will maintain nutritional status optimal parameters via gastrostomy feeding. 4. Resident # 1 was admitted to the facility 3/09/12 with a readmission date of [DATE] according to the Face Sheet (no date obtained). [DIAGNOSES REDACTED]. A review of the facility's weight report revealed Resident # 1's September 2012 weight was 131 pounds, October 2012 weight was 127.8 (2.44 % loss in one month) and the November 2012 weight was 126.2 (1.25% loss in one month). A review of laboratory results for Resident # 1, dated 9/17/12 revealed an [MEDICATION NAME] (amount of liquid protein in blood) test was 3.3 (normal 3.5-6.7). A Hemoglobin (proteins in red blood cells that carry oxygen) was 10.1 (normal 12 -15.5) and a Hematocrit (precentage of volumn of whole blood made up of red blood cells) of 30.8 (normal 34.9-44.5). During an interview on 11/15/12 at 8:40 a.m. the DON stated gradual weight loss was monitored by the Dietician during the monthly visit. The DON stated the dietician reviewed the weights of all residents to include tube fed residents and residents with wounds. Continued record review revealed Resident # 1, had a culture of a right hip wound collected 11/5/12 that was positive for Staphlococcus Aureus (a bacteria). Review of the quarterly MDS (Minimum Data Set), dated 8/14/12, revealed Resident #1 was coded in the Active [DIAGNOSES REDACTED]. Percent of calorie intake was coded as 51% or more and fluid intake was coded as 501 ml/day or more. Review of the consolidated physician's orders [REDACTED]. Review of the Care Plan for Resident # 1, dated as reviewed 8/22/12, revealed a problem "Resident # 9 receives all nourishment via PEG (gastrostomy) tube inserted 2/24/12 due to dysphagia and [MEDICAL CONDITION]". The goal was " Resident #1 will receive nutrients to meet or exceed base needs and have no signs/symptoms of dehydration, weight loss and malnourishment for the next 90 days". Interventions listed were the ordered feedings and water flushes. Observations of Resident # 1, during entrance rounds on 11/13/12 at 12:05 p.m., with RN C revealed [MEDICATION NAME] 1.5 running at 48 ml/hr. The date hung, written on the bottle, read 11/13/12 at 0100 (1:00 am). All 1500 ml of formula remained in the 1500 ml bottle. (According to the time hung 528 ml of formula should have been administered from the formula hanging). Observation on 11/13/12 at 4:20 p.m. revealed [MEDICATION NAME] 1.5 running at 48 ml/hr. The date hung, written on the bottle, read 11/13/12 at 0100 (1:00 am). Thirteen hundred (1300) ml of formula remained in the 1500 ml bottle. (According to the time hung 720 ml of formula should have been administered from the formula hanging). Observation of Resident # 1 on 11/14/12 at 6:55 a.m. revealed [MEDICATION NAME] 1.5 running at 48 ml/hr. The date hung, written on the bottle, read 11/13/12 at 1745 (5:45 p.m.). Twelve hundred (1200) ml of formula remained in the 1500 ml bottle. (According to the time hung 624 ml of formula should have been administered from the formula hanging). Observation of Resident # 1 on 11/14/12 at 9:15 a.m. revealed [MEDICATION NAME] 1.5 running at 48 ml/hr. The date hung, written on the bottle, read 11/13/12 at 1745 (5:45 p.m.). Twelve hundred (1200) ml of formula still remained in the 1500 ml bottle. (According to the time hung 768 ml of formula should have been administered from the formula hanging). Observation of Resident # 1 on 11/14/12 at 12:45 p.m. revealed the resident was not in the room and the pump with formula was hanging at the bedside. The pump was turned off. 5. Review of Resident # 8' s face sheet dated 8/31/12 revealed he was admitted to the facility on [DATE], re-admitted on [DATE], readmitted on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident #8's Quarterly MDS dated [DATE] revealed he was severely impaired, confused, forgetful, needed total assistance with his ADL's, and he was tube feed for nutrition Review of Resident # 8's consolidated physician's order [REDACTED]. Review of Resident # 8's nurse's notes revealed on 11/15/12 at 12 p.m. the nurse spoke to the dietician and discussed his weight loss and the dietician recommended to increase his tube feeding formula to [MEDICATION NAME] 1.2 at 70 ml/hr. Observation on 11/14/12 at 8:12 a.m. revealed Resident # 8's tube feeding pump was on and the [MEDICATION NAME] 1.2 formula was hung at 11/14/12 at 2:20 a.m. at a rate of 60 ml/hr. The formula bottle was at 1400 ml. The formula bottle should have read 1260 ml. Observation on 11/15/12 at 7:49 a.m. revealed Resident # 8's [MEDICATION NAME] 1.2 tube feeding formula was hung on 11/15/12 at 4:05 a.m. at a rate of 60 ml/hr and the marker on the tube feeding bottle read 1500ml. The formula bottle should have read 1380 ml. Observation on 11/15/12 at 3:55 p.m. revealed Resident # 8's tube feeding formula bottle was hung on 11/15/12 at 4:05 a.m. and the formula bottle read 1500ml. The formula bottle should have read 900 ml. Interview on 11/15/12 at 4:37 p.m. with LVN O revealed Resident # 8 had a 2 hour downtime for her tube feedings (random, not scheduled down time).. Interview on 11/15/12 at 3:55 p.m. with Resident # 8's spouse revealed the tube feeding pump was off since 2 p.m. during a shower. The tube feeding formula was hung at 11/15/12 at 4:05 a.m. with a rate of 60 ml/hr and the formula bottle marker was at 1200 ml. The bottle formula should have been at 900 ml. Review of Resident # 8's enteral feeding record dated November 2012 revealed on 11/14/12 was recorded as having used 493 ml of formula. The formula bottle should of read 1007 ml. Review of Resident # 8's facility Enteral Feeding Sheet MAR indicated [REDACTED]. This order was discontinued on 11/14/12 and a new 2 hour (did not specify exact times) p.m. time was ordered to provide for showers and care started on 11/14/12. During an interview on 11/14/12 the DON presented a document, dated 11/14/12, stating the feeding pumps (currently used by the facility) had been in use since 5/15/12. One In-service Training Attendance Roster, dated 5/15/12, revealed Feeding Pump training had been conducted from 10:00 am to 10:45 am. Nine nursing staff signed in as attending. According to the staff roster, presented to surveyors on 11/13/12, Five Registered Nurses and eleven Licensed Vocational Nurses (total of 19 licensed staff) were employed by the facility (leaving 10 nurses responsible for operating the feeding pumps untrained). During an interview on 11/15/12 at 5:55 p.m. the DON presented a letter from the company supplying the tube feeding formula verifying the accuracy of the ready to hang containers was no greater than 101% (assuring that bottle measurement are accurate labeled). A review of the facility's Policies and Procedures, signed and dated as reviewed 11/01/12, revealed in the section Enteral Nutrition: "We will provide nutritionall complete enteral feedings as ordered by the physician for the nourishment of residents who are unable to eat. Problems with the administration of the tube feeding are monitored and corrected by nursing. The Regional Dietician was notified by nursing of problems such as nausea, diarrhea, vomiting, abdominal distention, weight changes, pressure ulcers, electrolyte imbalances and abnormal Laboratory results". Review of a form from the American Scale Company, dated 10/10/12, (who provide scale calibration services for the facility) revealed the digital wheelchair and the Hoyer Manuel slide scale were calibrated and in working order. According to CMS form 672, signed and dated by the facility 11/13/12 there were 16 residents receiving tube feedings. The Dietary Department's diet orders revealed five residents who received Magic Cups on their trays.