Every finding on record at Monument Healthcare Millcreek

Resident 2 was admitted to the facility on [DATE] with diagnoses which consisted of displaced bimalleolar fracture of right lower extremity, displaced avulsion fracture of right talus, chronic pulmonary edema, congestive heart failure, chronic kidney disease, kidney transplant status, unspecified protein-calorie malnutrition, fistula of the intestine, contusion of the abdominal wall, dyspnea, disorders of phosphorus metabolism, and hypokalemia. On 1/20/26 through 1/21/26 resident 2's medical records were reviewed. On 10/29/25, resident 2's admission Minimum Data Set (MDS) Assessment documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated that the resident was cognitively intact. On 10/24/25, resident 2's physician ordered TPN 1600 milliliter (ml) to run continuously in the evening per the pharmacy instructions. The pharmacy order summary documented the following for resident 2's TPN:Start Volume - 100 mlStart Rate - 62.5 ml/hour (hr.)Start Period - 1.6 hrs.Run Volume - 1600 mlRun Rate - 125 ml/hr.Run Period - 12.8 hrs.End Volume - 100 mlEnd Rate - 62.5 ml/hr.End Period - 1.6 hrs.Overfill Volume - NoneContainer Type - Single ChamberCompounded Volume - 1800 mlThe order summary was last updated on 11/20/25. It should be noted that the total volume to be infused in the order summary was 1800 ml with a total run period of 16 hrs. On 12/29/25, resident 2's pharmacy label for the TPN documented Infuse intravenously 1800 ml continuously in the evening. Run at 125 ml/hr. over 12 hrs. It should be noted that the order summary start volume and start rate and the end volume and end rate did not match the pharmacy label nor did the combined run period times equaling 16 hrs. Additionally, it was unclear whether the pharmacy label had not matched the original physician orders since October 2025. Resident 2's progress notes revealed the following: a. On 12/28/25 at 11:01 PM, the Alert Charting note documented, Entered room to check on resident and found her connected to the TPN bag. The bag is empty. Bag is not on the pump. She has received her 1600 ml of TPN already although it is scheduled for 12 hours. VS [vital signs] assessed. Dr on call notified. BS [blood sugar] checked. Neuro check at her baseline. Lung sound clear x's [times] 4. Resident refuses to have her family called. States 'you can call them in the morning. Don't bother them this time of night.' Dr on call-DON [Director of Nursing]- and nurse manager notified. b. On 12/29/25 at 12:18 AM, the Order Note documented, .Received TPN over a short time period. New orders: STAT [immediate] CMP [complete metabolic panel] in the am, Head of bed elevated at all times, assess lungs every 2 hours, monitor every 2 hours for altered mental status, vital signs every 2 hours. Resident agrees with change in plan of care. New orders noted and implemented. c. On 12/29/25 at 9:26 AM, a physical medicine and rehabilitation follow up note documented, Patient assessed w/ [name of Medical Doctor omitted] this visit. [Resident 2] is observed in bed. Noted to be lethargic with altered mental status. Arousable to loud voice and tactile stimulation; however, patient closes eyes almost immediately upon opening. She reports constant, sharp chest pain, non radiating. Vitals stable on 3L [liters oxygen] NC [nasal cannula], denies SOB [shortness of breath]. d. On 12/29/25 at 6:01 PM, the Alert Charting note documented, Report from night shift received that patient had been given TPN bolus during the night. On call provider called and ordered STAT CMP for AM. When day nurse went into draw labs, patient very sleepy and displayed understanding and agreement upon getting blood drawn. RN returned around 9AM to give morning meds. Patient more difficult to arouse. She would respond to her name and wake up for a second and then go back to sleep. MD notified at this time. Physiatrist came around 9:15 [AM]. After examining her, she came out and reported to RN [registered nurse] and UM [unit manager] that patient was complaining of chest pain. UM told RN to ask patient if she would like to go to the hospital. Patient stated no. UM went to take [sic] to patient around 0927 [9:27 AM] and stated that we need to send her to the hospital. 911 called at 0930 [9:30 AM]. Daughter called at 0940 [9:40 AM] to inform her of situation. EMS [emergency medical services] showed up at 0940 and transferred patient out to [name omitted] hospital. RN followed up at 1300 [1:00 PM] and found out patient was admitted for sepsis. Resident 2's Neurological Assessment documented the following abnormalities from baseline: a. On 12/28/25 at 11:30 PM, resident 2's Heart Rate (HR) was 107, Blood Pressure (BP) was 155/51, and Respiratory Rate (RR) was 22. b. On 12/29/25 at 1:30 AM, resident 2's HR was 112, BP was 173/83, RR was 24, and Temperature was 99.1. c. On 12/29/25 at 3:30 AM, resident 2's HR was 105, and RR was 20. d. On 12/29/25 at 5:30 AM, resident 2's HR was 102, RR was 20, and eyes opened to speech which was a change from opening spontaneously. e. On 12/29/25 at 7:30 AM, resident 2's eyes opened to speech, and motor response was localized to pain which was a change from obeys commands. f. On 12/29/25 at 9:30 AM, resident 2's HR was 61, eyes opened to speech, verbal response was confused, and motor response was localized to pain. A handwritten note on the bottom of the neurological assessment form documented a blood sugar of 450 [at approximately 11:01 PM] before calling the provider and a blood sugar of 278 at 9:30 AM. On 12/29/25 the Nursing Home Emergency Transfer Notice documented the reason for transfer was chest pain, low BP, fever, and high HR. The form did not document that resident 2 had received a TPN bolus the night before. On 12/29/25, resident 2's Hospital History & Physical documented the chief complaint as abdominal pain and chest pain. The reason for the emergency department (ED) visit further documented that the resident came from a care facility due to fever, altered mental status, and complaints of chest pain and abdominal pain. Emergency Medical Services (EMS) noted febrile, tachycardia and initially hypotensive but then had a normal reading upon arrival to the ED. The physical exam documented that the resident was positive for chills, fatigue and fever, positive for abdominal pain, positive for myalgias, and positive for confusion. Resident 2's vital signs in the ED were BP was 119/57, HR was 106, RR was 28, and Temperature was 99.4. The chest x-ray impression documented underinflated lungs, no acute intrathoracic findings. Differential diagnoses included sepsis, urinary tract infection, pneumonia, viral ailment including influenza or COVID-19, line sepsis due to indwelling line. We will consider as well heart failure, renal failure. Electrolyte abnormality. It should be noted that no documentation could be found to indicate that the hospital was notified of the TPN bolus with a subsequent change in condition. Resident 2's facility abuse investigation summary documented, At approximately 1945 [7:45 PM], an agency RN initiated the residents ordered TPN infusion. The RN reported an IV [intravenous] pump was not present in the room and manually calculated the drip rate, regulating the infusion via roller clamp. It was later confirmed that an IV pump was present in the room. Between 2200-2230 [10:00 PM - 10:30 PM], the agency RN reported the TPN bag was approximately half full prior to leaving the shift. At approximately 2300-2330 [11:00 PM to 11:30 PM], the facility RN assessed the resident and observed the TPN bag was empty. The IV tubing was connected to the resident's PICC [peripherally inserted central catheter] line but was not routed through the IV pump. The TPN was infused over approximately 3 hours and 15 minutes, rather than the prescribed 12 hours. On the morning shift, the resident was noted to be more difficult to arouse than at baseline. The physician was notified. A subsequent evaluation noted complaints of headache, nausea, and chest pain. The resident later became confused and incoherent. At 0930 [9:30 AM], emergency services were activated . It was substantiated that the patient did receive the TPN administration incorrectly. The patient was sent to the ER [emergency room] due to her COC [change of condition] of lethargy, altered mental status and cognition which was initially believed to be related to the TPN error. On 1/20/26 at 12:36 PM, an interview was conducted with the Director of Nursing (DON) and the Administrator (ADM). The DON stated that she received a phone call at 11:00 PM on 12/28/25 from RN 1 and she reported that the TPN tubing was attached directly to resident 2's PICC line and not through the pump and that the TPN bag was empty. The DON stated that she confirmed that an IV pump was in the room the following day. The DON stated that the TPN infusion was hung between 7:30 PM and 8:00 PM as reported by the agency nurse who administered the TPN. The agency nurse stated that he could not find a pump so he figured out the drip rate, calculated the flow rate and used the tubing to count the drips per minute. The DON stated that the agency nurse did not mention the duration of the infusion that was used to calculate the drip rate. The DON stated that the TPN order with the rate of infusion, total volume, and duration of infusion was located on the bag from the pharmacy. The DON stated that the TPN order details should also be in the resident's medical records on the order. The DON stated that the agency nurse had not worked in the facility prior and the nurse was not allowed to return to the facility after the incident. The ADM stated that he reported the nurse's license to the Division of Professional Licensing (DOPL). The DON stated that the Medical Doctor (MD) was notified and ordered to monitor resident 2 every 2 hours. The DON stated that the nurse should be monitoring the VS for any changes in BP, HR, or RR. The DON stated that resident 2's VS monitoring documented an elevated heart rate and high blood pressure. The DON stated that the nurse was to notify the MD of any systolic blood pressure greater than 200 and any diastolic blood pressure greater than 100. It should be noted that the VS monitoring orders did not document any BP parameters for MD notification. The DON stated that resident 2's lung sounds were monitored and within normal limits throughout the shift. The DON stated that resident 2 had a change in mentation and increased confusion. The DON stated that the MD was notified of resident 2's change in condition at 9:30 AM. The DON stated that after the incident education was provided to the nurses on TPN administration and that agency staff were no longer allowed to administer or monitor TPN. The DON stated that she also determined that any future TPN orders would also need to be in the electronic medical records and not just on the label from the pharmacy. The DON confirmed that the TPN label documented to infuse at a rate of 125 ml/hr. with a total volume of 1600 ml, and a duration of 12 hrs. The ADM stated that the TPN was infused in 3.5 hrs. and not the ordered 12 hours. The ADM confirmed that no other residents have had orders for TPN since the date of resident 2's incident. On 1/20/26 at 12:49 PM, a telephone interview was conducted with RN 1. RN 1 stated that she took over resident 2's hallway at 10:00 PM from the agency nurse on the night of the incident. RN 1 stated that she was previously in a different hallway. RN 1 stated that the agency nurse gave a report that everyone was fine. Because it was a telephone interview, RN 1 was read the progress note dated 12/28/25 at 11:01 PM and RN 1 verified that was what she had written. RN 1 stated that whatever she had written in the progress note was what had transpired. RN 1 stated that she had verified that resident 2 had an IV pump located in her room on the night of the incident. RN 1 stated that the rate of infusion and length of infusion was located on the bag of TPN from the pharmacy and it was supposed to run for 12 hours. RN 1 stated that she had found the empty TPN bag at 10:00 PM and she was not sure the time it was hung for administration. RN 1 stated that resident 2 was alert and oriented, talking and appeared to be fine. RN 1 stated that the MD ordered to monitor resident 2 every 2 hours for lung sounds, orientation, and VS within normal range. RN 1 stated that complications with the bolus infusion of the TPN could include cardiac failure, lungs full of water, altered mental status, and that was what she was monitoring for. On 1/21/26 at 9:00 AM, a follow-up interview was conducted with the DON and ADM. The DON confirmed that per the TPN label the volume of 1600 ml infusing at a rate of 125 ml/hrs. should have taken 14.4 hrs. to complete and not 12 hours as documented on the label. The DON stated that the nurse should have clarified the order discrepancies with the pharmacy and then followed-up with the MD. The DON stated that she recalled the order being 125ml over 12 hrs. and was not sure if the order ever changed during the course of the treatment. The DON stated that she could see that there was some confusion with the order as it was written. On 1/21/26 at 1:17 PM, a telephone interview was conducted with Nurse Practitioner (NP) 1 and Medical Doctor (MD) 1. MD 1 stated that he and NP 1 were the consultant secondary team, and did not write any medication orders for resident 2. NP 1 stated that when she assessed resident 2 on 12/29/26, the resident complained of chest pain and appeared a bit altered from baseline. NP 1 stated that the nursing staff were aware of resident 2's condition. MD 1 stated that they spoke with the DON and the floor nurse caring for resident 2 and reported the new complaints of chest pain. MD1 stated that the DON informed him that resident 2 had received a bolus of TPN and they were doing an investigation into the situation. MD 1 stated that the nursing staff was aware of resident 2's change in condition and that it could possibly be caused by the TPN infusion. MD 1 stated that resident 2's primary team physician was aware of resident 2's condition. Review of the facility policy on Parenteral Nutrition (PN) documented the following under general guidelines: . 3. Guidelines for administering are as follows: a. The rate tapers upward for 1-2 hours when starting the infusion. b. Then the PN runs at a set rate for a determined time. c. The rate tapers downward for 1-2 hours before the infusion is stopped or discontinued. d. The time intervals and tapering rates will be determined by the physician or the pharmacist. e. The bag is then disconnected from the catheter and discarded. f. The catheter is flushed with saline/heparin per protocol. 4. Never stop or discontinue parenteral nutrition suddenly. a. The PN rate must be tapered downward over several hours to allow the pancreas to adjust to the decrease in glucose intake (and the subsequent decreased need for insulin). This will help prevent hypoglycemia. The policy was last updated 2/1/24.

Based on interview and record review it was determined that the facility did not ensure that residents received the treatment and care in accordance with professional standards of practice, related to pain management. Specifically 1 of 4 residents sampled, was hospitalized due to opiate toxicity. Resident Identifier: 4 Findings Included: Resident 4 was admitted to the facility on [DATE] with diagnoses which included sepsis, obstructive and reflux uropathy, and calculus of kidney. Review of resident 4's medical record was completed on 1/21/26. On 1/1/26 at 10:47 AM, a Physician's Progress Admit Note for resident 4 revealed that a medication reconciliation was done with the patient's family and his primary care physician's records. Morphine tablets (immediate release, 7.5 milligrams (mg) every 6 hours as needed), were ordered for resident 4's dorsalgia. On 1/2/26 at 1:49 PM, a Medical Doctor (MD) History and Physical Note for resident 4 stated, Patient with large kidney stones. Patient complains of ongoing pain and wants more morphine than he is getting. On 1/3/26 at 8:28 AM, a Nursing Progress Order Note for resident 4 stated, .Give 1/2 tab PO [by mouth] every 3 hours for pain AND Give 1 tablet by mouth every 3 hours as needed for pain. On 1/3/26, a physician's order for resident 4 revealed the following Morphine Sulfate Oral Tablet 15 mg. Give 0.5 tablet by mouth every 3 hours as needed for pain. On 1/3/26, a physician's order for resident 4 revealed the following Morphine Sulfate Oral Tablet 15 MG. Give 1 tablet by mouth every 3 hours as needed for pain. It should be noted the new physician order resulted in an increase of 150 mg of Morphine every 24 hours as needed. Further review indicated that, based on the prescribed frequency and dosage, there was a potential for a total of 180 mg of Morphine to be administered within a 24-hour period. On 1/5/26 at 2:51 PM, a Physician's Follow Up Note for resident 4 revealed the following. Interval History: Patient seen in his room patient relays to me that his family felt like his [sic] he was slurring his words today. Patient has a new cough and feels congested in the lungs Pain management adequate with morphine.Details : Chief Complaint: slurred speech.Respiratory : Lungs CTA, Other: He has a congested cough.Assessment/Plan:.Ongoing management of nephrostomy, pain management, awaiting surgery. Pain management with morphine. I think there is some intermittent dysarthria caused by the morphine and we need to back off on this unless needed for pain levels higher than 4. It should be noted that an updated morphine was not located in the medical record. On 1/6/26 at 5:26 AM, a Nursing Progress Order Note for resident 4 stated, Resident is lethargic and wasn't speaking clearly. He slept all night but was smiling and compliant with medication and breathing treatment. BP [blood pressure] 167/95, HR [heart rate] 122, oxygen with CPAP [Continuous Positive Airway Pressure] is 88, and temp [temperature] is 97.7. Orders for chest x-ray are in but [name redacted] never arrived, resident complained yesterday of SOB [shortness of breath] and coughing. DON [Director of Nursing], ADON [Assistant Director of Nursing], and MD notified. On 1/15/26 at 4:16 PM, a Nursing Progress Note for resident 4 states, Pt with low O2 [oxygen] sat [saturations] at 83%; groggy and dry mouthed; not eating meals well; lungs with rhonchi bilaterally; nebulizer treatment given, O2 placed at 2L [liter]/NC [nasal cannula]; effective; o2 SATs increased to 93-94%; NP [Nurse Practitioner] notified or change in status. On 1/17/26 at 2:08 AM, a Nursing Progress Note for resident 4 states, Pt [patient] yelling for help, upon entering room pt found between the bathroom and his bed on his Lt [left] side. When asked what happened pt stated I rolled out of bed, after careful evaluation, no injuries noted. Assisted x [times] 3 staff back into bed. Bed in lowest position, call light in reach. Pt instructed to call for assistance before getting out of bed, Pt stated I didn't know I was paralyzed MD, Wife, Administrator, DON, Unit Manager notified. On 1/17/26 at 8:18 AM, resident 4's MAR revealed 1 tablet of 15 mg of Morphine Sulfate Oral Tablet was given. Pain Level Noted as 10. On 1/17/26 at 10:30 PM, resident 4's MAR revealed 1 tablet of 15 mg of Morphine Sulfate Oral Tablet was given. Pain Level Noted as 7. On 1/18/26 at 7:38 AM, resident 4's MAR revealed 1 tablet of 15mg of Morphine Sulfate Oral Tablet was given. Pain Level Noted as 4. It should be noted that a total of 45 mg of Morphine Sulfate was administered in a 24 hour period. On 1/18/26 at 9:09 AM, a nursing progress note for resident 4 stated, Patient appears lethargic at this time. Oxygen saturation is unable to be obtained due to cold extremities; hands are cold to touch. Staff reported significant changes in patient condition compared to yesterday. Per report, patient experienced low oxygen saturation overnight. Oxygen has been titrated up to 5 L/min [minute] however, oxygen saturation remains unable to be obtained despite multiple attempts. Based on current assessment findings, including lethargy, inability to obtain oxygen saturation, cold extremities, and reported decline since yesterday. Patient is being transferred to [name redacted] via [name redacted] transportation. Dr. [name redacted] and management were notified of patient condition and transfer. Spouse, wife [name redacted], was notified; no answer-voicemail left requesting a call back. Patient's son, [name redacted], was also notified; no answer-voicemail left requesting call back for notification. Medication list, transfer records, and discharge documentation were sent with the patient. At time of transfer, vital signs were as follows: blood pressure 112/81 mmHg, temperature 97.1 F [Fahrenheit], pulse 78 bpm [beats per minute] , respirations 24 breaths per minute. Oxygen saturation remains unable to be obtained at this time. Blood sugar is 104 mg/dL [milligrams per deciliter]. Patient transferred in stable condition with ongoing concerns requiring further evaluation in the emergency department [ED]. The hospital ED provider notes dated 1/18/26 at 11:58 am, revealed the following. The patient arrives critically ill with hypoxia down to 68%, slow respiratory rate, confusion he will open his eyes. He is otherwise not very responsive.The patient is in critical condition, this patient's condition is life-threatening due to hypoxia, with ongoing risk of organ failure.He has been getting extra doses above the 0.5 tablets of morphine he supposed to be getting at least once a day maybe twice a day he has Narcan responsive and wakes up and his respiratory rate improved but his oxygenation does not, his blood pressure also improved with Narcan.the patient will be admitted to the intensive care unit with multiple diagnoses which include hypoxia, sepsis, and opiate toxicity.The following medications were administered: naloxone (NARCAN) 2mg in dextrose 5% (D%W) 500mL DRIP (has no administration in time range) .naloxone (NARCAN)0.4 mg/mL injection 0.2 mg (0.2 mg intravenously Given 1/18/26 1055) .naloxone (NARCAN)0.4 mg/mL injection 0.2 mg (0.2 mg intravenously Given 1/18/26 1230) On 1/21/26 at 9:19 AM, an interview with Licensed Practical Nurse (LPN) 1. revealed the following. LPN 1 stated when the physician gives an order, the nurse should verbally repeat the order back to the physician for verification. Once verification is completed the order is entered into the resident's medical record. LPN 1 stated he typically followed up with a provider if he encountered a morphine order with a frequency exceeding every four to six hours. LPN 1 stated that when administering pain medication, he evaluated parameters including pain levels, timing, the previous dose, and the resident's response. LPN 1 stated the resident should be able to verbalize the request for medication. LPN 1 stated that pain levels were subjective and that residents occasionally requested medication despite low pain levels. LPN 1 stated he would attempt to offer alternative interventions, but if the resident insisted, he administered the medication as prescribed. LPN 1 stated he had been resident 4's nurse previously when he returned back to work on 1/18/26, he was informed during shift report resident 4 had declined. LPN 1 stated that during the shift's initial assessment, resident 4 was alert but lethargic and requested a higher dose of morphine despite the LPN 1 offering a lower dose. LPN stated that his change of condition came within 3 hours. LPN 1 stated he did not follow up with the provider because the resident had been on morphine for a period of time and appeared to be tolerating the medication. LPN 1 stated he transferred resident 4, to the Emergency Department (ED) for shortness of breath and change in condition. On 1/21/26 at 2:44 PM, an interview was conducted with the Director of Nursing (DON). The DON stated she expected nurses to use nursing judgment to determine if the medication was appropriate. She noted that parameters for administering medication depended on the resident's pain level and the specific instructions determined by the physician. The DON stated that the specific dose administered depended on the resident's clinical status and the resident's request. She noted that if a resident requested pain medication, the administration was subject to the resident's preference. The DON stated that when a resident experienced a change in condition, such as changes in respiratory status or levels of congestion she expected staff to assess the resident and contact the physician. The DON stated the provider will send a communication thread for updated orders. The DON stated the nurse was responsible for updating the order, and the Nurse Manager was responsible for double-checking the entries for accuracy. The DON stated she expected when two different orders existed for the same opioid for nurses to contact the physician for additional guidance. The DON stated she believed that resident 4's morphine order should have been written as a range, one-half to one tablet, every three hours.

Based on interview and record review, the facility did not ensure each resident's drug regimen was free from unnecessary drugs. An unnecessary drug was defined as any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indication for its use; or in the presence of adverse consequences. Specifically, for 3 out of 37 sampled residents, 2 of the residents' blood pressure medications were administered outside of the physician's ordered parameters and the third resident was not given an ordered medication as scheduled. Resident identifier: 26, 28, and 146.1. Resident 26 was admitted to the facility on [DATE] with diagnoses which included, hypertensive chronic kidney disease, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, and atrial fibrillation. Resident 26's medical record was reviewed on 11/17/25 through 11/20/25. On 12/18/24, Metoprolol Tartrate oral tablet was ordered for hypertension, with the following parameters: Hold for systolic [blood pressure] < [less than] 110, hr [heart rate] < [less than] 60. The Medication Administration Record (MAR) for the months of September, October, and November 2025 revealed that Resident 26 received Metoprolol revealed that Metoprolol was administered 6 times when it should have been held per the physician ordered parameters: On 9/6/25, SBP was 107.On 9/9/25, SBP was 106.On 10/3/25, HR was 58.On 10/10/25, HR was 59.On 11/10/25, SBP was 100.On 11/14/25, SBP was 56. On 11/20/25 an interview was conducted at 3:06 PM with the Director of Nursing (DON). The DON stated that blood pressure medications should not be administered outside of the ordered parameters. 2. Resident 28 was admitted to the facility on [DATE] with diagnoses which included orthopedic aftercare following amputation, Type 2 DM, and morbid obesity. On 11/18/25 9:37 AM, an interview was conducted with resident 28. Resident 28 stated that when she was first admitted she missed 3 weeks of injections of her Trulicity (Dulaglutide) medication. Resident 28 stated that the nurse had to re-order the medication and it delayed her injection. Resident 28's medical records were reviewed 11/17/25 through 11/20/25. On 9/3/25, resident 28's physician ordered Dulaglutide Subcutaneous Solution Auto-injector 1.5 milligram (mg)/0.5 milliliter (ml) (Dulaglutide), Inject 1.5 mg subcutaneously one time a day every Sun (Sunday) for Diabetes. On 10/1/25, resident 28's physician ordered Dulaglutide Subcutaneous Solution Auto-injector 1.5 mg/0.5 ml (Dulaglutide), Inject 1.5 mg subcutaneously one time a day every Wed (Wednesday) for Diabetes. Resident 28's September 2025 Medication Administration Record (MAR) documented a code 9 on 9/7/25, 9/21/25, and 9/28/25. The MAR legend indicated that code 9 was see Nurse Note. Resident 28's progress notes revealed the following: a. On 9/7/25 at 11:15 AM, the Medication Administration Note documented that the Dulaglutide was waiting for delivery from the pharmacy. b. On 9/7/25 at 2:21 PM, the progress note documented, Pharmacy called to report that the resident's last labs show that hgb [hemoglobin] is over 8. They will not be sending it [Dulaglutide]. c. On 9/8/25 at 5:44 PM, the Medication Administration Note documented that the Dulaglutide was Given 9/8 at 1745 [5:45 PM] after patient said she hadn't gotten it, and [provider name omitted] said it was okay to give a day late. It should be noted that the provider notification was 24 hours after the medication was scheduled to be delivered. d. On 9/21/25 at 4:09 PM, the Medication Administration Note documented for the Dulaglutide, Resident to have family member bring it in. e. On 9/28/25 at 11:04 AM, the Medication Administration Note documented for the Dulaglutide, On order from pharmacy. On 11/19/25 at 1:28 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that if medication was unavailable for administration she would notify the Medical Doctor (MD) and ask for orders to hold or give when available. LPN 1 stated that they had difficulty getting the Dulaglutide medication and that it was due to a pharmacy issue. LPN 1 stated that she gave the medication on Wednesdays and then would reorder it for the following week's administration. LPN 1 stated that she thought that the insurance was not covering it but now it was. On 11/20/25 at 9:41 AM, an interview was conducted with the Doctor of Pharmacy (PharmD) District Director of Operations for the facility. The PharmD stated that medication delivery schedules were Monday through Friday at 2:30 PM or 8:00 PM, and stat [immediate] orders were within a 4 hour delivery window from the time they received the request. The PharmD stated that the Dulaglutide was dispensed on 9/3/25 and was delivered at 8:27 PM. The PharmD stated that the medication was delivered one time per week. The PharmD stated that the next delivery was on 9/9/25 at 3:09 PM, then on 9/21/25 at 8:05 PM, and then on 9/29/25 at 3:33 PM. The PharmD stated that on 10/1/25 the medication order changed to deliver on Wednesday. On 11/20/25 at 10:06 AM, an interview was conducted with the DON. The DON stated that she was not aware that resident 28 had missed 3 doses of the Dulaglutide medication. The DON stated that the nurse should notify the MD if a medication was not available for administration and ask for new orders. The DON stated that the nurse should then document that the MD was notified in a progress note. If it was coded 9 there should be a progress note with the documented reason the medication was not administered.3. Resident 146 was admitted to the facility on [DATE] with diagnoses which included displaced bimalleolar fracture of right lower leg, deep tissue injury (DTI) left heel, atrial fibrillation, cardiomyopathy, congestive heart failure, hypertension, and cardiomegaly. Resident 146's medical records were reviewed 11/17/25 through 11/20/25. On 8/12/25, resident 146's physician ordered Metoprolol Succinate Extended Release (ER) Oral Tablet 25 milligram (mg), Give 1 tablet by mouth one time a day for hypertension hold forsystolic blood pressure (BP) less than (<)110 or heart rate (HR)<60. Resident 146's August 2025 MAR revealed that Metoprolol was administered 4 times when it should have been held per the physician ordered parameters: On 8/18/25, BP was 106/57On 8/20/25, HR was 55On 8/21/25, BP was 102/60On 8/22/25, HR was 55. On 8/12/25, resident 146's physician ordered Amiodarone Hydrochloride (HCl) Oral Tablet 200 mg, Give 1 tablet by mouth two times a day [BID] for hypertension hold for systolic BP<110. Resident 146's August 2025 MAR revealed that Amiodarone was administered 6 times when it should have been held per the physician ordered parameters:8/16/25, AM BP was 100/538/18/25, AM BP was 106/578/18/25, PM BP was 109/48/21/25, AM BP was 102/60 8/21/25, PM BP was 100/608/22/25, PM BP was 100/62. On 11/20/25 at 12:03 PM, an interview was conducted with the DON. The DON stated that if the physician order said to hold for BP <110 or HR <60 then the nurse should hold the medication. The DON stated that she agreed that, based on the order parameters, the medications should have been held when they were administered.

Based on observation and interview it was determined that the facility was not adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or a centralized staff area for toilet facilities. Specifically, the facility had seven public bathrooms that were accessible by residents and were not equipped with a call light system. On 11/20/25, an observation was made of the public bathroom facilities. The 300 hallway bathroom near room [ROOM NUMBER] was observed and did not contain a call light inside. The 400 hallway bathroom near the nurse's station was observed and did not contain a call light inside. The bathroom next to the staff break room was observed and did not contain a call light inside. The bathroom next to the Human Resource office and front desk was observed and did not contain a call light inside. None of the public bathrooms were locked. On 11/20/25 at 2:36 PM, an interview was conducted with the Director of Maintenance (DOM). The DOM stated that the facility had 7 public bathrooms. The DOM stated that technically anyone could use any of the bathrooms at any time, including residents. The DOM stated that they had two bathrooms in the Administration hallway, one bathroom in the 400 hallway west, one bathroom in the 400 hallway east, one bathroom in the activities room, one bathroom in the 300 hallway, and one bathroom next to the front office. The DOM stated that he just replaced all the bathroom doorknobs and removed the dead bolt. The DOM stated that he never thought to put call lights in those bathrooms and did not know that they needed to have a call light.

Based on interview and record review it was determined, for 1 of 37 sampled residents, that the facility did not immediately inform or consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status or a need to alter treatment. Specifically, the physician was not notified when a resident's Trulicity was held. Resident identifiers: 28.Findings included:1. Resident 28 was admitted to the facility on [DATE] with diagnoses which included orthopedic aftercare following amputation, Type 2 DM, and morbid obesity. On 11/18/25 9:37 AM, an interview was conducted with resident 28. Resident 28 stated that when she was first admitted she missed 3 weeks of injections of her Trulicity (Dulaglutide) medication. Resident 28 stated that the nurse had to re-order the medication and it delayed her injection. Resident 28's medical records were reviewed 11/17/25 through 11/20/25. On 9/3/25, resident 28's physician ordered Dulaglutide Subcutaneous Solution Auto-injector 1.5 milligram (mg)/0.5 milliliter (ml) (Dulaglutide), Inject 1.5 mg subcutaneously one time a day every Sun (Sunday) for Diabetes. On 10/1/25, resident 28's physician ordered Dulaglutide Subcutaneous Solution Auto-injector 1.5 mg/0.5 ml (Dulaglutide), Inject 1.5 mg subcutaneously one time a day every Wed (Wednesday) for Diabetes. Resident 28's September 2025 MAR documented a code 9 on 9/07/25, 9/21/25, and 9/28/25 for see progress note. Resident 28's progress notes revealed the following: a. On 9/7/25 at 11:15 AM, the Medication Administration Note documented that the Dulaglutide was waiting for delivery from the pharmacy. b. On 9/7/25 at 2:21 PM, the progress note documented, Pharmacy called to report that the resident's last labs show that hgb [hemoglobin] is over 8. They will not be sending it. c. On 9/8/25 at 5:44 PM, the Medication Administration Note documented that the Dulaglutide was Given 9/8 at 1745 [5:45 PM] after patient said she hadn't gotten it, and [provider name omitted] said it was okay to give a day late. It should be noted that the provider notification was 24 hours after the medication was scheduled to be delivered. d. On 9/21/25 at 4:09 PM, the Medication Administration Note documented for the Dulaglutide, Resident to have family member bring it in. e. On 9/28/25 at 11:04 AM, the Medication Administration Note documented for the Dulaglutide, On order from pharmacy. On 11/19/25 at 1:28 PM, an interview was conducted with LPN 1. LPN 1 stated that if medication was unavailable she would notify the MD and ask for orders to hold or give when available. On 11/20/25 at 10:06 AM, an interview was conducted with the DON. The DON stated that she was not aware that resident 28 had missed 3 doses of the Dulaglutide medication. The DON stated that the nurse should notify the MD if a medication was not available for administration and ask for new orders. The DON stated that the nurse should then document that the MD was notified in a progress note.

Based on interview and record review it was determined, for 1 out of 37 sampled residents, that the facility did not ensure that the resident received treatment and care in accordance with professional standards of practice. Specifically, a resident was admitted with wounds and dressings on their bilateral feet and did not have wound care orders initiated until 9 days after admission. Resident identifier: 117.Resident 117 was admitted to the facility on [DATE] with diagnoses which included arthritis due to bacteria of left ankle and foot, gout, Methicillin-resistant Staphylococcus aureus (MRSA), diabetes mellitus, chronic kidney disease, congestive heart failure, pain, and edema. On 11/18/25 at 9:07 AM, an interview was conducted with resident 117. Resident 117 stated that he had both ankles surgically cleaned out and the left foot had MRSA. Resident 117 stated that he had 2 dressing changes completed since admission. Resident 117 stated that he was supposed to have dressing changes completed 3 times a week. Resident 117 stated that he went to the surgical doctor and had his dressing changed there one time. Resident 117's medical records were reviewed 11/17/25 through 11/20/25. On 10/24/25, resident 117's hospital history and physical documented status post left ankle incision and drainage [I & D]. The lateral aspect of the left ankle was packed with 1/4in [inch] iodoform packing and redressed. The hospital progress note documented that the left ankle was found to have MRSA septic arthritis and baceremia. The plan documented 4-6 weeks of intravenous Vancomycin treatment. Resident 117's hospital discharge orders dated 10/25/25 did not contain any orders for wound care. On 10/25/25, resident 117's nursing assessment documented under skin impairments that the site of the right outer ankle had Septic Arthritis Wash out 10/23, Dressing intact, right toes Dressing intact covering toe. On 10/25/25, resident 117 had a care plan created for has the potential for skin breakdown/pressure ulcers r/t [related to] Infection Lt [left] foot and ankle.has surgical incision to left lateral ankle and left medial ankle and right foot great toe. Interventions identified on the care plan included to administer treatments as ordered and monitor for effectiveness. On 11/2/25, resident 117's physician ordered Left Lateral Ankle Wound Care: Cleanse with wound cleanser, pat dry. Gently pack the wound with 1/4 iodoform then cover with adaptic. Cover with kerlix then Ace bandage 3 times a week and as needed (PRN) on Monday, Wednesday, and Friday. It should be noted that the wound care orders were initiated 9 days after admission to the facility. No documentation could be found of wound care that was completed prior to 11/2/25. On 11/19/25 at 9:16 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that the floor nurse would conduct the admission assessment for newly admitted residents. LPN 1 stated that the floor nurse along with a second staff member would review the discharge orders from the hospital and input the orders into the resident medical records. LPN 1 stated that if the resident was admitted with wounds or dressings it would be documented on the admission assessment and the nurse that did the assessment should verify orders for wound care and refer the resident to the wound care team. On 11/20/25 at 11:04 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that if a resident was admitted with wounds and dressings and did not have admission wound care orders she would expect the admitting nurse to follow-up with the Medical Doctor for wound care orders.

Based on interview and record review it was determined, for 1 out of 37 sampled residents, that the facility did not ensure that the resident was free from any significant medication errors. Specifically, multiple doses of Vancomycin were omitted from the residents scheduled medication administration. Resident identifier: 117. Resident 117 was admitted to the facility on [DATE] with diagnoses which included arthritis due to bacteria of left ankle and foot, gout, Methicillin-resistant Staphylococcus aureus (MRSA), diabetes mellitus, chronic kidney disease, congestive heart failure, pain, and edema. On 11/18/25 at 8:55 AM, an interview was conducted with resident 117. Resident 117 stated that he had a Peripherally Inserted Central Catheter (PICC) line in his right arm and had multiple daily doses of intravenous antibiotics. Resident 117 stated that he had 3 doses of Vancomycin that were missed by the facility. On 10/30/25, resident 117's physician ordered Vancomycin Hydrochloride (HCl) Solution Reconstituted, Use 1250 mg intravenously two times a day for Vancomycin therapy related to ARTHRITIS DUE TO OTHER BACTERIA, LEFT ANKLE AND FOOT and; METHICILLIN RESISTANT STAPHYLOCOCCUS AUREUS INFECTION, UNSPECIFIED SITE. The order was discontinued on 11/12/25. On 11/12/25, resident 117's physician ordered Vancomycin HCl Solution Reconstituted, Use 1 gram intravenously two times a day for Vancomycin therapy related to ARTHRITIS DUE TO OTHER BACTERIA, LEFT ANKLE AND FOOT and; METHICILLIN RESISTANT STAPHYLOCOCCUS AUREUS INFECTION, UNSPECIFIED SITE. Resident 117's Medication Administration Record (MAR) revealed the following: a. On 11/6/25 the evening dose of Vancomycin was documented as code 9. b. On 11/12/25 the morning dose of Vancomycin was documented as code 5. c. On 11/13/25 the evening dose of Vancomycin was documented as code 9. d. On 11/14/25, the evening dose of Vancomycin did not have any documentation that the medication was administered or held. The MAR legend indicated that a code 9 was see Nurse Note and a code 5 was HOLD see Nurse Note. It should be noted that no documentation was located in a nurse progress note to explain why the Vancomycin was held on 11/6/25, 11/12/25, 11/13/25, or 11/14/25. On 11/19/25 at 1:43 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that if medication was not available for the scheduled administration she would call the pharmacy to see where the medication was and why it was not delivered, and then she would call the Medical Doctor (MD) to notify that the medication was not administered. LPN 1 stated she would document a code 9 in the MAR for a medication that was unavailable and enter a progress note. LPN 1 stated that if a medication was coded 9 then it should have a progress note documented with the details of why it was not administered. LPN 1 stated that if there was no documentation in the MAR for a medication administration then it was flagged for the Director of Nursing (DON) or the Assistant Director of Nursing (ADON) to review. LPN 1 stated that her access to the MAR did not show if prior medication was missed. On 11/20/25 at 10:42 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that she expected that nursing staff notify the MD of any missed medication doses and then document a progress note why it was missed.

Based on interview and record review it was determined, for 1 of 37 residents sampled, that the facility did not notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fell outside of the clinical reference ranges. Specifically, a resident's Vancomycin trough levels were high and the Medical Doctor (MD) was not notified of those high values. Resident identifier: 117.Resident 117 was admitted to the facility on [DATE] with diagnoses which included arthritis due to bacteria of left ankle and foot, gout, Methicillin-resistant Staphylococcus aureus (MRSA), diabetes mellitus, chronic kidney disease, congestive heart failure, pain, and edema. On 11/18/25 at 8:55 AM, an interview was conducted with resident 117. Resident 117 stated that he had a Peripherally Inserted Central Catheter (PICC) line in his right arm and had multiple daily doses of intravenous antibiotics. Resident 117 stated that he had 3 doses of Vancomycin that were missed by the facility. On 10/30/25, resident 117's physician ordered Vancomycin Hydrochloride (HCl) Solution Reconstituted, Use 1250 mg intravenously two times a day for Vancomycin therapy related to ARTHRITIS DUE TO OTHER BACTERIA, LEFT ANKLE AND FOOT and; METHICILLIN RESISTANT STAPHYLOCOCCUS AUREUS INFECTION, UNSPECIFIED SITE. The order was discontinued on 11/12/25. On 11/12/25, resident 117's physician ordered Vancomycin HCl Solution Reconstituted, Use 1 gram intravenously two times a day for Vancomycin therapy related to ARTHRITIS DUE TO OTHER BACTERIA, LEFT ANKLE AND FOOT and; METHICILLIN RESISTANT STAPHYLOCOCCUS AUREUS INFECTION, UNSPECIFIED SITE. Resident 117's lab results for the Vancomycin trough documented the following high results: a. On 10/27/25, the result was 14.5, high b. On 11/1/25, the result was 18.2, high; c. On 11/14/25 at 4:30 PM, the result was 12.9, high; d. On 11/14/25 at 10:50 PM, the result was 14.6, high; and e. On 11/18/25, the result was 23.2, high. No documentation could be found to indicate that the MD was notified of the high Vancomycin trough results. On 11/19/25 at 1:43 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that the Vancomycin monitoring included a Vanco trough lab result that was sent to the MD for review and documentation that the MD was notified of the results would be located in a progress note. On 11/20/25 at 10:42 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that a progress note should document that the MD was notified of trough results and pharmacy recommendation of medication dose adjustment. The DON stated that nursing staff would notify the MD by phone of critical lab results and when the MD came to the building they would sign the all lab report to verify that they had seen the results.

Based on interview and record review it was determined, for 1 out of 37 sampled residents, that the facility did not file in the resident's clinical record signed and dated reports of radiological and other diagnostic services. Specifically, a resident 21's Kidney, Ureter, and Bladder (KUB) was not in the medical records. Resident identifier 21. Resident 21 was admitted to the facility on [DATE] with diagnoses which included traumatic subdural hemorrhage with loss of consciousness, quadriplegia, spinal stenosis, and post-traumatic stress disorder.Review of resident 21's medical record was completed on 11/17/25 through 11/20/25.On 11/2/25, a physician's order documented an immediate (STAT) KUB radiograph (x-ray).On 11/2/25 at 12:48 pm, a nursing progress alert note stated the following: The patient decided to stay in bed all day today. The nurse noted that the patient's abdomen was blooded with a lot of gas and administered a gas pill. The patient stated that he had a watery bowel movement yesterday and last night his colostomy exploded twice. The nurse reported to the Nurse Practitioner at which time a KUB was ordered.On 11/3/25 at 3:46 am, a nursing progress radiology results note revealed the following. Abdomen x-ray. Impression: increased fecal material. The doctor on call was notified. No new orders.It should be noted that no documentation of the x-ray results could be located in resident 21's medical record.On 11/20/25 at 1:15 pm, an interview was conducted with Licensed Practical Nurse (LPN) 3. LPN 3 stated once a physician gaves an order, the LPN would enter the order into the resident's medical record. LPN 3 stated a lab slip/request would be filled out and a call to the x-ray company to get a technician dispatched to the facility. LPN 3 stated she will fax the x-ray company the physician's order for their records. LPN 3 stated the x-ray company will fax over the results. LPN 3 stated that when she gets the results, she will contact the Director of Nursing (DON) and the physician. LPN 3 stated she will enter the results on to the resident's medical record and any additional orders from the physician. LPN 3 stated that she will then make a copy of the results and put one in the DON's office and the other in the physician's office. LPN 3 stated after that she is unaware of what happens with the results after placing them in the offices.On 11/20/25 at 1:54 pm, an interview was conducted with LPN 2. LPN 2 stated she will get an order from the physician. LPN 2 stated that she will then create an order on the resident's medical record. LPN 2 stated that she will call the mobile x-ray company. LPN 2 stated that the x-ray company will fax the results to the facility. LPN 2 will call the physician regarding the results and get any new orders. LPN 2 will make a copy of the fax, one goes to the physician, and the other one goes to the unit manager. LPN 2 stated that once the unit manager reviews the results, they will give it to medical records to be scanned and put on the resident's medical record.On 11/20/25 at 3:06 pm, an interview was conducted with the Regional Compliance Nurse (RCN). The RCN stated that she was unable to locate the KUB results for resident 21 on their medical chart. The RCN stated that she needed to ask the unit manager to retrieve it from the portal to be able to provide it to the State Surveyor.On 11/20/25 at 3:07 pm, an interview was conducted with the DON. The DON stated that x-ray results are faxed to the facility. The DON stated that the nurse will contact the physician with the results. The DON stated that the received fax is copied and given to the unit manager and the physician for review. The DON stated that after the results are reviewed the fax is forwarded to medical records to be attached to the resident's medical chart. The DON stated that management expects that to be done within a week from the ordered date.On 11/20/25 at 3:07 PM, an interview was conducted with the Administrator (ADM). The ADM stated that he expects to have any documentation attached to a resident's medical chart within a week of receipt date.

Based on observation, interview, and record review, it was determined that for 1 of 37 sampled residents, that the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections. Specifically, a resident was not placed on proper contact precautions. Resident Identifier: 117.Resident 117 was admitted to the facility on [DATE] with diagnoses which included arthritis due to bacteria of left ankle and foot, gout, Methicillin-resistant Staphylococcus aureus (MRSA), diabetes mellitus, chronic kidney disease, congestive heart failure, pain, and edema. On 11/18/25 at 8:55 AM, an interview was conducted with resident 117. Resident 117 stated that he had a Peripherally Inserted Central Catheter (PICC) line in his right arm and had multiple daily doses of intravenous antibiotics. Resident 117 stated that he had both ankles surgically cleaned out and the left foot had MRSA. A Personal Protective Equipment (PPE) cart was located inside the resident room and contained gloves and disposable gowns. A magnet with the number 6 printed on it was located on resident 117's doorframe on the outside of the door. No other signage was located on resident 117's door to indicate any type of Transmission Based Precautions. Resident 117's medical records were reviewed 11/17/25 through 11/20/25. On 10/24/25, resident 117's hospital history and physical documented status post left ankle incision and drainage [I & D]. The lateral aspect of the left ankle was packed with 1/4in [inch] iodoform packing and redressed. The hospital progress note documented that the left ankle was found to have MRSA septic arthritis and bacteremia. On 10/18/25, the left ankle aspiration and blood cultures were positive for MRSA and both specimens were susceptible to Vancomycin. The plan documented 4-6 weeks of intravenous Vancomycin treatment. On 10/25/25, the nursing admission evaluation documented that the resident was on Contact Precautions. The assessment further documented that the resident required Enhanced Barrier Precautions (EBP) due to his PICC line. The assessment documented under skin impairments that the site of the right outer ankle had Septic Arthritis Wash out 10/23, Dressing intact, right toes Dressing intact covering toe, and PICC line right upper extremity. On 11/3/25, resident 117 had an order for Enhanced Barrier Precautions due to wounds PICC line for antibiotics. On 10/25/25, resident 117 had a care plan initiated for .Enhanced Barrier Precautions r/t [related to] picc line, iv [intravenous] abx [antibiotics] and wounds. The interventions identified on the care plan were to don and doff gown and gloves per facility protocol for high contact care activities, a patient identifier would be on the resident's door frame, and perform hand hygiene per facility protocol. On 11/19/25 at 9:16 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that a number 6 magnet posted outside the resident door indicated that they were on precautions. LPN 1 stated that she would look in the resident chart on the homepage to verify the type of Transmission Based Precautions and what they were indicated for. LPN 1 stated that if a resident was on contact or droplet precautions it would indicate it on the resident's dashboard. On 11/19/25 at 2:01 PM, a follow-up interview was conducted with LPN 1. LPN 1 stated that they implemented EBP for cellulitis, urinary tract infections, for indwelling urinary catheter, for total parental nutrition (TPN), and for any intravenous access. LPN 1 stated that PPE for high contact care with EBP required the staff wear gloves only. LPN 1 stated that the Certified Nurse Assistants would wear gowns for brief changes and gowns would be donned when changing an indwelling catheter. LPN 1 was not able to state the difference between Contact Precautions or EBP and what PPE was required for each one. On 11/19/25 at 2:36 PM, an interview was conducted with the Director of Rehabilitation (DOR). The DOR stated that resident 117 came down to the gym for therapy services 5 days a week. The DOR stated that resident 117 was not on any Transmission Based Precautions. The DOR stated that resident 117 had a bandage on his toe but it was covered. The DOR stated that if resident 117 was on Contact Precautions he would not be allowed to come to the gym because it would be too easy to spread the infection in the gym. The DOR stated that when a resident was on Contact Precautions they provided therapy services in the resident's room and the staff wore a gown and gloves. The DOR stated that if they took any reusable equipment into a Contact Precautions room they would disinfect the equipment after use with Virex disinfectant. The DOR stated that they were notified of residents on Contact Precautions in their morning stand-up meetings and the resident would have a sign posted on the door with the type of PPE that should be utilized. The DOR stated that resident 117 had an infection in his wound because he was receiving antibiotics for it, but he did not know what the organism was. The DOR stated that if it was MRSA in the foot and it was contained then resident 117 could come down to the gym. The DOR stated that if the wound had any drainage then it would not be considered contained and he would not be safe in the gym. The DOR stated that they would visualize the dressing and if they could see that there was drainage on the bandage then the therapist would notify the nurse and inform them of it. Resident 117 was observed in the therapy room working on upper body equipment, and the resident was observed with bilateral socks on his feet. On 11/20/25 at 11:04 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that for a MRSA infection the resident would be on Contact Precautions for any high contact care and the wound needed to be contained. The DON stated that a dressing change, showers, or bed linen change were considered high contact care. The DON stated that staff should disinfect equipment between resident use. The DON stated that staff were informed of the TBP in the resident chart on the dashboard and the resident room would have a number 6 magnet on the door. The DON stated that if a resident was on Contact Precautions it would be posted on the resident's door. The DON stated that the number 6 was for EBP only and that was for wound care without a Multi-Drug Resistant Organism (MDRO), an open line [intravenous], catheter, colostomy, and tube feeds. The DON stated that for any high contact care provided the staff should apply gowns and gloves. Review of the facility Policy and Procedures for Managing Infections: Enhanced Barrier Precautions documented under implementation 1. Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms (MDROs) to residents. 2. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room). b. Personal protective equipment (PPE) is changed before caring for another resident. c. Face protection may be used if there is also a risk of splash or spray. 3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: a. dressing; b. bathing/showering; c. transferring; d. providing hygiene; e. changing linens; f. changing briefs or assisting with toileting; g. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.); and h. wound care (any skin opening requiring a dressing). The guidance further documented that EBPs were indicated for residents colonized or infected with MRSA. The guidance was last updated on February 1, 2024. Review of the facility Policy and Procedures for Managing Infections: Isolation - Categories of Transmission - Based Precautions documented under Contact Precautions 1. Contact precautions are implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. The guidance further documented, Staff and visitors wear gloves (clean, non-sterile) when entering the room. a. While caring for a resident, staff will change gloves after having contact with infective material (for example, fecal material and wound drainage). b. Gloves are removed and hand hygiene performed before leaving the room. c. Staff avoid touching potentially contaminated environmental surfaces or items in the resident's room after gloves are removed. 8. Staff and visitors wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed. The guidance was last updated on February 1, 2024. The Centers for Disease Control and Prevention (CDC) documented under Infection Control Basics for Health Care Providers to Use Contact Precautions for patients with known or suspected infections that represent an increased risk for contact transmission. The recommendations included to wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. The guidance further stated that donning PPE upon room entry and properly discarding before exiting the room was done to contain pathogens. The guidance also recommended limiting transport and movement of patients outside the room to medically necessary purposes. The guidance stated to use disposable or dedicated patient-care equipment (e.g., blood pressure cuffs) or to disinfect equipment before use on another patient. The guidance was last updated on April 3, 2024. https://www.cdc.gov/infection-control/hcp/basics/transmission-based-precautions.html The CDC guidance on Infection Control Guidance: Preventing Methicillin-resistant Staphylococcus aureus (MRSA) in Healthcare Facilities documented that healthcare providers should follow contact precautions when caring for patients with MRSA (colonized or carrying and infected). The guidance was last updated on June 27, 2025. https://www.cdc.gov/mrsa/hcp/infection-control/index.html

Based on observation, interview and record review it was determined, for 8 of 22 sampled residents, that the facility did not ensure that the environment remained as free of accident hazards as was possible. Specifically, water temperatures in residents bathrooms were high. Resident identifiers: 2, 32, 33, 38, 45, 160, 307, and 309. Findings include: 1. Resident 33 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Alzheimer's disease, dementia, muscle weakness, unsteadiness on feet and delusional disorders. On 10/30/23 at 11:21 AM, an observation was made of resident 33's bathroom in room [ROOM NUMBER]. The water temperature in the hand washing sink was 122.4 degrees Fahrenheit. An interview was conducted with resident 33. Resident 33 stated that she did not use cold water when she washed her hand and got cold water from the kitchen. Resident 33's medical record was reviewed. A quarterly Minimum Data Set (MDS) dated [DATE] revealed that resident 33 Brief Interview of Mental Status (BIMS) score of 6 which revealed severe cognitive impairment. The MDS further resident 33 required supervision with walking in corridor, locomotion on and off the unit. The MDS revealed resident 33 required limited one person physical assistance with personal hygiene. 2. Resident 160 was admitted to the facility on [DATE] with diagnoses that included chronic venous hypertension with bilateral lower extremity ulcers, heart failure, repeated falls and mild cognitive impairment. Resident 160's medical record was reviewed. An admission MDS dated [DATE] revealed that resident 160 had a BIMS score of 12 indicating mild cognitive impairment. The MDS also revealed that resident 160 was independent with activities of daily living. On 10/30/23 at 2:52 PM, a water temperature check revealed a maximum water temperature of 122 degrees. 3. Resident 2 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included palliative care, dementia, paranoid schizophrenia, lupus, and major depressive disorder. Resident 2's medical record was reviewed 10/30/23 through 11/2/23. A quarterly MDS stated 9/1/23 revealed that resident 2 had a BIMS score of 5. The MDS revealed resident 2 required 2 plus person extensive assistance with mobility and personal hygiene. On 10/30/23 at 2:14 PM, an observation was made of resident 2's bathroom in room [ROOM NUMBER]. The water temperature was 123.3 degrees Fahrenheit. 4. On 10/30/23 at approximately 10:00 AM, an observation was made of the water in the bathrooms in the front lobby. The water temperature was 123.2. The bathrooms were observed to be unlocked. 5. On 10/30/23 at 3:00 PM, an observation was made of room [ROOM NUMBER]'s bathroom. The water temperature was 123.1 degrees Fahrenheit. 6. Resident 38 was admitted to the facility on with diagnoses which included cerebrovascular disease, protein-calorie malnutrition, type 2 diabetes mellitus, asthma, muscle weakness, difficulty in walking, pressure ulcer of sacral region, dysphagia, adult failure to thrive, mild cognitive impairment, anxiety disorder, vitamin D deficiency, hyperlipidemia, and pain in right ankle. Resident 38's medical record was reviewed. Resident 38's Quarterly MDS from 8/14/23 documented that resident 38 had a BIMS of scored 11, which indicated moderate cognitive impairment. On 10/30/23 at 1:20 PM, resident 38's bathroom sink water was observed. The temperature of the hot water was 120.8 degrees Fahrenheit. On 10/30/23 at 1:23 PM, an interview with resident 38 was conducted. Resident 38 stated that she was able to get up to use the bathroom without supervision. Resident 38 stated that if the hot water in the sink was too hot, she would use the cold water to lower the temperature. 7. Resident 45 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation, hypertension, mild cognitive impairment, and hypokalemia. Resident 45's medical record was reviewed. Resident 45's MDS dated [DATE] revealed a BIMS of 13, which indicated intact cognition. On 10/30/23 at 2:07 PM, the resident's bathroom sink water was tested . The temperature of the hot water reached 123 degrees Fahrenheit. 8. Resident 32 was admitted to the facility on [DATE] with diagnoses that included subtrochanteric fracture of left femur, cognitive communication deficit, and dementia. Resident 32's medical record was reviewed. Resident 32's quarterly MDS dated [DATE] documented that resident 32 had a BIMS score of 13, which suggested intact cognition. On 10/30/23 at 2:12 PM, resident 32's bathroom sink water was tested . The temperature of the hot water reached 118 degrees Fahrenheit. 9. Resident 309 was admitted to the facility on [DATE] with diagnoses that included compression fracture of T7-T8 vertebra, hypertension, hyperlipidemia, and hypothyroidism. Resident 309's medical record was reviewed. A skilled nursing documentation note dated 11/2/23 indicated resident 309 was alert and oriented to person, place, time, and event. On 10/30/23 at 2:18 PM, resident 309's bathroom sink water was tested . The temperature of the hot water reached 124 degrees Fahrenheit. 10. Resident 307 was admitted to the facility on [DATE] with diagnoses that included heart failure, kidney disease, and hypertension. Resident 307's medical record was reviewed. The BIMS Interview/Observation document dated 10/25/23 indicated resident 307 had a BIMS score of 10, which suggested moderate cognitive impairment. On 10/30/23 at 2:22 PM, the resident's bathroom sink water was tested . The temperature of the hot water reached 124 degrees Fahrenheit. On 10/30/23 at 3:03 PM, an interview was conducted with the Maintenance Director. The Maintenance Director stated he checked water temperatures about once a week. The Maintenance Director stated he went room by room and using a thermometer to test the water temperatures. The Maintenance Director stated he checked 5 bathrooms temperatures per week. The Maintenance Director stated he checked the 100 hallway most recently. An observation was made of the facility boiler room. The mixing valve was observed to be at 80 degrees Fahrenheit. The Maintenance Director stated he adjusted the hot water heaters temperature. The Maintenance Director stated water temperatures were to be between 109 and 114 degrees Fahrenheit in resident areas. The Maintenance Director stated there was no thermometer on the boiler. The Maintenance Director stated that the he did not check the mixing valve temperature because it was always 80 degrees Fahrenheit. The Maintenance Director stated he had to go off of the temperature in the resident bathrooms. The Maintenance Director stated the bathrooms in the front lobby were on the same hot water system as the resident bathrooms in their rooms. On 11/2/23 at 11:26 AM, an interview was conducted with the Administrator. The Administrator stated he was not aware that the water temperatures were high and that the mixing valve was at 80 degrees Fahrenheit. 43212 45470

Based on observation and interview it was determined, for 3 of 22 sampled residents, that the facility failed to maintain a safe, clean, comfortable and homelike environment. Specifically, the water pressure and temperature of a shared bathroom sink was low. Resident identifiers: 23, 42, and 51 Findings include: 1. Resident 23 was admitted to the facility on [DATE] with diagnoses which include chronic respiratory failure with hypoxia, type 2 diabetes mellitus, difficulty in walking, muscle weakness, hypothyroidism, essential hypertension, anemia, polyneuropathy, vitamin B12 deficiency, major depressive disorder, anxiety disorder, dysphagia, Wernicke's encephalopathy, dysuria, pain in left hip, panic disorder, and hallucinations. Resident 42 was admitted to the facility on [DATE] with diagnoses which include chronic respiratory failure with hypoxia, morbid obesity, protein-calorie malnutrition, muscle weakness, difficulty in walking, hyperkalemia, essential hypertension, sleep apnea, gout, anxiety disorder, bradycardia, and depression. On 10/30/23 at 9:57 AM, an interview with resident 42 was conducted. Resident 42 stated that she was able to get up to use the bathroom sink. On 10/30/23 at 2:53 PM, resident 23's and resident 42's shared bathroom sink was observed. The water pressure of the sink was low. The water temperatures was observed to be at 70 degrees with only the hot water turned on. 43212 2. Resident 51 was admitted to the facility on [DATE] with diagnoses that included severe protein-calorie malnutrition, adult failure to thrive, schizophrenia and paranoid schizophrenia, muscle weakness and type 2 diabetes. Resident 51's medical record was reviewed. An admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. On 10/30/23 at 3:09 PM, the water temperature in resident 51's bathroom reached a maximum of 94 degrees Fahrenheit. On 10/30/23 at 3:09 PM, an interview with the Maintenance Director was conducted. The Maintenance Director stated that he checked the water temperatures of about five resident rooms each week. The Maintenance Director stated that he was unaware of the low water pressure and low water temperature.

Based on record review and interview, for 1 of 22 sampled residents, the facility did not ensure that the Preadmission Screening for individuals with a mental health disorder was performed by a person or entity other than the State Mental Health Authority prior to admission, and that because of the physical and mental condition of the individual, the individual required the level of services provided by the nursing facility, and whether the individual required specialized services. Specifically, a resident admitted with a mental health disorder did not have a Preadmission Screening Resident Review (PASRR) Level II recommended or completed. Resident identifier: 51. Findings include: Resident 51 was admitted to the facility on [DATE] with diagnoses that included severe protein-calorie malnutrition, adult failure to thrive, schizophrenia and paranoid schizophrenia. On 9/15/23, a PASRR I was completed for resident 51. The psychiatric diagnosis documented that resident 51 had schizophrenia disorder. The PASRR I also documented that Prior to admission the attending hospital physician certifies in writing that the applicant/resident will be admitted for 30 days or less following medical hospitalization . The documentation did not document that resident 51 had a diagnosis of schizophrenia under the Serious Mental illness (SMI) criteria which would indicate that a PASRR Level II would be needed. The evaluation documented that a Level I Screen indicates referral for Level II evaluation SMI is NOT needed citing Skilled Nursing Facility [SNF] short-term rehab [less than] 30 days. No documentation could be located in resident 51's medical record that a PASRR Level II had been completed. On 11/1/23 at 1:27 PM, an interview was conducted with the facility Social Worker (SW). The SW stated resident 51's husband could not take care of her and was trying to figure out what to do with her. The SW stated they did not intend for her to be staying as long as she has. The SW stated the resident had refused to go out for a personal visit with her psychiatrist. The SW stated he needed to submit a PASRR II for resident 51. The SW stated the process for submitting a PASRR II included sending the resident's face sheet from the hospital, the history and physical, a doctor's note and the PASRR I.

Based on observation, interview, and record review, for 1 of 22 sampled residents, the facility did not provide the necessary services to maintain good nutrition, grooming, and persona and oral hygiene for residents who were unable to carry out the activities of daily living. Specifically, a resident was not showered twice weekly according to his preferences. Resident Identifier: 158. Findings Include: Resident 158 was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure with hypoxia, pneumonia, muscle weakness, type 2 diabetes, acute kidney failure and major depressive disorder. On 10/30/23 at 10:18 AM, an interview was conducted with resident 158. Resident 158 stated he had only received one shower since his admission. Resident 158 stated he had not been offered a shower the day after he arrived. Resident 158 stated he would like at least 2 showers per week. Resident 158's medical record was reviewed between 10/30/23 and 11/2/23. An admission Minimum Data Set (MDS) dated [DATE] revealed that it was very important for the resident to choose between a tub bath, bed bath, shower or sponge bath. The MDS also revealed that resident 158 required substantial/maximum assistance with showers/bathing. A review of the Certified Nursing Assistant (CNA) documentation in the task section of the medical record revealed resident 158 received a bed bath and a shower on 10/25/23. The bathing task revealed that no bathing activity occurred on 10/29/23. No other days were accounted for. On 11/1/23 at 9:54 AM, an interview was conducted with CNA 1. CNA 1 stated residents in the facility received 2 to 3 showers per week. CNA 1 stated she did not know what resident 158's schedule was. CNA 1 stated showers were documented on a shower sheet and then in the resident's medical record. CNA 1 stated if a resident refused a shower, it would be marked on the shower sheet, and the CNA would notify the nurse. CNA 1 stated the nurse would talk with the resident and encourage a shower. CNA 1 stated if the resident continued to refuse, the nurse would have the resident sign the shower sheet acknowledging the refusal. CNA 1 stated if the resident did not have the cognitive capacity, they did not require the resident to sign. CNA 1 stated if a resident got upset, they would try to ask again later. On 11/1/23 at 10:54 AM, an interview was conducted with CNA 2. CNA 2 stated she did not work with resident 158 very much. CNA 2 stated resident 158's shower days were on Wednesdays and Saturdays. CNA 2 located the shower book at the nurses station and stated after shower sheets were completed, they were placed in the shower book. On 11/1/23 at 2:20 PM, an interview was conducted with the Director of Nursing (DON). The DON stated there was a resident shower schedule on each unit. The DON stated when showers were completed the shower sheets were filled out and the shower was documented in the resident's medical record. The DON stated if the resident refused, the nurse on the unit would talk to the resident. The DON stated if the resident continued to refuse they would try a third time. The DON stated if the resident refused a third time, the staff would respect the resident's wishes. The DON stated residents on hospice had their own schedule. The DON stated the nurse managers checked the shower sheets to ensure residents were getting showers. The DON stated the shower sheets were a tool to track resident showers and that it was not an official part of the resident's medical record. The DON stated she kept a binder with the completed shower sheets. The DON stated the CNAs should be documenting shower refusals in the resident's medical record. On 11/2/23 at 8:51 AM, a follow up interview was conducted with the DON. The DON stated she did not have any shower information for resident 158. The DON stated resident 158 received a shower last night but did not have any information that he had been provided any other showers.

Based on interview and record review it was determined, for 2 of 22 sampled residents, that the facility did not ensure that each resident's drug regimen was reviewed once a month by the licensed pharmacist and any irregularities were reported to the physician and were acted upon. Specifically, monthly pharmacy reviews identified irregularities that had not been implemented. Resident identifiers: 2 and 8. Findings include: 1. Resident 8 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included palliative care, morbid obesity, edema, senile degeneration of brain, and non-pressure chronic ulcer of right calf. Resident 8's medical record was reviewed 10/30/23 through 11/2/23. A form titled Consultation Report from the facility pharmacy dated 8/30/23. The form revealed that resident 8 had as needed physician's order that were not used within the previous 60 days. The medications were: 1. Miralax Packet 2. Milk of Magnesia 3. Fluticone nasal spray 50 mcg/act (PLEASE NOTE: this only pertains to prn order; resident does take the medication once daily routinely) 4. Benadryl tablet The physician's response was to accept the recommendations above, please implement as written. The physician signed the form on 9/5/23. Resident 8's physician's orders were reviewed. Resident 8 had the above physician's orders active. 2. Resident 2 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included encounter for palliative care, paranoid schizophrenia, chronic obstructive pulmonary disease, rheumatoid arthritis, major depressive disorder and dementia. Resident 2's medical record was reviewed 10/30/23 through 11/2/23. A form titled Consultation Report from the facility pharmacy dated 8/30/23. The form revealed that resident 2 had as needed physician's order that were not used within the previous 60 days. The medications were: 1. Senna Plus Tablet 2. Morphine Solution 3. Miralax powder 4. Milk of Magnesia 5. Fleet Enema 6. Dulcolax Suppository 7. Aspercreme The physician's response was to accept the recommendations above, please implement as written. The physician signed the form on 9/5/23. Resident 2's physician's orders were reviewed. Resident 2 had the above physician's orders active. On 10/31/23 at 2:00 PM, an interview was conducted with the Director of Nursing (DON). The DON stated she missed implementing the pharmacy recommendations for resident 2 and resident 8. The DON stated after the pharmacy recommendation were provided to the facility, the physician reviewed them with in a few days, and then the recommendations were implemented within 7 days. The DON stated she tried to to implement the recommendations as possible. On 11/1/23 at 2:26 PM, a follow up interview was conducted with the (DON). The DON stated she talked to Physician 1 and he wanted the medications discontinued for resident 2 and resident 8.

Based on interview and record review it was determined, for 1 of 22 sampled resident, the facility did not ensure residents were free of any significant medication errors. Specifically, a resident was administered double the dose of physician prescribed Lasix. In addition, the resident had an elevated potassium level prior to being administered double to dose of lasix and there was no physician follow-up documented. Resident identifier: 8. Findings included: Resident 8 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included palliative care, morbid obesity, edema, osteoarthritis, senile degeneration of brain, non-pressure chronic ulcer of right calf. Resident 8's medical record was reviewed from 10/30/23 through 11/2/23. A physician's order dated 9/16/23 and discontinued on 9/24/23 revealed Lasix 40 milligrams (mg). The instructions were to give 1 tablet by mouth two time a day for edema. In addition, Lasix 40 mg po [orally] BID [twice daily] for three days then back to lasix 40 mg qd [daily]. Resident 8's Medication Administration Record (MAR) September 2023 revealed Lasix 40 mg was administered twice daily 9/17/23 through 9/23/23. Resident 8 was administered lasix 40 mg in in the morning of 9/24/23. A physician's order dated 9/24/23 revealed Lasix Oral Tablet 40 MG. The instructions were to give 1 tablet by mouth two times a day for Edema. The order further revealed to administered BID for Three days then back to Lasix 40 mg qd. Resident 8's MAR September 2023 revealed Lasix 40 MG was administered twice daily starting 9/24/23 until 10/31/23. A review of resident 8's laboratory results revealed on 9/5/23 that potassium was 4.4 mmol/L (millimole per liter) and the reference interval was 3.5 to 5.2. A laboratory results dated [DATE] revealed resident had a potassium level of 3.2 which was low. The form was signed on 9/20/23 but did not have any follow-up information. A form titled Hospice IDG Comprehensive Assessment and Plan of Care Update Report revealed that resident 8 started on hospice 9/20/23. The medication list revealed Lasix 40 MG to be administered daily. Progress notes revealed the following entries: a. On 9/19/23 at 4:18 PM, :Resident talked with Nurse Practitioner and elected to go on Hospice services due to declining condition . There were no progress notes from 9/22/23 through 10/3/23. There was no information regarding changing or physician's order for the Lasix to be 40 mg twice a day. On 11/2/23 at 9:49 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 was observed to review the physician's order for the lasix to be administered twice daily for 3 days and then once daily. RN 1 stated they would have to call and clarify the order because the resident should be administered Lasix once daily after 9/27/23. On 11/2/23 at 10:04 AM, an interview was conducted with RN 2. RN 2 stated resident 8 had 2 different medication cards with Lasix in the medication cart. RN 2 stated resident 8 received Lasix in the morning and another dose at 4:00 PM. RN 2 stated she did not notice the physician's order to administered twice daily for 3 days and then daily. RN 2 stated if she had noticed she would have called the physician to clarify the dosage. It should be noted that RN 2's initials were documented on the Lasix medication in September 2023 and October 2023. On 11/1/23 at 3:43 PM, an interview was conducted with the Director of Nursing (DON). The DON stated when a physician provided a verbal order for medications the order was transcribed into the medical record. The DON stated after a resident was ordered medications, the Nurse Managers ran a report to review all newly medications entered into the electronic medical record system. The DON stated stated the Nurse Practitioner (NP) reviewed resident 8's laboratory values on 9/5/23 and 9/18/23 and there were no new physician's order. On 11/2/23 at 8:51 AM, an interview was conducted with the Director of Nursing (DON). The DON stated they talked to Physician 1 and he wanted to keep Lasix at 40 MG twice a day. The DON stated there should have been a clarification order put into the medical record. The DON stated resident 8 did not need to be on potassium because she was receiving Spironolactone. The DON stated Physician 1 was not concerned that resident 8 had a low potassium level. The DON stated that physician 1 was not planning on doing additional labs because of the Spironolactone. The DON stated that Physician 1 was the medical director and Physician 1 stepped in if staff were unable to get a hold of Physician 2. On 11/2/23 at 9:44 AM, an interview was conducted with Physician 1. Physician 1 stated he had intended to increase resident 8's Lasix to twice daily indefinitely and then follow up with laboratory results. Physician 1 stated that resident 8 transitioned to hospice after her potassium was checked. Physician 1 stated the NP was also involved and signed the laboratory values. Physician 1 stated when a resident was transitioned to hospice, then the hospice decided if laboratory draws were appropriate. Physicians 1 stated he was not aware the physician's order was to administer twice daily for 3 day and then daily. On 11/2/23 at 9:50 AM, an interview was conducted with resident 8's Hospice RN. Hospice RN stated that Physician 2 was resident 8's primary care physicians. Hospice RN stated Physician 1 was the facility medical director and provided his opinion regarding the best care for resident 8. Hospice RN stated that after Physician 1 provided a recommendation then Physician 2 was contacted and provided orders. Hospice RN stated resident 8 was receiving Lasix 40 mg twice daily. Hospice RN stated when resident 8 started on hospice, the plan was to order 40 mg once daily because she had edema. Hospice RN stated resident 8 needed to have the 50 mg twice daily because of her fluid. Hospice RN stated the facility provided laboratory results prior to resident 8 starting on hospice. Hospice RN stated resident 8 was on Spironolactone which was a potassium sparing diuretic, so resident 8 did not need a potassium supplement. Hospice RN stated staff were to watch symptoms of low potassium. Hospice RN stated that the symptoms were edema, any new heart palpitations and to mostly watch for comfort. Hospice RN stated residents receiving hospice services usually did not have labs completed. Hospice RN stated Physician 2 wanted the Lasix twice a day. Hospice RN stated she did not have documentation that Physician 2 had ordered Lasix twice daily. Hospice RN stated she needed to review resident 8's medications because she missed the dosage during her initial medication review and documented that resident 8 had Lasix 40 mg once daily.

Based on interview and record review, it was determined, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment were reported immediately, but not later than 2 hours after the allegation was made to the State Survey Agency (SSA). Specifically, for 1 out of 6 sampled residents, a resident to resident altercation was not reported to the SSA. Resident identifier: 2 Findings Included: Resident 2 was initially admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses that included, but were not limited, to Alzheimer's disease, dementia with behavioral disturbances, anxiety, and depression. Resident 2's medical record was reviewed on 7/21/23. Resident 2 was discharge from the facility on 6/15/23. On 6/15/23, an admission Minimum Data Set (MDS) assessment documented resident 2 had a Brief Interview for Mental Status score of 1 which indicated severe cognitive impairment. The MDS further documented resident 2 had verbal and physical behaviors. A care plan focus documented, [Resident 2] is/has potential to be physically aggressive r/t [related to] Dementia. 6/7/2023 Resident to resident altercation. Given. Scrape to right ring finger. 6/8/2023 Resident to resident altercation Given. No injury. Interventions were initiated on 6/14/23, and included: a. Administer medications as ordered. b. Assess and anticipate resident's needs: food, thirst. toileting needs, comfort level, body positioning, pain etc. c. Document observed behavior and attempted interventions in behavior log. Explosive outbursts. On 6/7/23 on 2:31 PM, an Event Note documented, Resident was involved with altercation with another resident this am where she was aggressor. Staff immediately intervened and separated residents. Much redirection throughout the day due to agitation periods towards staff and others. MD [medical doctor], daughter, DON [Director of Nursing] and ED [Executive Director] notified of earlier altercation. noted small scrape on right ring finger/hand. denies having pain or discomfort. MD notified of residents increased agitation episodes. New orders received to increase Depakote to 500 mg [milligrams] BID [twice a day] and Hydroxyzine 10 mg Q [every] 2 hours PRN [as needed]. Daughter notified of new orders. Will cont. [continue] to monitor and redirect as needed. On 6/8/23 at 4:24 PM, an Event Note documented, Resident continued with close monitoring throughout day d/t [due to] altercation. Had been taken to managers office, taken on walks in building, provided snacks and cares, redirection and meds [medications] have been effective at this time. On 6/8/23 at 6:57 PM, a Behavioral Note documented, Resident was fighting with another resident hitting her and pulling her hair. No injuries noted. The Facility Reported Incident reports and Exhibit 358 Sample Form for Facility Reported Incidents were reviewed and revealed the facility had not notified the SSA about the resident-to-resident altercation on 6/8/23. An incident report was the only documentation the facility had provided about the resident-to-resident altercation. On 7/20/23 at 1:51 PM, an interview was conducted with the Executive Director (ED). The ED stated he requested the staff notify him within 15 minutes if any kind of abuse was suspected. The ED stated he then would conduct interviews with staff or residents that witnessed or were involved in the incident. The ED stated he interviewed more residents and staff depending on the initial interviews with the appropriate people involved. The ED stated if an investigation was being conducted, he generally interviewed between 5 to 10 residents. The ED stated he talked to staff members to see if they witnessed the abuse, who it was reported to, and what time they notified someone. The ED stated he used all the evidence from the investigation to determine if abuse was substantiated or unsubstantiated. The ED stated he would then put all the information together and send it to the SSA. The ED stated he sent the Exhibit 358 report within 24 hours and the follow up within five business days. On 7/20/23 at 2:45 PM, a follow up interview was conducted with the ED. The ED stated they were unsure if the resident-to-resident altercation on 6/8/23, was reported to the SSA since it was the same thing that happened the day before on 6/7/23. The ED stated that was something he should have reported and staff actually witnessed both incidents.

Based on interview and record review, it was determined, in response to allegations of abuse, neglect, exploitation, or mistreatment, the facility failed to have evidence that all alleged violations were thoroughly investigated. Specifically, for 3 out of 6 sampled residents, the facility did not thoroughly investigate two resident to resident altercations. Resident Identifiers: 1, 2, and 6. Findings included: 1. Resident 2 was initially admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses that included, but were not limited to, Alzheimer's disease, dementia with behavioral disturbances, anxiety, and depression. Resident 2's medical record was reviewed on 7/21/23. Resident 2 was discharge from the facility on 6/15/23. On 6/15/23, an admission Minimum Data Set (MDS) assessment documented resident 2 had a Brief Interview for Mental Status score of 1 which indicated severe cognitive impairment. The MDS further documented resident 2 had verbal and physical behaviors. A care plan focus documented, [Resident 2] is/has potential to be physically aggressive r/t [related to] Dementia. 6/7/2023 Resident to resident altercation. Given. Scrape to right ring finger. 6/8/2023 Resident to resident altercation Given. No injury. Interventions were initiated on 6/14/23, and included: a. Administer medications as ordered. b. Assess and anticipate resident's needs: food, thirst. toileting needs, comfort level, body positioning, pain etc. c. Document observed behavior and attempted interventions in behavior log. Explosive outbursts. On 6/7/23 at 2:31 PM, an Event Note documented, Resident was involved with altercation with another resident this am where she was aggressor. Staff immediately intervened and separated residents. Much redirection throughout the day due to agitation periods towards staff and others. MD [Medical Doctor], daughter, DON [Director of Nursing] and ED [Executive Director] notified of earlier altercation. noted small scrape on right ring finger/hand. denies having pain or discomfort. MD notified of residents increased agitation episodes. New orders received to increase Depakote to 500 mg [milligrams] BID [twice a day] and Hydroxyzine 10 mg Q [every] 2 hours PRN [as needed]. Daughter notified of new orders. Will cont. [continue] to monitor and redirect as needed. On 6/8/23 at 4:24 PM, an Event Note documented, Resident continued with close monitoring throughout day d/t [due to] altercation. Had been taken to managers office, taken on walks in building, provided snacks and cares, redirection and meds [medications] have been effective at this time. On 6/8/23 at 6:57 PM, a Behavioral Note documented, Resident was fighting with another resident hitting her and pulling her hair. No injuries noted. The Facility Incident reports and Exhibit 358 Sample Form for Facility Reported Incidents were reviewed and documented the following additional information: a. On 6/7/23, the nursing description in the incident report documented resident 2 had become angry and agitated from the certified nursing assistant (CNA) trying to assist the resident with cares. Resident then walked out into the hallway and into another resident's room. Resident was found at the doorway yelling and swinging arms and hands at the other resident. The other resident was found to be yelling back and had her hands up in an attempt to block other resident's swinging arms. Both residents were separated. Additional notes stated that the Interdisciplinary Team committee believed resident 2's Alzheimer's, anxiety, and agitation had contributed to the incident. Exhibit 358 provided no further information. Staff and resident interviews were requested in regards to the investigation conducted but were not provided by the facility. Exhibit 359 did not indicate if the abuse was unsubstantiated, substantiated, or inconclusive. There was no further documentation provided to indicate a thorough investigation was conducted. b. On 6/8/23, the incident report documented a resident-to-resident altercation between resident 2 and her roommate. The report documented that resident 2 was found to be hitting and pulling resident 6's hair while stating resident 6 was her wife. Both residents were separated and resident 2 was put on a one on one and later sent to the emergency room due to her behaviors. No documentation was located to indicated an investigation was conducted. Exhibit 358 and exhibit 359 were not provided by the facility. 2. Resident 1 was admitted to the facility on [DATE] with the following diagnoses that included, but were not limited to, Alzheimer's disease, dementia, muscle weakness, schizophrenia, delusional disorders, and major depressive disorder. Resident 1's medical record was reviewed on 7/20/23. On 5/2/23, an annual MDS assessment documented that resident 1 had a BIMS score of 6 which indicated severe cognitive impairment. On 6/7/23, an Event Note documented, Resident had altercation with another resident this morning in her doorway of her room. Staff immediately separated residents. Noted skin tear on residents [sic] top of left hand by thumb, and a few small bruises on residents right forearm. Resident stated theyreally [sic] didn't hurt much. Skin tear cleansed, steri stripped and covered with non stick dressing. MD, DON and ED notified this morning after altercation. Message left for daughter for notification of incident. Resident stayed in room for breakfast and midmorning. Did come out for lunch and activities. Resident with no s/s [signs and symptoms] distress from incident. Pleasant and joking with staff this afternoon. Resident unable to recall what had happened this morning when asked this afternoon. Assist and redirection from staff as needed. Dressing to left hand intact. Resident stated not having any pain or discomfort on right arm or left hand this afternoon. CTM [continue to monitor]. The incident report documented that resident 1 had blocked resident 2 from entering her room and that was why the altercation had occurred. Exhibit 358 Sample Form for Facility Reported Incidents documented that resident 1 had been scratched by resident 2. According to Exhibit 358, staff stayed with resident 2 until she was no longer agitated. No new information was provided. Exhibit 359 Follow-up Investigation Report documented the facility had made a referral to a local hospital gero-psych [psychiatric] unit and the resident was later admitted the following day. No additional documentation such as resident or staff interviews were located or provided in regards to the investigation conducted. 3. Resident 6 was admitted to the facility on [DATE] with the following diagnoses that included, but were not limited to, Parkinson's disease, type 2 diabetes mellitus, essential hypertension, and major depressive disorder. Resident 6's medical record was reviewed on 7/20/23. On 6/30/23, a quarterly MDS assessment documented that resident 6 had a BIMS score of 2 which indicated severe cognitive impairment. On 6/8/23 at 5:15 PM, an Event Note documented, Resident was in the dining room and another resident came up to her and started to hit her and pulled her hair. She was yelling at her. There was two CNA's in there with them the nurses went in and took the other resident out so she would stop hitting her. We tried to calm her down by sitting her in the nurses station. We call her family to let her daughter know that we were sending her to her to [sic] the ER [emergency room ] for a psyche [psychiatric] eval [evaluation] and they admit her. The facility incident report was reviewed and documented the incident had happened in the resident 2's room with the roommate. The report documented that resident 2 had hit resident 6 with a paper and had pulled her hair. The residents were separated by staff. No documentation was provided to indicate which staff members had been interviewed about the altercation. No further documentation was located or provided to indicate an investigation was done. On 7/20/23 at 12:32 PM, an interview was conducted with CNA 1. CNA 1 stated resident 2 was very aggressive. CNA 1 stated resident 2 had walked into resident 1's room and scratched her. CNA 1 stated she notified the nurse when the situation happened. CNA 1 stated the nurse came and assessed the residents for injuries. CNA 1 stated resident 2 would go into other people's rooms and steal stuff. CNA 1 stated both staff and other residents were scared of resident 2 since she was so aggressive. CNA 1 stated resident 2 was not capable of abusing other resident's since she was not all there. CNA 1 stated she had not been asked any questions in regards to what she had witnessed between the two residents. On 7/20/23 at 12:47 PM, an interview was conducted with CNA 2. CNA2 stated if she suspected abuse or witnessed it, she notified the nurse and the ED. CNA 2 stated abuse happened in many ways such as physical, mental, or monetary abuse. CNA 2 stated a confused resident diagnosed with dementia was capable of abuse. CNA 2 stated resident 2 was combative and aggressive with other residents and staff. On 7/20/23 at 1:05 PM, an interview was conducted with Housekeeping (HK). The HK stated she saw resident 2 hit resident 6. The HK stated resident 2 was on top of resident 6 shaking and kicking her. The HK stated she notified the nurse of the incident. The HK stated resident 2 was taken out of her room and put close to the nurses station until she was taken to the hospital. The HK stated resident 2 had stated she was able to do whatever she wanted to resident 6 since that was her wife. The HK stated she had not been asked any questions in regards to what she had witnessed between the two residents. On 7/20/23 at 1:05 PM, an interview was conducted with resident 5. Resident 5 stated that she believed some residents should not be at the facility. Resident 5 stated there was a resident that was beating up another resident in the hallway and the staff acted quickly and got the resident off the other resident. Resident 5 stated that the next day the same resident attacked the roommate. Resident 5 stated that the resident was no longer living at the facility. On 7/20/23 at 1:51 PM, an interview was conducted with the ED. The ED stated he requested the staff notify him within 15 minutes if any kind of abuse was suspected. The ED stated he then would conduct interviews with staff or residents that witnessed or were involved in the incident. The ED stated he interviewed more residents and staff depending on the initial interviews with appropriate people involved. The ED stated if an investigation was being conducted, he generally interviewed between 5 to 10 residents. The ED stated he talked to staff members to see if they witnessed the abuse, who it was reported to, and what time they notified someone. The ED stated he used all the evidence for the investigation to determine if abuse was substantiated or unsubstantiated. The ED stated he would then put all the information together and send it to the State Survey Agency (SSA). The ED stated he wound send Exhibit 358 within 24 hours and Exhibit 359 within five business days. The ED stated there was an incident between resident 2 and resident 1. The ED stated he believed resident 2 had hit resident 1 with a magazine in the dining room. The ED stated they had conducted an Investigation and had staff interviews written down somewhere. The ED was then asked if he had substantiated abuse on the investigation conducted on 6/7/23, since there was no indication on Exhibit 359 to indicate what the evidence had concluded. The ED stated staff had witnessed the altercation between the two residents but the ED did not give a definitive answer on whether abuse had been substantiated or unsubstantiated. On 7/20/23 at 2:45 PM, a follow up interview was conducted with the ED. The ED stated they were unsure if the resident-to-resident altercation on 6/8/23, was reported to the SSA since it was the same thing that happened the day before on 6/7/23. The ED stated an investigation was not conducted for the resident-to-resident altercation on 6/8/23. On 7/27/23 at 10:24 AM, the ED provided additional information. A summary of the resident to resident altercation on 6/7/23, was provided. The summary had no dates or times to indicate when the investigation or interviews were conducted. A summary of the resident to resident altercation on 6/8/23, was provided. The summary had no dates or times to indicate when the investigation or interviews were conducted. [Note: The resident to resident altercation on 6/8/23, was not reported to the SSA and the ED was unable to provide an investigation during the abbreviated complaint survey. Staff members interviewed stated that they were not interviewed regarding the resident to resident altercation.] On 7/27/23 at 10:33 AM, an interview was conducted with the DON and ED. The DON stated that she was under the impression if there was no injury or emotional distress they did not need to report. The ED stated did they still need to report if both residents were confused.

Based on observation, interview and record review, the facility failed to establish an infection prevention and control program designed to prevent the development and transmission of COVID-19. Specifically, hand hygiene was not performed prior to entering and exiting a droplet precaution isolation room, and gloves were not donned prior to entering the droplet precaution isolation room. Findings include: On 11/3/2020 at 10:03 AM, an interview was conducted with the facility Infection Preventionist (IP). The IP stated that new admissions were quarantined for 14 days after admit on droplet/contact precautions, and were located on the facility isolation unit. The unit was located on the 200 and 300 hallway and was separated from the rest of the facility by a plastic barrier wall. The IP stated that the Personal Protective Equipment (PPE) worn by the staff on the unit was a surgical mask, goggles or face shield, disposable gowns, and gloves with resident contact or contact with objects within the resident room. On 11/3/2020 at 12:25 PM, observations were made of the facility quarantine/isolation unit. Observations were made of a PPE cart at the entrance door and near the nurse's station. Alcohol Based Hand Rub (ABHR) stations were located throughout the hallway. An observation was made of Certified Nurse Assistant (CNA) 3. CNA 3 stated that every time they entered a resident room they were to donn a gown in addition to the surgical mask and face shield that was universally worn inside the building. CNA 3 donned a disposable gown and entered room [ROOM NUMBER]. Hand hygiene was not performed nor were gloves donned prior to entering the droplet/contact isolation room. The CNA approached the doorway carrying a meal tray, set the meal tray down, doffed the disposable gown and exited the resident room carrying the meal tray. The meal tray was placed on a cart in the hallway. CNA 3 then obtained another disposable gown and a pair of gloves. CNA 3 donned the disposable gown and entered room [ROOM NUMBER] while carrying the gloves. Hand hygiene was not performed nor were the gloves donned prior to entering the droplet/contact isolation room. CNA 3 was observed to turn off the resident call light, pick up the TV remote and turn it on for the resident, and then hand the resident the remote. CNA 3 was observed to be bare handed while touching these surfaces inside the resident room. CNA 3 doffed the disposable gown, performed hand hygiene with ABHR and exited the room. An immediate interview was conducted with CNA 3. CNA 3 stated that gloves needed to be worn with any resident contact and if she touched anything inside the resident room. CNA 3 stated she forgot to donn the gloves and perform hand hygiene prior to entering room [ROOM NUMBER] and room [ROOM NUMBER]. The facility policy and procedure for Standard and Transmission Based Precautions for Coronavirus (COVID 19) ([DIAGNOSES REDACTED]-CoV-2) was reviewed. The policy designated residents who were admitted or readmitted as a unknown COVID-19 (Yellow) status and were to be on droplet plus contact precautions including eye protection. The policy further stated that All recommended COVID-19 PPE should be worn during care of residents under observation, which includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e. goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown. The policy stated that staff should perform hand hygiene with soap and water or ABHR; before and after all resident contact; contact with potentially infectious material; before applying gloves and after removal of gloves. On 11/3/2020 at approximately 12:40 PM, an interview was conducted with Licensed Practical Nurse (LPN) 3. LPN 3 was one of two licensed nurses that was assigned to the facility isolation unit. LPN 3 stated that everyone wore a surgical mask and face shield upon entrance to the unit. The isolation unit was accessed by staff from a doorway that exited directly outside the building. LPN 3 stated that in addition to the mask and face shield all staff were to wear a disposable gown and gloves when entering a resident room.

Based on interview, and record review it was determined that for 1 of 22 sample residents the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice. Specifically one resident had frequent constipation without bowel movements for 5-7 days throughout the month of October, and did not receive interventions, or change in plan of care. In addition no MD notification could be located in the medical record. Resident identifier: 9. Findings include: Resident 9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 10/21/19 at 10:51 AM, an interview was conducted with resident 9. Resident 9 stated that he had difficulties with ongoing constipation and he did not feel like his bowel regimen was strong enough. A review of the record was conducted 10/22/19 and revealed the following regarding resident 9's bowel movements for the last 26 days. a. Resident 9 did not have a bowel movement for 5 days from 9/28/19-10/5/19. b. Resident 9 did not have a bowel movement for 8 days from 10/5/19-10/14/19. c. Resident 9 did not have bowel movement for 7 days 10/16/19-10/23/19. A record review of physician orders, medication administrator record and progress notes was conducted for resident 9 on 10/22/19 and revealed the following. a. A physician order [REDACTED]. b. A physician order [REDACTED]. (Note: Resident 9's as needed Senna was not administered per the Medication Administration Record (MAR) in the month of (MONTH) 2019.) c. A progress note dated 10/20/19 stated: Resident for (sic) a suppository today per his requested (sic). d. A progress note dated 10/21/19 stated: Suppository was applied yesterday and today per resident requested (sic), no bowel movement (BM) at this time. will continue to monitor (WCTM). (Note: Resident 9 did not have any physician orders [REDACTED]. In addition, no documentation for interventions throughout the month of (MONTH) 2019 for constipation could be located in resident 9's medical record.) On 10/22/19 at 3:38 PM resident 9 was observed with Magnesium [MEDICATION NAME] at his bedside. Resident 9 stated the hospice nurse gave it to home for his constipation. About one fourth of the dose had been consumed. On 10/22/19 at 3:48 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that resident 9 had been constipated for a few days. RN 1 stated he was unaware if resident 9 had ongoing constipation problems. RN 1 stated that resident bowel movements were monitored, and that the facility electronic medical record system would alert staff if a resident had not had a bowel movement in 3 or more days. RN 1 stated that the nurses or nurse managers checked the report for bowel movements every morning. RN 1 stated that the facility had a bowel protocol, which consisted of; administer Milk of Magnesia (MOM) after 3 days in the AM, if no results administer a suppository that night. RN 1 stated if resident had not had a bowel movement after a suppository by the next day a Fleets enema should be administered. On 10/23/19 at 9:20 AM, Licensed Practical Nurse (LPN) 1 was interviewed. LPN 1 stated that resident 9 had frequent constipation. LPN 1 stated that resident 9 told her he had not had a bowel movement in 7 days, but that she thought it was more like 4 days. LPN 1 stated that she gave resident 9 prune juice in the AM on 10/23/19. LPN 1 stated that resident 9's constipation was usually addressed by the facility and hospice, but since he was a resident in the facility they tracked it and notified hospice if constipation occurred. LPN 1 stated that the facility had a bowel protocol, and that if a resident had not had a bowel movement for 3 days a suppository was administered, and if it was not successful that an enema would be administered. LPN 1 stated that if residents continued to have constipation after an enema, then a physician would be notified. LPN 1 stated that if a resident was on hospice the hospice company would also be notified and they would notify their physician. LPN 1 stated that if hospice was notified there would be a progress note of the hospice notification and the plan of care changes. LPN 1 stated that if someone had constipation the nurse would listen to the bowel sounds and would know if the constipation was bad because of the symptoms. LPN 1 stated that orders for interventions for constipation related to the bowel protocol were put in on admit and that any medication interventions for constipation should have a physician order [REDACTED]. On 10/23/19 at 9:24 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the facility had a bowel protocol and the physician orders [REDACTED]. DON stated that orders for milk of magnesia, [MEDICATION NAME], suppository and enema were started on admission. The DON stated that if a resident was on hospice the orders for bowel protocol on admission were determined by the hospice company. The DON stated that the facility ran a report daily for residents who were more than 3 days without a bowel movement. The DON stated that bowel protocol for the facility was to give milk of magnesia first, then [MEDICATION NAME], and then a suppository if resident had not had a bowel movement. The DON stated that all interventions for bowel protocol should have a physician order [REDACTED]. The DON stated that the nurses should notify hospice when a resident was having constipation and that notification would be documented in the progress notes. The DON stated that any medications or interventions that had been administered to resident 9 for constipation should have had a physician order [REDACTED]. The DON stated that she was not aware that resident 9 was having frequent constipation.

Based on interview and record review it was determined, for 3 of 32 sample residents, that the facility did not immediately inform or consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status. Specifically, facility staff did not notify the physician or there was a delay in notifying the physician when residents experienced a significant change in condition. Subsequently, two residents expired in less than 24 hours after the change in condition was noted by facility staff. Resident identifiers: 94, 107, and 210. Findings include: Harm: 1. Resident 94 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On [DATE], resident 94's medical record was reviewed. Review of the medical record revealed an Initial Data Collection Tool/Nursing Service form completed at 3:40 PM on [DATE]. Facility staff assessed resident 94 as being alert and oriented, able to communicate needs with clear speech, continent of bowel and bladder and that resident 94 required a ,[DATE] person assistance with transfers and ambulation. Review of the Progress Notes revealed the following entries: a. [DATE] 4:28 PM: [AGE] year old female is admitted to our facility at 3:40 PM from (name of local hospital). She was transported with our Van transportation sitting in her wheelchair. Pt (patient) has SOB (shortness of breath) at this time of admission her SAT (oxygen saturation) on RA (room air) was 65 %. Pt oxygen was off at this time of admission, pt was not connected to concentrator. Pt put on 2L (liters) NC (nasal cannula) SAT 98%. Education also given to the pt that she must be on oxygen all the time. Pt was treated after she fall (sic) home for decrease of functional mobility secondary to UTI. Pt will be (sic) continue on IV (intravenous) ABX (antibiotic) therapy for couple more days. No IV line present. IV line inserted 22 g (gauge) @ (at) left wrist at this time of admission. Pt is alert and oriented X2, able to communicate her needs. She requires one person assistance and ambulates very well without walker. Pt. has pul-ups (sic) in place and she is continent of both bowel and bladder. Vital Signs: 98.3 Tympanic temperature, Pulse 72/min (minute), Resp. (Respiratory) Rate 16/min., Blood Pressure ,[DATE]. b. [DATE] 1:16 AM: Charting for [DATE]: resident's DX (diagnosis): UTI, hx (history) of fall. Alert and oriented X2 with confusion. Meds (medications) taken whole without difficulty. O2 (oxygen) via NC to keep O2 sat above 90%. Resident was disoriented and took off NC several times; needs to be reoriented/redirected. Needs 1 person ext. (extensive) assist with ADLs (Activities of Daily Living). Continent of b/b (bowel and bladder). Uses FWW (Front wheeled walker) for mobility. Call light within reach. WCTM (Will continue to monitor). c. [DATE] 4:21 PM: (Resident 94) is alert and oriented self only, able to communicate to staff some wants and needs and staff to anticipate her wants and needs. Unable to ambulate this am related to weakness. Unable to swallow her medications this AM whole, medication crushed and able to swallow medications with medium (sic), Oxygen to keep saturations at 90%, resident redirected and reoriented often as nasal cannula removed and needed to be replaced. Usually 1 person extensive assist however was 2 person assist to move from her sitting walker to chair of comfort. Usually continent of b/b and today incontinent of b/b, noc (night) shift changed her prior to leaving and she remained incontinent rest of the day. Resident is here for Ground level fall with UTI. No IV access noted this AM. Hematoma to left wrist from yesterday IV access. [MEDICATION NAME] changed to IV to IM (intramuscularly) with [MEDICATION NAME] not available and await RX (pharmacy) to bring. No ASE (adverse side effects) to ABX. Speech therapy to assess and evaluation. Evaluation at lunch with speech therapy in room with her oxygen on and saturations 90 % on 3 LPM (liters per minute)/ NC. Family arrived to visit and complained that chair she was in wasn't comfortable, Maintenance alerted to situation and new chair obtained and delivered within moments of request. 2 nurses went to resident's room to check her and noted her not to have respirations or pulse and proceeded to start CPR (Cardio-Pulmonary Resuscitation) per POLST (Provider Order for Life-Sustaining Treatment) of full code. Alerted cna (Certified Nursing Assistant) to contact more personnel for assist. Crash cart and personnel arrived and turns taken with chest compressions and breaths. 911 arrived and utilized defibrillator and resident found asystole and pronounced/time of death 1355 (1:55 PM). Addendum: (name of Mortuary). Mortuary arrived and sent away by family and to be called when family is ready. Family at bedside with condolences cart. WCTM. No documentation could be found to show that facility staff notified the physician regarding the change in resident 94's condition. No documentation could be found to show that facility staff assessed resident 94 after her change in condition. No documentation could be found to show that facility staff obtained additional Vital Signs, after the initial Vital Signs were obtained on [DATE], at the time of admission. On [DATE] at 8:30 AM, the facility Medical Director/Doctor (MD) was interviewed via telephone. The MD was read the above progress entries and stated that resident 94 was showing Severe sudden, major physiological changes and because he had yet to see resident 94 that his tolerance for sending a new resident to the hospital was very low. The MD stated that he should have been notified of resident 94's change in condition. The MD stated that had he been called in the morning regarding her change of condition, he would have come to the facility to see resident 94 and then would have ordered laboratory values and an x-ray. The MD stated that resident 94's change of condition was beyond a little bit of confusion and Sundowning. On [DATE], the facility Director of Nursing (DON) was interviewed. The DON confirmed that the staff could have called the MD sooner. When asked when they notified the MD, the DON stated, After she (resident 94) coded. The DON further stated that he did not believe that the resident becoming incontinent after being continent and her confusion or inability to swallow pills or her need for extensive assistance signified a change in condition. The DON stated that he felt like the facility staff just had, bad charting. 2. Resident 210 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On [DATE], resident 210's medical record was reviewed. The following Progress Notes entries were made by facility staff after resident 210 returned from having a feeding tube placed: a. [DATE] 1:06 AM: Charting for [DATE]: Alert and oriented x ,[DATE]. Pleasant but non-cooperative with meds (medications). Feeding tube is patent, flushed with 150 cc (cubic centimeters) H2O (water) before and after feeding and running [MEDICATION NAME] 1.2 at 60 ml/hr (milliliters per hour). Needs 1 person assist with ADLs (Activities of Daily Living). Uses w/c (wheel chair) for mobility. Continent of b/b (bowel and bladder). Safety precautions in place. Call light within reach. Will CTM (continue to monitor). b. [DATE] 4:55 PM: Resident is lethargic, breathe through her mouth, turned feeding off at 7 AM, checked and flushed as ordered, head of bed elevated, was coughing and seems more weaker, opens eyes when called but sleeps again, refused all PO (by mouth) intake and resistive of oral care. At 1500 (3:00 PM) resident was SOB (short of breath), couldn't get Oxygen level using pulse oximetry, Put on O2 (oxygen) via NC (nasal cannula) sats (saturations) reads as 96 % at 2 lpm (liters per minute), called on call MD notified of situation ordered consider hospice. At 1540 (3:40 PM) (name) her son came and discussed his moms (sic) condition and mentioned hospice. Son is still undecided. No documentation could be found to show that facility staff notified the physician at 7 AM when resident 210's change of condition was first assessed by the facility staff. Facility staff documented that the physician was notified after 3 PM, after resident 210 had declined further. No documentation could be found to show that facility staff continued to assess resident 210 regarding her change in condition nor assess for the correct placement of the feeding tube and/or other adverse conditions regarding feeding tube placement or overfeeding. c. [DATE] 12:26 AM: Charting for [DATE]: Alert and oriented X 1. Non-compliant with meds and care. Refused meds. Feeding tube is patent and running [MEDICATION NAME] 1.2 via kangaroo pump at 60 ml/hr. Flushed with 150 ml before and after feeding. HOB (Head of bed) elevated > (greater than) 30 degree. Needs 1 person assist with ADLs. Uses w/c for mobility. O2 via NC to keep O2 sat above 90 %. Safety precautions in place. Call light within reach. Will CTM. Addendum: Late entry: charting for [DATE]: Resident was unresponsive, cold to touch, and pulseless, when this nurse went to check on resident at approx. (approximately) 5 am. An aid reported resident was responsive when checked at 4:30 and did not have any distress according to the aid. On-call MD, DON (Director of Nursing) and son were notified. Post-mortem care was given; feeding tube was removed. Report of resident passing was given to Day nurse. (Note: The Addendum entry was made and signed by the nurse on [DATE] at 1:15 AM.) On [DATE] at 8:30 AM, the facility Medical Director/Doctor (MD) was interviewed via telephone. The MD stated that he would expect facility staff to monitor for signs of reflux, nausea, vomiting, bloating, overfeeding, diarrhea, and aspiration in regards to a newly placed feeding tube. When the surveyor read the [DATE] 4:55 PM entry to the MD, the MD stated that hospice was not automatically ordered for a resident with potential aspiration symptoms. On [DATE] at 9:45 AM, MD 1 was interviewed via telephone. MD 1 stated that she remembered being notified regarding resident 210 on [DATE]. MD 1 stated that she was not told that resident 210 was hypoxic nor that resident 210's feeding tube had only been in place for one day. MD 1 stated that she was given the impression, by facility staff, that resident 210 had been declining for some time and had been refusing food and the tube feeding for some time. MD 1 further stated that she Got the impression from staff that resident 210's family had already been consulted and did not want anything further done with resident 210. MD 1 stated that she did not order Hospice but told the staff to provide comfort measures through the night and then things could be re-evaluated in the morning. MD 1 stated that if the family wanted comfort measures why had facility staff connected resident 210 back up to the feeding tube at 9:00 PM on the night she had received the call. On [DATE] at 10:30 AM, Registered Nurse (RN) 3 was interviewed. RN 3 was the nurse that had made the [DATE] at 4:55 PM entry. RN 3 stated that she had not called the MD at 7:00 AM when resident 210 was coughing and lethargic. RN 3 stated that resident 210 was coughing because the feeding tube was irritating her throat. RN 3 stated that she did not tell MD 1 that the feeding tube had only been in place one day because she was unaware that the feeding tube had only been placed the day before. RN 3 stated that she spoke with resident 210's son before calling the MD but had only told him that his mother was not eating. RN 3 stated that she mentioned Hospice to the son after contacting the MD. On [DATE] at 3:00 PM, the facility DON was interviewed. The DON stated that the only sign of aspiration that resident 210 showed was the coughing. The DON stated that he felt the facility staff had done everything they could for resident 210. 3. Resident 107 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On [DATE], resident 107's medical record was reviewed. Review of the physician's orders [REDACTED]. Check blood sugar 2 times daily and inject per sliding scale. Not a flex pass med. (medication). If BS (blood sugar) < (less than) 60 or > (greater than) 400 call MD (Medical Doctor). For BS < 60 follow hypoglycemic protocol. Review of the Hypoglycemic Protocol revealed the following: Call MD is (sic) blood glucose is less than 60 or greater than 400. 1. If resident is awake and alert, and blood glucose is less than 60 -Give fast-acting carbs (carbohydrates) ,[DATE] gm (grams) ***4 oz (ounces) juice or non-diet soda or 3 glucose tabs (tablets). -Recheck blood glucose in 15 minutes the (sic) if blood glucose is equal to or greater than 60, give protein snack/meal and call MD. -If blood glucose is less than 60 give fast-acting carbs and protein snack/meal. Recheck in 15 minutes and call MD with results. Review of resident 107's Medication Administration Record [REDACTED]. Review of the Progress Notes revealed the following entry on [DATE]: .Resident had Blood glucose 49, given Orange juice and re-check and 67 continues with OJ and BG (blood glucose) is 178. No documentation could be found to show that the physician was notified of resident 107's blood sugar of 49. Review of resident 107's MAR for [DATE] revealed that resident 107 had a documented blood sugar of 402 on [DATE]. No documentation could be found to show that the physician was notified for the greater than 400 blood sugar. On [DATE], the facility DON was interviewed. The DON confirmed that no documentation could be found to show that the physician was notified of the low blood sugar or the greater than 400 blood sugar.

Based on interview and record review it was determined, for 2 of 32 sample residents, that the facility did not ensure nor provide each resident with the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Specifically, facility staff did not notify nor inform the physician timely when two residents experienced a change in condition. Furthermore, facility staff did not continue to assess the residents' change in condition for a further decline. Subsequently, two resident's expired less than 24 hours after staff identified the residents' change in condition. Additionally, facility staff were not coordinating care with the Hospice agency. Resident identifiers: 2 and 94. Findings include: Harm: 1. Resident 94 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On [DATE], resident 94's medical record was reviewed. Review of the medical record revealed an Initial Data Collection Tool/Nursing Service form completed at 3:40 PM on [DATE]. Facility staff assessed resident 94 as being alert and oriented, able to communicate needs with clear speech, continent of bowel and bladder and that resident 94 required a ,[DATE] person assistance with transfers and ambulation. Review of the Progress Notes revealed the following entries: a. [DATE] 4:28 PM: [AGE] year old female is admitted to our facility at 3:40 PM from (name of local hospital). She was transported with our Van transportation sitting in her wheelchair. Pt (patient) has SOB (shortness of breath) at this time of admission her SAT (oxygen saturation) on RA (room air) was 65 %. Pt oxygen was off at this time of admission, pt was not connected to concentrator. Pt put on 2L (liters) NC (nasal cannula) SAT 98%. Education also given to the pt that she must be on oxygen all the time. Pt was treated after she fall (sic) home for decrease of functional mobility secondary to UTI. Pt will be (sic) continue on IV (intravenous) ABX (antibiotic) therapy for couple more days. No IV line present. IV line inserted 22 g (gauge) @ (at) left wrist at this time of admission. Pt is alert and oriented X2, able to communicate her needs. She requires one person assistance and ambulates very well without walker. Pt. has pul-ups (sic) in place and she is continent of both bowel and bladder. Vital Signs: 98.3 Tympanic temperature, Pulse 72/min (minute), Resp. (Respiratory) Rate 16/min., Blood Pressure ,[DATE]. b. [DATE] 1:16 AM: Charting for [DATE]: resident's DX (diagnosis): UTI, hx (history) of fall. Alert and oriented X2 with confusion. Meds (medications) taken whole without difficulty. O2 (oxygen) via NC to keep O2 sat above 90%. Resident was disoriented and took off NC several times; needs to be reoriented/redirected. Needs 1 person ext. (extensive) assist with ADLs (Activities of Daily Living). Continent of b/b (bowel and bladder). Uses FWW (Front wheeled walker) for mobility. Call light within reach. WCTM (Will continue to monitor). c. [DATE] 4:21 PM: (Resident 94) is alert and oriented self only, able to communicate to staff some wants and needs and staff to anticipate her wants and needs. Unable to ambulate this am related to weakness. Unable to swallow her medications this AM whole, medication crushed and able to swallow medications with medium (sic), Oxygen to keep saturations at 90%, resident redirected and reoriented often as nasal cannula removed and needed to be replaced. Usually 1 person extensive assist however was 2 person assist to move from her sitting walker to chair of comfort. Usually continent of b/b and today incontinent of b/b, noc (night) shift changed her prior to leaving and she remained incontinent rest of the day. Resident is here for Ground level fall with UTI. No IV access noted this AM. Hematoma to left wrist from yesterday IV access. [MEDICATION NAME] changed to IV to IM (intramuscularly) with [MEDICATION NAME] not available and await RX (pharmacy) to bring. No ASE (adverse side effects) to ABX. Speech therapy to assess and evaluation. Evaluation at lunch with speech therapy in room with her oxygen on and saturations 90 % on 3 LPM (liters per minute)/ NC. Family arrived to visit and complained that chair she was in wasn't comfortable, Maintenance alerted to situation and new chair obtained and delivered within moments of request. 2 nurses went to resident's room to check her and noted her not to have respirations or pulse and proceeded to start CPR (Cardio-Pulmonary Resuscitation) per POLST (Provider Order for Life-Sustaining Treatment) of full code. Alerted cna (Certified Nursing Assistant) to contact more personnel for assist. Crash cart and personnel arrived and turns taken with chest compressions and breaths. 911 arrived and utilized defibrillator and resident found asystole and pronounced/time of death 1355 (1:55 PM). Addendum: (name of Mortuary). Mortuary arrived and sent away by family and to be called when family is ready. Family at bedside with condolences cart. WCTM. No documentation could be found to show that facility staff notified the physician regarding the change in resident 94's condition. No documentation could be found to show that facility staff assessed resident 94 after her change in condition. No documentation could be found to show that facility staff obtained additional Vital Signs, after the initial Vital Signs were obtained on [DATE], at the time of admission. On [DATE] at 8:30 AM, the facility Medical Director/Doctor (MD) was interviewed via telephone. The MD was read the above progress entries and stated that resident 94 was showing Severe sudden, major physiological changes and because he had yet to see resident 94 that his tolerance for sending a new resident to the hospital was very low. The MD stated that he should have been notified of resident 94's change in condition. The MD stated that had he been called in the morning regarding her change of condition, he would have come to the facility to see resident 94 and then would have ordered laboratory values and an x-ray. The MD stated that resident 94's change of condition was beyond a little bit of confusion and Sundowning. On [DATE], the facility Director of Nursing (DON) was interviewed. The DON confirmed that the staff could have called the MD sooner. When asked when they notified the MD, the DON stated, After she (resident 94) coded. The DON further stated that he did not believe that the resident becoming incontinent after being continent and her confusion or inability to swallow pills or her need for extensive assistance signified a change in condition. The DON stated that he felt like the facility staff just had, bad charting. 2. Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of resident 2's medical record was completed on [DATE]. A review of resident 2's care plan dated [DATE], revealed that resident 2 was receiving hospice services. No notes could be located in resident 2's medical record from resident 2's hospice nurse. On [DATE] at 9:20 AM, Registered Nurse (RN) 2 was interviewed. RN 2 stated that the facility coordinated care with the Hospice company by the Hospice company leaving their visit notes under the Hospice tab of the resident's hard chart. RN 2 stated that resident 2's hospice nurse should have been faxing notes over after she visited resident 2. RN 2 further stated that the hospice notes should have been filed under the hospice tab of resident 2's hard chart. RN 2 stated that the facility had always struggled to get notes from resident 2's hospice company. On [DATE] at 9:30 AM, the Medical Records Director (MRD) was interviewed. The MRD stated that he left three months of notes in residents' hard charts. The MRD stated that he only thinned hospice notes when they get out of control The MRD did not have any hospice notes for resident 2. On [DATE] at approximately 9:45 AM, the Assistant Director of Nursing (ADON) was interviewed. The ADON was not able to locate any hospice notes for resident 2. On [DATE] at approximately 12:30 PM, the facility Director of Nursing (DON) provided the Hospice notes for resident 2. The DON stated that the notes, for resident 2, from [DATE] to current had just been faxed from the Hospice company. On [DATE] at approximately 2:00 PM, the facility DON stated that since the facility had provided the faxed notes, he felt that the facility was communicating with the Hospice company to coordinate care.

Based on interview and record review it was determined, for 1 of 32 sample residents, that the facility did not ensure that a resident who had been able to eat enough alone or with assistance was not fed by enteral methods and a resident who was fed by enteral means received the appropriate treatment to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers. Specifically, facility staff implemented the Registered Dietitian's recommendations for one day before obtaining an order from the physician for a feeding tube. Additionally, after the feeding tube was placed, facility staff did not continue to assess the resident for complications related to the feeding tube placement nor notify the physician in a timely manner when the resident did exhibit a change in condition. Subsequently, the resident was found to be deceased approximately 40 hours after having the feeding tube inserted. Resident identifier: 210. Findings include: Resident 210 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On [DATE], resident 210's medical record was reviewed. Review of resident 210's hospital stay Clinical Flowsheet revealed that on [DATE], staff at the hospital had documented that resident 210 weighed 113.08 pounds. Review of the Initial Data Collection Tool/Nursing Service form, completed on [DATE] by facility staff, revealed that facility staff documented that resident 210 weighed 99.8 pounds. (Note: According to the weight obtained by facility staff, resident 210 lost 13.28 pounds in 2 days.) On [DATE], the facility Registered Dietitian (RD) completed a Nutrition Data Collection/Assessment for resident 210. The RD documented the following: Current weight: 100 lbs. (pounds) Comments: Nsg (Nursing) tried medpass but she won't drink it. Son reports common for her to eat poorly @ (at) hospital . but eats well @ home. Nutrition Intervention: Diet as ordered, rec. (recommend) SLP (Speech Language Pathology) eval. (evaluation), rec. to DR (Dining Room) for meals to get supervision et (and) assist. Enc. (encourage) PO (by mouth) food / fluid. Review of the SLP evaluation dated [DATE] revealed the following: The pt. (patient) was seen multiple times on ,[DATE] and ,[DATE] for swallowing screening. She refused all foods regardless of texture. She said she did not feel hungry. She was free from signs of aspiration with limited sips of thin liquids. The pt's (patient's) son said she ate very little at the hospital but ate well at home previously. This appears to be an appetite issue, not a swallowing problem. Further ST (Speech Therapy) is not indicated at this time. Review of the Resident Progress Notes revealed the following entries: a. [DATE] 7:32 PM: Resident alert, oriented to self, able to make needs known, compliant with medications and cares, works with therapy for strengthening, uses wheelchair for mobility, Eats in the dining room, able to feed self after set up, had less than 50 % of breakfast, refused lunch and dinner, offered fluids frequently bit (sic) just take couple of small sips, Called son 2X and left a message, 1830 (6:30 PM) returned call and stated that she eats good at home, eat a little at hospital. He will visit her tomorrow and bring her food. b. [DATE] 5:46 PM: resident continues having poor appetite, MD (Medical Doctor) in facility ordered [MEDICATION NAME] 15 mg (milligrams) PO QHS (every hour of sleep) to stimulate appetite. c. [DATE] 1:28 PM: rse (resident) reviewed for wts (weights) at RAR (Resident At Risk). current wt (weight) 91 lbs from 100 lbs. intake ,[DATE] %. res has poor appetite. RD recommends vanilla frozen nutritional treat BID (twice daily) with mighty shake TID (three times daily) at this time. wctm (will continue to monitor). d. [DATE] 12:50 PM: Resident has been refusing to eat breakfast, she took couple of sips of her orange juice this morning. She is tired and sleepy, she seems weak. She took couple of sips of med pass this morning, she refuse to drink it this afternoon. Nurse has call son and notified him of his mother's refuse (sic) to medication and food. He was ask if he would give consent for NG (naso-gastric) tube if doctor order, he reply he would and hope his mother would not take off. Doctor will be in today and will be notified. e. [DATE] 4:53 PM: MD has order placement of NG tube, appointment made at (name of local hospital) Radiology for tomorrow, [DATE] at 1330 (1:30 PM). Formula order [MEDICATION NAME] 1.2 at 60 ml/hr (milliliters per hour) at nighttime (2100 on and off 0700) (9:00 PM on and off 7:00 AM). Dietary has order Flush water 150 ml, four times a day (two flushes before and after feedings and two additional during day). Review of the Medication Administration Record [REDACTED]. Additionally, resident 210 received only one day of the RD recommendations of the vanilla frozen nutritional treat and vanilla mighty shake before facility staff obtained the order to have the NG tube placed. The interventions put into place by the MD and the RD, for resident 210's weight loss and poor appetite were given for only 1 - 3 days before facility staff obtained family and MD permission to have the feeding tube placed. No documentation could be found to show that facility staff were assisting resident 210 in the Dining Room during meals. No documentation could be found to show that facility staff evaluated resident 210's likes and dislikes in regards to food. No documentation could be found to show that facility staff encouraged resident 210's son to bring in food from home that resident 210 enjoyed. The following Progress Notes entries were made by facility staff after resident 210 returned from having the feeding tube placed: a. [DATE] 1:06 AM: Charting for [DATE]: Alert and oriented x ,[DATE]. Pleasant but non-cooperative with meds (medications). Feeding tube is patent, flushed with 150 cc (cubic centimeters) H2O (water) before and after feeding and running [MEDICATION NAME] 1.2 at 60 ml/hr. Needs 1 person assist with ADLs (Activities of Daily Living). Uses w/c (wheel chair) for mobility. Continent of b/b (bowel and bladder). Safety precautions in place. Call light within reach. Will CTM (continue to monitor). b. [DATE] 4:55 PM: Resident is lethargic, breathe through her mouth, turned feeding off at 7 AM, checked and flushed as ordered, head of bed elevated, was coughing and seems more weaker, opens eyes when called but sleeps again, refused all PO intake and resistive of oral care. At 1500 (3:00 PM) resident was SOB (short of breath), couldn't get Oxygen level using pulse oximetry, Put on O2 (oxygen) via NC (nasal cannula) sats (saturations) reads as 96 % at 2 lpm (liters per minute), called on call MD notified of situation ordered consider hospice. At 1540 (3:40 PM) (name) her son came and discussed his moms (sic) condition and mentioned hospice. Son is still undecided. No documentation could be found to show that facility staff notified the physician at 7 AM when resident 210's change of condition was first assessed by the facility staff. Facility staff documented that the physician was notified after 3 PM, after resident 210 had declined futher. No documentation could be found to show that facility staff continued to assess resident 210 regarding her change in condition nor assess for the correct placement of the feeding tube and/or other adverse conditions regarding feeding tube placement or overfeeding. c. [DATE] 12:26 AM: Charting for [DATE]: Alert and oriented X 1. Non-compliant with meds and care. Refused meds. Feeding tube is patent and running [MEDICATION NAME] 1.2 via kangaroo pump at 60 ml/her. Flushed with 150 ml before and after feeding. HOB (Head of bed) elevated > (greater than) 30 degree. Needs 1 person assist with ADLs. Uses w/c for mobility. O2 via NC to keep O2 sat above 90 %. Safety precautions in place. Call light within reach. Will CTM. Addendum: Late entry: charting for [DATE]: Resident was unresponsive, cold to touch, and pulseless, when this nurse went to check on resident at approx. (approximately) 5 am. An aid reported resident was responsive when checked at 4:30 and did not have any distress according to the aid. On-call MD, DON (Director of Nursing) and son were notified. Post-mortem care was given; feeding tube was removed. Report of resident passing was given to Day nurse. (Note: The Addendum entry was made and signed by the nurse on [DATE] at 1:15 AM.) On [DATE] at 8:30 AM, the facility Medical Director/Doctor (MD) was interviewed via telephone. The MD stated that he would expect facility staff to monitor for signs of reflux, nausea, vomiting, bloating, overfeeding, diarrhea, and aspiration in regards to a newly placed feeding tube. When the surveyor read the [DATE] 4:55 PM entry to the MD, the MD stated that hospice was not automatically ordered for a resident with potential aspiration symptoms. On [DATE] at 9:45 AM, MD 1 was interviewed via telephone. MD 1 stated that she remembered being notified regarding resident 210 on [DATE]. MD 1 stated that she was not told that resident 210 was hypoxic nor that resident 210's feeding tube had only been in place for one day. MD 1 stated that she was given the impression, by facility staff, that resident 210 had been declining for some time and had been refusing food and the tube feeding for some time. MD 1 further stated that she Got the impression from staff that resident 210's family had already been consulted and did not want anything further done with resident 210. MD 1 stated that she did not order Hospice but told the staff to provide comfort measures through the night and then things could be re-evaluated in the morning. MD 1 stated that if the family wanted comfort measures why had facility staff connected resident 210 back up to the feeding tube at 9:00 PM on the night she had received the call. On [DATE] at 10:30 AM, Registered Nurse (RN) 3 was interviewed. RN 3 was the nurse that had made the [DATE] at 4:55 PM entry. RN 3 stated that she had not called the MD at 7:00 AM when resident 210 was coughing and lethargic. RN 3 stated that resident 210 was coughing because the feeding tube was irritating her throat. RN 3 stated that she did not tell MD 1 that the feeding tube had only been in place one day because she was unaware that the feeding tube had only been placed the day before. RN 3 stated that she spoke with resident 210's son before calling the MD but had only told him that his mother was not eating. RN 3 stated that she mentioned Hospice to the son after contacting the MD. On [DATE] at 3:00 PM, the facility DON was interviewed. The DON stated that the only sign of aspiration that resident 210 showed was the coughing. The DON stated that he felt the facility staff had done everything they could for resident 210.

Based on observation, interview and record review, it was determined the facility did not provide the necessary care and services to maintain the highest practical physical well-being in accordance with the comprehensive assessment and plan of care for 1 of 40 sample residents. Specifically, a resident was not turned or repositioned for an extended period of time which resulted in an open wound. Resident identifier: 103. Findings include: Resident 103 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/27/16 at 7:38 AM, an observation was made while Registered Nurse (RN) 3 and Certified Nurse Assistant (CNA) 4 provided incontinence care to resident 103. Resident 103 had an open round on his right buttock area that was approximately the size of q-tip head. RN 3 applied Butte Paste on the open wound. Resident 103's medical record was reviewed on 4/27/16. Review of a significant change Minimum Data Set (MDS) assessment, dated 1/28/16, revealed that the facility staff assessed resident 103 as requiring extensive assistance of two or more people during transfers and while moving from a seated position. Review of the physician's orders [REDACTED]. 1. 4/25/16 at 4:30 PM: Wound care to (right) buttock - clean (with) wound cleaner, cover (with) foam drsg (dressing) . (Change) Q (every) day and PRN (as needed). 2. 6/20/13: Barrier cream with every toileting/brief change PRN - 6 time(s) a day. On 4/27/16 from 7:50 AM though 11:39 AM, a continuous observation was conducted on resident 103. The following was noted: 1. 7:50 AM, resident 103 was propelled into the dining room on the Special Needs Unit (SNU). 2. 8:05 AM, resident 103's breakfast was delivered. Resident 103 was assisted by CNA 4. 3. 9:00 AM, resident 103 was removed from the dining room and placed behind the medication cart next to the nurse's station. (Note: Resident 103 was not repositioned to provide off-loading on the buttocks.) 4. 10:08 AM, resident 103 was propelled to the dining room on the 500 hall to attend an activity. 5. 10:32 AM, resident 103 was observed to rock himself forward and backwards as if attempting to reposition himself. 6. 11:39 AM, RN 4 propelled resident 103 back to his room. CNA's 4 and 5 were observed while providing incontinence care. Resident 103's brief was removed and was dry. Resident 103's open wound on the right buttock did not have a dressing in place. There was a open wound to the medial aspect of the previous open area. CNA 5 left resident 103's room to get RN 1. RN 1 entered the room at approximately 11:45 AM to observed resident 103's buttocks. RN 1 stated that the new wound was not there this morning. RN 1 was unable to state what resident 103's wound order was. (Note: The facility staff did not reposition resident 103 in a manner that off-loaded his buttocks for 4 hours and 49 minutes.) An interview was conducted with CNA 4 on 4/27/16 at 10:00 AM. CNA 4 stated resident 103 was not on his list of assigned residents and that he had not repositioned the resident that day. An interview was conducted with the MDS Coordinator on 4/27/16 at 1:45 AM. The MDS Coordinator stated that residents were to be repositioned every two hours. An interview was conducted with RN 1 on 4/27/16 at 1:50 PM. RN 1 stated that resident 103 was repositioned by RN 4 and a CNA just prior to going to the activity on the 500 hall. An interview was conducted with RN 4 on 4/27/16 at 1:55 PM. RN 4 stated that she and CNA 4 quickly scooted resident 103 up in his wheelchair. RN 4 stated that resident 103 was not stood up and that he was slid backwards in his wheelchair prior to going to the activity on the 500 hall. On 4/25/16 at 4:29 PM, RN 2 documented in the electronic progress notes, Doing dressing changes and CNA noted redness in small area on buttocks. Orders written for added tx (treatment) to current wound orders. Review of the NON-PRESSURE SKIN CONDITION RECORD revealed that on 4/25/16 resident 103 sustained a maceration wound that was under scrotum. The wound measured 0.3 cm (centimeters) X (by) 0.3 cm X 0.1 cm. (Note the open wound was on the right buttock.) On 4/27/16 at 3:40 PM, RN 1 documented in the electronic progress notes, Rt (resident) had a new area with redness and very small opening noted to peri area, near previous reddened area, dressing replaced and Staff educated to reposition Rt every 1-2 hours and prn. Rt repositioned every 1 1/2 hours, Rt is totally dependent on 2-3 persons for all transfers, . On 4/27/16 at 6:58 PM, RN 3 documented in the the electronic progress notes, .new wound noted on rt (right) buttocks.no new recommendations at this time. An interview was conducted with resident 103's primary care physician (PCP) on 4/28/16 at 2:16 PM. The PCP stated that the new wound on the right buttock skin fold, was approximately 3 cm outside the anus and was not on a pressure point.

Based on interview and record review, it was determined the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 4 of 6 sampled residents. Specifically, two sample residents experienced a delay in being transferred to the emergency room after a significant change in condition occurred which resulted in harm. Additionally, two residents [MEDICATION NAME] medication patches were not applied or removed appropriately but did not result in harm. Resident identifier's: 3 , 4, 5 and 7. Findings include: 1. Resident 3 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident 3's medical record was reviewed on [DATE]. Review of nursing notes revealed the following entries: a. On [DATE] at 9:35 AM, .Patient complains of abdominal pain. b. On [DATE] at 3:04 PM, .pt (patient) c/o (complains of) increased pain and increased nausea more than usual. MD(medical doctor) notified and MD visited with pt. MD ordered to contact pt's surgeon. contacted surgeon's office and left a call back msg (message). c. On [DATE] at 9:44 AM, .prn (as needed) pain medication given per request. d. On [DATE] at 10:00 AM, resident 3's blood pressure was ,[DATE]. e. On [DATE] at 4:48 PM, .contacted pt's surgeon office spoke to surgeon's assistant regarding pt's increase Nausea, increase abdominal pain, low BP (blood pressure) of ,[DATE] and decrease appetite. Per order pt was sent to (name of hospital) ER (emergency room ) for further evaluation and tx (treatment) at 1400 (2:00 PM). (Note: There was a 53 hour delay in treatment from the time the resident started complaining of abdominal pain until the the time the resident was transported to the to the hospital. Further more, there was a 24 hour delay in making contact with the surgeon as ordered by the facility doctor.) According to Hospital Discharge Instructions dated [DATE] resident 3 was admitted to the hospital on [DATE] for epigastric pain, ischemic [MEDICAL CONDITION], recurrent [MEDICAL CONDITION] [MEDICAL CONDITIONS] and discharged from the hospital on [DATE]. On [DATE] at 2:28 PM, resident 3 was interviewed. Resident 3 was alert and oriented and stated that her illness began on [DATE]. She stated that she had been hospitalized for [REDACTED]. Resident 3 further stated that she had been hospitalized twice in the past month for [MEDICAL CONDITION]. Resident 3 stated that she almost died the day of her hospitalization and was told by her surgeon that she would not have made it had she not insisted on going to the hospital. 2. Resident 5 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident 5's medical record was reviewed on [DATE]. On [DATE] at 3:24 PM, Registered Nurse (RN) 3 documented resident 5's Blood glucose check done this am at 0730 (7:30 AM) patient was 62 and unresponsive, vitals were done and WNL (within normal limits). Attempted to give patient orange juice but she was not able to swallow. Checked glucose again at 1030 (10:30 AM) and it was 44, MD notified 1ml (milliliter) [MEDICATION NAME] given SQ (subcutaneous) at 11:10 (11:10 AM) and bs (blood sugar) checked again at 11:25 (11:25 AM) it was 123 and ten minutes later it was 192. MD ordered to send patient to ER. Patient sent to (local hospital) via (name of ambulance company). Left message on answering machine of family at 1300 (1:00 PM) and spoke to patient's husband at 1400 (2:00 PM). MOD (manager on duty) and DON (director of nursing) notified. A SBAR (situation, background, assessment, request) Communication Form and Progress Note dated [DATE] revealed the following information, BS checked at 0730 (7:30 AM) was 62, attempted to give her O.J. (orange juice), patient was unresponsive. [MEDICATION NAME] given at 11:10 (AM) bs- 123 at 11:25 (AM) then 257, MD ordered to send her to E.R. A WITNESS STATEMENT FORM dated [DATE], written by RN 3 reveled the following information regarding an incident which occurred on [DATE] with resident 5, Patient was breathing when I did my initial morning assessment. Patient was lethargic and would not open her eyes, patient was responsive to touch when sternal rub performed, patient moaned and grimaced but did not open her eyes and would not get up. MD was notified and [MEDICATION NAME] drops where given then SQ [MEDICATION NAME] given after I received the order from the MD. I went into the patients room every ,[DATE] minutes to check on her and blood sugar was checked every 15 minutes. On [DATE] at 10:15 AM, an interview was conducted with RN 3. RN 3 stated she had not worked with resident 5 until [DATE]. RN 3 stated she asked the Speech Therapist (ST) 1 if resident 5 was usually unresponsive, and he stated resident 5 was usually very talkative and active. RN 3 stated she did not contact the MD until resident 5's blood sugar had dropped in to the 40's, even though the resident was unresponsive. RN 3 stated after texting the Assistant Director of Nursing (ADON) she called MD 1 and when he did not answer she immediately hung up and texted MD 1. RN 3 stated after MD 1 did not respond to her text she called MD 2 as instructed by the ADON, but he also did not answer. RN 3 confirmed she did not leave a voicemail for MD 1 or MD 2. RN 3 stated she felt she did the right thing by calling the doctor but admitted , I should have called sooner. The following text message conversation from [DATE] between RN 3 and the ADON were reviewed and transcribed with the consent of RN 3 from her personal cell phone: a. On [DATE] at 10:35 AM, the following text message was sent from RN 3 to the ADON, Her (resident 5) bs has dropped to 49, should I call the Dr. (doctor)? b. On [DATE] at 10:35 AM, the following text message was received by RN 3 from the ADON, Yes ASAP (as soon as possible). AlwAys (sic) call with anything lower than 60. c. On [DATE] at 10:36 AM, the following text message was sent by RN 3 to the ADON, Ok. d. On [DATE] at 10:51 AM, the following text message was sent by RN 3 to the ADON, I called (name of MD 1), he did not answer, I sent him a text but haven't heard back yet. e. On [DATE] at 11:06 AM, the following text message was received by RN 3 from the ADON, Send to (name of a MD 2). The following text message conversation from [DATE] between RN 3 and MD 1 were reviewed and transcribed with the consent of RN 3 from her personal cell phone: a. On [DATE] at 10:45 AM, the following text was sent from RN 3 to MD 1, 310 (The room number of resident 5) bs was 62 at 0730 it is now 49, vitals are WNL but she is non responsive, should I send her to the hospital? She is full code. b. On [DATE] at 11:53 AM, the following text was received by RN 3 from MD 1, Sorry I just got this. The protocol is for [MEDICATION NAME] and [MEDICATION NAME]. I hope that happened. c. On [DATE] at 12:01 PM, the following text message was sent from RN 3 to MD 1, Yes I gave her [MEDICATION NAME] Sq, now her bs is 192 and she is still unresponsive. d. On [DATE] at 12:42 PM, the following text message was received by RN 3 from MD 1, Send her in. e. On [DATE] at 12:59 PM, the following text message was sent from RN 3 to MD 1, Ok. The facility Hypoglycemic Protocol = Blood Glucose Less than 60 revealed the following information, If BG (blood glucose) is less than 60 (and) res (resident) is unconscious; Give [MEDICATION NAME] 1 mg (milligram) IM(intramuscularly)/SQ call EMS (emergency medical services) (and) MD. On [DATE] at 12:15 PM, a second interview was conducted with RN 3. RN 3 stated she did not document the BS which she did every 15 minutes or any assessments of resident 5 when she went in to her room every five to ten minutes. RN 3 stated from 7:30 AM to 1:00 PM, resident 5 did not respond to any stimuli besides a sternal rub. RN 3 stated she did go to RN 4, who was working on another hall, for assistance when resident 5's BS had dropped in to the 40's. RN 3 stated she and RN 4 had to search for five to ten minutes to find the [MEDICATION NAME] to administer to resident 5. RN 3 stated the [MEDICATION NAME] was supposed to be stocked in the medication carts, but that they could not find any in the medication cart. RN 3 stated she didn't think resident 5's BS dropped below 60 until 10:30 when resident 5's BS was 44. RN 3 stated she had seen the facility hypoglycemic protocol sheet in resident 5's chart, but that she Had not been trained on it. RN 3 stated the facility DON went over the policy with her today ([DATE]). RN 3 stated she was unaware the policy stated to call EMS if a resident's BG was less than 60 and the resident was unconscious until this surveyor pointed it out. On [DATE] at 12:43 PM, an interview was conducted with the facility DON. The DON stated a change in condition could be a change in cognition level, a change in vital signs, or anything that would be not considered normal for the resident. The DON stated if a resident experienced a change in condition, the MD and family should be notified immediately. The DON stated she did not know why RN 3 waited so long to call the MD. The DON stated she would have expected RN 3 to notify the MD when RN 3 knew that resident 5's mental status was altered. (Note: Resident 5 was admitted to a local hospital on [DATE] with bacterial pneumonia, urinary tract infection, leukocytosis and an abnormal head CT (computerized tomography scan). Resident 5 was discharged back to the facility on [DATE].) 3. Resident 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 4's medical record was reviewed on [DATE]. Resident 4's Physician order [REDACTED]. a. [MEDICATION NAME] 25 mcg (micrograms)/hr (hour) [MEDICATION NAME] APPLY EVERY 72 HOURS Topical every 3 days DX (diagnosis): PAIN. b. [MEDICATION NAME] 12 mcg/hr [MEDICATION NAME] APPLY WITH 25 MG (sic) PATCH EVERY 3 DAYS (37 MCG TOTAL) Topical every 3 days DX: PAIN. Resident 4's ED (emergency department) Physician Report dated [DATE] revealed the following information, .He (resident 4) was found to have a (sic) ,[DATE] [MEDICATION NAME]es on. 4. Resident 7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On [DATE] at 8:30 AM, resident 7 was observed as RN 3 administered the resident's morning medications. A brief interview was conducted with resident 7 when the nurse had to step out of his room for a moment. Resident 7 stated he did not always get his medications as ordered. Resident 7 stated he sometimes had to remind the nurses what he was supposed to receive. Resident 7 stated his [MEDICATION NAME]es were supposed to be changed every seven days, on Fridays. The resident stated he had to remind the nurse on Sunday, [DATE], that his patch had not been changed for nine days. Resident 7 revealed the patch on his shoulder was dated [DATE]. Review of resident 7's Medication Administration Record [REDACTED]. Nurses' documentation on resident 7's MAR indicated [REDACTED]. On [DATE] at approximately 8:30 AM, RN 3 was interviewed. RN 3 verified resident 7's physician had ordered the resident's clonodine patch to be changed every 7 days. RN 3 stated the [MEDICATION NAME] had last been changed two days late.

Based on interview and medical record review, it was determined that for 4 of 15 sample residents the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well being. Specifically, residents' rashes were not treated in a timely manner resulting in prolonged discomfort for the residents. Resident Identifiers: 5, 6, 10, & 11. Findings include: 1. Resident 11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 11's medical record was reviewed on 10/20/10. It was documented on a physician's progress note, dated 4/19/10, that resident 11 had a rash on her trunk. No documentation could be found in the chart to show the facility treated the rash identified by the physician on 4/19/10 until 4/29/10. It was documented in the Nurse's Notes on 4/29/10, that the facility medical director had been in to see resident 11 and had taken a biopsy of the rash on resident 11's abdomen. The physician also ordered for resident 11 to receive Bactrim DS by mouth twice daily for 2 weeks and [MEDICATION NAME] 10 mg (milligrams) by mouth everyday for uticaria. It was documented in the Nurse's Notes on 4/30/10 that resident 11 was to have [MEDICATION NAME] ointment twice daily in both nares and under all fingernails for 14 days and a [MEDICATION NAME] shower 3 times weekly for 14 days for a potential staph infection. The treatments initiated would have ended on 5/14/10. Review of the medical record revealed a lab signed by the facility medical director on 5/5/10. The results of the biopsy performed on 4/29/10 were documented on the lab. The [DIAGNOSES REDACTED]." It was documented under the "Comments" section of the lab results, "The punch biopsy shows spongiosis, ... The presence of abundant eosinophils is most consistent with hypersensitivity reaction such as drug eruption, allergic contact [MEDICAL CONDITION] or bug bite. No documentation could be found in the chart to show the medical director changed the treatment for [REDACTED]. It was documented in the Nurse's Notes from 5/11/10 through 5/14/10 that resident 11's rash was still present in spite of the antibiotic treatment, [MEDICATION NAME] to fingernails and nares, and the [MEDICATION NAME] shower. It was documented on a physician's progress note, dated 5/18/10, that resident 11's skin rash was resolving. Review of resident 11's medical record revealed a surgical pathology report completed on 5/10/10 for the punch biopsy done on resident 11's abdomen on 4/29/10. The pathology report had been signed by the physician on 5/20/10. It was documented on the pathology report under the comments section that, "The punch biopsy shows spongiosis ... The presence of abundant eosinophils is most consistent with hypersensitivity reaction such as drug eruption, allergic contact [MEDICAL CONDITION] or bug bite. ... Infrequently, similar tissue reaction pattern can also be encountered in early uticarial phase of a bullous disorder; therefore, clinical correlation and follow-up is recommended." It was documented in the Nurse's Notes, dated 5/21/10, that resident 11 was to receive [MEDICATION NAME] 1% topically to rash on her torso twice daily for 10 days for an allergic rash. The treatment ordered would have ended on 5/31/10. No documentation could be found in resident 11's medical record to show that resident 11 was treated for [REDACTED]. It was documented by facility staff on weekly skin integrity data sheets that resident 11 had a rash starting on her abdomen and spreading to her back, arms, thighs, and hands from 5/2/10 through 9/16/10 when resident 11 was diagnosed with [REDACTED]. It was documented in the Nurse's Notes, dated 7/2/10, that, "Rash on skin not improving. (Resident 11) told CNA (Certified Nursing Assistant) during game: "I am on fire." Talked with (name) Unit Manager and (name) Staff Development Coordinator. (Name) told me to talk with family to check about resident 11 being seen by a Dermatologist. ... Resident's daughter called me back. She agreed that her mother needs to see a Dermatologist. She wants us to schedule and coordinate with the Doctor." No evidence could be found in resident 11's medical record to show facility staff made an appointment with a dermatologist until 9/16/10 when she was diagnosed with [REDACTED]. It was documented in the Nurse's Notes, dated 7/8/10, that resident 11 was to receive Keflex 500 mg three times daily for 1 week and [MEDICATION NAME] cream everyday to rash. The treatment was ordered 6 days after resident 11 complained of being on fire. It was documented in the Nurse's Notes, dated 7/11/10, that resident 11's rash continued to be "troublesome." It was documented on a physician's orders [REDACTED]." It was documented on a physician's progress note, dated 7/20/10, that resident 11 had a new onset rash/[MEDICAL CONDITION]. The laboratory results for the culture ordered on [DATE] was located in the medical record and showed the physician had been notified of the results on 7/24/10 and requested the lab be placed in her box. The results of the culture showed that resident 11 had Staphylococcus aureus, which was sensitive to several antibiotics. No evidence could be found in resident 11's medical record to show that resident 11 was treated for [REDACTED]. It was documented on a physician's orders [REDACTED]. The treatment ordered was similar to the treatment ordered on [DATE], which was not effective in treating resident 11's persistent rash. It was documented in the Nurse's Notes, dated 8/30/10, that resident 11 had increased redness and rash to hands and was to receive [MEDICATION NAME] antibiotic ointment to both hands three times daily for 10 days. No documentation could be found in resident 11's medical record to show facility staff were treating the persistent rash with anything other than the [MEDICATION NAME] to her hands. It was documented on a Referral to Physicians and Clinics, dated 9/16/10, by a Dermatologist that resident 11 was infected with scabies. On 10/21/10 the Director of Nursing (DON) was interviewed regarding resident 11's persistent rash. The DON stated that the follow-up that was recommended on the pathology report was done by the facility's medical director and that the medical director was treating the rash. The DON further stated in an interview on 10/26/10 that the facility's interventions for resident 11 when the rash didn't respond to treatment was to monitor the rash. On 10/26/10 the DON stated that the reason the facility did not send resident 11 to a Dermatologist in July when the family agreed to the visit was because resident 11's daughter wanted them to coordinate with the doctor. She further stated the facility had coordinated with the medical director. 2. Resident 5 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident 5's medical record was reviewed on 10/18/10. On 4/30/10 a physician's orders [REDACTED]. On 5/25/10 a physician's note revealed that resident 5 had been experiencing a rash, but that it was now resolved. On 6/2/10 weekly skin check documentation revealed that resident 5 started experiencing a "rash." Resident 5 was documented as having a rash every week from 6/2/10 through 10/15/10. On 6/16/10 Interdisciplinary Team Notes documented that resident 5's rash was discussed. On 7/21/10 a physician's orders [REDACTED]. On 7/25/10 lab results for resident 5 were received at the facility revealing that she had a [MEDICAL CONDITION]-Resistant Staphylococcus Aureus (MRSA) infection. On 7/26/10 physician orders [REDACTED]. On 8/30/10 a physician's orders [REDACTED]. On 9/16/10 resident 5 visited a dermatologist and was subsequently diagnosed with [REDACTED]. 3. Resident 10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 10's medical record was reviewed on 10/18/10. On 5/3/10 a physician's note revealed that resident 10 did not have a rash, however, [MEDICATION NAME] and Bactrim were prescribed for 14 days. On 6/2/10 weekly skin check documentation revealed that resident 10 started experiencing a "rash." Resident 10 was documented as having a rash every week from 6/2/10 through 10/16/10. On 7/22/10 lab results for resident 10's rash culture were received at the facility. Resident 10's physician interpreted the results as a "possible hypersensitivity." On the lab results sheet, the physician documented that resident 10 receive [MEDICATION NAME] cream for 2 weeks and a [MEDICATION NAME] shower three times a week. In addition the physician documented that if there was no improvement the facility should start a trial of [MEDICATION NAME]. On 7/25/10 physician telephone orders were written for resident 10 to receive [MEDICATION NAME] cream applied for 2 weeks and [MEDICATION NAME] ointment applied for 10 days. No mention of the [MEDICATION NAME] showers or [MEDICATION NAME] was made on the telephone order. On 8/24/10 a physician's note revealed that resident 10 had a [MEDICATION NAME] papular pruritic rash. Resident 10 was subsequently prescribed additional [MEDICATION NAME] cream for two weeks and [MEDICATION NAME] ointment for 10 days. On 9/2/10 a physician's orders [REDACTED]. On 9/16/10 resident 10 visited a dermatologist and was subsequently diagnosed with [REDACTED]. 4. Resident 6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 6's medical record was reviewed on 10/19/10,. A "weekly skin integrity data collection" sheet, dated 4/27/10, showed that resident 6 had a "Rash to arms, trunk, ABD (abdomen)". A telephone order, dated 4/30/10 was located in resident 6's medical record. The telephone order read "[MEDICATION NAME] showers or bed bath three times a week for 14 days. . . Potential staph (staphylococcus) infection." A telephone order, dated 5/2/10 read "Bactrim DS (Double strength) 1 (by mouth) BID (twice daily) for 14 days. . . [MEDICATION NAME] oint (ointment) BID in both nares (and) under all fingernails." A "weekly skin integrity data collection" sheet, dated 5/4/10, showed that resident 6 had a "Rash on back, arms, trunk ABD." A nurses note, dated 5/14/10, read ". . . On ABX (antibiotic) for rash. . . :. A "weekly skin integrity data collection" sheet, dated 6/1/10, showed that resident 6 had a "Rash", however, the location of the rash was not documented. A "weekly skin integrity data collection" sheet, dated 6/2/10, showed that resident 6 had a "Rash to back (and) chest." A nurses note, dated 6/6/10 read ". . . Continues to have rash to front (and) back of torso. . . ". "Weekly skin integrity data collection" sheets, dated 6/8/10 and 6/15/10 showed that resident 6 had a "Rash" on his "Back/Chest." "Weekly skin integrity data collection" sheets, dated 6/21/10 and 6/29/10, showed that resident 6 had a "Rash". The sheet contained a picture of a body that was circled, indicating that resident 6 had a rash on both his back and his chest/abdomen area. A "weekly skin integrity data collection" sheet, dated 7/6/10, showed that resident 6 had a "Rash", however, the location of the rash was not documented. "Weekly skin integrity data collection" sheets, dated 7/14/10, 7/20/10, 7/27/10, 8/3/10, 8/10/10, 8/17/10, 8/24/10, 8/31/10, 9/6/10, 9/8/10, 9/14/10, 9/17/10 and 9/18/10 showed that resident 6 had a "Rash" on his "Back/Chest." The following nurses notes were noted in resident 6's medical record: a. 8/8/10 - "Cont. (continue) to have rash to much of body." b. 8/13/10 - ". . . pt (patient) continues having patch of raised, itchy skin mainly to UE (Upper Extremities)". c. 8/14/10 - ". . . Cont. itching (and) scratching upper extremities (and) back." d. 9/4/10 - ". . . Skin (with) rashes to arms noted. . . ". e. 9/5/10 - ". . . Rashes to arms noted. . . ". f. 9/7/10 - "Spoke with son (name of son) about dermatology consult. Son okay'ed (sic) but requested to make appt (appointment) himself (at) (name of hospital) (and) take pt. to appt. Will inform (name of facility) of appt. date (and) time. g. 9/9/10 - ". . . rashes (and) pruritis ongoing. Skin care given. . . ". A physician progress notes [REDACTED]. . . 86 (year old) man had an eruption of a cutaneous rash about 2 months after entering into a rest home in [DATE]. The rash is located on arms, back, and ankles. His son (name of resident 6's son), reports extreme pruritis and hemorrhagic excoriations. Previous treatment included [MEDICATION NAME] and [MEDICATION NAME]. The rash intermittently improves and then worsens. . . Additionally, (name of resident 6's son) reports that other residents in the rest home are similarly affected and some have been referred to outside physician (sic) for further evaluation and treatment since the (sic) [MEDICAL CONDITION] have not resolved either. . . Skin: On back, abdomen, chest, behind bilateral ears, waist, forearms, thighs, and lower legs, there are several [DIAGNOSES REDACTED]tous scaly papules and plaques, some with linear excoriations and dry hemorrhagic crusts. On his chest and abdomen, there is evidence of lichenification. . . Scraping on wrists, thenar eminence, behind ears, chest, abdomen, and lower legs, (three times)- no evidence of fungal elements, scabies, or scybala. . . The differential [DIAGNOSES REDACTED]. . . We discussed the differential diagnoses. Based on the history of multiple affected residents at the Rest home, our suspicion is high for scabies infestation or arthropod attach. However, this was not identified on today's scraping. We will proceed with empiric treatment of [REDACTED]. . Instructed patient and his son for dosing to be 3 pills of 6 mg once, and then repeat one week later. He will return to clinic in 3 weeks. . .". The following nurses notes were noted in resident 6's medical record: a. 9/10/10 - "Returned from VA dermatology appt. (with) new orders to start Ivermectin 3 mg (milligrams) 6 tabs now and repeat dosage in (one) week. F/U (follow up) appt. on 10/7/10. b. 9/16/10 - ". . . On skin care to affected areas.". c. 9/17/10 - ". . . Skin assessed - continues with rash on trunk - frontal (and) posterior." d. 9/18/10 - ". . . Cont. skin rask on trunk, arm, back, dry skin. Cont scratching arm (and) trunk." e. 9/21/10 - ". . . Rash appears to be improving. . . ". f. 9/25/10 - ". . . Generalized rash on trunk (and) legs, back, dry skin. . . ". g. 9/27/10 - ". . . Rash shows improvement. Res cont to scratch arms (and) abdomen. . . ". h. 9/29/10 - ". . . Cont (with) some scratching to torso, arms, but rash does seem to show improvement. . . ". A physician progress notes [REDACTED]. At last visit, the ddx (differential diagnosis) included scabies, other orthropod assault, [MEDICAL CONDITION] NOS (not otherwise specified) and drug eruption. Skin scrapings were negative, but given his pruritis and history that other residents in his rest home are similarly affected, he was treated empirically for scabies with 2 doses of Ivermectin 18 mg 1 week apart. The pt's son reports that with this treatment both his father's itching and appearance of his skin are much improved. . . SKIN: face, chest, abd, back, BLE (bilateral lower extremities) BUE (bilateral upper extremities), hands examined. Diffuse to (moderate to severe) xerosis; abdomen and back: patches of hyperpigmentation; Upper back: Two erosions with hemorrhagic crust; Finger webs (without) burrows and crusts. . . Scabies- given the history, clinical presentation, and it's response to Ivermectin, rash most likely was the result of scabies infestation. Explained to pts. son the risk of reinfection if other residents of the nursing home are still affected. . .". A "weekly skin integrity data collection" sheet, dated 10/12/10, read ". . . Resolving rash". A "weekly skin integrity data collection" sheet, dated 10/15/10, read "Skin intact. . . Dry. . . Rash improving." A "monthly summary", date 10/16/10, read "Rashes improving." On 10/21/10 an interview was conducted with the facility Director of Nursing (DON) and Infection Control Officer (ICO). The DON and ICO stated that during the months of May and June of 2010 multiple attempts were made to determine the cause of the residents' rashes, including environmental and housekeeping sources. The DON and ICO stated that no identifiable cause of the rashes could be determined. In addition, the DON and ICO stated that no new rashes appeared after May 2010. When asked about the timeliness of the cares provided for the residents' rashes, the DON and ICO stated that the medical director and residents' physicians had addressed the cares and treatments the residents received regarding the rashes. When asked about the multiple redundant treatments provided for the residents' rashes, the DON and ICO stated that the treatments provided were per the physician orders.

Based on observation, interview and record review it was determined that for 1 of 15 sampled residents the facility did not ensure that a resident fed by a gastrostomy tube received the necessary treatment and services to prevent dehydration and aspiration pneumonia. Resident 4 required multiple acute care hospitalization s and treatment for [REDACTED]. Findings include: Resident 4 was originally admitted to the facility on [DATE]. Resident 4 has had six discharges and readmissions since 11/20/08. The most recent re-admission to the facility was 5/5/09. Resident 4's [DIAGNOSES REDACTED]. Resident 4 had a gastrostomy tube for nutritional support and hydration. A review of resident 4's medical record was completed on 6/3/09. A Nutritional Data Collection/Assessment was completed on resident 4, by the facility consultant Registered Dietician (RD) on 1/20/09. The RD documented the following assessment data regarding resident 4: a. Resident 4 was to receive nothing by mouth. b. Resident 4 had a PEG (Percutaneous Endoscopic Gastrostomy) A review of dietary orders and nutrition progress notes for resident 4 was completed on 6/3/09. a. 3/4/09 - a physician telephone ordered clarified that resident 4 was able to have "ice chips/melted H20 (water)" by mouth only if oral hygiene protocol completed three times a day. Per this order, the resident was to be seated at a 90 degree angle while drinking. Oral hygiene to include a rinse with antibacterial mouthwash. b. 3/5/09 - The RD documented that resident 4 was now receiving ice chips by mouth. Within this progress note, the RD made two different recommendations for how many water [MEDICATION NAME] resident 4 was to receive each day; she recommended a 150 cc water [MEDICATION NAME] four times each day as well as a 150 cc water [MEDICATION NAME] three times a day. The RD also recommended that nursing should flush resident 4's gastrostomy tube with 60 cc water at the beginning and end of each [MEDICATION NAME] feeding; twice each day. Within this progress note, the RD also documented two different total amounts of free water resident 4 should receive each day; 2300 cc and 2450 cc. Further, the RD documented that she had spoken with speech therapy and nursing and that they had decided resident 4 would benefit from a combination pump that would infuse both formula and water simultaneously. Note: By 6/3/09, the facility had not received the combination pump for resident 4. c. 3/26/09 - The RD documented that resident was out to the hospital for treatment of [REDACTED]. The RD recommended an increase of free water [MEDICATION NAME] to 150 cc six times per day, and to discontinue the 60 cc water flush twice daily. d. 3/30/09 - A physician telephone order was obtained to and prescribed that resident 4 receive [MEDICATION NAME] Ringers, an intravenous fluid, one bag per shift for three days. e. 4/2/09 - The RD documented that she expected the dual feeding pump to become available and ordered resident to receive 25 cc per hour during the 15 hour night feeding, for a total of 375 cc extra water per day. f. 4/4/09 - The RD documented her recommendation of a water flush of 150 cc at the beginning and end of resident 4's 15 hour night feed and 150 cc water [MEDICATION NAME] four additional times per day for a total of 2615 cc free water every 24 hours. The RD further documented that once the dual feeding pump was available, an extra 375 cc water to be given per day for a total of 2990 cc total free water per day. The RD indicated that the additional water via the dual feeding pump would ensure adequate hydration for resident 4. g. 5/7/09 - The RD documented a quarterly note on resident 4 that stated resident was out to the hospital on [DATE] for treatment of [REDACTED]. The RD clarified the water flush to be 200 cc water at the beginning and end of the tube feed every day and suggested changing resident 4's feeding to a 22 hour continuous schedule again to reduce the risk of aspiration. Note: An interview was held with RN 2 on 6/1/09 at 10:50 AM. RN 2, who was the unit manager, stated she had checked resident 4's gastrostomy tube and found nothing wrong with it. RN 2 stated the gastrostomy tube did not need to be changed, but the night shift nurses liked having resident 4's feedings as a [MEDICATION NAME] feed every two hours as opposed to the continual night feed that was recommended by the RD. h. 5/26/09- The RD documented that resident 4's gastrostomy tube needed to be replaced, but that it was adequate to administer [MEDICATION NAME] feedings. The RD documented a new order for 100 cc water to be given at each feeding, every two hours (12 times per day), for a total of 3315 cc total free water every 24 hours. Note: It was not clear how the 100 cc water [MEDICATION NAME], given every two hours, would equal the 3315 cc total free water documented by the RD. On 5/28/09 at 1:22 PM, an interview was held with the facility consultant RD regarding resident 4's recurrent dehydration and aspiration pneumonia. The RD stated that she had made several changes to the amount of fluids that were to be given to resident 4, and that despite the changes resident 4 continued to become dehydrated. The RD further stated that in March and April 2009 she had discussed the idea of a dual feeding pump for resident 4 with the facility Interdisciplinary Team (IDT) and that the IDT agreed that resident 4 would likely benefit from a dual feeding pump. The RD stated the dual pump had not yet been delivered. On 5/28/09 at 3:47 PM, an interview was held with RN 2 regarding the dual feeding pump that had been agreed upon for resident 4. RN 2 stated the pump had been ordered; however, there was a problem with some of the pumps parts and it was sent back When asked if she knew when the dual pump would be obtained, RN 2 stated that she did not know. On 6/1/09, an interview was held with the Director of Nursing (DON) about the dual feeding pump for resident 4. The DON stated that they were unable to get the pump from their preferred vendor. The DON stated the facility was still attempting to find the dual feeding pump from another vendor. The DON did not know how long it would take to get the pump to the facility. On 5/28/09, at 3:28 PM, an interview was held with the facility Speech Therapist (ST). The ST stated that in early March 2009, she approved a plan that would allow resident 4 to have "Ice chips at the bedside" because the resident had been complaining of a dry mouth. The ST stated that because resident 4 was alert and able to do his own oral hygiene, he was able to have the ice chips at his bedside and consume them as he wished. A review of nursing notes for resident 4 was completed. The following was documented: a. 3/3/09 - ". . . Resident may have ice chips only!" b. 3/5/09 - ". . . Cont. to be NPO (nothing by mouth) except ice chips." c. 3/6/09 - "Physician ordered VS (Vital Signs) (with) (oxygen saturation levels) q shift (for) 72 (hours); Portable CXR (Chest X Ray) (2-view). for assessment of possible URI (Upper Respiratory Infection)." d. 3/6/09 at 10:00 PM - "Results of Chest x-ray reported to (Name of resident 4's attending physician) (positive) mild infiltrates in both lower lungs. N.O. (New Order). [MEDICATION NAME] 1 gram IM (for) 5 days; [MEDICATION NAME] 300 mg. TID (for) 7 days in liquid form. . . ". e. 3/7/09 - ". . . Abx (antibiotic) therapy continues for aspiration pneumonia. . . " f. 3/17/09 - "Pt. had critical labs come back from pharmacy (sic). (name of resident 4's attending physician) notified. N.O. given for IV fluids, [MEDICATION NAME] IM (for) 5 days, et (and) stat BMP in AM. . . ". g. 3/18/09 - "Sent to (name of acute-care hospital) per (name of resident 4's attending physician) for rehydration (at) 1300 (1:00 PM) via (name of ambulance company). . . ". h. 3/23/09 - "Resident return admit to (name of long-term care facility). Dx. Pneumonia. Continues NPO. . . ". i. 3/26/09 - "Discussed in IDT/NAR (Interdisciplinary team / nutrition at risk). Pt. current condition (and) nutritional needs, wt. stable, gained wt (weight) back (secondary to) dehydration. . . Cont. feedings with (increased) H20." j. 3/30/09 - ". . . and dry lips and poor skin turgor and dry mouth. . . (order for) [MEDICATION NAME] ringers 1 bag (every) shift (for) 3 days. Dx. possible dehydration . . . Need nutritional consult. Risk for dehydration." l. 4/2/09 - "Discussed at RAR (Resident at Risk). . . fluid fluctuations continue. Recent trip to ER (emergency room ) didn't follow his feeding protocol. m. 4/2/09 - "N.O. Once dual feeding pump available (name of feeding pump) Give H20 (at) 25 ml (per hour) (for) 15 hours during nocturnal enteral feeding (extra 375 ml H20 per day). . . ". n. 4/7/09 - ". . . (name of resident 4's attending physician) notified of residents request for d/c of peripheral IV. (no) orders to d/c. . . (name of resident 4's attending physician) wants to leave in d/t (due to) possible (increased) risk of dehydration. . . ". o. 5/2/09 - ". . . Resp. (Respiratory) rate (irregular). Having periods of apnea [MEDICATION NAME] (about) 20 seconds. . . Mouth dry. . . Received permission to send to ER if (all right) with family as he is a full code. . . ". p. 5/7/09 - "RAR to discuss current conditions and nutritional needs. . . Continue with tube feedings and recently diagnosed with [REDACTED]. Feeding via PEG tube increased, as well as, H20 via PEG tube increased. Labs to be drawn following new feeding recommendations." The following speech therapy notes were documented in resident 4's medical record: a. 1/19/09 - The ST documented that resident 4 has a PEG tube and that he continues to demonstrate overt signs and symptoms of dysphagia affecting his diet and swallow safety. The ST further documented that resident 4 has difficulty recalling the education given to him by the ST and the importance of therapeutic trials. The ST documented that resident 4 had experienced coughing during 3 of the 3 attempted trials and that he had a wet vocal quality as well and that resident 4's daughter wanted the ST treatments to be "conservative" at this time. b. 1/20/09 - The ST documented that resident 4 demonstrated a wet 'gurgly' voice when therapist entered room and that she did not attempt any food trials this day. The ST also documented that resident 4 was unable to clear his voice with a throat clear and that he did not understand the cough cue she was giving him. c. 1/21/09- The ST documented that resident 4 had difficulty remembering the education she had been providing him from day to day. The ST further documented that resident 4 had demonstrated aspiration on trials of nectar thick liquids during her treatment that day and that she was unable to elicit a cough. The ST further documented that resident 4 had a cough after trials. d. 1/22/09- The ST documented that she was continuing to educate resident 4 on a daily basis on daily goals and that resident 4 has dysphagia that can cause pneumonia. e. 1/27/09- The ST documented that resident 4 was unable to suck nectar thick juice through a straw, suggesting oral weakness and that she did not attemtp any trials that day. f. 1/28/09- The ST documented that resident 4 continues to demonstrate over signs and symptoms of aspiration, including a wet voice quality, and that he experiences throat clear and coughing after trials of oral food and liquids. g. 2/4/09- The ST documented that resident 4 continued to demonstrate overt signs and symptoms of aspiration, to include mucus and wet voice after trials of nectar thick liquids. h. 2/11/09- The ST documented that resident 4 continues to demonstrate oral pharyngeal dysphagia and that a modified [MEDICATION NAME] swallow study (MBSS) was completed 2/9/09 that documented that resident 4 had significant oral pharyngeal dysphagia secondary to oral weakness and that resident 4's swallow function was limited. i. 2/20/09- The ST documented that resident 4 had coughed up green mucus during his ST treatment and that resident 4 had trials of ice chips as resident 4 had been complaining of a dry throat. The ST further documented was showing signs and symptoms after trials of ice chips on 2 out of the 4 trials and that resident 4 had a wet voice after 6 of 6 trials. The ST documented that she would continue trials and educated on when it would be appropriate for resident 4 to receive ice chips. j. 2/26/09 - The ST documented that resident 4 was rinsing with an antibiotic mouthwash after brushing his teeth two times per day. The ST also documented that resident 4 had coughed up a significant amount of green mucus after a trial of orange juice. k. 2/27/09 - The ST documented that spoke to resident 4 about having ice chips and thin water at the bedside as he had been complaining of a dry mouth. Educated patient about risk of aspirating the water, including pneumia and this leading to death. The patient verbalized understanding and questioned if he should not do it due to the risk of pneumonia. The ST documented she explained the risk of pneumonia versus the benefit of a wet mouth. l. 3/5/09 - "Provided caregiver education to nurses (names of 2 facility nurses) re (regarding) importance of checking for (signs and symptoms) of (pneumonia) (secondary to) (increased) risk of (aspiration pneumonia) (with) pt. (resident 4) consuming ice chips (and) melted ice po today. Pt. sounded congested, nurse checked pts lungs and they sounded clear. . . ". m. 3/6/09 - "Pt. complaining of illness today. Pt. demonstrating (signs and symptoms) of congestion, showing (signs and symptoms) of respiratory illness. Pt. educated on risks vs. benefits of continuing receiving ice chips po (versus) stopping ST. Stated pt. may be demonstrating illness (after) trial of po ice chips. ST informed nursing. Pt. does not have fever and lungs are clear. Spoke with daughter (name of resident 4's daughter), over phone, pt. to return to NPO status, educated daughter of pt. current condition and this this may relate to trial of PO trial, that pt. is now NPO. Daughter agreed. . . Pt. (patient) to return to NPO status, incl. (including) (no) ice chips (secondary to) showing s/s (signs and symptoms) of chest congestion and s/s of respiratory illness. Nursing to closely follow pt. respiratory status, incl. temperature checks and listening to pts. lungs. Pt. to continue oral hygiene care. . . " o. 3/8/09. "Pt. lungs x-rayed over weekend. Pt. dx (diagnosed ) (with) (pneumonia). Pt. currently NPO." p. 3/12/09. "Pt. given 3 trials nectar-thick liquids via cup, small sips. Wet vocal quality noted after each trial requiring multiple throat clears (and) swallows to clear residue. Pt. coughing throughout session. Pt. unable to recall swallow exercises." q. 3/17/09. "Provided caregiver education to pts. three children. . . education (regarding) pt. current condition of weak swallow musculature, how that affects swallow (function), how that differs from 'normal' swallow. . . Discussed pt. current NPO status and continuum of options incl (including) completely NPO (as he currently is), pleasure feedings, ice chips during day. . . Also discussed the possible correlation between PO intake and pt. hx (history) of PN (pneumonia), incl (including) pt. most recent PN (pneumonia), which occured (after) P.O. trial of ice chips. . . (resident 4) will be d/c (discontinued) from skilled S.T. in one week. . . given how pt. hx of PN (pneumonia) and known swallowing impairment, pt. being on N.P.O (Nothing by mouth) is the 'safest' option at this time to minimize the risk of PN (Pneumonia). . . (name of resident 4's daughter) stated 'I don't want to give him anything.' A speech therapy care plan, dated 1/15/09 was located in resident 4's medical record. Under the Reason for Treatment section, the speech therapist documented the following: "Pt. has PEG tube, demonstrates severe dysphagia (and) requires skilled S.T. (Speech Therapy) to address swallow, safety. diet." Under the heading of Short Term Goals, the ST documented "1. Pt. will tolerate therapeutic trials of nectar thick liquids (and) mechanical soft/puree food (without) aspiration. 2. Complete oral/pharyngeal strengthening ex (exercises) 5x10 reps (repetitions) with (limited assist). 3. Complete oral hygiene protocol 3 (times) per day." Under the heading of Long Term Goals, the ST documented "Maintain swallow (function) while maintaining health (and) QOL (Quality of Life)." On 5/28/09 at 1:58 PM, resident 4's tube feeding order was reviewed by the surveyor. Before 2:00 PM, LPN 5 had already initialed that she had given the 2:00 PM, 4:00 PM, and 6:00 PM water flushes to resident 4. On 5/28/09 at 2:15 PM, an observation was made of LPN 5 giving resident 4 his 2:00 [MEDICATION NAME] feeding and water flushes. LPN 5 proceeded to give resident 4 one can of formula and the ordered 100 cc of water. After administering the [MEDICATION NAME] feeding, LPN 5 left resident 4's room. At that time, Resident 4 was questioned, by the surveyor, about the frequency of his feedings and water flushes. Resident 4 stated that he was supposed to get a [MEDICATION NAME] feeding and water flush every two hours, but with the exception of the feeding he had just received, he had not received a feeding since sometime "in the middle of the night." On 6/1/09 at 3:42 AM, the surveyor arrived to the 500 hall and was in direct vision of resident 4's room until 6:27 AM. During this time, LPN 1 only went into resident 4's room one time, at approximately 6:02 AM. During this time, the surveyor accompanied LPN 1 to resident 4's room to watch the [MEDICATION NAME] feeding be administered. Upon entering resident 4's room, LPN 1 checked resident 4's blood sugar level. After checking resident 4's blood sugar, LPN 1 started to remove her isolation gown, mask and gloves. When asked if she was finished with resident 4, LPN 1 stated "Yep, we're done." LPN 1 did not administer a [MEDICATION NAME] feeding to resident 4 from 3:42 AM to 6:27 AM. On 6/1/09, at 5:01 AM, the surveyor reviewed resident 4's current MAR's (Medication Administration Records) and enteral flowsheets. LPN 1 had already initalled that she had given the 2:00 AM, 4:00 AM and 6:00 AM [MEDICATION NAME] feedings. A telephone interview was held with LPN 1 on 6/1/09 at 11:30 AM. LPN 1 was asked about the [MEDICATION NAME] feedings that should have been administered to resident 4 at 4:00 AM and 6:00 AM. Initially, LPN 1 stated that she had accidentally given resident 4 two cans of [MEDICATION NAME] at 3:00 AM, so she held his 6:00 AM feeding and water flush. After further discussion, LPN 1 stated that she had accidentally missed the 2:00 AM feeding, so she administered 2 cans of [MEDICATION NAME], instead of one can. When asked why the 4:00 AM and 6:00 AM feedings were not administered, LPN 1 stated that she had experienced a busy night and must have forgotten them. Surveyor asked LPN 1 the reason she had signed that all 3 [MEDICATION NAME] feedings were given, before they were due. LPN 1 stated that she must have made a mistake and should have circled the [MEDICATION NAME] feedings indicating they were not given.*Note: Upon returning to the facility two days later, on 6/3/09, it was noted that LPN 1 had worked at least one shift since 6/1/09 and still had not circled the missed feedings. The following physician progress notes [REDACTED]. a. 1/17/09. "81 (year old) (male) admitted to (name of long-term care facility) on 1/14/09 from (name of discharging facility) where she (sic) was treated for [REDACTED]. . . ". A progress note was written by resident 4's attending physician on 3/10/09. The note documented that resident was being (re) admitted with aspiration pneumonia. Under the heading "Discussion", resident 4's attending physician documented "On 3/16/09 noted in nurses note elevated temp (at) 100.5 and behaviors that were a (change) for him. Had (increased) weakness. STAT (Immediate) labs ordered. CBC (Complete Blood Count), BMP (Basic Metabolic Panel), and UA (urinalysis). Noted that labs were critical but results are not in chart. IV fluids ordered (with) [MEDICATION NAME] IM (intramuscular) (for) 5 days with another STAT BMP in (the morning). . . ". A progress note was written by resident 4's attending physician on 3/24/09. The note documented "81 (year old) (male) admitted to (name of long-term care facility) on 3/28/09 from (name of acute-care hospital) where he presented (with) dehydration, RLL PNA (Right Lower Lobe Pneumonia) and [MEDICAL CONDITION] (high sodium level). . . ". *Note- [MEDICAL CONDITION] is an indication of dehydration. A progress note was written by resident 4's attending physician on 4/22/09. The note documented "81 (year old) male readmitted to (name of long-term care facility) from (name of acute-care hospital). Sent to (name of acute-care hospital) for hydration. Admit DX (Diagnosis) with pneumonia and dehydration. . . NPO status with [DEVICE]. . . [MEDICATION NAME] was d/c (discontinued) on 03/30 and LR ([MEDICATION NAME] Ringers) 1 liter (every) shift initiated (for) 3 days for hydration. Nutritional consult ordered along with CBC. . . Will soon start a dual pump feeding in order to minimize risk of dehydration." A progress note was written by resident 4's attending physician on 5/23/09. The note documented "81 (year old) male readmitted to (name of long-term care facility) from (name of acute-care hospital) on 05/05/09. . . Pneumonia-MRSA ([MEDICAL CONDITION]). . . Dysphagia/aspiration. . . H20 200 ml (milliliter) flush (at) beginning and end of feeding. . . Noted referral for nutritional consult. Mucous membranes dry."

Based on observation, resident and staff interviews and record review, it was determined that the facility did not ensure that 1 of 15 sampled residents received the necessary nutritional support to maintain weight and nutritional status. Resident identifier 4. Findings include: Resident 4 was originally admitted to the facility on [DATE]. Resident 4 has had six discharges and readmissions since 11/20/08. The most recent re-admission to the facility was 5/5/09. Resident 4 was an [AGE] year old male with [DIAGNOSES REDACTED]. A review of Resident 4's weight record was completed on 6/3/09. Per documentation, resident 4's experienced a significant weight loss between 1/14/09 and 5/20/09. Resident 4's weights were recorded as follows: a. 1/14/09 - 168.10. Note: Resident 4 was readmitted to the facility on this date following a nearly three week hospitalization . b. 1/15/09 - 154.00 Note: Per interview with RN2, on 5/28/09, facility staff re-weighed resident 4 on 1/15/09 because the 168.10 weight on 1/14/09 was significantly higher than the resident's weight when he left the facility three weeks earlier. c. 1/21/09 - 157.70 d. 1/28/09 - 150.10 e. 2/4/09 - 147.20 f. 2/11/09 - 147.2 g. 2/18/09 - 148.30 h. 2/25/09 - 150.10 i. 3/5/09 - 150.60 j. 3/11/09 - 144.80 k. 3/18/09 - 141.40 Note: Resident 4 was discharged to an acute care hospital on [DATE] for treatment of [REDACTED]. pneumonia and dehydration. Resident 4 was readmitted to the facility on 3/23/09. l. 3/23/09 - 168.10 m. 3/25/09 - 155.80 n. 4/2/09 - 147.90 o. 4/8/09 - 151.00 p. 4/15/09 - 147.90 q. 4/22/09 - 146.80 r. 4/30/09 - 141.20 s. 5/5/09 - 147.50 Note: Resident 4 was discharged to an acute care hospital on [DATE] for treatment of [REDACTED]. dehydration. Resident 4 was re-admitted to the facility on [DATE]. t. 5/13/09 - 141.80 u. 5/20/09- 148.80 A Nutritional Data Collection/Assessment was completed on resident 4, by the facility consultant Registered Dietician (RD) on 1/20/09. The RD documented the following assessment data regarding resident 4: a. Resident 4 was to receive nothing by mouth. b. Resident 4 had a PEG (Percutaneous Endoscopic Gastrostomy) tube. c. Resident 4 was to receive [MEDICATION NAME] 1.2 at 85 cc (cubic centimeters) per hour for 22 hours. d. Resident 4 had dysphagia and had increased nutrient needs. e. Resident 4 had a history of [REDACTED]. decreased [MEDICATION NAME]. f. Resident 4's current weight was 154, which represented a significant weight loss of 9.9 percent over 45 days. A review of dietary orders and nutrition progress notes for resident 4 was completed on 6/3/09. a. 1/29/09 - The RD documented that resident 4's current weight was 150.1 pounds, which was a loss of 7.6 pounds, or 4.8 percent over a one week period; a significant weight loss. b. 2/5/09 - The RD documented that resident 4's weight was 147.2 pounds, which was a loss of 2.9 pounds, or 2 percent in one week. The RD recommended to increase resident 4's enteral feeding of [MEDICATION NAME] to 90 cc per hour, over 22 hours per day. Note: This was a 5 cc per hour increase. c. 3/5/09 - The RD recommended to increase resident 4's enteral feeding of [MEDICATION NAME] from 90 cc to 95 cc per hour over 22 hours. Further, the RD documented that she had spoken with speech therapy and nursing and that they had decided resident 4 would benefit from a combination pump that would infuse both formula and water simultaneously. Note: By 6/3/09, the facility had not received the combination pump for resident 4. d. 3/6/09 - A physician's telephone order was obtained to administer [MEDICATION NAME] at 95 cc per hour from 6:00 PM through 9:00 AM (15 hours) and also a [MEDICATION NAME] enteral feeding of [MEDICATION NAME], in the amount of one and a half cans (360 cc), twice daily. e. 3/12/09 - The RD documented that resident 4 had additional weight loss to 144.8 pounds. The RD recommended to increase resident 4's [MEDICATION NAME] enteral feedings of [MEDICATION NAME] to 2 cans (480 cc), twice daily. f. 4/2/09 - The RD documented she had received a request for a consult of resident 4 on 3/31/09. The RD documented that resident 4 was in the hospital upon her arrival and that resident's most current weight was 147.9 pounds; down 7.9 pounds, or 4.9 percent in one week, and represented a significant weight loss. She further documented that she expected the dual feeding pump to become available. g. 4/2/09 - A physician telephone order clarified resident 4's diet as [MEDICATION NAME] at 95 cc per hour, from 6:00 PM through 9:00 AM, (15 hours), and give an additional [MEDICATION NAME] of one and a half can (360 cc), twice daily. g. 4/4/09 - The RD recommended that resident 4's enteral feedings of [MEDICATION NAME] be changed to 95 cc per hour for 15 hours and a [MEDICATION NAME] of 360 cc, twice daily. h. 4/16/09 - The RD documented that resident 4's current weight was 147.9 pounds, which was down 3.1 pounds, or 2.1 percent. i. 4/30/09 - The RD documented that resident 4's weight was down 5.6 pounds, or 3.9 percent over two weeks and that this weight loss was despite the fact that resident 4 was receiving 38 kcal per kilogram per day. The RD suggested an increase of resident 4's [MEDICATION NAME] feed to 2 cans (480 cc), twice daily. j. 5/7/09 - The RD documented that resident had a 4.4 gain over the past week, however, he had been out to the hospital from 5/2/09 through 5/5/09 and that resident 4 had been diagnosed with [REDACTED]. k. 5/14/09 - The RD documented resident 4's current weight was 141.8, which was down 5.7 pounds or 3.9 percent over one week and that resident 4's [MEDICATION NAME] was low, at 2.3 mm/dL. l. 5/26/09 - The RD documented that resident 4's enteral feeding of [MEDICATION NAME] were changed from continuous to [MEDICATION NAME] on 5/23/09 because his PEG tube needed to be replaced, documenting that the PEG was adequate for [MEDICATION NAME] feedings. The new order was for [MEDICATION NAME] at 220 cc every 2 hours; 12 times per day. The RD further documented that this new schedule provided an additional 265 kcal more per day than the previous order, but would not suggest a decrease at the current time since weight loss had been a concern for resident 4 in the past. On 5/28/09, an interview was held with the facility consultant RD regarding resident 4's. The RD stated that she was not sure why resident 4 was continuing to loose weight. The RD stated that she has made several changes to resident 4's feeding to attempt to stop the weight loss. The RD stated that on 4/2/09 she had discussed the idea of a dual feeding pump for resident 4 with the Interdisciplinary Team (IDT) and all had agreed that resident 4 would likely benefit from a dual feeding pump as it would deliver both the enteral formula and the water, simultaneously. The RD indicated that the facility had not yet received the dual feeding pump. On 5/28/09 at 3:47 PM, an interview was held with RN 2 regarding the dual feeding pump that had been ordered for resident 4 in March 2009. RN 2 stated the pump had been ordered; however, some of the parts were not available and they had to send it back. RN 2 stated she was unsure when the facility would receive the dual feeding tube. On 6/1/09, an interview was held with the Director of Nursing (DON) regarding the dual feeding pump for resdient 4. The DON stated that they had been unable to obtain the pump because their preferred vendor did not carry this type of pump. She stated the facility was still attempting to find one at another location. The DON did not know how long it would take to obtain the pump for resident 4. On 2/6/09, RN 2 documented on a Braden scale for predicting pressure sore risk that resident 4 scored a two under the heading of nutrition. By definition printed on the Braden scale form, a score of two indicated that the resident "Receives less than optimum amount of liquid diet or tube feeding." A review of laboratory test results for resident 4 was completed on 6/3/09. Per the laboratory, utilized by the facility, the normal range for [MEDICATION NAME] was 3.5 to 5.0. Resident 4's [MEDICATION NAME] levels were as follows: a. 1/12/09 - 2.6. b. 3/24/09 - 2.2. c. 5/1/09 - 2.8. The laboratory result form for this test included the an entry that, "Verified by repeat analysis." This laboratory result form also contained a written note, by a facility nurse, to "Notify Nutritionist. Consult." d. 5/6/09 - 2.3. e. 5/11/09 - 2.5. Resident 4 had an acute care hospitalized from [DATE] to 3/23/09. On 3/19/09, a physician documented the following progress note: "Dietary consult for low [MEDICATION NAME]. The patient is wasted and malnourished." A care plan was located in resident 4's chart to address his risk for weight loss. The care plan was dated 1/14/09 and had not been updated since that time. The Goal for this identified problem was, "Will maintain adequate nutrition AEB (as evidenced by) no significant weight change greater than 5% in 30 days, greater than 7.5% in 90 days, and greater than 10% in 180 days." A review of Resident At Risk notes for resident 4 was completed on 6/3/09. The following enteries were documented: a. 4/30/09 - Resident 4's weight was down 5.6 pound this week and that the feeding was increased. b. 5/7/09 - The RAR team had decided to continue with the tube feedings and that resident 4 had recently been diagnosed with [REDACTED]. The note further stated that labs were to be drawn following new feeding recommendations. c. 5/14/09 - Resident 4's weight had decreased another 4.8 pounds. An interview was held with LPN 5 on 5/28/09 at 1:45 PM. regarding resident 4's diet orders. When asked the amount of feeding resident 4 was currently receiving, LPN 5 responded that resident 4 was receiving [MEDICATION NAME] feedings due to a problem with his gastrostomy tube. LPN 5 stated, "I think he gets a couple of [MEDICATION NAME] during my shift." LPN 5 verified that she was working a 12 hour shift, from 6:00 AM to 6:00 PM. When asked to clarify the specific amount resident 4 received, LPN 5 stated "Well, I give him one and one half cans three times during my shift, so that is three cans." LPN 5 corrected herself and stated she gave resident 4 four cans during her shift. Note: Per current diet orders, resident 4 was to receive 220 cc of [MEDICATION NAME] every two hours, or just over five cans. On 5/28/09, resident 4's tube feeding order was reviewed by the surveyor. At 1:58 PM, LPN 5 had already initialled that she had given the 2:00 PM, 4:00 PM, and 6:00 PM [MEDICATION NAME] feedings to resident 4. When interviewed why she had already signed that the 2:00 PM, 4:00 PM, and 6:00 PM feedings were already signed as given, LPN 5 stated she must have made a mistake. LPN 5 further stated that she had mistakenly reported the incorrect amount and number of feedings resident 4 was to receive during her shift. On 5/28/09 at approximately 2:25 PM, an interview was held with resident 4. When asked how many [MEDICATION NAME] feedings he had received that day, resident 4 stated that the feeding at 2:15 PM was the first feeding he had received since "the middle of the night." On 6/1/09 at 3:42 AM, the surveyor arrived to the 500 hall and was in direct vision of resident 4's room until 6:27 AM. During this time, LPN 1 only went into resident 4's room one time, at approximately 6:02 AM. During this time, the surveyor accompanied LPN 1 to resident 4's room to watch the [MEDICATION NAME] feeding be administered. Upon entering resident 4's room, LPN 1 checked resident 4's blood sugar level. After checking resident 4's blood sugar, LPN 1 started to remove her isolation gown, mask and gloves. When asked if she was finished with resident 4, LPN 1 stated "Yep, we're done." LPN 1 did not administer a [MEDICATION NAME] feeding to resident 4 from 3:42 AM to 6:27 AM. On 6/1/09, at 5:01 AM, the surveyor reviewed resident 4's current MAR's (Medication Administration Records) and enteral flowsheets. LPN 1 had already initalled that she had given the 2:00 AM, 4:00 AM and 6:00 AM [MEDICATION NAME] feedings. A telephone interview was held with LPN 1 on 6/1/09 at 11:30 AM. LPN 1 was asked about the [MEDICATION NAME] feedings that should have been administered to resident 4 at 4:00 AM and 6:00 AM. Initially, LPN 1 stated that she had accidentally given resident 4 two cans of [MEDICATION NAME] at 3:00 AM, so she held his 6:00 AM feeding and water flush. After further discussion, LPN 1 stated that she had accidentally missed the 2:00 AM feeding, so she administered 2 cans of [MEDICATION NAME], instead of one can. When asked why the 4:00 AM and 6:00 AM feedings were not administered, LPN 1 stated that she had experienced a busy night and must have forgotten them. Surveyor asked LPN 1 the reason she had signed that all 3 [MEDICATION NAME] feedings were given, before they were due. LPN 1 stated that she must have made a mistake and should have circled the [MEDICATION NAME] feedings indicating they were not given.*Note: Upon returning to the facility two days later, on 6/3/09, it was noted that LPN 1 had worked at least one shift since 6/1/09 and still had not circled the missed feedings.

Based on interview and record review it was determined that the facility did not obtain laboratory services in a timely manner to meet the needs of 1 of 15 sample residents. Resident identifier: 14. Findings include: Resident 14 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 5/28/09 resident 14's medical record was reviewed. On 1/18/09 physician's admission orders [REDACTED]. On 1/27/09 a physician's telephone order was written to have a comprehensive metabolic panel (CMP), complete blood count (CBC), phosphorous level, and ammonia level drawn for resident 14. Per facility records the CMP was collected on 1/29/09 at 9:17 PM, with the results being received by the facility on 1/30/09 at 10:55 AM. On 6/2/09 the Director of Nursing (DON) sent a letter to surveyors regarding the delay in drawing resident 14's laboratory tests as ordered on [DATE]. In the letter, the DON stated that the lab ordered 1/27/09 was not drawn the same day because the laboratory technician had already visited the facility that day. The DON stated that the lab was drawn on 1/28/09 at 5:08 PM, but that on 1/29/09 at 1:00 PM the laboratory company notified the facility that resident 14's blood samples had been contaminated during shipment and that "at that time, the nurse ordered the lab to be redrawn as a routine lab." On 1/29/09 at 1:00 PM resident 14 visited his nephrologist, who wrote an order for [REDACTED]. The lab was not drawn until 9:17 PM on 1/29/09. Results were reported by the laboratory company to the facility on [DATE] at 10:55 AM. Upon review of resident 14's medical record, the facility did not obtain the stat BMP as ordered by resident 14's nephrologist on 1/29/09, however the facility did draw the routine CMP on 1/29/09. When the CMP results were received by the facility on 1/30/09, resident 14's potassium level was at 8.0 mmol/L (millimoles/Liter). The laboratory report indicated that a normal range for potassium was 3.5 to 5.5, and that a result of 8.0 mmol/L was critically high. On 1/30/09 at 12:40 PM a physician's telephone order was written for resident 14's potassium chloride to be discontinued. On 6/3/09 an interview was conducted with the DON. The DON stated that per facility policy, if a physician requested a "stat order" the lab would be expected to be drawn within 3 to 4 hours. On 6/3/09 the DON provided surveyors with a copy of the "Laboratory Agreement" that the facility had with the laboratory. The agreement documented that the laboratory was responsible to contact the facility with results of the tests within "5 hours for a 'STAT' exam" following the specimen collection. Resident 14's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 1/30/09 resident 14 was treated at a local hospital due to the critically high level of potassium.