Every finding on record at Marquis Care at Centennial Hills

Based on observation, interview, record review and document review, the facility failed to provide documented evidence perineal care was being routinely provided for a resident with an indwelling catheter for 1 of 38 sampled residents (Resident 58). The deficient practice placed the resident at risk for a urinary tract infection (UTI). Findings include:Resident 58 (R58) was admitted on [DATE], with diagnoses including pressure ulcer of the right and left buttock and bed confinement status.A nursing admission assessment dated [DATE], revealed R58 was admitted with Foley catheter due to urine retention.On 06/23/2026 in the morning, R58 laid in bed alert while a covered urinary bag hung from the left side of the bed. The urinary tubing was not clear and appeared to have encrustation (build-up of minerals, crystals from body fluids). R58 indicated the Foley catheter had not been changed since admission and was uncertain if the urinary bag and tubing had been replaced.On 06/24/2026 at 9:35 AM, with R58's permission a Certified Nursing Assistant (CNA) removed blanket and unstrapped incontinent brief and asked R58 to widen thighs as much as tolerated. A strong, foul odor became evident as the perineal (area between the vulva and anus in females) area was exposed. The CNA confirmed the strong foul odor and described the urinary tubing as appearing to have sediments, but the urinary bag contained clear yellow urine.On 06/24/2026 at 9:40 AM, the CNA explained the facility protocol was to wash catheter insertion sites with soap and water every day, but the CNA was not assigned to R58 today. R58 reported staff only washed vaginal area with soap and water on shower days on Tuesdays and Fridays but not daily, one CNA always does it while the others don't.On 06/24/2026 at 9:45 AM, the Licensed Practical Nurse (LPN) assigned to R58 entered the room and confirmed strong malodor was coming from the resident's perineal area and there were sediments in the urinary tubing. The LPN indicated expecting CNAs to report abnormalities to nurses. The LPN was present when R58 emphasized perineal area was washed with soap and water on shower days but not on a daily or per shift basis.On 06/24/2026 at 9:55 AM, the LPN reviewed R58's electronic health record (EHR) and confirmed there were no orders for catheter care or perineal wash related to R58's catheter. The LPN could not speak to where the CNAs may be documenting perineal wash and how often urinary bags were replaced.On 06/24/2026 at 11:10 AM, the Resident Care Manager (RCM) indicated R58 was admitted with a Foley catheter on 04/06/2026 and explained care related to Foley catheters were not entered as physician orders but rather only in the resident's care plan. The RCM indicated interventions in the care plan such as daily perineal wash with soap and water were visible to the CNAs by Kardex (quick reference patient information or cheat sheet of a patient's care plan).The Urinary indwelling catheter care plan initiated 04/06/2026, documented to change urinary drainage bag as needed, catheter care with soap and water every day, maintain closed drainage system, secure tubing to prevent pulling and trauma. R58's Kardex read, catheter care with soap and water every day.R58's care plan for urinary catheter indicated interventions to change urinary drainage bag as needed and catheter care with soap and water every day.The medical record lacked documented evidence CNAs were performing daily perineal cleansing for R58.On 06/24/2026 at 11:26 AM, the Director of Nursing (DON) explained Foley care interventions did not require a physician's order and were covered by the facility's standards of care and corroborated the RCM's explanation care plan interventions would reflect in the resident's Kardex and should remind CNAs of tasks to be performed. The DON confirmed given the facility's current process for documenting care; the DON could not provide specific documentation attesting CNAs were performing daily perineal wash for R58. The DON indicated R58 was alert and credible and the observation which was witnessed by a CNA and an LPN suggested perineal care may have been provided routinely to R58 which placed the resident at risk for a urinary tract infection (UTI).The facility's Urinary Catheter Care policy revised March 2018 documented the purpose of the procedure was to prevent UTIs. Daily catheter care was a standard of practice, documented daily by resident standards of care. Provide perineal care with soap and water daily. Abnormal findings would be documented in the progress notes.

Based on observation, interview, record review, and document review, the facility failed to ensure the timely removal of an unused intravenous (IV) catheter for one of 38 sampled residents (Resident 52). The deficient practice had the potential to place the resident at risk for complications associated with an unused peripheral IV catheter, including inflammation of the vein, infection, and pain. Findings include:Resident 52 (R52) was admitted [DATE] with diagnosis including severe protein-calorie malnutrition, end stage renal disease, and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side.A Minimum Date Set assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 10, which indicated moderately impaired cognition.On 06/23/2026 at 9:46 AM, R52 was observed with a peripheral IV catheter in the right forearm secured by a transparent dressing. The dressing was not dated. A visible amount of dark, dried blood was observed at the catheter insertion site beneath the transparent dressing. R52 reported not knowing what the IV catheter was being used for and stated it had not been used recently. R52 was unable to recall when the IV was last used.A Skin/Wound admission Note dated 06/09/2026 documented a skin assessment was completed and identified R52 had a 22-gauge peripheral IV in the right outer arm.A Nursing admission assessment dated [DATE], documented a peripheral IV line was present in the right arm.A review of R52's medical record did not identify a physician order for the peripheral IV catheter, including orders for flushing, dressing changes, or other IV catheter maintenance.On 06/23/2026 at 9:55 AM, a Licensed Practical Nurse (LPN), confirmed R52 had a peripheral IV catheter in the left forearm, the transparent dressing was undated and a visible amount of dried, dark blood was present at the catheter insertion site beneath the dressing. The LPN reported the IV catheter was not in use. The LPN explained it was reported to the LPN the IV catheter had previously been removed. The LPN reported not noticing the IV catheter remained in place. The LPN stated the IV catheter should have been removed upon R52's admission from the hospital due to the risk of infection.A physician order dated 06/23/2026, documented peripheral IV was to be removed related to non-use. An Interdisciplinary Progress Note dated 06/23/2026, documented the nurse was unaware R52 still had a peripheral IV access in the right forearm. R52 was asked if the IV catheter could be removed and R52 stated not now, I am in too much pain. Pain medication was provided, awaiting effectiveness to attempt to remove peripheral IV catheter once again.An Interdisciplinary Progress Note dated 06/23/2026 at 6:07 PM, documented peripheral IV catheter to top of right forearm was discontinued.On 06/26/2026 at 3:40 PM, the Director of Nursing (DON) reported R52's peripheral IV catheter was identified upon admission to the facility on [DATE]. The DON reported the resident was not admitted with IV medication or antibiotic orders requiring the IV catheter. The DON acknowledged there were no physician orders for ongoing IV catheter care including dressing changes or maintenance, and there was no indication the IV catheter had been used or cared for since the resident's admission. The DON stated the IV catheter should have been removed upon admission because there was not a need for it and to reduce the risk of infection. A facility policy titled Catheter Insertion and Care revised 2023, documented the purpose of the procedure was to prevent complications with intravenous therapy, including catheter related infections. Site care, assessment, and dressing changes were to be performed.

Based on observation, interview, and document review the facility failed to ensure; 1) food items were dated with an opened, discard and/or expiration date and 2) food items were stored sealed or covered. The deficient practice placed residents at risk for foodborne illness. Findings include:1) On 06/23/2026 at 7:38 AM, the kitchen dry storage area contained the following items in various sized containers which lacked an open, discard and/or expiration date on each receptacle:-one container whole bay leaves-one container parsley flakes-one container crushed red pepper-one container Italian seasoning-one container ginger-one container ground cinnamon-one container cinnamon sticks-one container curry powder-one container dill weed-one container light chili powder-one container ground cumin-one container paprika-one container onion-one container steak seasoning-two containers of lemon & pepper seasoning salt-two containers of ground nutmeg-one bottle imitation vanilla flavor-one box pure cane dark brown sugar-two boxes of potato pearls extra rich mashed potatoes-one large container soy sauce-one large container sugar-one large container flour-one large container riceOn 06/23/2026 at 7:38 AM, the kitchen refrigerator contained one 5-gallon container of mango water which lacked a label, and an open, discard and/or expiration date on the receptacle.2) On 06/23/2026 at 7:38 AM, the kitchen freezer contained an open cellophane bag of waffles placed in an open French toast box and an opened cellophane bag of garlic bread, both of which lacked a label, and an open, discard and/or expiration date on the packaging.On 06/23/2026 at 7:50 AM, the Director of Food and Nutrition Services explained when a food product was opened, an open date would immediately be placed on the item. The expectation was for staff to write the open or discard date on the top of each opened container or to place a sticker label on the product packaging with the dates. The Director of Food and Nutrition Services confirmed freezer items were left in open cellophane bags and waffles were placed in an opened French toast box. The Director of Food and Nutrition Services explained freezer items were expected to be kept separate in own labeled box or receptacle, bagged items would be closed, sealed or covered, and the large containers of sugar, flour and rice should be dated when the food item was rotated out.On 06/24/2026 at 8:30 AM, the kitchen dry storage area contained an open cellophane bag of enriched macaroni product fettuccine and an opened cellophane bag of enriched macaroni product farfalle, both of which lacked an open, discard and/or expiration date on the packaging.On 06/24/2026 at 8:30 AM, the Director of Food and Nutrition Services confirmed the findings of the opened cellophane bags of fettuccine and farfalle. The Director of Food and Nutrition Services explained the products should have been placed in a covered container with an open date or sticker label placed on them.The facility policy titled Food Labeling and Dating, undated, documented all food and supplies would be labeled and dated according to Federal/State regulations and per company policy. The procedure for labeling and dating items was to write the date the item was prepared or opened.The facility policy titled Storage of Dry Food and Supplies, dated 04/2020, documented dry food and supplies would be stored according to policy guidelines and state regulations. Guidelines included; metal or plastic containers with tight fitting covers must be used for storing products, all food should be tightly sealed and labeled with the date it was stored, only approved storage containers and food grade vinyl bags could be used for food storage, open boxes were to be effectively re-sealed and items to be stored in properly labeled, sealed containers or tightly closed food-grade plastic bags after being opened.The facility policy titled Storage of Frozen and Refrigerated Foods, revised 08/12/2019, documented frozen and refrigerated foods would be stored according to policy guidelines and state regulations. Guidelines included; refrigerated/frozen products must be properly labeled with stored date, food needs to be labeled with name of the product and expiration or discard date if removed from the original packaging, food should be stored in approved covered containers, properly reseal packages of foods that have been opened to prevent freezer burn and spoilage.

Based on observations, interview and document review the facility failed to ensure that the resident had access to an operational and functional call light for 1 of 38 sampled residents (Resident 97), resulting in the resident being unable to summon staff assistance when needed. This deficient practice has the potential to place residents at risk for unmet care needs, delayed response times, and compromised health and safety. Findings include: Resident 97 (R97) was admitted on [DATE] with a diagnosis of unspecified dementia with additional behavioral disturbance. On 06/23/2026 at 11:23 AM, R97's call light was observed to be non operational and not functional for resident use. R97 was observed attempting to activate the call light; however, no light illuminated and no signal was generated to alert staff. R97 reported that the call light was not functioning and informed staff that the device was inoperable and could not be used to request assistance.On 06/23/2026 at 11:28 AM, a Licensed Practical Nurse (LPN) indicated when a call light was non functional, staff were required to check on the resident every 15 minutes to ensure the resident's safety and to compensate for the lack of an operational call system. The LPN indicated a non working call light was identified by a white indicator light on the call system panel. The LPN confirmed R97 had a white indicator light illuminated on the call system panel when the maintenance technician entered the room to test the call light, indicating that R97s call light was not operational. The LPN opened the facility's TELLS work order system and verified there was no active work order entered for R97s malfunctioning call light.On 06/23/2026 at 11:37 AM, a maintenance technician was asked to verify the status of the call light. Upon testing, the maintenance technician confirmed the call light did not function and did produce a white indicator light on the call system panel, which indicated non-operational. At the time of the observation, the maintenance technician verified there was no work order in the facility's system for the malfunctioning call light, despite the call light being identified as non operational. The facility's policy titled Answering the Call Light (undated) indicated when a call light was not operational, staff were required to submit a work order and provide increased monitoring.

Based on interview, record review and document review, the facility failed to ensure a physician's order was clarified and the accurate amount of medication and water was documented per the physician's order for 1 of 21 sampled residents (Resident 10). The deficient practice had the potential for the resident not receiving the maximum therapeutic effect of the medication and inaccurate documentation of the resident's fluid intake. Findings include: Resident 10 (R10) R10 was admitted on [DATE], with diagnoses including gastrostomy status (a surgical procedure used to insert a tube, often referred to as a G-tube, through the abdomen and into the stomach) and dependence on respirator (ventilator) status. The physician's order dated 12/10/2024, documented Protein Gel/Liquid (medication) 30 milliliters (ml) two times a day, mix in water if administered via enteral tube (G-tube), flush with 30 ml before and after administration. Document total consumed of Protein Gel and water. R10's Medication Administration Record (MAR) for May 2025, documented the following amount in ml for the administration of Protein Gel/Liquid in the morning (AM) and at bedtime/hour of sleep (HS): - 30 ml in AM and 30 ml at HS daily from 05/01/2025 to 05/12/2025 - 150 ml in AM and 30 ml at HS on 05/13/2025 - 150 ml in AM and 30 ml at HS on 05/14/2025 - 150 ml in AM and 120 ml at HS on 05/15/2025 - 150 ml in AM and 150 ml at HS on 05/16/2025 - 150 ml in AM and 30 ml at HS on 05/17/2025 - 60 ml in AM and 30 ml at HS on 05/18/2025 - 30 ml in AM and 30 ml at HS daily from 05/19/2025 to 05/27/2025 - 30 ml in AM and 120 ml at HS on 05/28/2025 - 30 ml in AM and 30 ml at HS daily from 05/29/2025 to 05/31/2025 R10's MAR for June 2025, documented the following amount in ml for the administration of Protein Gel/Liquid in the morning (AM) and at bedtime/hour of sleep (HS): - 30 ml in AM and 30 ml at HS daily from 06/01/2025 to 06/03/2025 - 150 ml in AM and 30 ml at HS on 06/04/2025 - 30 ml in AM and 30 ml at HS on 06/05/2025 - 150 ml in AM and 30 ml at HS on 06/06/2025 - 150 ml in AM and 150 ml at HS on 06/07/2025 - 150 ml in AM and 30 ml at HS daily from 06/08/2025 to 06/14/2025 - 30 ml in AM and 30 ml at HS daily from 06/15/2025 to 06/20/2025 - 90 ml in AM and 150 ml at HS daily from 06/21/2025 to 06/22/2025 - 90 ml in AM and 30 ml at HS on 06/23/2025 - 150 ml in AM and 30 ml at HS daily from 06/24/2025 to 06/25/2025 On 06/26/2025 at 9:16 AM, the Registered Dietitian (RD) revealed R10's hydration status was being monitored. The RD confirmed the 30-ml documentation in the MAR for the administration of Protein Gel/Liquid to R10 was not realistic. The RD indicated the accurate documentation should have been 150 ml two times a day. The RD explained the resident should have consumed 30 ml of Protein Gel/Liquid plus 120 ml of water. On 06/26/2025 at 9:50 AM, a Registered Nurse (RN) explained 30 ml of Protein Gel/Liquid would have been mixed with 120 ml water then flushed the G-tube with 10 ml water before and after medication administration. The RN indicated 150 ml should have been documented in the MAR every time the Protein Gel/Liquid was administered to R10. The RN confirmed 30 ml or less than 150 ml were documented in the MAR for the administration of Protein Gel/Liquid to R10. The RN indicated the order was to give Protein Gel/Liquid 30 ml mix in water if administered via enteral tube, flush with 30 ml before and after administration, then document total consumed of Protein Gel/Liquid and water. The RN explained documenting 30 ml in the MAR was not accurate. The RN acknowledged the physician's order was not followed. On 06/26/2025 at 9:57 AM, a Licensed Practical Nurse (LPN) explained documenting 30 ml in the MAR was not accurate and not in accordance with the physician's order for the administration of Protein Gel/Liquid to R10. The LPN revealed 30 ml Protein Gel/Liquid would have been mixed with 60 ml water. The LPN explained 90 ml would have been documented in the MAR for the total amount of Protein Gel/Liquid and water consumed. On 06/26/2025 at 10:08 AM, the Director of Nursing (DON) acknowledged the physician's order for the administration of R10's Protein Gel/Liquid was confusing. The DON indicated the order should have been clarified. The DON explained the order should have included the amount of water to mix with the Protein Gel/Liquid. The DON indicated the nurses were expected to document the total amount of Protein Gel/Liquid plus the water consumed in the administration of the medication. The DON acknowledged documenting 30 ml or 60 ml in the MAR for the administration of the medication was not accurate and unrealistic. The DON explained the total amount of Protein Gel/Liquid and water provided to the resident and documented in the MAR should have been at least 150 ml. The DON confirmed 30 ml was frequently documented in R10's MAR for May 2025 and June 2025. On 06/26/2025 at 1:19 PM, the RD indicated accurate documentation of R10's fluid intake was important in the assessment and monitoring of the resident's nutritional needs. The RD explained an accurate documentation would help the RD determine whether to adjust the resident's feeding and determine the interventions to address the resident's nutritional needs. The RD revealed the nurses were expected to document the accurate amount of Protein Gel/Liquid and water R10 had consumed per the physician's order. The facility's policy titled Physician Medication Orders dated 08/09/2024, documented physician orders for medications and treatments were to be documented in the clinical record as provided per order, unless clinical condition contraindicated administration/delivery of the order at that time.

Based on observation, interview, record review and document review, the facility failed to ensure restorative nursing services were provided per therapy recommendations for 1 of 21 sampled residents (Resident 40). The deficient practice had the potential for the resident's further decline in range of motion (extent of movement a joint could perform). Findings include: Resident 40 (R40) R40 was admitted on [DATE], with diagnoses including hemiplegia, tracheostomy status, and bed confinement status. R40's Occupational Therapy (OT) Discharge summary dated [DATE], documented the following: - Discharge Location: Resident discharged to reside in the facility. - Discharge Reason: Need for Skilled Services Ended. - Discharge Recommendations: Equipment / Other Recommendations: Hand rolls and positioning - Follow-Up Programs Established / Trained = Home Exercise Program (HEP) - Program Initiated / Established: Upper Extremity HEP R40's Quarterly Minimum Data Set (MDS) dated [DATE], documented the resident had impairment on both sides of upper and lower extremity. R40's medical record lacked documented evidence the resident was on exercise program or restorative nursing program and hand rolls were being applied to the resident per the therapy discharge recommendations. On 06/24/2025 at 9:05 AM, R40 was lying in bed and was observed to have hand contractures with no splint or hand rolls placed. On 06/27/2025 at 8:33 AM, R40 was lying in bed with no splint or hand rolls in place. On 06/27/2025 at 8:34 AM, a Registered Nurse (RN) confirmed R40 had contractures on both hands and the RN had not seen hand rolls applied to the resident. The RN indicated not being aware if the resident was receiving exercises or restorative nursing services. The RN revealed having worked five days a week in the unit where R40 resided. On 06/27/2025 at 8:46 AM, a Certified Nursing Assistant (CNA) indicated not seeing R40 with hand rolls in place since the start of the shift at 6:30 AM. The CNA confirmed not being sure if the resident needed hand rolls. The CNA explained the night shift CNA did not report during the change of shift about the resident using hand rolls. On 06/27/2025 at 9:01 AM, the Director of Rehabilitation (DOR) explained, upon a resident's discharge from therapy, the DOR would provide therapy recommendations to the Director of Nursing (DON) using the Restorative Assessment/Referral form. The staff and restorative nursing assistant (RNA) team were trained by therapy in implementing the therapy recommendations. The DOR revealed R40 was discharged from OT on 04/23/2025 because goals were met. The DOR indicated the therapy recommendations included HEP which referred to RNA program, consisted of three to five days a week for range of motion (ROM) and splinting, and hand rolls like washcloth or towel roll on both hands. The DOR confirmed the DON was notified of the therapy recommendations for R40. The DOR could not locate the copy of R40's Restorative Assessment/Referral form when requested. The DOR acknowledged there was a potential for skin breakdown and further decline in ROM if hand rolls or RNA were not provided to R40. On 06/27/2025 at 9:33 AM, the DON explained the DOR would provide the completed Restorative Assessment/Referral form to the DON, with therapy recommendations, upon a resident's discharge from therapy. Upon receipt of the form, the DON would enter the recommendations in the resident's electronic health record (EHR) and enter in Tasks portion of the EHR to prompt the RNAs of the specific treatment for the resident. The DON would update the resident's care plan to include the RNA program. The DON confirmed R40 was not on RNA program at this time and restorative nursing services had not been started upon R40's discharge from occupational therapy on 04/23/2025. The DON revealed a copy of the therapy recommendations written in the Restorative Assessment/Referral form had not been received. The DON indicated not being aware of the OT recommendations when R40 was discharged from therapy. The DON explained hand rolls referred to the washcloth placed on a resident's hand and RNAs would apply the hand rolls as indicated in the resident's treatment plan for RNA. The DON acknowledged R40 could have further decline in ROM if RNA was not provided. The DON confirmed the use of hand rolls and RNA program were not included in R40's care plan. The facility's policy titled Restorative Services dated 09/13/2023 documented, upon discharge from skilled therapy services, the therapist would make a determination if restorative services were recommended. If determination was made, a restorative services referral would be completed and given to the Director of Nursing Services (DNS/DON) or Resident Care Manager (RCM), as delegated, for implementation.

Based on observation, interview, record review and document review, the facility failed to ensure Oxygen (O2) was administered according to physician's orders for 1 of 21 sampled residents (Resident 31). The deficient practice had the potential to lead to O2 toxicity and exacerbation of the residents' underlying health conditions. Findings include: Resident 31 (R31) R31 was admitted on [DATE], with diagnoses including peripheral vascular disease, atherosclerotic heart disease, and adult failure to thrive. On 06/24/2025 at 9:31 AM, R31 was lying in bed and receiving O2 via nasal cannula (NC) connected to an Oxygen concentrator (a medical device that separates oxygen from air, providing a higher concentration of oxygen to individuals who need supplemental oxygen therapy). The concentrator was turned on and set at 2.5 liters per minute (LPM). A physician order dated 03/15/2023 documented Oxygen at 2 LPM via NC continuously. R 31's Care Plan dated 05/13/2025, documented R31 had inadequate compromised respiratory function as evidenced by a history of respiratory distress with interventions including O2 use per physician orders. On 06/25/2025 at 12:48 PM, R31 was lying in bed and receiving O2 via NC connected to an Oxygen concentrator. The concentrator was turned on and set at 2.5 LPM. On 06/25/2025 at 12:51 PM, a Licensed Practical Nurse (LPN) explained when orders were obtained from a physician for a resident to receive O2, the O2 was set up, administered, and titrated by the nurses. On 06/25/2025 at 12:58 PM, the LPN entered R31's room and confirmed R31's O2 flow rate was set at 2.5 LPM. The LPN verified R31's physician order was for 2 LPM and the flow rate was incorrect. On 06/26/2025 at 12:16 PM, the Director of Nursing (DON) reviewed R31's medical record and confirmed R31's order for O2 was 2 LPM via NC and explained staff were expected to follow the physician's order. The facility policy titled Oxygen Administration- Level III, updated 05/06/2019, documented while the resident was receiving oxygen therapy, adjust the oxygen delivery device so it is comfortable, and the proper flow of oxygen was being administered.

Based on observation, interview, record review and document review, the facility failed to ensure a resident received the medication as ordered for 1 of 21 sampled residents (Resident 243). The deficient practice had the potential for the resident having adverse events for not receiving physician prescribed medication. Findings include: Resident 243 (R243) R243 was admitted on [DATE], with diagnoses including type 2 diabetes mellitus without complications and hyperlipidemia. The physician's order dated 06/16/2025 at 8:55 PM, documented Semaglutide Oral Tablet 7 milligrams (mg) by mouth in the morning related to type 2 diabetes mellitus without complications. The start date was 06/17/2025. The order was discontinued on 06/19/2025 at 2:28 PM and the reason was clarification. The physician's order dated 06/19/2025 at 2:28 PM, documented Semaglutide Oral Tablet 7 mg by mouth in the morning related to type 2 diabetes mellitus without complications. The start date was 06/21/2025. The Interdisciplinary (IDT) Progress Note dated 06/19/2025 at 2:28 PM, documented R243 stated having Semaglutide 7 mg tablets at home and the resident's friend would bring in the medication either tomorrow or on Saturday. Order updated to start on Saturday (06/21/2025). R243's Medication Administration Record (MAR) for June 2025, lacked documented evidence the resident received Semaglutide 7 mg tablet from 06/17/2025 to 06/25/2025 as ordered. R243's admission Minimum Data Set, dated [DATE], documented the resident's Brief Interview for Mental Status score was 15 (total score from 00 to 15) interpreted as cognitively intact. On 06/24/2025 at 10:17 AM, R243 revealed there had been an issue with getting the resident's diabetic medication. R243 explained the facility advised the medication for diabetes the resident was taking at home was not available from the pharmacy. The resident was not aware how long it had been withheld but verbalized the staff had requested the resident to have a family member bring in the home stock supply of medication. On 06/25/2025 at 8:22 AM, during the medication administration pass observation, a Registered Nurse (RN) prepared R243's medications. The RN indicated R243's Semaglutide 7 mg was not available in the medication cart. At 8:30 AM, the RN checked the emergency medication dispensing system to verify if the medication was available. The RN confirmed Semaglutide 7 mg was also not available in the emergency medication dispensing system. The RN notified the Charge Nurse. On 06/25/2025 at 12:47 PM, the Charge Nurse explained R243 should have started receiving Semaglutide 7 mg on 06/17/2025. The Charge Nurse revealed getting a fax message (facsimile/the telephonic transmission of scanned-in printed material, including text or images) from pharmacy on 06/19/2025. The Charge Nurse indicated the fax message documented the medication (Semaglutide 7 mg) was not covered by the resident's insurance. The Charge Nurse indicated asking R243 if the resident had the supply of the medication at home and updated the resident about the fax message from pharmacy. The Charge Nurse revealed the resident stated having the medication at home and would ask a friend to bring the medication on Saturday, 06/21/2025. The Charge Nurse confirmed changing the physician's order for the medication to start on 06/21/2025. The Charge Nurse explained the nurses should have followed up with the resident and the physician about the medication not being available. The Charge Nurse indicated working at the facility every Wednesday, Thursday, and Friday. The Charge Nurse acknowledged having informed the physician on 06/25/2025 about the unavailability of R243's Semaglutide 7 mg when the Charge Nurse became aware the resident had not been receiving the medication. On 06/25/2025 at 2:40 PM, the RN explained if a medication was not available, the RN would call the pharmacy to follow-up. The RN indicated the physician would be notified right away, in real time, then document in the progress notes the follow-up and communication made with the physician and pharmacy. The RN revealed not being aware R243's family would provide the resident's Semaglutide 7 mg. On 06/25/2025 at 3:02 PM, the Director of Nursing (DON) indicated the Charge Nurse received the communication from pharmacy thru fax and was expected to follow up the request or clarification from pharmacy. The DON provided a copy of the fax message from pharmacy dated 06/18/2025 about R243's Semaglutide 7 mg tablet. The fax documented: - Urgent - Response Required. This medication was over $1000 for a 30-day supply and was being billed to the facility (required override). - Please reach out to the provider to change to a less expensive drug. Resident was not on Metformin which was the first line therapy for diabetes mellitus type 2. The DON confirmed there was no documented evidence the pharmacy's recommendation per the fax dated 06/18/2025 was followed through upon. The DON indicated the Charge Nurse should have followed up on the pharmacy's recommendation for R243's Semaglutide per the fax on 06/18/2025. The DON explained the Charge Nurse should have called the physician to change the order to a less expensive drug per the pharmacy recommendation. The DON indicated per verification with pharmacy, the facility received the fax message from pharmacy regarding the recommendation to reach out to the physician (provider) to change to a less expensive drug on 06/18/2025 at 7:55 AM, but the facility did not respond to pharmacy's recommendation. The DON revealed another fax message from pharmacy was sent to the facility on [DATE] regarding R243's Semaglutide 7 mg tablet. The fax documented: - Urgent - Response Required. The order could not be delivered due to: Over Facility Limit. - The medication was over your facility dollar limit amount. If you would like the medication to be filled, please obtain appropriate authorization per your facility policy. - Pharmacy would need authorization to bill the facility. The DON confirmed not having been notified about the unavailability of R243's Semaglutide 7 mg tablet until today, 06/25/2025. The facility's policy titled Administering Medications dated 01/29/2025, documented medications must be administered in accordance with the orders, including any required time frame. Medications not available to be administered per physician's order; pharmacy would be contacted to determine time of medication delivery. If a medication was not available within 24 hours, the Director of Nursing Services (DNS/DON) would be contacted per the 24-hour report. Medications not available within 72 hours, the physician would be notified.

Based on observation, interview and document review, the facility failed to discard expired milk stored in a refrigerator located in the kitchen, an ice pack in the first floor nourishment room freezer, and employee food from the freezer located in second floor nourishment room. The deficient practice has the potential to lead to bacterial growth and foodborne illnesses. Findings include: On 06/24/2025 at 8:00 AM, the milk refrigerator located in the kitchen, had a quart of expired silk milk dated 06/13/2025. On 06/24/2025 at 8:20 AM, the nourishment room located on the first floor, had an ice pack placed in the resident freezer. On 06/24/2025 at 8:30 AM, the nourishment room located on the second floor, had employee personal food items inside the nourishment freezer, which included a protein shake and a pizza. On 06/24/2025 at 8:02 AM, the Director of food and nutrition, verified the milk was expired and should have been discarded. On 06/24/2025 at 8:22 AM, the Charge Nurse (CN) stated the ice packs are used for residents if they have pain and expressed the ice packs should not be stored in the nourishment freezer. The CN explained the ice packs were placed in the freezer by physical therapy for easy access. On 06/24/2025 at 8:24 AM, the Director of food and nutrition, verified there was an ice pack in the resident freezer and acknowledged the ice pack should have not been placed in the nourishment freezer and discarded the ice pack. On 06/24/2025 at 8:32 AM, the Director of food and nutrition verified there were personal food items inside the nourishment freezer and stated employee food is not allowed in the freezer and discarded the food. On 06/27/2024 at 8:07 AM, the Director of Nursing (DON) explained personal food items and ice packs are not allowed in the resident nourishment refrigerators or freezers. On 06/27/2025 at 11:03 AM, facility policy titled storage of frozen and refrigerated food dated 08/12/2019, documented no foods should be stored past the expiration date.

Based on interview, record review and document review, the facility failed to update discharge instructions and failed to notify the physician of the changes in the discharge plan for 1 of 4 sampled residents (Resident 1). The deficient practice had the potential for a resident not to receive the necessary provisions for continuation of care. Findings include: Resident 1 (R1) R1 was admitted on [DATE] and discharged on [DATE] with diagnoses including urinary tract infection, atrial fibrillation, and unstageable pressure ulcer site unspecified. The physician discharge summary dated 02/18/2025 documented to discharge R1 home with home health, Registered Nurse (RN), Physical Therapy (PT), and Occupational therapy (OT) for maximizing strength and safety. A discharge order request dated 02/18/2025 documented discharge services of home health, nursing, PT, OT, social worker, bath aide and wound care three times a week for pressure wound on sacrum and right heel. An Interdisciplinary Team (IDT) discharge note date 02/18/2025 at 12:47 PM, documented the social worker received a message from R1's insurance provider indicating R1's family member cancelled the home health consult and reported the family will do wound care themselves. An IDT discharge note dated 02/18/2025 at 1:47 PM, documented R1's family were educated about discharge instructions. The Discharge Instruction document with effective date 02/10/2025 documented home health services consisting of Nursing, PT, OT, Social Worker, bath aid and wound care was the instructions educated to R1 and family. R1's face sheet (demographics) documented date of discharge 02/18/2025 at 3:48 PM. On 02/20/2025 at 12:00 PM, the Director of Nursing (DON) verified staff were notified prior to the discharge that home health and wound care were cancelled. The DON confirmed this was a change in the discharge plan and the facility should have followed up to ensure family was able to manage the care and education was provided if required. On 02/20/2025 at 12:45 PM, a social worker confirmed R1's discharge plan changed, and the physician should have been made aware. The social worker stated Adult Protective Services could also have been contacted to follow up. On 02/20/2025 at 1:12 PM, the Director of Rehab (DOR) stated being part of the IDT team and were aware the family had canceled home health. The DOR stated with the services having been canceled the discharge would not be safe as R1 required assistance with transfers, wound care, and activities of daily living. The physician should have been notified and there should be a follow up such as notifying Adult Protective Services for a welfare check. On 02/20/2025 at 1:53 PM, the DON confirmed the discharge instructions provided by the nurse to R1 were for home health and wound care services. The expectation was for the staff to communicate and update the discharge documentation. On 02/20/2025 at 2:42 PM, a Registered Nurse (RN) stated was unaware R1's family cancelled the home health, and the discharge instructions should have been updated. The facility policy titled Anticipated Discharge Summary- Post Discharge Plan with revision date 11/2017, documented discharge instructions were to provide instructions, and to communicate needs for the resident's safe transition to community setting such as home, or independent living.

Based on interview, record review and document review, the facility failed to provide documented evidence wound care treatments were provided per the physician's order for 1 of 4 sampled residents (Resident 1). The deficient practice had the potential to place the resident at risk for delayed healing of a wound. Findings include: Resident 1 (R1) R1 was admitted on [DATE] and discharged on [DATE] with diagnoses including urinary tract infection, atrial fibrillation, and unstageable pressure ulcer site unspecified. A physician's order dated 12/05/2024 documented Silvadene External Cream 1 % (Silver Sulfadiazine) apply to sacrum topically every day shift, every other day for skin impairment. Cleanse stage 3 pressure injury to sacrum with normal saline and pat dry, apply no sting skin prep to surrounding skin, apply Silvadene/ Triad mix to wound bed, cover with calcium alginate then cover with dry dressing. R1's Treatment Administration Record (TAR) for the stage 3 pressure area of the sacrum lacked documented evidence wound care treatments were completed on 12/28/2024 and 01/27/2025. On 02/20/2025 at 10:50 AM, a Licensed Practical Nurse (LPN) who identified as the wound care nurse, verbalized wound treatments were documented in the TAR. If treatments were missed a progress note was made. The wound care nurse reviewed the TAR for December 2024 and January 2025 and confirmed the undocumented treatment for 12/28/2024 and 01/27/2025. The wound care nurse verbalized documentation in the record was needed to indicate why the treatment was not signed as being performed, with no signature there was no way to verify the treatment was completed. On 02/20/2025 at 11:38 PM, the Director of Nursing (DON) stated staff were to document performance of wound care treatments on the TAR. If the treatment was refused or staff were unable to complete the treatment, a note would be entered on the TAR. If the TAR was blank, it indicated there was no documentation. The DON stated the expectation was for something to be documented on the TAR regarding what occurred with the resident. The DON confirmed there was no documented evidence the treatment was performed on 12/28/2024 and 01/27/2025 for R1. The facility policy titled Wound Care- Level II with revision date of 03/2017, documented the following information would be recorded in the resident's medical record: -Wound care provided (TAR) -The date and time the wound care was given, electronically recorded. -The name and title of the individual performing the wound care. -Notify the Charge Nurse and/or Director of Nursing if the resident refuses the wound care. Complaint # NV00073269

Based on interview, record review and document review, the facility failed to provide documented evidence a resident's midline (a long, thin, flexible tube inserted into a large vein of the upper arm used to administer medication into the bloodstream) was removed, and a site assessment was performed upon discharge for 1 of 4 sampled residents (Resident 1). This deficient practice had the potential for an increased risk of infection and to compromise the residents' health. Findings include: Resident 1 (R1) R1 was admitted on [DATE] and discharged on [DATE] with diagnoses including urinary tract infection, atrial fibrillation, and unstageable pressure ulcer site unspecified. A physician's order dated 02/18/2025 documented to discontinue midline related to completion of intravenous (IV) medication regimen. On 02/20/2025 at 2:35 PM, a Registered Nurse (RN) stated when an order for the midline removal was received from the physician, the removal was documented in the progress notes and was to include an assessment indicating the condition of the site, if there was any bleeding, or other concerns noted. R1's medical record lacked documentation the midline was discontinued, and a site assessment was performed. On 02/20/2025 at 3:11 PM, the Director of Nursing (DON) confirmed the midline removal for R1 should have been recorded on the Medication Administration Record (MAR) and a progress note entered to reflect an assessment of the site, any signs of infection and how R1 tolerated the process.

Based on observation, interview, record review, and document review, the facility failed to ensure an assessment for the use of bilateral mitten restraints for a resident was completed accurately and consent for the mitten restraints was obtained from the resident or the appropriate representative for 1 of 20 sampled residents (Resident #44). The deficient practice had the potential to cause physical and psychosocial harm to the resident. Findings include: Resident #44 (R44) Resident # 44 was admitted on [DATE], with diagnoses including acute respiratory failure, anxiety disorder, type 2 diabetes mellitus, dementia, nontraumatic intracerebral hemorrhage, hypoxemia, tracheostomy, and gastrostomy. Assessment: On 07/23/2024 at 3:21 PM, Resident #44 was observed wearing bilateral hand mitts (a restrictive type of mitten to prevent residents from pulling out invasive devices such as intravenous lines, feeding or airway tubes). The active care plan details Resident #44 was ventilator dependent, at risk for skin impairment/pressure ulcer related to cognitive impairment, immobility, and the vision is in question due to severe communication impairment. The Care plan also documented the hand mitts to both hands were to prevent pulling on tubing. The Physician Order dated 05/31/2024, documented bilateral hand mitts to prevent dislodgment of lifesaving medical device. Remove q (every) 2 hours for comfort and skin integrity. R44's medical record revealed a physical restraint/ assistive device assessment was performed on 06/10/2024. The assessment documented the resident's cognitive status as confused, developmentally delayed, and nonverbal. The assessment documented the hand mitts were in place to prevent the resident from pulling out the gastrostomy tube (a tube inserted into the resident's stomach for feeding) and the tracheostomy tube (a tube inserted into the resident's airway through the tracheal area of the neck and connected to a ventilator for respiratory support). The assessment indicated the resident was educated on what will happen if the trach is removed, but were not sure if the resident understood. The nurse completing the assessment had checked both the attestation boxes. One box documented the resident understood the facility had determined the resident does not have an assessed need for a restrictive and/or assistive device, but the resident requested to have device/devices in place as described per the resident's right. The other box attested the resident understood the facility has determined the resident had been assessed for the need for a restrictive and/or assistive device and the resident understood the risk/benefits and alternatives that have been described and agree to the devices to be utilized. 07/25/2024 at 1:35 PM, the Resident Care Manager (E23) stated the resident could probably not request to have the devices in place. The manager was not aware if the resident could understand the risk/benefits or could agree for the devices to be used. Consent: The restraint/assistive device assessment documented verbal consent was obtained from the resident's significant other and not from the resident's next of kin. On 07/25/2024 at 03:08 PM the charge nurse indicated when calls are needed for orders or consents for R44, a primary family member is called first. The charge nurse further explained if the primary family member does not respond, will move on to the next family member, who will normally respond back to the calls. Facility policy titled Use of Restraints documented, restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor) . Should a resident not be capable of making a decision, the surrogate or sponsor may exercise the right of the use or non-use of a restraint.

Based on observation, interview, record review, and document review the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) level two referral was completed for 1 of 20 sampled residents (Resident #36). The deficient practice had the potential to deprive the resident of concern and other residents of necessary behavioral health services. Resident #36 (R36) R36 was readmitted on [DATE], with diagnoses including pulmonary edema, acute respiratory failure with hypoxia, anxiety disorder, mood disorder, generalized anxiety disorder, post-traumatic stress disorder, and major depressive disorder. On 07/23/2024 in the afternoon, R36 was sitting on the bed. R36 stated had been at the facility for about 8 years and the care and services at the facility were good. A PASARR level one document dated 12/27/2016, revealed R36 did not have dementia, mental illness (MI), intellectual disability, (ID) mental retardation (MR) or any related condition (RC) and was deemed appropriate for nursing facility placement. A review of psychiatry notes revealed R36's post-traumatic stress disorder (PTSD) was first diagnosed on [DATE], generalized anxiety disorder on 03/17/2017, mood disorder on 03/15/2017, and anxiety disorder on 02/16/2018. On 07/25/2024 at 10:34 AM, the Resident Care Manager (E24) stated the PTSD is believed to be from military service. The anxiety disorder is from the PTSD, and the resident takes medicine for both. The mood disorder is from the depression, manic episodes, and refusal of cares. The psychiatrist goes to the social service director and keeps the director abreast of the patient issues. Social services were responsible for the PASARR's. On 07/25/2024 at 10:48 AM, the Social Services Director (SSD)(E22) and the Social Worker (SW)(E25) explained the SSD was responsible for completing the online PASARR requests. The SSD indicated not being aware of social services' involvement with identifying and referring residents who met criteria for PASARR two referrals, unless the mental disorder was interfering with their daily living, they were suicidal, or were sent out to the hospital for psych issues. The Assistant Administrator confirmed social services' involvement with identifying and referring residents who met criteria for PASARR two referral, was to be completed in their morning meeting. When asked if the resident's diagnoses of anxiety disorder, mood disorder, generalized anxiety disorder, post-traumatic stress disorder, and major depressive disorder would be representative of mental illness, intellectual disability, or a related condition that the Medicaid Service Manual documents a PASARR II must be completed for, both the SSD and the SW stated these diagnoses would be an indication. The medical record lacked documented evidence R36 was referred for a PASARR level two screening. The facility's document titled, The Division of Health Care Financing and Policy- Medicaid Services Manual- for Nursing Facilities Policy dated 05/01/2015, documented when an individual has been identified with possible indicators of mental illness, intellectual disabilities or related condition, a PASARR Level II screening must be completed to evaluate the individual and determine if nursing facility services and/or specialized services are needed and can be provided in the nursing facility. Examples include: a resident who exhibits behavioral, psychiatric, or mood related symptoms suggesting a presence of a mental disorder (where dementia is not the primary diagnoses), or an intellectual disability or related condition was not previously identified and evaluated through PASARR. Social services would be responsible for keeping track of each resident's PASARR screening status and referring to appropriate authority.

Based on observations, interviews, record reviews, and document reviews, the facility failed to ensure documentation accurately reflected medications and treatment services were provided. Specifically, this pertained to 1) wound care treatment; 2) ACE wrap (elastic bandage); 3) Oxygen (O2) therapy; and 4) diuretic medication . This deficient practice could potentially have led to severe harm, including ineffective wound management, an increased risk of respiratory complications, inadequate compression therapy, and compromised medication management. Findings include: A facility policy titled Administering Medications dated 04/08/2019, medications should be administered in a safe and timely manner and as prescribed. Medications or treatments must be administered in accordance with the orders, including any required time frame. Resident 48 (R48) R48 was admitted on [DATE], and readmitted on [DATE], with diagnoses including edema, anemia, congestive heart failure, effusion, chronic obstructive pulmonary disease (COPD), and heart failure. The Brief Interview of Mental Status documented a score of 15/15, which indicated R48's cognitive status was intact. 1) Wound Care Treatment: A physician order dated 07/09/2027, documented to cleanse skin tear to right forearm with normal saline, pat dry, apply no sting barrier film to peri wound, apply xeroform, and clear acrylic dressing every three days and as needed (PRN) on day shift for skin impairment. On 07/23/2024 at 1:19 PM, R48 was alert, oriented, and verbally responsive. R48's right forearm had a clear dressing dated 07/18/2024, which was peeling off. R48 indicated was admitted to the facility with the wound, which occurred when it got caught in the bed rail while in the hospital. R48 was uncertain about the frequency of the wound treatment but indicated it was treated when the Wound Care Treatment Nurse (WCTN) came for treatment. R48 indicated the last treatment occurred last week and did not refuse any wound care treatment. The Treatment Administration Record (TAR) dated 07/21/2024 documented the wound care treatment was provided to R48's right forearm, with Wound Care Treatment Nurse 1 (WCTN 1) signing off to indicate completion, despite the dressing being dated 07/18/2024. On 07/23/2024 at 1:41 PM, a Licensed Practical Nurse (LPN) confirmed the observation the clear wound dressing on R48's right forearm was dated 07/18/2024, old and peeling off. The LPN indicated the TAR was signed off or checked by WCTN 1 indicating the wound care treatment was successfully provided. The LPN indicated WCTN 1 was unavailable for interview and had already left the building. On 07/25/2024 at 11:56 AM, Wound Care Treatment Nurse 2 (WCTN 2) explained the process involved obtaining orders for wound care treatment, providing the treatment as scheduled, and documenting completion. WCTN 2 verified WCTN 1 had modified the TAR dated 07/21/2024 to reflect R48's refusal of treatment and the absence of treatment. WCTN 2 explained if a resident refused treatment, it should have been reoffered, and if treatment could not be provided, the physician should have been notified. WCTN 2 further explained while the wound care team could edit documentation, accurate recording of whether treatment was completed was expected on the same day as the scheduled treatment. On 07/25/2024 at 12:09 PM, WCTN 1 confirmed the treatment scheduled for 07/21/2024 was not provided but was inaccurately documented as successfully administered in the TAR. WCTN 1 explained was off the following day (07/22/2024) and had forgotten to correct the record. On 07/24/2024, WCTN 1 clarified had edited the documentation to reflect R48's refusal and verbalized R48 was asleep at the time and did not refuse the treatment. WCTN 1 confirmed the physician was not notified about the missed treatment on 07/21/2024, and accurate documentation was not maintained. On 07/25/2024 at 12:46 PM, the Director of Nursing (DON) indicated WCTNs were expected to provide wound treatment as ordered and maintain accurate documentation. 2) ACE wrap (elastic bandage): A Physician order dated 07/21/2024, documented to apply ACE wrap to bilateral lower extremities in the morning at 8:00 AM for edema and remove per schedule at 8:00 PM. On 07/23/2024 at 2:01 PM, R48 was in bed with both lower extremities edematous (swollen). The ACE wrap, ordered to treat the edema, was on the bedside table and not applied. R48 indicated taking medications with a recently increased dosage and indicated the ACE wrap was helping reduce the swelling, but were applied inconsistently. The Medication Administration Record (MAR) dated 07/23/2024 documented R48's ACE wrap was applied and in place. The ACE wrap was observed lying on the resident's bedside table. On 07/23/2024 at 2:50 PM, the ACE wrap was lying on top of R48's bedside table. The LPN confirmed R48's edema and an order for a diuretic and ACE wrap as treatment. The LPN confirmed the ACE wrap was not applied despite being documented as successfully applied. The LPN indicated the CNAs were responsible for the application of the ACE wrap. The LPN explained the Licensed Nurses oversee resident care, including the application of the ACE wrap, but failed to ensure the wrap was in place before signing off the TAR or documenting it was applied when the wrap had not been applied. The LPN confirmed the TAR was inaccurately documented. On 07/23/2024 at 1:55 PM, a Certified Nursing Assistant (CNA) indicated the Licensed Nurses or the wound nurses were responsible for putting on the ACE wrap not the CNAs. The CNA indicated being unaware of which residents should have ACE wraps and had no access to physician orders unless instructed by the Licensed Nurses. On 07/25/2024 at 10:37 AM, the Assistant Director of Nursing (ADON) indicated the nursing staff was responsible for applying the ACE wraps and ensuring were applied as ordered. The ADON verbalized the staff were expected to document or sign the MAR or TAR only after the task had been completed. 3) Oxygen (O2): A physician order dated 07/08/2024, documented O2 at 2-4 liters per minute (LPM) via nasal cannula. May titrate to keep O2 saturation greater than 90 percent (%) related to chronic obstructive pulmonary disease (COPD) with exacerbation. On 07/23/2024 at 10:06 AM, R48 was in the therapy session, O2 via concentrator was left on at bedside and flowing at 5 LPM, the nasal cannula was on the chair, O2 tubing was dated 07/24/2024. On 07/23/2024 at 2:50 PM, R48 was in bed, alert and oriented. R48's O2 was flowing at 5 LPM via nasal cannula. R48 reported the therapy had been completed before lunch. R48 indicated had received O2 at 3 LPM continuously at home and the same flow rate at the facility. R48 did not exhibit any signs or symptoms of shortness of breath. The MAR dated 07/23/2024, documented R48's O2 was flowing and administered at 3 LPM continuously via nasal cannula. On 07/23/2024 at 2:50 PM, the LPN confirmed R48's O2 was flowing at 5 LPM continuously via nasal cannula. The LPN verified and confirmed R48's O2 order was for 2-4 LPM. The LPN explained the O2 flow meter had not been checked but had been documented in the MAR as 3 LPM. The LPN indicated the O2 flow meter should have been verified and documented accurately, but the O2 order had been inaccurately administered and documented. On 07/24/2024 in the morning, the Charge Registered Nurse (CRN) indicated the staff were expected to document accurately after the order was verified and completed. On 07/25/2024 at 10:25 AM, the ADON indicated the documentation accuracy was crucial to the resident's care. Staff were expected to verify and administer medications and treatments as ordered. On 07/25/2024 at 3:32 PM, the Director of Respiratory Services explained if a resident with a diagnosis of COPD received too much oxygen when it was not needed, it could potentially suppress the resident's respiratory drive. A facility policy titled Oxygen Administration dated March 2015, indicated the need to verify a physician's order. The policy instructed staff to review the physician's order or facility protocol for O2 administration. An assessment was required before administering O2 and while the resident was receiving it. Cross reference to Tag F684 41903 4) Diuretic Medication: Resident 56 (R56) R56 was admitted on [DATE] and readmitted on [DATE], with diagnosis including Parkinson's disease with dyskinesia and fluctuations, atrial fibrillation, and major depressive disorder. An Order Summary Report documented a physician order for Lasix (a medication used to remove excess fluid in the body) Oral Tablet 40 milligrams (mg), give one tablet by mouth one time a day for edema (swelling). On 07/25/2024 at 8:55 AM, during medication administration observation, a nurse pulled out of the medication cart an empty medication packet labeled Lasix Oral Tablet 40 mg. The nurse explained the Lasix was not available in the cart and would order it from the pharmacy. The nurse reported did not know how long it would take the pharmacy to deliver the Lasix. The nurse confirmed the Lasix was not administered to R56 along with the rest of R56's medication. On 07/26/2024 in the morning, review of R56's medication administration record revealed the nurse had documented administered Lasix Oral Tablet 40 mg on 07/25/2024 at 9:24 AM. The medical record lacked documented evidence of where the nurse had obtained the administered medication from. On 07/26/2024 at 12:30 PM, the Director of Nursing (DON), explained Lasix was a medication available in the Pyxis (an automated medication dispensing system) which the nurse could have accessed. The DON further explained the Nurse could have also requested medication from the pharmacy, however, the Pyxis was the first choice to best administer medication to residents in a timely manner as ordered. On 07/26/2024 at 2:05 PM, the DON confirmed the Lasix administered to R56 had not been removed from the Pyxis and also confirmed the pharmacy did not provide the medication to the Nurse. The DON further explained had contacted the nurse who admitted to the DON the Lasix administered to R56 was borrowed from another nurse and belonged to another resident. The DON acknowledged the Lasix belonging to another resident should not have been borrowed from another nurse, both for safety reasons and it created a shortage of medication for another resident. A policy titled Medication Administration General Guidelines revised 01/01/2023, documented medications were to be administered as prescribed in accordance with good nursing principles and practices. Medications supplied for one resident were never to be administered to another resident.

Based on observation, interview, record review, and document review, the facility failed to ensure: 1) the wound care treatment was provided as ordered to treat impaired skin; 2) the ACE wrap (elastic bandage) was applied as ordered to treat edema; and 3) the Oxygen flow meter rate was administered as ordered to treat chronic obstructive pulmonary disease (COPD) for 1 of 20 sampled residents (Resident 48). These deficient practices had the potential to cause delayed wound healing, increased risk of complications related to poor circulation and compromised respiratory function. Findings include: Resident 48 (R48) R48 was admitted on [DATE], and readmitted on [DATE], with diagnoses including edema, anemia, congestive heart failure, effusion, COPD, atrial fibrillation and heart failure. The Brief Interview of Mental Status dated 07/13/2024, documented a score of 15/15, which indicated R48's cognitive status was intact. 1) Wound Care Treatment The admission Skin Integrity Report dated 07/07/2024 documented R48 had a skin tear on the right forearm measuring 1.5 centimeters by 1.0 centimeters, which was well approximated. The surrounding tissue was fragile, intact. A Physician order dated 07/09/2027, documented to cleanse skin tear to right forearm with normal saline, pat dry, apply no sting barrier film to peri wound, apply xeroform and clear acrylic dressing every three days and as needed (PRN) on day shift for skin impairment. A Care plan revised 07/19/2024, documented to provide treatment as ordered. On 07/23/2024 at 1:19 PM, R48 was alert, oriented, and verbally responsive. R48's right forearm had a clear dressing dated 07/18/2024, which was peeling off. R48 indicated was admitted to the facility with the wound, which occurred when it got caught in the bed rail while in the hospital. R48 was uncertain about the frequency of the wound treatment but indicate it was treated when the Wound Care Treatment Nurse (WCTN) came for treatment. R48 indicated the last treatment was last week and did not refuse any wound care treatment. The Treatment Administration Record (TAR) dated 07/21/2024, documented the wound care treatment was provided to R48's right forearm. Wound Care Treatment Nurse 1 (WCTN 1) signed off the TAR to indicate completion. On 07/23/2024 at 1:41 PM, a Licensed Practical Nurse (LPN) confirmed the observation the clear wound dressing on R48's right forearm was dated 07/18/2024, old and peeling off. The LPN indicated the TAR was signed off or checked by WCTN 1 indicating the wound care treatment was successfully provided. The LPN indicated WCTN 1 was unavailable for interview and had already left the building. On 07/25/2024 at 11:56 AM, Wound Care Treatment Nurse 2 (WCTN 2) explained the process involved obtaining orders for wound care treatment, providing the treatment as scheduled, and documenting completion. WCTN 2 confirmed the treatment administration record dated 07/21/2024 had been edited by WCTN 1 to indicate R48 refused the treatment. WCTN 2 explained if a resident refused treatment, it should have been reoffered, and if treatment could not be provided, the physician should have been notified. On 07/25/2024 at 12:09 PM, WCTN 1 confirmed the treatment scheduled for 07/21/2024 was not provided, but was inaccurately documented as successfully administered in the TAR. WCTN 1 explained was off the following day and forgot to correct the record. WCTN 1 indicated on 07/24/2024, the documentation was edited to indicate R48 refused the wound treatment, but WCTN 1 clarified R48 was asleep at the time and did not refuse the treatment. WCTN 1 confirmed the physician was not notified about the missed treatment on 07/21/2024, and accurate documentation was not maintained. On 07/25/2024 at 12:46 PM, the Director of Nursing (DON) indicated that WCTNs were expected to provide wound treatment as ordered and maintain accurate documentation. 2) ACE wrap (elastic bandage) The Nursing Admission assessment dated [DATE], documented R48 had present edema (swelling) on right and left lower extremities of 1 + pitting, capillary refill of less than 3 seconds. A physician order dated 07/21/2024, documented to apply ACE wrap to bilateral lower extremities in the morning at 8:00 AM for edema and remove per schedule at 8:00 PM. On 07/23/2024 at 2:01 PM, R48 was in bed with both lower extremities edematous (swollen). The ACE wrap, ordered to treat the edema, was on the bedside table, but not applied. R48 indicated taking medications with a recently increased dosage and indicated the ACE wrap was helping reduce the swelling, but was applied inconsistently. The Medication Administration Record (MAR) dated 07/23/2024 documented R48's ACE wrap was applied and in place. The ACE wrap had been observed lying on the resident's bedside table. On 07/23/2024 at 2:50 PM, the ACE wrap was lying on top of R48's bedside table. The LPN confirmed R48's edema and an order for a diuretic and ACE wrap as treatment. The LPN confirmed the ACE wrap was not applied despite being documented as successfully applied. The LPN indicated the CNAs were responsible for the application of the ACE wrap. The LPN explained the Licensed Nurses oversee resident care, including the application of the ACE wrap, but failed to ensure the wrap was in place before signing off the TAR or documenting it was applied when it was not. On 07/23/2024 at 1:55 PM, a Certified Nursing Assistant (CNA) indicated the Licensed Nurses or the wound nurses were responsible for putting on the ACE wrap, not the CNAs. The CNA indicated being unaware of which residents should have ACE wrap and had no access to physician orders unless instructed by the Licensed Nurses. On 07/25/2024 at 10:37 AM, the Assistant Director of Nursing (ADON) indicated the nursing staff was responsible for applying the ACE wraps and ensuring the wraps were applied as ordered. The ADON verbalized the staff were expected to document or sign the MAR or TAR only after the task had been completed. A facility policy titled Administering Medications dated 04/08/2019, medications should be administered in a safe and timely manner and as prescribed. Medications or treatments must be administered in accordance with the orders, including any required time frame. 3) Oxygen (O2) A physician order dated 07/08/2024, documented O2 at 2-4 liters per minute (LPM) via nasal cannula. May titrate to keep O2 saturation greater than 90 percent (%) related to chronic obstructive pulmonary disease (COPD) with exacerbation. A Care plan dated 07/08/2024, documented R48 had inadequate/ compromised respiratory function due to respiratory failure, congestive heart failure and COPD/ The interventions included was to administer the medications and O2 use as ordered. On 07/23/2024 at 10:06 AM, R48 was in the therapy session, O2 via concentrator was left on at bedside and flowing at 5 LPM, the nasal cannula was on the chair, and O2 tubing was dated 07/24/2024. On 07/23/2024 at 2:50 PM, R48 was in bed, alert and oriented. R48's O2 was flowing at 5 LPM via nasal cannula. R48 reported finishing the therapy before lunch. R48 indicated had received O2 at 3 LPM continuously at home and the same flow rate at the facility. R48 did not exhibit any signs or symptoms of shortness of breath. The MAR dated 07/23/2024, documented R48's O2 was flowing and administered at 3 LPM continuously via nasal cannula. On 07/23/2024 at 2:50 PM, the LPN confirmed R48's O2 was flowing continuously at 5 LPM via nasal cannula. The LPN verified and confirmed R48's O2 order was for 2-4 LPM. The LPN explained had not checked the O2 flow rate, but had documented it in the MAR as 3 LPM. The LPN further explained accurate verification and documentation of the O2 flow meter were necessary, but the administration and documentation of the O2 order were inaccurate. On 07/24/2024 in the morning, the Charge Registered Nurse (CRN) indicated the staff were expected to document accurately after the order was verified and completed. On 07/25/2024 at 10:25 AM, the ADON indicated the documentation accuracy was crucial to the resident's care. The ADON expected staff to verify and administer medications and treatments as prescribed. On 07/25/2024 at 3:32 PM, the Director of Respiratory Services explained if a resident with a diagnosis of COPD received too much oxygen when it was not needed, it could potentially suppress the resident's respiratory drive. A facility policy titled Oxygen Administration, dated March 2015, indicated the need to verify a physician's order. The policy instructed staff to review the physician's order or facility protocol for O2 administration. Before administering O2 or while the resident was receiving it, an assessment was required.

Based on observation, interview, record review, and document review, the facility failed to implement floating heels to prevent pressure ulcers for 1 of 20 sample residents (Resident #11). The deficient practice had the potential to expose the resident to an avoidable skin injury. Findings included: Resident #11 (R11) R11 was admitted on [DATE], with diagnoses including hypertension, diabetes, epilepsy, CVA, and chronic hypoxia. A physician order dated 04/26/2024 documented floating heels while in bed for skin integrity. A Braden Scale for predicting pressure sore risk assessment dated [DATE] indicated R11 had moderate risk for pressure sore. On 07/23/24, at 10:00 AM, R11 was in bed without any heel protectors, and the heels were not floating. A registered nurse confirmed the observation and explained the bed should have been in a position to allow heels to float. The bed was in a flat position, which did not prevent the heels from coming into direct contact with the mattress. On 07/25/2024 at 2:00 PM, R11 was in bed and was not wearing heel protectors, and the heels were not floating. The RN confirmed the observation and, after reviewing the medical record, acknowledged R11's heels should have been floating to prevent pressure ulcers. A care plan dated 05/24/2024 revealed R11 was at risk for skin impairment related to friction, incontinence, bruises, diabetes, chronic progressive diseases, and decreased mobility. The care plan's approaches included float heels with pillows to relieve pressure on bony prominence and heel and foot drop protector boots on both feet while in bed. On 07/25/2024 in the afternoon, the Director of Nursing explained the floating heels procedure was a nursing intervention and should have been implemented following the plan of care. The facility policy titled Prevention of Pressure Injury-Level II, dated 05/15/2019, stipulated when a resident is in bed, any attempt should be made to keep heels off of the bed by placing a pillow or a Keen Heel Float device.

Based on observation, interview, record review, and document review, the facility failed to complete a post fall assessment and neurological checks after an unwitnessed fall for 1 of 20 residents (Resident 38). The failed practice could have contributed to increased pain and a delay of necessary medical interventions. Findings include: Resident 38 (R38) R38 was admitted on [DATE] with diagnosis including polyneuropathy, unilateral primary osteoarthritis of right hip, dizziness and giddiness. A Care Plan initiated 02/11/2024, documented R38 was at risk for falls due to muscle weakness and history of falls. A Fall/Post Fall assessment dated [DATE] documented a history of falls, and R38 remained at risk for falls related to unsteady gait with poor safety awareness. On 07/23/2024 at 9:51 AM, R38 reported fell asleep sitting on bed and fell on the floor approximately one week before. R38 reported had right hip pain after the fall. A Fall Note dated 07/09/2024, documented R38 reported fell asleep while lying down on edge of bed and fell on the floor on right side. R38 reported right hip and right leg were slightly sore. R38's medical record lacked documented evidence a post fall assessment and neurological checks were completed for the fall R38 reported on 07/09/2024. On 07/24/2024 at 2:02 PM, the Director of Nursing (DON) reported had spoken to the nurse R38 had reported the fall to. The nurse had acknowledged to the DON fall protocol was not followed due to the resident reporting the fall two days after it happened. The DON explained the post fall assessment and neurological checks should have been completed regardless of when R38 reported the fall. The DON further acknowledged the recent increased pain reported by R38 could have been related to the fall. On 07/24/2024 at 3:52 PM, a Charge Nurse (CN), reported a post fall assessment and neurological checks had to be completed regardless of whether the fall was identified immediately or reported by a resident later and whether or not it was a witnessed or unwitnessed fall. The CN explained the benefits to the resident of a post fall assessment and neurological checks completed included identification of injuries and correct care provided. On 07/25/2024 at 8:16 AM, a Registered Nurse (RN) reported the pain on right hip R38 complained about, may have been related to the recent fall. The RN explained even if R38 reported the fall days later, an assessment and neurological checks should have been completed as part of the fall protocol. A policy titled Accidents and Incidents Investigating and Reporting revised 05/2018, documented date and time the accident or injury took place, nature of the injury/illness (e.g. fall), circumstances surrounding the accident or injury, the condition of the injured resident including vital signs, and other pertinent data as necessary or required should have been included in the resident's clinical record. A policy titled Falls and Fall Risk Managing revised 11/2022, documented if falls recurred despite initial interventions, staff would implement additional or different interventions, or indicate why the current approach remains relevant.

Based on observation, interview, record review, and document review, the facility failed to ensure: 1) water flushes were provided following the admission of a tube feeding-dependent resident, or the physician was notified when the hydration needs were not successfully met for 1 of 20 sampled residents (Resident 188), and 2) the resident's weight was obtained in a timely manner for 1 of 20 sampled residents (Resident 39). These deficient practices could have potentially resulted in severe dehydration, compromised nutritional status, increased risk of medical complications, and delayed recovery. Findings include: 1) Resident 188 (R188) R188 was admitted on [DATE], with diagnoses including dysphagia (difficulty swallowing), gastrostomy (tube inserted into the stomach for nutrition and hydration) status and malignant neoplasm of lip, oral cavity and pharynx. The Nursing Admission assessment dated [DATE], documented an initial Brief Interview of Mental Status score of 15/15, indicating R188's cognitive status was intact. On 07/23/2024 at 10:08 AM, R188 was lying in bed, alert and verbally oriented. The water bag (part of the tube feeding equipment) was full at 1000 milliliters (ml), labeled with a date and time (07/22/2024, 7:30 PM) and R188's name. A Licensed Practical Nurse (LPN) indicated R188 had been admitted on [DATE] around 6:00 PM, was dependent on tube feeding (TF), and was NPO (nothing per Orem or nothing by mouth). The LPN explained R188 had requested water, but due to swallowing difficulties, R188 could not drink. The LPN further explained the TF solution had caused R188 stomach discomfort, leading to a hold on the TF while awaiting instructions. On 07/23/2024 at 10:11 AM, R188 expressed the tube feeding (TF) and water flushes had not been administered immediately upon admission because the TF pumps were not working properly and had to be changed three times. R188 verbalized upon receiving a small amount of TF infusion, R188 experienced stomach discomfort, leading to the TF being held and no water flushes being given. R188 indicated the following day after admission had requested a sip of water because R188's mouth was very dry and uncomfortable, making it hard to cough out the phlegm but the LPN had declined to honor the request. The Dietitian assessment dated [DATE], documented R188's hydration needs as follows: -1080 ml of free water. -Flush order: 250 ml every 6 hours (1000 ml/day). -Flush the enteral tube with 30 ml of water before and after each medication administration. -5-10 ml between each medication. -Dilute/dissolve each non-liquid medication with 15 ml of fluid. -Free water in TF: 1080 ml. -Fluids given with enteral flushes: 1000 ml/day. -Total fluids given by tube: 2080 ml/day. R188's medical records lacked documented evidence the water flushes were administered as ordered. On 07/24/2024 at 12:07 PM, the Registered Dietitian (RD) indicated the assessment was the estimated fluids R188 should have received if successfully administered based on R188's needs. The RD indicated since the water flushes via enteral pump were not administered R188's fluid needs had not been met. The RD verified and confirmed the same water bag prepared upon R188's admission on 07/22/2024, was not being infused and the water bag was still full. The Speech Therapy Treatment Encounter dated 07/23/2024, documented R188 was referred to speech therapy services for nothing per Orem (NPO) or nothing by mouth with gastrostomy tube. R188 expressed taking small sips of water to moisten mouth and also assist with cough reflex. R188 edentulous (lacking teeth) and was limited to no movement of tongue upon commands. R188 able to articulate speech 75-80%. Trialed thin liquids via very small sips, was able to initiate swallow without overt signs and symptoms of aspiration. Discussed/educated with med nurse and Director of Rehabilitation Services, R188 may have the small sips of water as requested and supervised by spouse or nursing. On 07/24/2024 at 11:04 AM, same water bag was at bedside hung in the pole, not infused. R188's family was at bedside expressed R188 had not received any hydration for almost 24 hours, resulting in a dry mouth and throat. R188 requested water to sip to moisten the mouth or loosen phlegm. R188 had a history of lip and lymph node cancer, which affects saliva production. The family indicated the Speech Therapist assessed R188 and indicated R188 could sip water, but the LPN did not provide the request or at least to moisten the mouth with a swab. On 07/24/2024 at 11:04 AM, the attending physician indicated the staff were expected to administer the water flushes as scheduled and if not carried out timely, should notify the physician or the RD to obtain new orders. The Physician indicated the prolonged deprivation of the hydration was unacceptable. On 07/24/2024 at 11:26 AM, a Registered Nurse (RN) explained the process was to obtain TF orders upon resident's admission and administer immediately. The RN indicated if the TF was not successfully administered the physician or RD should have been notified for new orders. The RN indicated if the resident refused or was unable to successfully provide water flushes, the physician or RD should have been notified immediately to keep the resident hydrated. On 07/24/2024 at 11:47 AM, the Charge RN indicated the Licensed Nurses were expected to administer the TF and water flushes timely as ordered. The Charge RN confirmed the water flushes had not been provided as ordered since the bag of water prepared on 07/22/2024, was still full and not being infused. The Charge RN indicated the Licensed Nurses were expected to provide the water flushes to R188 timely as ordered or notify the physician if unable to carry out the orders. On 07/24/2024 at 12:07 PM, the RD removed the TF formula and water bag from R188's bedside. The RD indicated was unaware the TF formula and fluids had not been successfully provided to R188. The RD explained the LPN could have administered the water through the percutaneous endoscopic gastrostomy (PEG) tube using a syringe to meet R188's hydration. The RD indicated the Licensed Nurses were expected to notify either the RD or the physician of any concerns related to the TF or the resident's hydration to prevent delays in administration. The RD confirmed lacked documented evidence R188's hydration needs had been met. On 07/24/2024 at 1:33 PM, the Director of Nursing (DON) indicated the resident's hydration source was expected to be administered timely as ordered or the physician should be notified if there were any interruptions. On 07/26/2024 at 9:19 AM, the Speech Therapist (ST) indicated R188 was evaluated on 07/23/2024, in the early afternoon. The ST indicated R188 was alert and oriented, answering questions with limited lingual and tongue movement. The ST allowed R188 to sip water, observing no coughing and easy initiation of swallowing. The ST confirmed it was safe for R188 to swallow the water, which helped moisten the mouth and enabled R188 to cough out the phlegm. The ST discussed the assessment with the assigned LPN. The ST indicated had not been notified earlier of R188 ' s and the family's request. On 07/26/24 at 9:29 AM, the Director of Rehabilitation Services (DORS) indicated R188 was evaluated following day of admission. The DORS indicated R188 had undergone a mandible replacement, which caused limitations in lingual ability, but R188 was very alert and oriented. The DORS verbalized R188's family expressed frustration over not receiving timely hydration. R188 appeared tired and quiet at the time. The DORS indicated the family was involved in and familiar with R188's care. The DORS recounted a discussion with the family about the concentrated urine color during the first hours of admission, which improved after water flushes were administered the following day. The DORS indicated the assigned LPN should have reached out to the physician or Rehabilitation Services for assistance if R188 had concerns with swallowing. The DORS verbalized it was unacceptable for R188 not to receive hydration for almost 24 hours following admission. The DORS indicated the LPN should not have argued with R188's family, but instead R188's hydration needs should have been timely communicated or addressed timely. A facility policy titled Resident Hydration and Prevention of Dehydration dated 05/12/2021, documented the facility would endeavor to provide adequate hydration and to prevent and treat dehydration. If potential inadequate intake and or signs and symptoms of dehydration, individual preferences, physician would be informed. Nursing would monitor and document fluid intake and the dietitian would be kept informed of the status. 50289 2) Resident 39 (R39) R39 was admitted to the facility on [DATE], with diagnoses including infection of tracheostomy stoma, chronic pain, nontraumatic intracerebral hemorrhage, unspecified intestinal obstruction, acute embolism and thrombosis, and bed confinement. R39's Weight Summary report, documented a January weight of 218.7 pounds (lbs.) on 01/12/2024. No weights were tracked or monitored for April 2024. According to the weight task history, R39 was on monthly weights from 01/10/2024 until 05/15/2024 when the resident was switched to weekly weights due to weight loss. R39's Weight Report documented weights from January 2024 through July 2024 as follows: -07/22/2024: 198.4 lbs. -07/15/2024: 197.0 lbs. -07/08/2024: 196.8 lbs. -07/01/2024: 196.2 lbs. -06/17/2024: 198.4 lbs. -06/10/2024: 196.4 lbs. -06/03/2024: 196.0 lbs. -05/27/2024: 196.4 lbs. -05/13/2024: 195.8 lbs. -05/12/2024: 194.0 lbs. -03/12/2024: 220.0 lbs. -02/12/2024: 216.8 lbs. -01/12/2024: 218.7 lbs. On 07/24/2024 at 10:43 AM, the Dietician (E14) revealed the patient had had a 26 lb. weight loss from March 12, 2024, to May 12, 2024. According to the dietician, they would have liked to have caught this in April, but because no weights were taken and no report was run to follow up on the need for reweights, this resident's weight was missed. The dietitian stated that R39 was on the list to have the weight taken, however, there was no documentation from the Restorative Nursing Assistants (RNAs) on why they missed taking R39's weight. The dietician added the RNAs may have been pulled to work the floor that day, but the dietician stated could not be 100% sure this was the reason. On 07/24/2024 at 4:55 PM, R39's physician assistant (E17) revealed that the patient had been put on diuretics to reduce edema, had infections, and wounds. The physician also stated that R39's weight loss was a desirable loss. R39's active care plan documented the resident should be monitored for signs and symptoms of fluid overload, edema, respiratory distress, weight gain, vital signs changes and venous distention. The Dietician assessment dated [DATE], documented R39's BMI indicates extreme obesity and the patient's nutritional needs were to be based on an adjusted desired weight since a slow weight loss would be appropriate. A facility policy titled Weight Assessment and Intervention documented the nursing staff is to measure resident weights on admission (within first 24 hours), and weekly for four weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly thereafter. Weights will be recorded through POC, EMAR or directly in Weights/Vitals tab of the resident record. The facility will review monthly weight variances to follow individual weight trends over time.

Based on observation, interview, record review, and document review, the facility failed to ensure adequate tube feeding (TF) formula was provided as ordered to a resident who was TF-dependent or to notify the physician when it could not be carried out in a timely manner for 1 of 20 sampled residents (Resident 188). This deficient practice had the potential to compromise the resident's nutritional status and overall health, leading to malnutrition, dehydration, and an increased risk of infection. Findings includes: Resident 188 (R188) R188 was admitted on [DATE], with diagnoses including dysphagia (difficulty swallowing) and gastrostomy. The Nursing Admission assessment dated [DATE], documented R188's short and long memory as intact. R188 had a gastric feeding tube in place. A Care Plan dated 07/23/2024, documented R188 required TF in maintaining or improving nutritional status related to chewing problems and swallowing impairment. The goal included providing the TF as ordered, monitoring, and reporting formula intolerance to a physician or Registered Dietitian. On 07/23/2024 at 10:08 AM, R188 was lying in bed, alert and verbally oriented. The unhooked TF Glucerna 1.2 formula was at the bedside at approximately 1000 milliliters (ml), labeled with a date and time (07/22/2024, 7:30 PM) and R188's name. A Licensed Practical Nurse (LPN) indicated R188 had been admitted on [DATE] around 6:00 PM, was dependent on TF, and was nothing per Orem (NPO) or nothing by mouth. The LPN explained the Glucerna TF had caused R188's stomach discomfort, leading to hold the TF while waiting for instructions. On 07/23/2024 at 10:11 AM, R188 expressed the tube feeding (TF) had not been administered immediately upon admission because the TF pumps were not working properly and had to be changed three times. R188 had experienced stomach discomfort, leading to the holding of the TF Glucerna. R188's medical records lacked documented evidence a physician order was obtained for Glucerna through a gastrostomy tube. The Nursing Progress Notes dated 07/23/2024 at 1:20 AM, documented R188 refused the TF Glucerna and the stomach was hurting. The Dietitian assessment dated [DATE], documented Diabetisource 55 milliliters per hour (ml/hr.) via PEG tube. Total volume per 24 hours: 1320 (1584 kilo/calories, 79 gram protein, 1080 ml free water). The Scheduling Details dated 07/23/2024, documented to administer Diabetisource at a rate of 55 ml/hr. through the PEG tube. Total volume of 1320 ml per 24 hours. To start at 6:00 PM. A Physician order dated 07/23/2024 at 2:38 PM, documented to administer Diabetisource for 500 ml at 8:00 AM, 12:00 PM, and 5:00 PM with a total of 1500 ml via PEG tube using a syringe. The Medication Administration Record (MAR), documented the Diabetisource bolus of 500 ml was administered only once on 07/23/2024 and on 07/24/2024 at 8:00 AM. On 07/24/2024 at 10:45 AM, the same TF Glucerna formula bag was observed at the bedside with approximately 1000 ml, labeled with the date and time 07/22/2024, 7:30 PM. R188's family was present and indicated had spoken to the Licensed Nurse regarding R188 taking Diabetisource at home before hospitalization instead of Glucerna. The family reported R188 had taken a bolus of Diabetisource, two cartons (500 ml), in the afternoon on 07/23/2024, after 4:00 PM, after reminding the Licensed Nurse about R188's feeding, and again at 8:00 AM on 07/24/2024. The family expressed concerns about the inadequacy of R188's nutrition for almost 24 hours following admission. On 07/24/2024 at 11:04 AM the attending physician indicated the staff were expected to administer the TF as scheduled and if not carried out timely should notify the physician or the RD to obtain new orders. The Physician indicated it was not acceptable to delay the administration of the R188's nutrition. On 07/24/2024 at 11:26 AM, the Registered Nurse (RN) confirmed the TF formula had not been administered upon admission on 07/22/2024 and was only administered once on 07/23/2024 in the afternoon and again on 07/24/2024 at 8:00 AM. The RN explained the process was to obtain TF orders upon the resident's admission and administer immediately. The RN indicated if the TF was not successfully administered, the physician or RD should have been notified for new orders. The RN confirmed there was no documented evidence the physician or RD was notified when the TF was not administered or when the TF was inadequate for almost 24 hours following R188's admission. On 07/24/2024 at 11:47 AM, the Charge RN indicated the Licensed Nurses were expected to administer the TF formula timely as ordered to meet the resident's nutritional needs or notify the physician if there were any interruptions. On 07/24/2024 at 12:07 PM, the Registered Dietitian (RD) indicated had not been notified R188 was not tolerating the TF Glucerna and had assumed it was infusing overnight since it was hung at the bedside, but observed the TF bag was still full at 1000 ml. The RD indicated the Licensed Nurses were expected to notify the physician or the RD to obtain new orders. The RD confirmed R188's adequate nutritional needs had not been met in a timely manner. On 07/24/2024 at 1:33 PM, the Director of Nursing (DON) explained if the resident refused the TF formula for any reason, it should have been reoffered or the physician should have been notified to obtain new orders to ensure timely and adequate nutritional delivery. A facility policy titled Enteral Nutrition dated 04/29/2019, documented adequate nutritional support through enteral feeding would be provided to residents as ordered. Enteral feeding orders would be written to ensure consistent volume infusion. The following information would be included to ensure the full volume would be infused, regardless of any interruption of feeding.

Based on policy review, record review and interview, the facility failed to transfer a resident in a timely manner (Resident #1). Findings include: The facility's policy, Change in a Resident's Condition or Status (revised [DATE]), documented the Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been: .c. A reaction to medication; d. A significant change in the resident's .condition . f. Refusal of treatment or medications (2) or more consecutive times . g. A need to transfer the resident to a hospital . The facility's policy, Alert Charting---Clinical Assessment (revised [DATE]), documented The nurse shall assess and document identified changes in condition of residents, as identified. The facility policy is to assure the adequate monitoring and appropriate interventions for all residents whenever a change of condition, new admission, antibiotic therapy, or incident occurs . 2. The resident will be assessed by licensed nurse on duty. Assessment shall include as appropriate, but not limited to; a. vital signs .level of consciousness . h. Onset, duration, severity of the change . 3. The licensed nurse will notify the physician and the responsible party and document in the clinical record the date, time of notification and the person informed. 4. Assessment findings shall be clearly documented in the resident's clinical record . The facility's Making an Emergency Transfer or Discharge policy (revised ,[DATE]) documented . 1. Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will implement the following procedures: a. call 911; b. Notify the resident's Attending Physician . On [DATE], Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. The order set, dated [DATE], indicated Resident #1 was a full code. Code status: CPR (Cardiopulmonary resuscitation) and call 911 was listed on the order set. The progress notes in the medical record documented: A day shift nurse documented the resident refused the house supplement and 4 different medications at 11:31 AM on [DATE]. On [DATE] at 2:23 PM, the last set of documented vital signs were entered in the medical record: blood pressure ,[DATE]; oxygen saturation 88%; pulse 120; temperature 98.8 F. Nurse #3 documented (and indicated via interview) the resident was unable to swallow 3 different medications at 4:56 PM on [DATE] (so medication was held). A minute later, Nurse #3 documented shortness of breath and apnea and administered [MEDICATION NAME] (an opioid pain medication). At 5:06 PM, Nurse #3 documented unable to obtain the resident's oxygen saturation level. The medical record lacked documented evidence a nurse assessed the resident for a change of condition or obtained vital signs (Body temperature, Pulse rate, Respiration rate (rate of breathing) and Blood pressure). The medical record lacked documented evidence a nurse notified a physician. On [DATE] at 2:50 PM, Nurse #3 indicated full code residents were transferred out of the facility. When asked why vital signs were not obtained, Nurse #3 indicated vital signs were not requested by the nurse in charge during the shift. Nurse #3 indicated vital signs should be obtained within an hour or less of a transfer. On [DATE] sometime prior to 7:35 PM, clarified by Nurse #2 at 4:00 PM on [DATE], Nurse #2 notified hospice the resident needed to be transferred. Nurse #2 expected hospice to notify the physician. The medical record lacked documented evidence physician notification occurred. The Hospice nurse told Nurse #2 to follow the Skilled Nursing Facility's protocol. On [DATE] at 9:00 PM, Nurse #2 documented the resident was unresponsive with frequent episodes of apnea, cold/clammy/pale skin and unable to obtain oxygen saturation. The medical record lacked documented evidence a nurse assessed the resident for a change of condition or obtained vital signs. The medical record lacked documented evidence a nurse notified a physician. On [DATE] at 11:00 PM, the facility transferred the resident to acute care. On [DATE] at 3:15 PM, Nurse #2 indicated the facility transferred full code residents out with a change in condition. Nurse #2 told a nursing assistant to obtain the resident's vital signs, but the nursing assistant did not enter them. Nurse #2 was asked to identify the nursing assistant and was unable to do so. The vital signs documented at 2:23 PM were the same as on the facility's transfer form at 11:00 PM on [DATE]. On [DATE] at 4:00 PM, Nurse #2 was unaware the vital signs were the same on the transfer form as those entered at 2:23 PM, excepting respirations. Nurse #2 indicated the resident was assessed but could not identify the time, and the assessment was not documented. When asked why the resident was not transferred after Nurse #3 could not obtain an oxygen saturation at 5:06 PM, Nurse #3 indicated it was a hectic shift, and day shift should have transferred the resident. Nurse #3 indicated asking the day nurse about not transferring the resident at shift report and did not get a reply from the day nurse. On [DATE] at 10:45 PM, Nurse #3 called the family and documented their request to transfer the resident to an emergency department and then documented contacting emergency medical services for a transfer. On [DATE] at 4:00 PM, Nurse #3 indicated the non-emergency number for emergency medical services was called instead of 911. Nurse #3 was asked to distinguish an emergency vs. a non-emergency transfer. Nurse #3 indicated an emergency would be if vital signs were abnormal for an unexplained reason, like oxygen saturation < 80%. (The first oxygen saturation recorded at the acute care facility at approximately 11:54 PM the night of the transfer was 80% with the resident receiving 15 liters of oxygen. The resident was intubated and put on a ventilator. The resident received ,[DATE] liters via nasal cannula at the facility). When asked why 911 was not utilized, Nurse #3 did not know but indicated 911 should have been called instead of the non-emergent number. When asked why the family was called before activating emergency medical services, Nurse #3 indicated feeling pressured. On [DATE] at 5:00 PM, the Director of Nursing indicated in the given scenario of the resident in question, it was an emergency when nurses could not obtain the resident's oxygen saturation, and when the resident was unresponsive. Vital signs should have been taken, 911 should have been called, alert charting with a full assessment should have been completed. Despite documented changes occurring several hours prior during the shift, Nurse #3 did not transfer the resident until 11:,[DATE]:05 PM. The resident later expired. Complaint #NV 200

Based on record review, document review and interview, the facility failed to monitor a resident's change in condition to ensure appropriate care for 1 of 11 sampled residents (Resident #1). Findings include: Resident #1 Resident #1 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the record revealed the resident had a complex history including decubitus ulcers, recurrent urinary tract infections, and [MEDICAL CONDITIONS]. The resident received all her nutrition through a gastrostomy tube ([DEVICE]) with water flushes every four hours. The resident's [DEVICE] feedings were changed based on the family's request and the dietician's recommendations. The physician's orders [REDACTED].= 0 units (U), 151 - 200 = 2 U; 201 - 250 = 4 U; 251 - 300 = 6U; 301 - 400 = 10 U; 401 - 600 = 12 U and call MD (medical doctor). During the month of July 2012 through August 5, 2012, the resident's BS measured between 99 and 150. The resident did not require any Insulin coverage. On August 6, 2012, the physician changed the Blood Sugar monitoring to three times a week at night, on Monday, Wednesday and Friday. The resident's blood sugar remained stable until 8/29/12 when the BS registered 163 and the resident required 2 Units of Insulin. The results of the BS taken on 8/31/12 at 8:00 PM, was 286 and the resident received 8 units of Insulin. On 8/31/12 at 11:55 PM, the nurse's notes documented the resident was short of breath, had a change in mental status and had an elevated blood pressure (150/84). The physician was notified and orders received for Chest x-ray, Fasting Blood Sugar and a Urine culture and sensitivity. Results of the fasting blood sugar done on 9/1/12 at 4:30 AM revealed the BS was 489 (Critically High) - Normal range 70 - 99. Documentation in the nurse's notes revealed the nursing staff received the laboratory report in the evening of 9/1/12. The physician was notified. There were no new orders received at that time. There was no Insulin given on 9/1/12. The staff monitored the resident's vital signs including the blood pressure (BP), pulse and temperature, on 9/2/12. There was no documented evidence the resident's BS was monitored on 9/2/12. On 9/3/12 at 11:27 AM, the resident had an elevated temperature to 101.1 degrees. Tylenol 650 milligrams (mg) was given. The temperature was checked again at 2:00 PM, and had gone down to 99.2. On 9/3/12 at 4:57 PM, the resident had a further decrease in mental status and was not responding. The BS was 441 and 10 Units of Insulin was given. The resident was transferred to the acute care facility for follow up. On 11/7/12 in the afternoon, the Resident Care Manager (RCM) was interviewed. The RCM confirmed there was no documented evidence Resident #1's BS was rechecked on 9/1/12 or checked on 9/2/12. The RCM verbalized she contacted the Licensed Nurse (LN) who cared for the resident on 9/1/12. The LN verbalized she did not recheck the resident's BS. The LN indicated she had contacted the physician and the physician did not give any new orders to administer Insulin or to recheck the BS. Therefore, it was not done. The RCM explained Resident #1 was receiving a tube feeding of Fibersource HN, which was not recommended for Diabetics. The FBS (Fasting Blood Sugar) was taken on 9/1/12 at 4:30 AM, during the time the resident was receiving the tube feeding. Therefore, the BS was not considered a FBS, was not accurate, and the resident was not given Insulin. When the RCM was asked if the resident's BS should have been rechecked, or monitored since it was so high, the RCM responded, "Yes, that's basic nursing judgement." On 11/16/12 at 9:00 AM, interviewed Resident #1's physician by telephone. The physician confirmed he was notified of the resident's elevated BS on 9/1/12. The physician did not give any new Insulin orders since he believed the resident was receiving sliding scale Insulin coverage 4 times a day as the resident had when the resident was readmitted to this facility. The physician added the BS should have been rechecked and monitored more closely since it was so elevated. The physician was asked why the resident was transferred to the acute care facility on 9/3/12. The physician verbalized the resident's BS was still high and the resident had a change in mental status. The resident needed to be monitored more closely. The facility policy titled Diabetes - Clinical Protocol, revised April 2007, documented: - "Monitoring and Follow-Up... - (3) For the resident receiving insulin who is well controlled: monitor blood glucose levels twice a day if on insulin; monitor 3 to 4 times a day if on intensive insulin therapy or sliding-scale insulin; monitor as indicated if the individual is fasting before a medical procedure, has returned to the facility after a significant abscence, or has an acute infection or illness." Review of Resident #1's medical record from the acute facility revealed Resident #1 had a BS of 492 and temperature of 101 degrees upon admission to the ER (emergency room ). The resident was diagnosed with [REDACTED]. The resident was started on IV (Intravenous) Insulin, IV hydration, and antibiotics. Complaint #NV 546

Based on interview, clinical record reveiw, and policy review, the facility failed to ensure a gastrostomy feeding was ordered according to facility policy for 1 of 13 sampled residents (Resident #13), the facility did not follow up a resident's request for 1 of 13 sampled residents (Resident #4), and did not ensure a physician was notified of a change in condition in accordance with facility policy for 1 of 13 sampled residents (Resident #4). Findings include: Resident #13: Resident #13 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 12/17/2012, the resident's physician ordered 1 can [MEDICATION NAME] HN, every 4 hours 5 times a day, everyday. The order did not designate an oral or gastrostomy tube route. The resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Resident #13's dietary type is listed as NPO (nothing by mouth). On 02/06/2013 at 1:52 PM, the Director of Nursing was interviewed. She stated the order should have included a designated route. The facility provided the policy titled, "Physician Medication Orders" (MED-PASS 2001), which stated in part, "...Orders for medications must include: a. Name and strength of the drug; b. Quantity or specific duration of therapy; c. Dosage and frequency of administration; d. Route of administration if other than oral; and e. Reason or problem for which given..." Resident #4: Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #4's clinical record, dated 01/20/2013 at 10:45 AM stated in part, "Found resident laying on floor on right side with right wrist under ribcage. Head resting on floor with both knees bent. No noted injuries, right temple red and blanchable, faded momentary later... Resident asked staff not to tell her daughter (name) that she fell again. Resident stated that she stood up to reach for something on the bed, the chair alarm stated sounding and she unplugged it and lost her balance and fell on floor...Charge nurse to call daughter (name), and update physician...". The facility's Administrator was interveiwed on 02/06/2013 at 12:30 PM. He stated the facility should not have notified the resident's daughter since she asked the daughter not be notified. He provided the policy titled, "Resident Rights Guidance for All Nursing Procedures". The policy stated in part, "Purpose To provide general guidelines for resident rights while caring for the resident...Resident right of refusal (medications and treatment)". After the fall, neurological checks were started on Resident #4. Her record indicated on 01/20/2013 at 10:27 PM, she was "alert and oriented". On 01/21/2013 at 4:42 AM, the resident "...slept most of the night. Periods when awake, resident had signs of increased confusion...". There was no notation the physician was notified. On 01/21/2013 at 10:59 AM, the nurse documented "noticed increased confusion, slurred speech...Resident incoherent, + (plus) hallucinations, stated 'Oh look at that Christmas Tree', no tree present...Daughter informed, she said increased confusion of resident was noticed last night". The physician was notified and the resident was transferred to an acute facility for evaluation. The policy titled "Neurological Assessment" was reviewed with the Director of Nursing 02/06/2013 at 1:52 PM. She acknowledged the policy stated in part, "Any change in vital signs or neurological status in a previously stable resident should be reported to the physician immediately".

Based on interviews and record review, the facility failed to ensure one resident (Resident #2) was properly hydrated to prevent dehydration which necessitated transfer to the acute care hospital for 1 of 11 sampled residents. Findings included: Resident #2 Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2 was discharged from the acute care hospital on [DATE]. Resident #2's Discharge Summary dated 9/27/12, indicated due to the resident's unwillingness to eat and drink liquids, intravenous fluids may be required at the long term care facility. The resident had a PICC (Peripherally Inserted Central Catheter) line for this purpose. On 9/28/12, the facility nurses progress notes for Resident #2 indicated the resident pulled out the PICC line and the Foley catheter. On 9/28/12, the physician ordered intravenous (IV) fluids for Resident #2 due to poor fluid intake. On 9/29/12, the nurses progress notes for Resident #2 indicated the resident pulled out the IV and refused to have it re-inserted. The note indicated the facility would monitor. On 9/29/12, the nurses progress notes for Resident #2 indicated the [MEDICATION NAME] lock was reinserted and the resident had an IV of Normal Saline at 100 cc (cubic centimeter) per hour times 500 cc consumed. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. There was no documentation in the clinical record Resident #2 received more hydration by IV. The Follow-up Question Report for Resident #2 dated 9/27/12-10/08/12 revealed the following: Fluid intake (total consumed for the day) 9/28/12 = 160 cc 9/29/12 = 320 cc 9/30/12 = 260 cc 10/1/12 = 380 cc 10/2/12 =270 cc 10/3/12 = 250 cc 10/4/12 = 310 cc 10/5/12 = 600 cc 10/6/12 = 60 cc 10/7/12 = 70 cc 10/8/12 = 720 cc The Resident Hydration and Prevention of Dehydration Policy (revised 12/2008) documented: "...Policy Statement This facility will endeavor to provide adequate hydration and to prevent and treat dehydration. Policy Interpretation and Implementation 7. Nurse's Aides will provide and encourage intake of bedside, snack and meal fluids on a daily and routine basis as part of daily care. Intake will be documented in the medical records. Aides will report intake of less than 1200 ml (milliliter)/day to nursing staff. 8. If potential inadequate intake and/or signs and symptoms of dehydration are observed, intake and output monitoring will be initiated and incorporated into the care plan, ADL (Activities of Daily Living) in the care plan. ADL status, diagnosis, individual preferences, habits and cognitive and mental status will be considered in all interventions. Physician will be informed. 11. Laboratory tests may be ordered to assess hydration if intake and symptoms indicate possible significant dehydration..." On 11/15/12 in the afternoon the Resident Care Manager (RCM) reviewed the Follow-up Question Report for Resident #2. The RCM indicated Resident #2 did not receive enough fluid according to the form. Resident #2's chart lacked documentation the resident's fluid intake was monitored. Resident #2 was transferred to the acute care hospital on [DATE] by request of family member for evaluation of the Resident's swollen right lower extremity. Resident #2 was transferred to the acute care hospital via ambulance on 10/8/12. The resident was triaged in the Emergency Department (ED) and admitted to the acute care facility on 10/9/12. Resident #2's laboratory results performed in the acute care facility's ED included: Sodium-154 (normal 135-144) Chloride-115 (normal 95-105) Blood Urea Nitrogen-54 (normal 8-24) A Consultation was order with a nephrologist on 10/11/12. The physician diagnosed Resident #2's [MEDICAL CONDITION] and acute kidney injury due to severe dehydration severe volume depletion and [MEDICAL CONDITION]. The nephrologist documented, the patient (Resident #2) appeared malnourished and probably extremely volume depleted and behind fluid with leading [MEDICAL CONDITION] and mild azotemia (excess urea and other nitrogenous wastes in the blood) which seems slightly improved. Will order PICC line and TPN and assess swallowing and oral intake. Resident #2 had a PE[DEVICE] (Percutaneous Endoscopic Gastrostomy) placement on 10/16/12 due to the resident's severe dysphagia (swallowing disorder). Resident #2's Transfer Summary from the acute care facility on 10/22/12, indicated the residents acute kidney injury was resolved to include the [MEDICAL CONDITION] and the volume depletion. Complaint #NV 354