Every finding on record at Natchitoches Community Care Center

Based on observation, record review and interview the facility failed to provide care and services that met professional standards of quality by failing to ensure nurse practitioner's orders were transcribed as ordered. The facility failed to transcribe a verbal wound care order for 1 (#2) of 3 (#1, #2, #3) sampled residents. Findings: Review of the facility's policy and procedure dated 01/09/2022 titled, Wound Care read in part . Wound Care Orders .; Each individual wound site requires a separate wound care order .; Orders should include; Wound location, Method for cleaning the wound, Primary Dressing . and Frequency of dressing change. Review of Resident #2's clinical record revealed an admit date of 02/10/2025, with diagnoses which included Type 2 Diabetes Mellitus With Foot Ulcer, Cerebral Infarction, Foot Drop- Left Foot; Muscle Wasting And Atrophy; Muscle Weakness and Abnormalities Of Gait And Mobility. Review of Resident #2's Care Plan revealed in part I have actual impairment to skin integrity of the right rear thigh r/t abrasion. Review of Resident #2's Physician's Orders revealed in part . Apply Nystatin powder to yeast on back of upper right thigh daily until healed; one time a day for yeast with a start date of 05/21/2025. There was no wound care order for the #16 Abrasion to the Rear Right Thigh. Review of Resident #2's Skin and Wound Evaluation dated 05/26/2025 revealed in part . #16-Abrasion; Type: Abrasion, Location: Rear Right Thigh; Acquired: In- House Acquired- date unknown; Exudate: Moderate Serosanguineous; Treatment: Cleaning Solution: Generic Wound cleanser; Primary Dressing: Other: Nystatin, Collagen; Secondary Dressing: Dry; Notes: area is cleaned with wound cleanser, pat dry nystatin and collagen is applied with a bordered gauze dressing to cover. Observation of wound care for Resident #2's right lower posterior thigh on 05/28/2025 at 8:51 a.m. with S4 LPN Treatment Nurse revealed Resident #2's right lower posterior thigh had a small, circular opened abrasion within a fungal area. S4 LPN Treatment Nurse cleaned the opened abrasion and fungal area with the normal saline soaked 4x4 gauze and then observed S4 LPN Wound Care Nurse wipe around Resident #2's open abrasion with a skin prep. S4 LPN Treatment Nurse then applied the nystatin powder to Resident #2's opened abrasion and fungal area and left the wound bed uncovered. Observation of the back of Resident #2's right lower leg on 05/28/2025 at 1:56 p.m. with S1 DON and S3 RN Treatment Nurse revealed the fungal area and a small, circular opened abrasion. S3 RN Treatment Nurse revealed the fungal area was being treated with Nystatin powder only, the opened abrasion had no treatment orders. Interview with S3 RN Treatment Nurse on 05/28/2025 at 2:20 p.m. confirmed the wound documented as an abrasion to Resident #2's right rear thigh on the Wound Skin Evaluation dated 05/26/2025 was the same wound that we observed earlier for Resident #2. S3 RN Treatment nurse confirmed the orders from the Skin/ Wound Evaluation Assessment were not carried over to Resident #2's Physician orders and there were no active Physician orders for the opened abrasion to Resident #2's right rear thigh. Interview with S2 WCNP on 05/29/2025 at 11:10 a.m. revealed he was made aware of the opened abrasion to Resident #2's right rear thigh on 05/26/2025. S2 WCNP revealed that he gave a verbal wound care order to cleanse the open abrasion with Wound Cleanser, Apply Nystatin Powder and Collagen and cover with a dry dressing on 05/26/2025. S2 WCNP confirmed that the verbal order he gave was not transcribed in Resident #2's Physician orders and not implemented, but should have been. Interview with S1 DON and S3 RN Treatment Nurse on 05/29/2025 at 3:06 p.m. confirmed Resident #2's verbal wound care orders from S2 WCNP for the open abrasion to Resident #2's right rear thigh were not transcribed into Resident #2's Physician Orders, but should have been.

Based on observation and interview the facility failed to follow infection control practices to prevent the development and transmission of infection. The facility failed to ensure staff prepared a clean work area prior to providing wound care and sanitize hands between glove changes for 1 (Resident #2) of 3 (#1,#2, and #3) sampled residents reviewed for infection control. Findings: Review of the facility's policy and procedure dated 01/09/2022 titled, Wound Care read in part . Steps in the Procedure; Prepare a clean, dry work area at bedside; Remove gloves, perform hand hygiene, reapply gloves. Review of Resident #2's clinical record revealed an admit date of 02/10/2025, with diagnoses which included Type 2 Diabetes Mellitus With Foot Ulcer, Cerebral Infarction, Foot Drop- Left Foot; Muscle Wasting And Atrophy; Muscle Weakness and Abnormalities Of Gait And Mobility. Review of Resident #2's Care Plan revealed in part Fungal Skin Infection with Interventions to include Administer anti-fungal medication as ordered. I am at risk for developing multi-drug resistant organism (MDRO) infections related to wound with Interventions to include Staff will perform proper hand hygiene. Review of Resident #2's Physician's Orders revealed in part . Apply Nystatin powder to yeast on back of upper right thigh daily until healed; one time a day for yeast with a start date of 05/21/2025. Observation of wound care for Resident #2's right posterior thigh on 05/28/2025 at 8:51 a.m. with S4 LPN Treatment Nurse revealed S4 LPN Treatment Nurse placed a barrier pad on Resident #2's side table. S4 LPN Treatment Nurse did not remove Resident #2's personal items from the side table or wipe down the side table prior to placing the pad on the side table. S4 LPN Treatment Nurse repositioned Resident #2 onto her left side to reveal Resident #2's small, circular opened abrasion. S4 LPN Treatment Nurse changed her gloves without sanitizing between removal of old gloves and application of the new gloves. S4 LPN Treatment Nurse proceeded with wound care and cleaned Resident #2's wound. S4 LPN changed her gloves, did not sanitize hands and then applied new gloves. S4 LPN Treatment Nurse proceed with wound care. S4 LPN Treatment Nurse removed her gloves, did not sanitize hands and donned new gloves. S4 LPN Treatment Nurse completed Resident #2's wound care. Interview with S4 LPN Treatment Nurse on 05/28/2025 at 9:02 a.m. confirmed that S4 LPN Treatment Nurse did not remove Resident #2's personal items from the side table and did not wipe down the table prior to placing the barrier pad before Resident #2's wound care treatment, but should have. S4 LPN Treatment Nurse confirmed that she did not sanitize her hands after removing her gloves in between applying new gloves during Resident #2's Wound Care treatment, but should have. Interview with S1 DON on 05/29/2025 at 3:04 p.m. confirmed S4 LPN Treatment Nurse should have removed Resident #2's personal items from and wiped down the side table prior to placing the barrier pad, but did not. S1 DON confirmed S4 LPN Treatment Nurse should have sanitized her hands in-between each glove change throughout Resident #2's wound care, but did not.

Based on record review and interview, the facility failed to ensure the resident's right to receive mail in a timely manner for 1 (#1) resident out of 3 (#1, #2, & #3) sampled residents reviewed for resident rights. Findings: Review on 02/12/2025 of the facility's policy titled Mail and Electronic Communication revised on May 2017 revealed in part .4. Mail and packages will be delivered to the resident within 24 hours of delivery on premises or to the facility's post office box (including Saturday deliveries). Review of Resident #1's medical record revealed an admitted [DATE] with diagnoses that included in part . Type 2 DM, Unspecified Protein-Calorie Malnutrition, Metabolic Encephalopathy, and Unspecified Atrial Fibrillation. Review of Resident #1's Quarterly MDS with an ARD of 12/04/2024 revealed a BIMS score of 15, which indicated the resident was cognitively intact. Review of the MDS revealed Resident #1 required setup or clean-up assistance with eating, substantial to maximal assistance with toileting hygiene, showering, rolling left and right, sitting to lying, lying to sitting on side of bed, sitting to standing, and with chair/bed to chair transferring. In an interview on 02/10/2025 at 9:15 a.m., Resident #1 stated in January 2025 S3Household Coordinator brought her a stack of mail, about 12 or 13 pieces of mail. Resident #1 stated the mail was date stamped when it was received by the facility and some of the mail was very old. Resident #1 stated she thought it was all of her mail for 2024. Resident #1 stated the mail included some bills and some letters from the company that sends her retirement check stating her retirement checks had not been cashed. In an interview on 02/10/2025 at 1:54 p.m., S3Household Coordinator stated she gave Resident #1 the mail S4Accounts Manager had given her. S3Household Coordinator stated she gave it immediately to Resident #1 when it was given to her. In an interview on 02/10/2025 at 2:00 p.m., S4Accounts Manager stated she began working at this facility about 5 months ago. S4Accounts Manager said there was a lot of mail piled up in the office when she started. S4Accounts Manager stated no one told her what to do with the mail, so she asked about four different people what to do because everyone's mail was piled up. S4Accounts Manager confirmed Resident #1 had about 6 pieces of mail, some of which were date stamped over 5 months ago, and said she gave it to her Household Coordinator to give to Resident #1. In an interview on 02/11/2025 at 12:00 p.m., S1Administrator acknowledged Resident #1's mail was not provided to the resident timely. S1Administrator stated it was because Resident #1 signed over her insurance benefits and handling of her trust fund to the facility and that they pay Resident #1's bills. S1Administrator acknowledged Resident #1 probably should get the mail addressed to her even if it was a bill or insurance information. S1Administrator acknowledged the facility had a timeline to get mail to the residents.

Based on observation, interview and record review, the facility failed to ensure a resident was treated with respect and dignity and cared for in a manner that promoted maintenance or enhancement of his or her own quality of life. The facility failed to treat a resident with respect and dignity by failing to adhere to and honor religious dietary preferences for 1 (#1) of 4 (#1, #2, #3, and #4) residents sampled for resident rights. Findings: Review of the facility policy titled Resident Food Preferences revealed in part .individual food preferences will be assessed upon admission and communicated to the interdisciplinary team; upon the resident's admission (or within 24 hours after admission) the Dietary Manager or designee with identify a resident's food preferences; staff with interview the resident directly to determine current food preferences based on history and life patterns related to food. Record Review revealed Resident #1 was admitted to the facility on [DATE]. Resident #1 had diagnoses that included in part . Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right Dominant Side, Muscle Wasting and Atrophy, Dysphagia, and Pain. Review of Resident #1's Admission MDS with ARD of 10/07/2024 revealed Resident had a BIMS of 11, indicating moderate cognitive impairment. Resident #1 required setup/clean up assistance for eating. Review of Resident #1's Care Plan revealed in part . 10/04/2024- I have dietary preferences related to (Religious) no pork. Review of Resident #1's Physician Orders dated 10/02/2024 revealed in part . Regular diet, Regular texture, Regular - Thin liquids consistency; NO PORK. Review of Resident #1's Screening for Nutrition V2 signed by S3 Dietary Manager on 10/07/2024 revealed, in part .Resident Preferences-Requests for ethnic/special foods/snacks: Muslim, no Pork or pork products. Telephone interview on 12/19/2024 at 11:37 a.m. with Resident #1 revealed she requested a salad with turkey on 11/15/2024, but was served ham which was against her religious beliefs. Interview on 12/26/2024 at 10:52 a.m. with S3 Dietary Manager confirmed Resident #1 was served a chef salad with ham despite religious preferences for no pork or pork products on 11/15/2024. S3 Dietary Manager confirmed staff removed the ham and gave the same salad back to Resident #1. S3 Dietary Manager stated the homemaker was ultimately responsible for ensuring food served to residents was appropriate according to orders/preferences/allergies. S3 Dietary Manager confirmed Resident #1 should have been served a new salad without ham on 11/15/2024. Interview on 12/26/2024 at 2:26 p.m. with S4 ADON confirmed Resident #1 was served a salad with ham on 11/15/2024. S4 ADON confirmed Resident #1 should not have been served a salad with ham, or the same salad after the ham was removed, because it was Resident #1's religious preference to not consume pork. Interview on 12/26/2024 at 2:40 p.m. with S2 DON confirmed the homemaker was responsible for ensuring food served to residents was appropriate according to orders/preferences/allergies. Interview on 12/30/2024 at 9:46 a.m. with S5 CNA revealed she served Resident #1 a salad with ham on 11/15/2024. S5 CNA stated after removing the ham, she attempted to return the same salad to Resident #1, and Resident #1 became upset and refused the salad. S5 CNA stated she should not have served Resident #1 a salad with ham. S7 Homemaker was not available for interview at time of survey.

Based on interview and record review, the facility failed to ensure their grievance policy was followed. The facility failed to record a grievance within the appropriate timeframe for 1 (Resident #1) of 4 (Resident #1, Resident #2, Resident #3, and Resident #4) residents sampled for resident rights. Findings: Review of the facility policy titled Resident Care Grievance Policy revealed, in part . The facility will investigate all grievances and filed complaints relating to any Resident; Grievances/Complaints are to be submitted to the Administrator who is named as the Grievance Official or their designee who will lead a thorough and impartial investigation of the allegations; Written grievances may be recorded on the Resident Grievance Form and all other grievances should be recorded in the Risk Management section of the resident's electronic health record; A review of the grievance should be available within five business days of receiving the grievance; The Grievance Official or designee will review the finding with the person (designee) investigating the complaint to determine what corrective actions need to be taken. Grievance decisions should include date grievance was received, a summary of the resident's grievance, the steps taken to investigate the grievance, a summary of pertinent findings regarding the resident's concerns, a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken as a result of the grievance and the date the decision was issued. The Administrator or his/her designee must contact or meet with the complainant and discuss the findings of the report with the concerned parties. If the grievance is substantiated, the Administrator and/or designee will discuss the findings and the implemented corrective actions with the complainant. There is to be clear documentation of discussions including date, time and persons apprised of outcome. Record Review revealed Resident #1 was admitted to the facility on [DATE]. Resident #1 had diagnoses that included in part . Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right Dominant Side, Muscle Wasting and Atrophy, Dysphagia, and Pain. Resident #1 was discharged on [DATE]. Review of Resident #1's Admission MDS with ARD of 10/07/2024 revealed a BIMS of 11, which indicated moderate cognitive impairment. Resident #1 required setup/clean up assistance for eating. Review of Resident #1's Care Plan revealed, in part . I have dietary preferences r/t (Religious) no pork initiated on 10/04/2024. Review of Resident #1's Physician Order dated 10/02/2024 revealed; Regular diet, Regular texture, Regular - Thin liquids consistency; NO PORK. Review of Resident #1's Screening for Nutrition V2 signed by S3 Dietary Manager on 10/07/2024 revealed, in part .Resident Preferences-Requests for ethnic/special foods/snacks: Muslim, no Pork or pork products. Review of the facility's grievance log revealed a grievance regarding food service incidents for Resident #1 dated 12/03/2024 at 4:04 p.m. Review of the facility's grievance report dated 12/03/2024 revealed, in part .State Ombudsman presented to the facility to follow up on a complaint that was made before Resident #1 was discharged to home. Resident #1 was prepared a chef salad with ham on 11/15/2024. Resident #1's religious beliefs forbid pork. S5 CNA removed ham and served the same salad to Resident #1. Resident #1 was not happy that it was the same salad and not a new one. Telephone interview on 12/19/2024 at 11:37 a.m. with Resident #1 revealed she requested a salad with turkey on 11/15/2024, but was served a salad with no meat. Resident #1 was told the salad had contained ham, which had been removed because consuming pork was against her religious beliefs. Resident #1 refused the salad and reported the incident to a dietary aide and to a nurse. Resident #1 stated on the following Monday, S4 ADON advised her she was now handling the complaint. Interview on 12/26/2024 at 10:52 a.m. with S3 Dietary Manager confirmed Resident #1 was served a chef salad with ham on 11/15/2024. S3 Dietary Manager confirmed staff removed the ham and gave the same salad back to Resident #1. S3 Dietary Manager stated the homemaker was ultimately responsible for ensuring food served to residents was appropriate according to orders/preferences/allergies. S3 Dietary Manager confirmed Resident #1 should have been served a new salad without ham on 11/15/2024. S3 Dietary Manager confirmed she was notified of incident on 11/15/2024. S3 Dietary Manager stated Resident #1 was still angry 1-2 days after this incident, and wanted to speak to S3 Dietary Manager. S3 Dietary Manager confirmed she did not file a grievance prior to 12/03/2024, but should have. Interview on 12/26/2024 at 2:26 p.m. with S4 ADON confirmed Resident #1 was served a salad with ham on 11/15/2024. S4 ADON confirmed Resident #1 should not have been provided a salad with ham, or the same salad after ham was removed, because it was her religious preference to not consume pork.

Based on interview and record review, the facility failed to ensure the provider documented a clinical rationale for a denial of a psychoactive medication dosage reduction for 1 (#3) of 4 (#1, #2, #3, and #4) sampled residents. The facility failed to ensure the provider documented in the medical record a clinical rationale when the dosage reduction was clinically contraindicated. Findings: Review of the facility's current policy titled, Unnecessary Drugs Psychotropic and Antipsychotic Medications and Non-Pharmacological Intervention with an effective date of 09/06/2022 stated in part .The physician shall respond to reports of untoward medication response by changing or stopping problematic medications/medication dosing or provide clear documentation (based on resident and data assessment) of the rationale for the benefit/risk of medication/medications dosages .Initiate a Gradual Dose reduction (GDR) . In instances that GDRs are contraindicated, documentation of a clinical rationale initiating why a GDR is contraindicated should be documented by the prescribing/treating clinician. Review of Resident #3's medical record revealed an admitted [DATE]. Diagnoses that included in part . Parkinson's Disease Without Dyskinesia, Major Depressive Disorder, Single Episode, Type 2 Diabetes Mellitus Without Complications, and Essential Primary Hypertension. Review of Resident #3's Admission MDS with an ARD of 12/10/2024 revealed a BIMS score of 15, which indicated the resident was cognitively intact. Resident #3 received antidepressants during the last 7 days or since admission/entry, or re-entry is less than 7 days. Review of Resident #3's care plan with a target date of 03/06/2025 revealed the resident had depression. Approaches included: pharmacy to review monthly or per protocol. Review of Resident #3's current physician's orders revealed an order to give one 50mg Trazodone HCl (antidepressant) tablet by mouth at bedtime related to Major Depressive Disorder. Review of Resident #3's medical record revealed a form titled, Pharmaceutical Consultant Report Psychoactive Gradual Dose Reduction that was signed and dated by S2 DON and S6 NP on 12/10/2024. The Pharmacist requested a GDR for Trazodone 50mg. The form read; justification for not reducing a psychoactive must have a documented, valid clinical rationale to be considered clinically contraindicated as to why the reduction is not desired at this time. S6 NP documented NO for if a dosage reduction was appropriate. S6 NP documented YES for minimal effective dose. There was no documentation of a valid clinical rational/reason for the denial of a dosage reduction for the antidepressant. On 12/26/2024 at 1:40 p.m., an interview and record review was conducted with S2 DON. S2 DON reviewed Resident #3's Pharmaceutical Consultant Report Psychoactive Gradual Dose Reduction form dated 12/10/2024. S2 DON revealed she was not sure what documentation was needed on the GDR form. S2 DON telephoned S6 NP at time of interview for clarification. S6 NP confirmed via speakerphone that she did not document a clinical rationale on the GDR form, when she continued the Trazadone 50mg for Resident #3, but should have.

Based on record reviews and staff interviews, the facility failed to ensure MDS (minimum data set) assessments were accurate for 1 (#3) of 3 (#1, #2 and #3) sample residents. The facility failed to ensure resident #3's MDS accurately reflected her skin conditions and nutritional status at the time of the ARD (assessment reference date). Findings: Review of resident #3's clinical records revealed most recent admission on 06/18/2024 entered from skilled nursing facility with diagnoses that include but not limited to congestive heart failure, Alzheimer's disease with late onset, vascular dementia, diabetes mellitus with diabetic neuropathy, peripheral vascular disease, acquired absence of other left toe, and essential hypertension. Review of resident #3's Quarterly MDS with ARD 10/16/2024 revealed Resident #3 was on a prescribed weight loss management. Further review of Resident #3's Quarterly MDS revealed nothing was entered for ulcers, wounds and skin problems. During an interview on 11/07/2024 at 10:45 a.m. S4 MDS nurse reported that she obtained information to complete a resident's MDS by reading the medical records and nurses' documentations. S4 MDS nurse reported the reason she coded physician-prescribed weight-loss regimen was due to resident #3 being on a diuretic. S4 MDS nurse reported she thought resident #3's wound had been resolved before the assessment reference date 10/16/2024 for the MDS, but it was not. Review of resident #3's Nurse's Notes dated 10/10/2024 documented by S5 LPN (Licensed Practical Nurse) revealed resident #3 had sores on her pinky toes, the left one looks worse than the right. Cleaned & applied a Band-Aid. Treatment nurse aware. Weekly Skin Inspection performed. During an interview on 11/07/2024 at 10:20 a.m. S5 LPN reported resident #3 did have wounds to her right lower leg and toes of her feet. Review of resident #3's November 2024 Physician Orders revealed the following orders: 1. Lasix Oral Tablet 40mg (milligram) (Furosemide) Give 0.5 mg tablet by mouth one time a day for CHF (congestive heart failure). 2. Regular diet pureed text, regular, thin liquids consistency. 3. Clean laceration #12 to right lateral foot 5th toe with wound cleanser, pat dry, apply medihoney, cover with bordered gauze. One time a day every 2 days. 4. Clean diabetic ulcer #11 to right medial calf with normal saline or wound cleanser, pat dry, apply steri- strips if needed, cover with bordered gauze one time a day every 3 days. Review of resident #3's Weekly Skin and Wound Evaluation dated 10/15/2024 revealed the wound is a laceration to the right medial calf. Acquired in house, exact date 10/07/2024. Review of resident #3's Foot Care Progress Note dated 10/09/2024 revealed chief complaint nail dystrophy. Due to resident pass medical history of type 2 diabetes with amputation of left toe and current right lower leg wound, resident is a high risk for foot complications/foot injuries/nail deformities.

Based on record reviews and interviews, the facility failed to ensure nursing staff provided nursing and related services to assure residents maintained the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by individual plans of care. The facility to notify the Registered Dietician (RD) in a timely manner when 1 (#1) of 2 (#1, #2) residents who received tube feedings order was changed to an equivalent tube feeding. Findings: Review of Resident #1's face sheet revealed an initial admitted [DATE] and a re-entry to facility on 07/01/2024 with the following medical diagnoses but not limited to cerebral infraction, gastrostomy status and ileus. Review of Resident #1's November 2024 Physician Orders revealed: 9/26/2024: Enteral feed: two times a day Peptamen 1.5 @ 40ml (milliters)/hr (hour) continuous will provide: 1440 kcals (kilocalories), 65 grams protein, 739 mls free water. 11/4/2024: Enteral Feed: every day and night shift; Give Pivot 1.5 Equivalent till Peptamen is available Review of Resident #1's Quarterly MDS (Minimum Data Sets) dated 09/11/2024 revealed a BIMS (Brief Interview of Mental Status) of 14 indicating cognitively intact. Further review of Resident #1's Quarterly MDS revealed Resident #1 received nutrition by feeding tube and mechanically altered diet. Review of Resident #1's Nurses Notes revealed: 11/03/2024 at 6:36 a.m. Resident Peptamen 1.5 tube feeding is out of stock. Per S2 NP (Nurse Practitioner) able to substitute Pivot 1.5 till Peptamen comes in. And inform the dietician. 11/05/2024 at 2:44 p.m. Peptamen 1.5 remains out of stock. Pivot order has not arrived at this time. Consulted with Registered Dietician. Waiting on recommendation. 11/5/2024 at 4:00 p.m. Peptamen 1.5 arrived at facility. During a telephone interview on 11/06/2024 at 3:30 p.m. S2 NP reported she was notified the facility was out of Peptamen 1.5 on 11/03/2024 and wanted to change the tube feeding order to an equivalent. S2 NP reported the nurse was given a telephone order to use the equivalent and to inform S3 Registered Dietician Resident #1 was receiving an equivalent. During a telephone interview on 11/06/2024 at 3:50 p.m. S3 Registered Dietician reported S1 DON called and notified her by email on 11/05/2024 that the facility was out of Peptamen and Resident #1 was receiving Pivot 1.5 as an equivalent. During an interview on 11/06/2024 at 4:30 p.m. S1 DON (Director of Nursing) reported the order for Pivot 1.5 was given by S2 NP on 11/3/2024 and S2 NP also told the nurse to inform the Registered Dietician. S1 DON reported the facility did not have a policy related to notifying the Registered Dietician about tube feedings orders. S1 DON reported S7 Clinical Coordinator should have informed S3 Registered Dietician that Resident #1 was receiving Pivot 1.5 for Peptamen 1.5 equivalent and did not when she returned to work on Monday 11/04/2024. S1 DON reported she notified S3 Registered Dietician by telephone and email on 11/05/2024 that the facility was out of Peptamen 1.5 and Resident #1 was receiving Pivot 1.5 as an equivalent. During a telephone interview on 11/07/2024 at 3:00 a.m. S6 LPN (Licensed Practical Nurse) reported on 11/03/2024 Resident #1 was out of tube feeding Peptamen 1.5. S6 LPN reported S2 NP was notified and a telephone order was received to start Pivot 1.5 at a continuous rate of 40 ml/hr and to inform the registered dietician. S6 LPN reported she did not notify S3 Registered Dietician that Resident #1 was receiving Pivot 1.5.

Based on record review and interview, the facility failed to ensure a resident was treated with respect and dignity for 1 (Resident #1) of 3 (Resident #1, Resident #2, & Resident #3) sampled residents. Findings: Review of Resident #1's medical record revealed an admitted [DATE] with diagnoses that included in part .Cerebral Infarction, Gout, Hypertension, and Major Depressive Disorder. Review of Resident #1's annual MDS with an ARD of 05/14/2024 revealed a BIMS score of 12 which indicated the resident had moderately impaired cognition. Review of the MDS revealed Resident #1 was independent with eating, toilet hygiene, and rolling left and right. Resident #1 required set up assistance with sitting to lying or lying to sitting on the side of the bed and with transferring from chair/bed to chair. Review of Resident #1's care plan with a target completion date of 08/25/2024 revealed a problem area of having a behavior problem that stated the resident occasionally uses profanity and aggressive language when irritated. Interventions included I will be assisted to develop more appropriate methods of coping and interacting, I will be encouraged to express feelings appropriately, Approach/speak to me in a calm manner, and Monitor my episodes of behavior and attempt to determine underlying cause. In an interview on 08/28/2024 at 10:10 a.m., Resident #1 said she wanted to move out of this facility because Everything is wrong here. Resident #1 explained she was supposed to get a thyroid pill every morning but recently she didn't get it so she went to the nurses' station to tell the nurse. Resident #1 said the nurse told her she had given it to her and she just didn't remember because she was sleeping. Resident #1 stated S3 LPN/ADON slammed the nurses' station door in her face. Resident #1 stated this made her mad and she began to bang on the door until S3 LPN/ADON opened it. Resident #1 stated she called the nurse a liar and the nurse pushed her on her shoulders and she said she pushed the nurse back. Resident #1 stated she fell down, hurt her left hip, and bruised the back of her right hand. Resident #1 said when the nurse put her hands on her, it made her feel bad. Resident #1 said, She shoved on me to get me out of the way and I got mad. Resident #1 said, I just don't want to stay here. Resident #1 said she did tell a nurse that she didn't want S3 LPN/ADON to take care of her anymore because I don't think she'll take good care of me. Resident #1 said, I just want to call my family to come get me. Resident #1 stated when a nurse came in this morning to give her the purple pill, she remembered the incident again and it made her mad all over again. In an interview on 08/28/2024 at 11:05 a.m., S5 LPN stated on morning of 08/23/2024, she was getting report from S3 LPN/ADON who had worked the night shift. S5 LPN stated Resident #1 came up to them and said she didn't receive her purple pill this morning. S5 LPN stated S3 LPN/ADON told Resident #1 that she gave it to her. S5 LPN stated Resident #1 called her a liar. S5 LPN stated S3 LPN/ADON told Resident #1 she had left it on the table with some water. S5 LPN said Resident #1 went back to her room to look and came back to them and was pointing her finger and said, You're lying. S5 LPN stated Resident #1 told S3 LPN/ADON You are in my space and then S3 LPN/ADON told Resident #1, No, you're in my space. S5 LPN stated S3 LPN/ADON then slammed the door in Resident #1's face while Resident #1's hands were on the door facing. S5 LPN stated Resident #1 then began beating on the glass in the nurses' station door and said she was afraid it would break and told S3 LPN/ADON she'd better open the door. S5 LPN stated S3 LPN/ADON opened the door, walked to Resident #1, put her hands on the resident's shoulders and tried to turn her around. S5 LPN stated Resident #1 began to resist and said, You don't touch me and they began to scuffle and Resident #1 fell . In an interview on 08/28/2024 at 11:10 a.m., S6 CNA reported she heard the commotion at the nurses' station door on the morning of 08/23/2024. S6 CNA stated she saw S3 LPN/ADON close the door in Resident #1's face. S6 CNA stated a minute later she could hear S3 ADON/LPN and Resident #1 both yelling and saw arms flying. S6 CNA stated she could hear that Resident #1 was loud and agitated. S6 CNA stated Resident #1 ended up on the floor. The facility's video surveillance footage from the incident on 08/23/2024 was observed on 08/28/2024 at 1:02 p.m. with S1 Administrator and S2 DON. The footage revealed at 7:03 a.m. on 08/23/2024, Resident #1 walked to the doorway of nurses' station and held a conversation with people inside the nurses' station. Resident #1 then walked back to her room. Resident #1 was seen walking back to the doorway of the nurses' station at 7:04 a.m. and was standing in the doorway talking to the people in the nurses' station again. At 7:05 a.m., the nurses' station door was abruptly shut closed by someone inside the nurses' station, while Resident #1 was still standing in the doorway. Resident #1 began to hit the glass in the door with her fist. S3 LPN/ADON opened the door and reached out toward Resident #1 with both hands and was seen holding Resident #1's arms and walking the resident backwards away from the doorway toward the day room. They began moving together with their arms locked together and Resident #1 fell to the floor inside the doorway of the nurses' station. In an interview on 08/28/2024 at 2:45 p.m., S4 RN/CC (Clinical Coordinator) for Hall 1 stated she arrived to work on 08/23/2024 about 8:00 a.m. S4 RN/CC stated S3 LPN/ADON had already left and staff reported the incident to her. S4 RN/CC stated she assessed Resident #1 and found a left hip bruise that Resident #1 said was tender to the touch. S4 RN/CC stated she got an x-ray order from S7 NP and called x-ray to come. S4 RN/CC stated she, S8 ADON, and S5 LPN went in together to talk to Resident #1. S4 RN/CC stated Resident #1 told them she went back to the nurses' station and called S3 LPN/ADON a liar and S3 LPN/ADON closed the door in her face, which made her mad and that was why she banged on the glass. S4 RN/CC stated Resident #1 told them when S3 LPN/ADON put her hands on her shoulders, she got nervous and dizzy and fell down. S4 RN/CC stated Resident #1 said S3 LPN/ADON was trying to get her to go back to her room. S4 RN/CC stated she asked Resident #1 if she wanted S3 LPN/ADON to take care of her again and Resident #1 said No. S4 RN/CC stated she watched the surveillance video with S1 Administrator and saw S3 LPN/ADON close the door in Resident #1's face, which was very inappropriate. In an interview on 08/28/2024 at 3:23 p.m., S8 ADON reported on 08/23/2024 she arrived to work around 8:00 a.m. and S5 LPN informed her that S3 LPN/ADON had an altercation with Resident #1 and explained what happened. S8 ADON stated she reported it to S1 Administrator and they watched the surveillance video from the camera inside the team room/nurses' station and could visualize the inside of the team room, the door, the two nurses, and Resident #1 in the doorway. S8 ADON stated on the video she observed S3 LPN/ADON slam the door in Resident #1's face. S8 ADON stated Resident #1 was close to being hit by the door. S8 ADON stated S3 LPN/ADON later opened the door and she and Resident #1 got into an altercation and Resident #1 ended up falling. S8 ADON confirmed S3 LPN/ADON slammed the door in Resident #1's face. S8 ADON stated Resident #1 was standing in the doorway with her hands on the door facing and she didn't know how her fingers didn't get slammed in the door. S8 ADON explained Resident #1 then began to hit the door window with her fist. S8 ADON explained S3 LPN/ADON then opened the door, walked toward Resident #1 and touched her, and Resident #1 fell . S8 ADON reported she, S4 RN/CC, and S5 LPN then went in to assess Resident #1 and interview her. She said Resident #1 told them S3 LPN/ADON touched her first and pushed her on the shoulders stating she didn't know if she was trying to push her back to her room or what. In a telephone interview on 08/28/2024 at 4:06 p.m., S9 CNA stated she observed Resident #1 walk to the nurses' station and tell S3 LPN/ADON she didn't give her the medicine she was supposed to get. S9 CNA stated S3 LPN/ADON told the resident she gave it to her. S9 CNA stated S3 LPN/ADON pushed Resident #1 out the door and slammed the door in Resident #1's face. S9 CNA stated Resident #1 started hitting the glass on the door with her fist. S9 CNA stated S3 LPN/ADON opened the door and Resident #1 swung at S3 LPN/ADON and then they began tussling. S9 CNA stated S3 LPN/ADON pushed the resident down to the ground. In an interview on 08/29/2024 at 7:14 a.m., S10 CNA stated on 08/23/2024 she heard Resident #1 and S3 LPN/ADON having a conversation about medicine. S10 CNA stated the conversation got loud with both of them yelling and then S3 LPN/ADON slammed the door hard in Resident #1's face. She said Resident #1 got mad and started pounding on the door, then she saw S3 LPN/ADON open the door and she saw them both swinging at each other. S10 CNA stated she and another CNA ran over as Resident #1 fell to the floor. S10 CNA stated they assisted the resident up and to the couch. S10 CNA stated Resident #1 was really upset saying she couldn't stay here. In an interview on 08/29/2024 at 7:52 a.m., S3 LPN/ADON stated on the morning of 08/23/2024 when she was counting narcotics with S5 LPN, Resident #1 came and told S5 LPN she needed her purple pill, and said she told her she had given it to her. S3 LPN/ADON said Resident #1 left, went to her room and returned a few minutes later and said, No you didn't and said she told her, Yes I did. She said Resident #1 stated the cups were not on her table and she said she explained to Resident #1 that she woke her up, she took the medicine, and she took the cups back out to her medicine cart. S3 LPN/ADON stated Resident #1 said, You're lying. S3 LPN/ADON stated Resident #1 said to stop saying her name and was adamant that she didn't get her medication. S3 LPN/ADON stated she closed the door by pushing it to and said the door shuts loudly. S3 LPN/ADON stated Resident #1 was standing right outside the doorway when she closed it. S3 LPN/ADON stated Resident #1 started beating the glass with a hand with a ring on it with her fist, her right one. S3 LPN/ADON stated it was loud and she was afraid it would break the glass so she opened the door. S3 LPN/ADON stated she put her right hand on Resident #1's upper left arm and said, Let me bring you back to your room. S3 LPN/ADON stated Resident #1 called her a white b#@*# and swung at her with her right fist. S3 LPN/ADON stated she grabbed Resident #1's right forearm to stop it. S3 LPN/ADON stated Resident #1 spun around to try to get her hand free and landed on her behind. S3 LPN/ADON stated she did close the nurses' station door on Resident #1 to try to deter the resident, but, looking back it was probably not a good idea. In an interview on 08/29/2024 at 8:56 a.m., S1 Administrator stated the slamming of the door could have been avoided. S1 Administrator stated she didn't feel like S3 LPN/ADON abused Resident #1 but S3 LPN/ADON was placed on a 30 day improvement plan and retrained on Handling Aggressive Behaviors, Management of Behavioral Challenges, Abuse, Neglect, and Exploitation in the Elder Care Setting, and Managing Anger prior to returning to work.

Based on observations, interviews and record reviews, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility's Administration failed to ensure an adequate system was in place to ensure RD recommendations for PEG tube feedings were accurately transcribed into the medical record, failed to provide adequate nutrition to maintain weight, and failed to notify the physician when a resident complained of hunger, nausea, and requested to have her tube feeding rate increased for 1 (#26) of a total of 5 (#4, #16, #26, #96, and #98) residents who received nutrition by PEG tube feedings in the facility. This deficient practice resulted in an Immediate Jeopardy situation for Resident #26 on 07/05/2024 at 3:02 p.m., when S4 RN Clinical Coordinator incorrectly entered a physician's order for a nutritional feeding rate at 25 ml/hr instead of the recommended rate of 45 ml/hr. S19's RD Progress Notes dated 07/05/2024, revealed recommendations for Diabetisource AC (nutritional feeding) at 45 ml/hr. Review of Resident #26's medical record revealed she had received Diabetisource AC at 25 ml/hr from 07/05/24 to 07/15/2024, instead of the recommended Diabetisource AC at 45 ml/hr. Review of Resident #26's progress notes dated 07/13/2024 revealed, Resident #26, who was cognitively intact, and able to communicate by typing messages on her phone, communicated to S6 LPN that she wanted her feedings increased because she was hungry, nauseated, and felt like she was losing too much weight. During an interview on 07/15/2024 at 10:26 a.m. with Resident #26, she typed on her phone that she was hungry and losing weight. Observations at that time revealed Diabetisource AC infusing via her PEG tube at 25 ml/hr. In an interview with S4 RN Clinical Coordinator on 07/16/2024 at 2:49 p.m., she stated she misread the RD recommendation, and entered the order as Diabetisource 25 ml/hr., instead of the recommended 45 ml/hr. Resident #26 had a significant weight loss of 9.6 pounds (7.79% body weight), between 07/05/2024 and 07/16/2024. S1Administrator and S2 DON were notified of the Immediate Jeopardy situation on 07/17/2024 at 4:21 p.m. The Immediate Jeopardy was removed on 07/18/2024 at 4:45 p.m., as confirmed by onsite verification through observations, interviews, and record reviews the facility implemented an acceptable Plan of Removal (POR) prior to the survey exit. This deficient practice continued at a potential for more than minimal harm for any resident on PEG tube feeding in the facility that may receive new dietary recommendations. Findings: Cross Reference F658 Cross Reference F692 Review of the facility's policy titled, Medication Orders (Revised November 2014) revealed the following, in part: The purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders. 2. A current of orders must be maintained in the clinical record for each resident. Review of the facility's Info: Orders Communication Methods Explained (Updated January 31, 2024) revealed the following, in part: When adding a new order, users may select any of the following communication methods: Phone-means the physician called on the phone and communicated an order to the user and it will pend signature. Verbal-means the physician was present and verbally communicated an order to the user and it will pend signature. Prescriber Written-means the physician wrote the order on a prescription pad and signed it, then handed it to the user. There is no electronic signature trail of a prescriber written order. It is assumed the facility scanned the hard copy with a signature on it. Review of the facility's policy titled, Dietician (Revised October 2017) revealed the following, in part: 1. A qualified Dietician or other clinically qualified nutrition professional will help oversee food and nutritional services provided to the residents . 9. Our facility's Dietician is responsible for, but not necessarily limited to: a. Assessing nutritional needs of residents; An observation and interview on 07/15/2024 at 10:26 a.m., revealed Resident #26 had a feeding pump infusing Diabetisource AC at 25 ml/hr., with the water flush set at 150 ml/6hrs. At that time, Resident #26 typed I'm hungry, I'm losing weight on her phone, then typed I'm getting one capful of feeding an hour. During that time, Resident #26's daughter entered the room, and said her mother's tube feeding was not enough, and she had lost weight. Resident #26's daughter explained she was here today to talk to someone about her mother's tube feeding, and being hungry. An interview on 07/16/2024 at 2:49 p.m. with S4 RN Clinical Coordinator, revealed she was responsible for carrying out dietary recommendations for Resident #26 on 07/05/2024. She indicated that Resident #26 was NPO with tube feedings, and getting bolus feedings of Diabetisource AC 250ml every 8 hours, and flush with 150ml of water every 8 hours. S4 RN Clinical Coordinator said that Resident #26 was assessed by S19 RD on 07/04/2024, with recommendations to increase Diabetisource to 250ml carton every 6 hours, and flush with 150 ml of water every 6 hours, to increase Resident #26's caloric intake from 900Kcals to 1200Kcals. S4 RN Clinical Coordinator stated that on 07/05/2024, S7 ADON requested S19 RD give her the rate for continuous feeding on a pump because Resident #26 was staying long-term. She stated that the S19 RD sent an email on 7/05/2024 recommending Diabetisource AC at 45 ml/hr. S4 RN Clinical Coordinator stated that she called S10 NP and misread the recommendation to S10 NP. S4 RN Clinical Coordinator indicated that she entered the order as 25 ml/hr., instead of the recommended 45 ml/hr. S4 RN Clinical Coordinator stated I read the recommendation wrong. During an observation and interview of Resident #26 on 07/16/2024 at 3:12 p.m., when asked how she was feeling today, Resident #26 typed I feel better. Before I was hungry and nauseous after taking medicine on an empty stomach. Resident #26 then typed It felt like they were starving me and there was nothing I could do. I asked the nurse practitioner if I'm gonna die. An interview on 07/16/2024 at 4:00 p.m. with S2 DON and S20 QI Nurse, revealed there was not one standard facility process for obtaining, communicating and carrying out dietary recommendations. S2 DON stated the clinical coordinator for each house was responsible for obtaining and carrying out the dietary recommendations for their residents. S2 DON reported that the facility did not have a system for ensuring recommendations from the Registered Dietician were accurately communicated and accurately entered. S20 QI Nurse, stated We don't have one, but we will have one today. An interview on 07/16/2024 at 4:55 p.m. with S7 ADON revealed that she was the direct supervisor for S4 RN Clinical Coordinator. S7 ADON reported she amended the order for Resident #26 on 07/09/2024 to reflect on the EMAR for the day and night shift. However, she reported that she did not review the rate of the infusion, and did not compare the order to the dietary recommendations. S7 ADON confirmed Resident #26 should have been getting 45 ml/hr of Diabetisource instead of the 25 ml/hr she received from 07/05/2024 through 07/15/2024. A telephone interview on 07/17/2024 at 09:09 a.m. with S19 RD, revealed she made recommendations on 07/04/2024 to increase Resident #26's PEG feeding from Diabetisource 250ml every 8 hours to provide 900 Kcals, to Diabetisource 250ml every 6 hours to provide 1200 Kcals to increase her caloric intake. S19 RD reported that S7 ADON emailed her and requested a continuous rate recommendation on 07/05/2024. S19 RD reported she recommended Diabetisource AC to be infused at 45 ml/hr, and flushed with 150 ml of water every 6 hours, or flush at 25 ml/hr if Resident #26 was on a continuous infusion. S19 RD confirmed that Resident #26 should have received 45 ml/hr instead of 25 ml/hr, as recommended on 07/05/2024. S19 RD confirmed that receiving 25 ml/hr contributed to Resident #26's weight loss.

Based on observations, interviews, and record reviews, the facility failed to ensure services were provided to meet professional standards of quality, by failing to accurately transcribe and implement recommendations from the Registered Dietician, and failing to notify the physician when a resident complained of hunger, nausea, and requested to have her tube feeding rate increased for 1 (#26) of a total of 5 (#4, #16, #26, #96, and #98) residents receiving nutrition by PEG tube feedings in the facility; and failing to perform and document a Comprehensive Skin Assessment for 1 (Resident #19) of 3 (Resident #19, Resident #28, Resident #101) Residents reviewed for Pressure Ulcers. The total Sample Size was 34. Findings: This deficient practice resulted in an Immediate Jeopardy situation for Resident #26 on 07/05/2024 at 3:02 p.m., when S4 RN Clinical Coordinator incorrectly entered a physician's order for a nutritional feeding rate at 25 ml/hr instead of the recommended rate of 45 ml/hr. S19RD's Progress Notes dated 07/05/2024, revealed recommendations for Diabetisource AC (nutritional feeding) at 45 ml/hr. Review of Resident #26's medical record revealed she had received Diabetisource AC at 25 ml/hr from 07/05/24 to 07/15/2024, instead of the recommended Diabetisource AC at 45 ml/hr. Review of Resident #26's progress notes dated 07/13/2024 revealed, Resident #26, who was cognitively intact, and able to communicate by typing messages on her phone, communicated to S6 LPN that she wanted her feedings increased because she was hungry, nauseated, and felt like she was losing too much weight. During an interview on 07/15/2024 at 10:26 a.m. with Resident #26, she typed on her phone that she was hungry and losing weight. Observations at that time revealed Diabetisource AC infusing via her PEG tube at 25 ml/hr. In an interview with S4 RN on 07/16/2024 at 2:49 p.m., she stated she misread the RD recommendation, and put in the order as Diabetisource 25 ml/hr., instead of the recommended 45 ml/hr. Resident #26 had a significant weight loss of 9.6 pounds (7.79% body weight), between 07/05/2024 and 07/16/2024. S1Administrator and S2 DON were notified of the Immediate Jeopardy situation on 07/17/2024 at 4:21 p.m. The Immediate Jeopardy was removed on 07/18/2024 at 4:45 p.m., as confirmed by onsite verification through observations, interviews, and record reviews the facility implemented an acceptable Plan of Removal (POR) prior to the survey exit. This deficient practice continued at a potential for more than minimal harm for any resident on PEG tube feeding in the facility that may receive new dietary recommendations. Findings: Resident #26 Review of the facility's policy titled, Medication Orders (Revised November 2014), revealed the following, in part: The purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders. 2. A current list of orders must be maintained in the clinical record for each resident. Review of the facility's policy titled, Emergency and/or Alternate Physician Care (Revised April 2013), revealed the following, in part .All residents shall be provided with emergency and/or alternative physician care. 2. Should an emergency arise, and the resident's attending physician is not available, the emergency physician on-call must be contacted . 5. The staff will use appropriate procedures to contact physicians, depending on arrangements and the urgency of the situation . 6. If a physician and his/her backup coverage do not respond timely or appropriate manner to the facility notification of medical issues, the nursing staff will contact the medical director for assistance. Review of the facility's Info: Orders Communication Methods Explained (Updated January 31, 2024), revealed the following, in part: When adding a new order, users may select any of the following communication methods: Phone - means the physician called on the phone and communicated an order to the user, and it will pend signature. Verbal - means the physician was present and verbally communicated an order to the user, and it will pend signature. Prescriber Written - means the physician wrote the order on a prescription pad and signed it, then handed it to the user. There is no electronic signature trail of a prescriber written order. It is assumed the facility scanned the hard copy with a signature on it. Review of Resident #26's medical record revealed an admitted [DATE], with diagnoses that included in part .Cerebral Infarction, Retention of Urine, Gastrostomy Status, Ileus, Neuromuscular Dysfunction of the Bladder, Aphasia, Dysphasia, and Type 2 Diabetes Mellitus. Review of Resident #26's MDS with an ARD of 06/22/2024, revealed she had a BIMS score of 13, which indicated she was cognitively intact. Review of Resident #26's physician's orders read in part as follows: 07/05/2024 - Enteral feed order: Continuous diabetic source 25 ml/hour 150 ml water flush q6hrs . Review of Resident #26's current care plan with a problem onset date of 06/21/2024, revealed a problem of I require tube feeding, I receive Diabetisource 250ml every 8 hours with 150ml flush every 8 hours. Interventions included: I am dependent with tube feeding and water flushes. I will have a RD to evaluate quarterly and as needed. Monitor caloric intake, estimate needs. Make recommendations for changes to tube feeding as needed. The care plan had not been updated to reflect the 07/05/2024 RD recommendations for Diabetisource AC at 45 ml/hr + 150 ml q 6hrs (or 25 ml/hr. flushes if continuous). Review of an email correspondence revealed the following was sent to several employees including S2 DON, S7 ADON and S4 RN Clinical Coordinator: 07/04/2024 at 2:03 p.m. - S19 Registered Dietician sent recommendations to increase Diabetisource from 250 ml every 8 hours, to Diabetisource 250 ml every 6 hours. 07/05/2024 at 8:52 a.m. - S7 ADON responded to S19 RD, and requested the continuous rate for a feeding pump. 07/05/2024 at 10:23 a.m. - S19 RD responded with recommendation for Diabetisource AC at 45 ml/hr + 150 ml q 6 hrs (or 25 ml/hr. flushes if continuous). Will provide 1296 Kcals, 65 gm protein, 883 mls free water (1422 mls TFW). Review of Resident #26's Electronic Medication Administration Record (EMAR) for July 2024, revealed she received Diabetisource 25 ml/hr from 07/05/2024 through 07/15/2024. Review of Resident #26's medical record revealed the following weights which represented a significant weight loss of 7.79% between 07/05/2024 and 07/16/2024: 06/19/2024 125.8 lbs Wheelchair 07/02/2024 125.8 lbs Wheelchair 07/05/2024 123.2 lbs Wheelchair 07/16/2024 113.6 1bs Wheelchair Review of Resident #26's progress notes revealed that on 07/13/2024 at 12:41 p.m. S6 LPN wrote Resident states that she is feeling hungry and nauseated and feels like she is losing too much weight. Gave her Zofran and it was ineffective. She is requesting to have her feedings increased. Called and left message for the physician. Will continue to monitor. An observation and interview on 07/15/2024 at 10:26 a.m., revealed Resident #26 had a feeding pump infusing Diabetisource AC at 25 ml/hr., with the water flush set at 150 ml/6hrs. At that time, Resident #26 typed I'm hungry, I'm losing weight on her phone, then typed I'm getting one capful of feeding an hour. During that time, Resident #26's daughter entered the room, and said her mother's tube feeding was not enough, and she had lost weight. Resident #26's daughter explained she was here today to talk to someone about her mother's tube feeding, and being hungry. An interview on 07/16/2024 at 2:49 p.m. with S4 RN Clinical Coordinator, revealed she was responsible for carrying out dietary recommendations for Resident #26 on 07/05/2024. She indicated that Resident #26 was NPO with tube feedings, and getting bolus feedings of Diabetisource AC 250ml every 8 hours, and flush with 150ml of water every 8 hours. S4 RN Clinical Coordinator said that Resident #26 was assessed by S19 RD on 07/04/2024, with recommendations to increase Diabetisource to 250ml carton every 6 hours, and flush with 150 ml of water every 6 hours, to increase Resident #26's caloric intake from 900Kcals to 1200Kcals. S4 RN Clinical Coordinator stated that on 07/05/2024, S7 ADON requested S19 RD give her the rate for continuous feeding on a pump because Resident #26 was staying long-term. She stated that the S19 RD sent an email on 7/05/2024 recommending Diabetisource AC at 45 ml/hr. S4 RN Clinical Coordinator stated that she called S10 NP and misread the recommendation to S10 NP. S4 RN Clinical Coordinator indicated that she entered the order as 25 ml/hr., instead of the recommended 45 ml/hr. S4 RN Clinical Coordinator stated I read the recommendation wrong. During an observation and interview of Resident #26 on 07/16/2024 at 3:12 p.m., when asked how she was feeling today, Resident #26 typed I feel better. Before I was hungry and nauseous after taking medicine on an empty stomach. Resident #26 then typed It felt like they were starving me and there was nothing I could do. I asked the nurse practitioner if I'm gonna die. An interview on 07/16/2024 at 4:00 p.m. with S2 DON and S20 QI Nurse, revealed there was not one standard facility process for obtaining, communicating and carrying out dietary recommendations. S2 DON stated the clinical coordinator for each house was responsible for obtaining and carrying out the dietary recommendations for their residents. S2 DON reported that the facility did not have a system for ensuring recommendation from the Registered Dietician were accurately communicated and accurately entered. S20 QI Nurse, stated We don't have one, but we will have one today. An interview on 07/16/2024 at 4:55 p.m. with S7 ADON revealed that she was the direct supervisor for S4 RN Clinical Coordinator. S7 ADON reported she amended the order for Resident #26 on 07/09/2024 to reflect on the EMAR for the day and night shift. However, she reported that she did not review the rate of the infusion, and did not compare the order to the dietary recommendations. S7 ADON confirmed Resident #26 should have been getting 45 ml/hr of Diabetisource instead of the 25 ml/hr she received from 07/05/2024 through 07/15/2024. A telephone interview on 07/17/2024 at 8:38 a.m. with S10 NP, revealed that he typically follows the Registered Dietician's recommendations. He stated That's what she specializes in. He reported he did not remember talking to S4 RN Clinical Coordinator about Resident #26's PEG feeding. He revealed that he would have followed the RD's recommendations for the 45ml per hour infusion rate. A telephone interview on 07/17/2024 at 09:09 a.m. with S19 RD, revealed she made recommendations to increase Resident #26's PEG feeding from Diabetisource 250ml every 8 hours to provide 900 Kcals, to Diabetisource 250ml every 6 hours to provide 1200 Kcals to increase her caloric intake. S19 RD reported that S7 ADON emailed her and requested a continuous rate recommendation on 07/05/2024. S19 RD reported she recommended Diabetisource AC to be infused at 45 ml/hr, and flushed with 150 ml of water every 6 hours, or flush at 25 ml/hr if Resident #26 was on a continuous infusion. S19 RD confirmed that Resident #26 should have received 45 ml/hr instead of 25 ml/hr, as recommended on 07/05/2024. S19 RD confirmed that receiving 25 ml/hr contributed to Resident #26's weight loss. An interview on 07/17/2024 at 12:05 p.m. with S2 DON revealed she was told by S6 LPN on 07/14/2024 about Resident #26 being hungry. S2 DON reported that she emailed S19 RD on 07/14/2024 about Resident #26's PEG feeding and complaints of hunger. S2 DON stated that S19 RD responded on 07/15/2024, and recommended to increase the tube feeding by 10ml every 4 hours until Resident #26 reached 45 ml/hr. S2 DON stated she was not aware of the issue with Resident #26's tube feeding rate until it was brought to her attention by the surveyor. A telephone interview on 07/17/24 at 12:15 p.m. with S6 LPN revealed that Resident #26 told her on 07/13/2024 around lunch time that she was hungry, losing weight and wanted her tube feeding to be increased. S6 LPN reported that she called Resident #26's attending physician and left a message, but never received a call back. S6 LPN stated that on 07/14/2024, towards the end of her shift, she saw S2 DON at the facility and reported to her what Resident #26 had said. A telephone interview on 07/18/2024 at 1:18 p.m. with S10 NP revealed that he did not remember any nurse calling him about the recommendations for Diabetisource to be infused at 25 ml/hr, and he did not sign any order for Diabetisource to be infused at 25 ml/hr. He reported that he thought 25ml/hour was a low rate. In an interview on 07/18/2024 at approximately 1:30 p.m., S2 DON reported she was not notified by S6 LPN about Resident #26's complaints of hunger and weight loss until the afternoon of 07/14/2024. S2 DON reported she emailed the S19 RD at that time and received an email the following morning on 07/15/2024 at 10:02 a.m. from the S19 RD to increase Resident #26's tube feedings. S2 DON acknowledged S6 LPN should have continued attempting to reach a medical provider when she did not hear back from the physician on 07/13/2024. 47004 Resident #19 Review of the facility's current policy titled Wound Care dated 01/09/2022 read in part . A comprehensive skin assessment is completed within 24 hours of admit/readmit to facility. Comprehensive skin assessment includes completion of the Braden Risk Assessment. The Braden Risk Assessment is completed by the nursing staff: Within 24 hours of admission, weekly x4 after admit/readmit, quarterly and annually. Record Review revealed Resident #19 was admitted to the facility on [DATE] with diagnoses that included in part . Chronic Kidney Disease, Stage 5, Type 2 Diabetes Mellitus, Congestive Heart Failure, Unspecified Protein Calorie Malnutrition, Dependence on Renal Dialysis, Chronic Pulmonary Edema, Cerebral Infarction, and Generalized Muscle Weakness. Review of Resident #19's Quarterly MDS with an ARD of 04/10/2024, revealed Resident #19 had a BIMS of 15(cognitively intact). Resident #19 required Substantial/Maximal assistance from staff for toileting, showering/bathing, dressing, and personal hygiene. Record review revealed Resident #19 was hospitalized with a diagnosis of Congestive Heart Failure on 06/27/2024 and returned to the facility on [DATE]. Record review revealed a Braden Scale for Predicting Pressure Sore Risk assessment was completed on 07/08/2024, instead of 24 hours after return from the hospital. Interview on 07/16/2024 at 9:13 a.m. with Resident #19 revealed when she returned to the facility from being hospitalized from 06/27/2024 - 07/04/2024, she had a sore on her butt. Resident #19 revealed the facility did not treat her butt until 07/15/2024. Interview on 07/16/2024 at 11:10 a.m. with S9 Treatment Nurse, revealed nursing staff perform weekly skin inspections on residents and notify her of any changes. S9 Treatment Nurse stated on 07/14/2024, staff reported a break in Resident #19's skin, on her bottom. S9 Treatment Nurse stated she assessed Resident #19 on 07/14/2024, and staged the wound as a Stage 2 pressure ulcer to the resident's coccyx. S9 Treatment Nurse stated she notified S10 NP and received wound care orders to treat Resident #19's wound. S9 Treatment Nurse revealed Resident #19 was hospitalized , but she was not notified of Resident#19 returning to the facility with a wound. Interview on 07/16/2024 at 3:15 p.m. with S10 NP revealed he was made aware Resident #19 developed a stage 2 pressure ulcer to her coccyx on 07/14/2024, and provided wound care orders. Interview on 07/17/2024 at 9:08 a.m. with S9 Treatment Nurse, revealed she was responsible for performing Comprehensive Skin Assessments on residents. S9 Treatment Nurse confirmed a Comprehensive Skin Assessment was required to be completed and documented when a resident was readmitted following hospitalization . S9 Treatment Nurse confirmed a Braden Scale for Predicting Pressure Sore Risk should have been completed and documented within 24hrs of Resident #19's return from the hospital on 07/04/2024, but it had not been completed until 07/08/2024. Review of Resident #19's Active Orders revealed in part . Clean Stage 2 Pressure Ulcer to coccyx with normal saline or wound cleanser, apply calazinc, apply collagen, and apply foam border dressing. Order date: 07/15/2024 Weekly Skin Inspection. One time a day, every Monday. Order date: 07/17/2023.

Based on observation, interview, and record review the facility failed to ensure a resident with a PEG tube maintained acceptable parameters of nutritional and hydration status consistent with the resident's comprehensive assessment for 1 (#26) of a total of 5 (#4, #16, #26, #96, and #98) residents receiving nutrition by PEG tube feedings in the facility. This deficient practice resulted in an Immediate Jeopardy situation for Resident #26 on 07/05/2024 at 3:02 p.m., when S4 RN Clinical Coordinator incorrectly entered a physician's order for a nutritional feeding rate at 25 ml/hr instead of the recommended rate of 45 ml/hr. S19 RD's Progress Notes dated 07/05/2024, revealed recommendations for Diabetisource AC (nutritional feeding) at 45 ml/hr. Review of Resident #26's medical record revealed she had received Diabetisource AC at 25 ml/hr from 07/05/24 to 07/15/2024, instead of the recommended Diabetisource AC at 45 ml/hr. Review of Resident #26's progress notes dated 07/13/2024 revealed, Resident #26, who was cognitively intact, and able to communicate by typing messages on her phone, communicated to S6 LPN that she wanted her feedings increased because she was hungry, nauseated, and felt like she was losing too much weight. During an interview on 07/15/2024 at 10:26 a.m. with Resident #26, she typed on her phone that she was hungry and losing weight. Observations at that time revealed Diabetisource AC infusing via her PEG tube at 25 ml/hr. In an interview with S4 RN on 07/16/2024 at 2:49 p.m., she stated she misread the RD recommendation, and put in the order as Diabetisource 25 ml/hr., instead of the recommended 45 ml/hr. Resident #26 had a significant weight loss of 9.6 pounds (7.79% body weight), between 07/05/2024 and 07/16/2024. S1Administrator and S2 DON were notified of the Immediate Jeopardy situation on 07/17/2024 at 4:21 p.m. The Immediate Jeopardy was removed on 07/18/2024 at 4:45 p.m., as confirmed by onsite verification through observations, interviews, and record reviews the facility implemented an acceptable Plan of Removal (POR) prior to the survey exit. This deficient practice continued at a potential for more than minimal harm for any resident receiving PEG tube feeding in the facility that may receive new dietary recommendations. Findings: Review of the facility's policy titled, Weight Assessment and Intervention (Revised March 2022), revealed the following, in part: 5. The threshold for significant unplanned and undesired weight loss will be based on the following criteria: a. 1 month - 5% weight loss is significant; greater than 5% is severe . Interventions for undesirable weight loss are based on careful consideration of the following: a. Resident choice and preferences. b. Nutrition and hydration needs of the resident . The use of supplementation and/or feeding tubes; Review of the facility's policy titled, Dietician (Revised October 2017) revealed the following, in part: 1. A qualified Dietician or other clinically qualified nutrition professional will help oversee food and nutritional services provided to the residents . 9. Our facility's Dietician is responsible for, but not necessarily limited to: a. Assessing nutritional needs of residents; Review of Resident #26's medical record revealed an admitted [DATE] with diagnoses that included in part .Cerebral Infarction, Retention of Urine, Gastrostomy Status, Ileus, Neuromuscular Dysfunction of the Bladder, Aphasia, Dysphasia, and Type 2 Diabetes Mellitus. Review of Resident #26's MDS with an ARD of 06/22/2024 revealed she had a BIMS score of 13, which indicated she was cognitively intact. Review of Resident #26's physician's orders revealed in part the following: 07/05/2024 - Enteral feed order: Continuous Diabetisource 25 ml/hour with 150 ml water flush every 6 hours . Review of Resident #26's current care plan with a problem onset date of 06/21/2024, revealed a problem of I require tube feeding, I receive Diabetisource 250ml every 8 hours with 150ml flush every 8 hours. Interventions included: I am dependent with tube feeding and water flushes. I will have a RD to evaluate quarterly and as needed. Monitor caloric intake, estimate needs. Make recommendations for changes to tube feeding as needed. The care plan had not been updated to reflect the 07/05/2024 RD recommendations for Diabetisource AC at 45 ml/hr + 150 ml q 6hrs (or 25 ml/hr. flushes if continuous). Review of Resident #26's clinical record revealed a Registered Dietician Nutritional Assessment: Summary Note: dated 07/04/2024, which read in part: NPO w/ tube feedings: Diabetisource 250ml q 8 hrs + 150ml flush q 8 hrs. Providing: 900 kcals, . Recommend: To more closely meet estimated nutrition needs increase Diabetisource to 250ml carton q 6 hrs + 150 ml flush q 6 hrs. Will provide 1200 kcals, 60 gm protein and 818 mls free water (1418 mls TFW). Signed by S19 RD. Review of an email correspondence revealed the following was sent to several employees including S2 DON, S7 ADON and S4 RN Clinical Coordinator: 07/04/2024 at 2:03 p.m. - S19 RD sent recommendations to increase Diabetisource from 250 ml every 8 hours, to Diabetisource 250 ml every 6 hours. 07/05/2024 at 8:52 a.m. - S7 ADON responded to S19 RD, and requested the continuous rate for a feeding pump. 07/05/2024 at 10:23 a.m. - S19 RD responded with recommendation for Diabetisource AC at 45 ml/hr + 150 ml q 6 hrs (or 25 ml/hr. flushes if continuous). Will provide 1296 Kcals, 65 gm protein, 883 mls free water (1422 mls TFW). Review of Resident #26's Electronic Medication Administration Record (EMAR) for July 2024 revealed she received Diabetisource 25 ml/hr from 07/05/2024 through 07/15/2024. Review of Resident #26's medical record revealed the following weights which represented a significant weight loss of 7.79% between 07/05/2024 and 07/16/2024: 06/19/2024 125.8 lbs Wheelchair 07/02/2024 125.8 lbs Wheelchair 07/05/2024 123.2 lbs Wheelchair 07/16/2024 113.6 lbs Wheelchair Review of Resident #26's progress notes revealed that on 07/13/2024 at 12:41 p.m. S6 LPN wrote Resident states that she is feeling hungry and nauseated and feels like she is losing too much weight. Gave her Zofran and it was ineffective. She is requesting to have her feedings increased. Called and left message for the physician. Will continue to monitor. An observation and interview on 07/15/2024 at 10:26 a.m., revealed Resident #26 had a feeding pump infusing Diabetisource AC at 25 ml/hr., with the water flush set at 150 ml/6hrs. At that time, Resident #26 typed I'm hungry, I'm losing weight on her phone, then typed I'm getting one capful of feeding an hour. During that time, Resident #26's daughter entered the room, and said her mother's tube feeding was not enough, and she had lost weight. Resident #26's daughter explained she was here today to talk to someone about her mother's tube feeding, and being hungry. An observation on 07/16/2024 at 9:04 a.m. revealed Resident #26 in her room with a tube feeding pump infusing Diabetisource AC at 45 ml/hr with the water flush set at 150 ml every 6 hours. Resident #26 was smiling and typed feeling better. An interview on 07/16/2024 at 2:49 p.m. with S4 RN Clinical Coordinator, revealed she was responsible for carrying out dietary recommendations for Resident #26 on 07/05/2024. She indicated that Resident #26 was NPO with tube feedings, and getting bolus feedings of Diabetisource AC 250ml every 8 hours, and flushed with 150ml of water every 8 hours. S4 RN Clinical Coordinator said that Resident #26 was assessed by S19 RD on 07/04/2024, with recommendations to increase Diabetisource to 250ml carton every 6 hours, and flush with 150 ml of water every 6 hours, to increase Resident #26's caloric intake from 900Kcals to 1200Kcals. S4 RN Clinical Coordinator stated that on 07/05/2024, S7 ADON requested S19 RD give her the rate for continuous feeding on a pump because Resident #26 was staying long-term. She stated that the S19 RD sent an email on 7/05/2024 recommending Diabetisource AC at 45 ml/hr. S4 RN Clinical Coordinator stated that she called S10 NP and misread the recommendation to S10 NP. S4 RN Clinical Coordinator indicated that she put in the order as 25 ml/hr., instead of the recommended 45 ml/hr. S4 RN Clinical Coordinator stated I read the recommendation wrong. During an observation and interview of Resident #26 on 07/16/2024 at 3:12 p.m., when asked how she was feeling today, Resident #26 typed I feel better. Before I was hungry and nauseous after taking medicine on an empty stomach. Resident #26 then typed It felt like they were starving me and there was nothing I could do. I asked the nurse practitioner if I'm gonna die. An observation on 07/16/2024 at 3:32 p.m. revealed Resident #26 being weighed in the Therapy room in her wheelchair. Resident #26's weight was 113.6 pounds. An interview on 07/16/2024 at 4:00 p.m. with S2 DON and S20 QI Nurse, revealed there was not one standard facility process for obtaining, communicating and carrying out dietary recommendations. S2 DON stated the clinical coordinator for each house was responsible for obtaining and carrying out the dietary recommendations for their residents. S2 DON reported that the facility did not have a system for ensuring recommendation from the Registered Dietician were accurately communicated and accurately entered. S20 QI Nurse, stated We don't have one, but we will have one today. An interview on 07/16/2024 at 4:55 p.m. with S7 ADON revealed that she was the direct supervisor for S4 RN Clinical Coordinator. S7 ADON reported she amended the order for Resident #26 on 07/09/2024 to reflect on the EMAR for the day and night shift. However, S7 ADON stated that she did not review the rate of the infusion, and did not compare the order to the dietary recommendations. S7 ADON confirmed Resident #26 should have been getting 45 ml/hr of Diabetisource instead of the 25 ml/hr she received from 07/05/2024 through 07/15/2024. A telephone interview on 07/17/2024 at 8:38 a.m. with S10 NP, revealed that he typically follows the Registered Dietician's recommendations. He stated That's what she specializes in. He reported he did not remember talking to S4 RN Clinical Coordinator about Resident #26's PEG feeding. He revealed that he would have followed the RD's recommendations for the 45ml per hour infusion rate. A telephone interview on 07/17/2024 at 09:09 a.m. with S19 RD, revealed she made recommendations to increase Resident #26's PEG feeding from Diabetisource 250ml every 8 hours to provide 900 Kcals to Diabetisource 250ml every 6 hours to provide 1200 Kcals to increase her caloric intake. S19 RD reported that S7 ADON emailed her and requested a continuous rate recommendation on 07/05/2024. S19 RD reported she recommended Diabetisource AC to be infused at 45 ml/hr, and flushed with 150 ml of water every 6 hours, or flush at 25 ml/hr if Resident #26 was on a continuous infusion. S19 RD confirmed that Resident #26 should have been receiving 45 ml/hr instead of 25 ml/hr, as recommended on 07/05/2024. S19 RD confirmed that receiving 25 ml/hr contributed to Resident #26's weight loss. An interview on 07/17/2024 at 12:05 p.m. with S2 DON revealed she was told by S6 LPN on 07/14/2024 about Resident #26 being hungry. S2 DON reported that she emailed S19 RD on 07/14/2024 about Resident #26's PEG feeding and complaints of hunger. S2 DON stated that S19 RD responded on 07/15/2024, and recommended to increase the tube feeding by 10ml every 4 hours until Resident #26 reached 45 ml/hr. S2 DON stated she was not aware of the issue with Resident #26's tube feeding rate until it was brought to her attention by the surveyor. A telephone interview on 07/17/24 at 12:15 p.m. with S6 LPN revealed that Resident #26 told her on 07/13/2024 around lunch time that she was hungry, losing weight and wanted her tube feeding to be increased. S6 LPN reported that she called Resident #26's attending physician and left a message, but never received a call back. S6 LPN stated that on 07/14/2024, towards the end of her shift, she saw S2 DON at the facility and reported to her what Resident #26 had said.

Based on observation and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections. The facility failed to ensure the following: 1. Staff performed proper hand hygiene during meal service. 2. Staff followed proper infection control practices during wound care. This deficient practice had the potential to affect all residents who reside in the facility. The total resident census was 108. Findings: 1. Observation on 07/15/2024 at 11:45 a.m. of meal service on X Hall dining room revealed S11 CNA assisted Resident #12, and Resident #33 whom were seated together at a table. Review of Resident #12's dietary card revealed she was a full assist with all meals. Review of Resident #33's dietary card revealed she required adaptive equipment: Sippy Cup, Weighted Utensils, and Divider Plate for every meal. Observation revealed S11 CNA assisted Resident #12, and Resident #33 while seated between each resident. S11 CNA physically touch assisted each resident, and did not perform hand hygiene between assisting the residents. Interview on 07/15/2024 at 12:00 p.m. with S11 CNA revealed Resident #12 and Resident #33 were to be assisted by staff with meals. S11 CNA revealed she did not perform hand hygiene between assisting Resident #12 and Resident #33, but should have. Interview on 07/15/2024 at 12:07 p.m. with S12 LPN confirmed staff were to perform hand hygiene between assisting residents during meal service. 2. Observation on 07/17/2024 at 10:04 a.m. revealed S9 Treatment Nurse performed wound care on Resident #19 while S13 Treatment Nurse assisted. S9 Treatment Nurse and S13 Treatment Nurse donned gown and gloves as Resident #19 required Enhanced Barrier Precautions. Wound care supplies were set up on a bedside table next to Resident #19's bed. The treatment cart remained parked on X Hall, outside of Resident #19's room door. S9 Treatment Nurse performed wound care and requested S13 Treatment Nurse obtain cal zinc ointment from the treatment cart on X Hall. S13 Treatment Nurse then exited Resident #19's room and entered hallway without doffing gown and gloves that were used during high contact resident care. Interview on 07/17/2024 at 10:20 a.m. with S13 Treatment Nurse confirmed she should have removed gown and gloves prior to exiting Resident #19's room to gather supplies from the treatment cart on X Hall that contained clean supplies.

Based on record review and interview, the facility failed to adequately monitor 1 (#18) resident out of 5 (#1, #18, #58, #71, & #82) reviewed for unnecessary medications. The facility failed to adequately monitor Resident #18 for edema while on a diuretic and for side effects and effectiveness while on an antidepressant. Findings: Review of Resident #18's medical record revealed an admitted [DATE] with diagnoses that included in part .Alzheimer's Disease, Heart Failure, Hypertension, and Other Depressive Disorders. Review of Resident #18's Quarterly MDS with an ARD of 06/26/2024 revealed a BIMS score of 4, which indicated severe cognitive impairment. Review of the MDS revealed the resident required partial to moderate assistance with eating, substantial to maximal assistance with toilet hygiene and sitting to standing, and partial to moderate assistance with sitting to lying and lying to sitting on side of bed. Review of Resident #18's current physician's orders revealed the following orders: 09/29/2023: Furosemide (a diuretic) Tablet 40 mg-Give 40 mg by mouth one time a day for edema 09/28/2023: Lexapro (an antidepressant) Tablet 5 mg-Give 5 mg by mouth one time a day for depression Review of Resident #18's current care plan revealed in part the following . I have depression related to Dementia. Interventions included .I will remain free of signs and symptoms of distress, symptoms of depression, anxiety or sad mood by/through review date. I will have administer medications as ordered. Monitor/document for side effects and effectiveness. I have hypertension related to Congestive Heart Failure. Interventions included .Administered my anti-hypertensive medications as ordered. Monitor for side effects such as orthostatic hypotension and increased heart rate and effectiveness. I will be monitored for and document any edema. Notify MD. Review of the July 2024 MAR revealed no documentation for monitoring for edema related to Lasix or monitoring for effectiveness or side effects related to the use of Lexapro. In an interview on 07/17/2024 at 3:35 p.m., S8 Clinical Coordinator confirmed there was no documentation in Resident #18's medical record of monitoring for edema, monitoring for side effects of Lexapro, or monitoring for effectiveness of Lexapro and confirmed there should be.

Based on observation, record review, and interview, the facility failed to ensure appropriate care and services had been provided for 1(Resident #19) of 1 resident reviewed for dialysis. The facility failed to ensure a Dialysis Communication Form was completed to include the resident's status prior to sending resident to dialysis facility. The total Sample Size was 34. Findings: Record Review revealed Resident #19 was admitted to the facility on [DATE]. Resident #19 had diagnoses that included in part . Chronic Kidney Disease, Stage 5, Type 2 Diabetes Mellitus, Congestive Heart Failure, Unspecified Protein Calorie Malnutrition, Dependence on Renal Dialysis, Chronic Pulmonary Edema, Cerebral Infarction, and Generalized Muscle Weakness. Review of Resident #19's Quarterly MDS with an ARD of 04/10/2024 revealed Resident #19 had a BIMS of 15 (cognition intact). Review of Resident #19's Care Plan with target completion date of 10/15/2024 revealed the following in part . I have chronic Kidney disease. I have a Catheter site to Right Chest Wall. Interventions included in part . Hemodialysis Tuesday, Thursday, Saturday. Interview on 07/16/2024 at 9:13 a.m. with Resident #19 revealed she received dialysis service Tuesday, Thursday, and Saturday. Resident #19 was observed with a right upper chest wall catheter for dialysis services. Resident #19 stated the nurses send her to dialysis with a binder. Review of Resident #19's Dialysis communication binder on 07/16/2024 at 9:35 a.m. revealed on 05/02/2024, 05/04/2024, 05/07/2024, 05/16/2024, 05/18/2024, 05/25/2024, 05/30/2024, 06/04/2024 and 06/18/2024 the dialysis communication forms were not completed by facility staff to include in part .problems or concerns noted since last visit, current diet, current fluid restrictions, and vital signs. Interview on 07/16/2024 at 9:41 a.m. with S12 LPN revealed nursing staff was responsible to complete a dialysis communication form to send with residents prior to dialysis. S12 LPN revealed any medications, vitals, and changes resident had since last dialysis treatment was to be documented on the dialysis communication form. Interview on 07/16/2024 at 10:40 a.m. with S2 DON revealed nursing staff assessed residents prior to sending the resident out for dialysis. S2 DON revealed the nurse was to document vitals and any necessary information that needed to be communicated to the dialysis center on the Dialysis Communication form. S2 DON revealed that Dialysis Communication form was sent with the resident to dialysis. S2 DON reviewed Resident #19's 05/2024- 07/2024 Dialysis communication forms. S2 DON confirmed on 05/02/2024, 05/04/2024, 05/07/2024, 05/16/2024, 05/18/2024, 05/25/2024, 05/30/2024, 06/04/2024 and 06/18/2024 dialysis communication forms were not completed prior to sending Resident #19 to dialysis, but should have been. Telephone interview on 07/17/2024 at 9:44 a.m. with RN at contracted Dialysis Facility revealed she reviewed communication binder for all residents who present to dialysis. RN stated she reviewed the form to review vitals when residents present to dialysis. RN stated the dialysis staff documented vitals and any other pertinent information post treatment on the same communication form. RN stated the facility frequently did not complete the dialysis communication form prior to sending residents for dialysis.

Based on observation, interview, and record review, the facility failed to ensure Residents who are unable to carry out ADLS (Activities of Daily Living) received the necessary services to maintain good grooming and personal hygiene for 2 (#33 and #77) of 7 (#4, #5, #26, #30, #33, #42, and #87) Residents reviewed for ADL's. The facility failed to ensure a Resident (#33) received nail and oral care, and failed to ensure a Resident (#77) received incontinent care. The total Sample Size was 34. Findings: Review of the facility policy titled: Activities of Daily Living (ADLs), Supporting dated 03/2018 read in part . Appropriate care and services will be provided for Residents who are unable to carry out ADLs independently, with the consent of the Resident and in accordance with the plan of care including: a. Hygiene (bathing, dressing, grooming, and oral care.) c. Elimination (toileting). Resident #33 Review of Resident #33's Electronic Health Record revealed Resident #33 was admitted to the facility on [DATE]. Resident #33 had diagnoses that included in part . Alzheimer's Disease, Parkinson's Disease with Dyskinesia, Generalized Muscle Weakness, Anxiety Disorder, Dementia, and Epilepsy. Review of Resident #33's Quarterly MDS with ARD of 05/15/2024 revealed Resident #33 had a BIMS of 06 (Severe Cognitive Impairment). Resident #33 required Substantial/Maximal Assistance from staff for Eating, Oral Hygiene, Toileting, Showering/Bathing, Dressing, and Personal Hygiene. Review of Resident #33's Care Plan with a target completion date of 08/14/2024 revealed in part . ADL self-care deficit related to Cerebrovascular Disease and Parkinson's. Interventions included: Extensive assistance by (1) staff with personal hygiene and oral care. I will have oral care routinely: brush teeth, rinse mouth with wash. Observation on 07/15/2024 at 10:54 a.m. of Resident #33 revealed a thick white substance in her mouth and on teeth, with strong mouth odor. Resident #33 revealed staff did not help her brush her teeth. Resident #33 stated I have to do all that, they do not help me. Resident #33 was observed with long, dirty finger nails with brown substance beneath nail beds. Observation on 07/16/2024 at 10:03 a.m. of Resident #33 revealed a thick white substance in her mouth and on teeth, with strong mouth odor. Resident #33 stated staff did not brush her teeth, or clean her face today. Resident #33 observed with long length nails, with brown substance beneath the nail beds. Resident #33 stated she liked her nails trimmed short, and would like staff to clean them. Interview on 07/16/2024 at 10:07 a.m. with S12 LPN revealed Resident #33 was bathed on Tuesdays, Thursdays, and Saturdays, and CNA's were to perform personal and oral hygiene on resident's daily. S12 LPN stated it was the responsibility of the night shift CNA's to get Resident #33 up, ready, and perform personal/oral hygiene. S12 LPN observed Resident #33 and confirmed Resident #33 was in need of oral and nail care. 44844 Resident #77 Review of Resident #77's Electronic Health Record revealed Resident #77 was admitted to the facility on [DATE], with diagnoses that included in part .Paroxysmal Atrial Fibrillation, Secondary Malignant Neoplasm of other Digestive Organs, Restless Leg Syndrome, Major Depressive Disorder, Muscle Wasting and Atropy Left and Right Shoulder, Other Lack of Coordination, Unspecified Osteoarthritis, Shortness of Breath and Urinary Tract Infection. Review of Resident #77's Annual MDS with an ARD of 06/26/2024, revealed a BIMS score of 12 (moderately impaired cognition). Resident #77 was dependent with toileting and bathing, and required the assistance of 2 or more staff. Resident #77 had impairment on both sides of lower extremities and was incontinent of both bowel and bladder. Review of Resident #77's Care Plan with a target date of 09/26/2024, revealed in part .ADL self-care performance related to muscle weakness. Approaches included: Toilet Use - I am not toileted. I am dependent on staff for incontinence care of bowel and bladder. Interview on 07/15/2024 at 10:47 a.m. with Resident #77 revealed staff did not change her incontinent brief while she was in her wheelchair. Resident #77 revealed staff had to use a mechanical lift to transfer her from the bed to wheelchair, and vice versa. Resident #77 revealed the 7:00 a.m. to 3:00 p.m. staff assisted her up to her wheelchair in the mornings, and the evening shift assisted her back to bed between 3:30p.m. - 4:00 p.m. Resident #77 revealed staff assisted her up to her wheelchair between 8:30 a.m. - 9:00 a.m. this morning. Resident #77's sister was in the room and stated she was worried that Resident #77 would develop a Urinary Tract Infection from sitting in her urine for long periods of time. Observation and interview on 07/15/2024 at 1:00 p.m. revealed Resident #77 in therapy. Resident #77 stated she had not been changed. Observation and interview on 07/15/2024 at 2:25 p.m. revealed Resident #77 sitting in a wheelchair in her room. Resident #77 stated staff had not offered to change her. Resident #77 revealed she had called for assistance to be changed in the past, but it made her feel uncomfortable to ask, because staff knew they were suppose to change her every 2 hours. Interview on 07/16/2024 at 10:00 a.m. and 10:30 a.m., with S14 [NAME] Clerk, revealed Resident #77 left the facility around 9:10 a.m. that morning for an appointment, and returned to the facility around 10:15 a.m. Observation and interview on 07/16/2024 at 11:00 a.m. with Resident #77 revealed she was in therapy in a wheelchair. Resident #77 revealed she had not received incontinent care since she returned from her appointment around 10:00 a.m. today. Resident #77 stated she asked S15 CNA to change her before she went to therapy this morning, but S15 CNA told her she would change her after therapy. Resident #77 stated on yesterday (07/15/2024), 3:00 p.m. to 11:00 p.m. staff assisted her to bed at 3:30 p.m. Resident #77 revealed she did not receive incontinent care from 9:00 a.m. until 3:30 p.m. on 07/15/2024. Interview on 07/16/2024 at 1:00 p.m. with S15 CNA, revealed she was the CNA assigned to Resident #77 on 07/15/2024 and 07/16/2024, on the 7:00 a.m. to 3:00 p.m. shift. S15 CNA revealed she assisted Resident #77 to her wheelchair yesterday (07/15/2024) between 8:00 a.m. and 9:00 a.m., and confirmed she did not provide incontinent care to Resident #77 for the remainder of her shift. S15 CNA stated the evening shift staff (3:00 p.m. to 11:00 p.m.), would assist Resident #77 back to bed. S15 CNA revealed Resident #77 was a heavy wetter and she should have provided incontinent care for Resident #77. S15 CNA revealed on 07/16/2024 she assisted Resident #77 up to her wheelchair (didn't remember the exact time). Resident #77 left the facility around 9:10 a.m. for an appointment. S15 CNA stated Resident #77 asked her to be changed, and she told Resident #77 to wait until after therapy. S15 CNA revealed she was aware that incontinent residents should be changed at least every 2 hours. Interview on 07/16/2024 at 1:05 p.m. with S8 RN Clinical Coordinator, revealed residents should be checked by staff at least every 2 hours for incontinent episodes, and changed as needed. S8 RN Clinical Coordinator confirmed Resident #77 was assisted to her wheelchair between 9:00 a.m. and 10:00 a.m., and assisted back to bed between 3:00 p.m. and 4:00 p.m. on 07/16/2024. S8 RN Clinical Coordinator revealed when Resident #77 returned from her appointment this morning she should have been given incontinent care. S8 RN Clinical Coordinator stated S17 CNA Household Coordinator was responsible for ensuring staff were providing incontinent care to dependent residents. Interview on 07/16/2024 at 1:11 p.m. with S17 CNA Household Coordinator revealed she was responsible for ensuring staff provided incontinent care for dependent residents. S17 CNA Household Coordinator revealed Resident #77 should have received incontinent care at least every 2 hours. S18 CNA stated she was unaware that Resident #77 was not provided incontinent care timely. Observation on 07/16/2024 at 1:30 p.m., revealed S15 CNA, S16 CNA and S17 CNA Household Coordinator assisted Resident #77 to bed using a mechanical lift. Resident #77 had on 2 adult briefs which were wet, and had a strong urine odor. Interview on 07/16/2024 at 1:39 p.m. with S8 RN Clinical Coordinator revealed Resident #77 wore 2 adult briefs because she was a heavy wetter. Interview on 07/16/2024 at 1:44 p.m. with S2 DON confirmed Resident #77 should have been changed when she asked to be changed, and should have been offered incontinent care at least every 2 hours.

Based on observations, interviews, and record review the facility failed to ensure that each Resident was treated with respect and dignity in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for 2 ( #19, and #32) out of 34 sampled residents. The facility failed to: 1. Ensure the privacy of Resident #19 while staff provided wound care. 2. Ensure staff did not stand while assisting Resident #32 during a meal service. Findings: Review of the facility's policy titled Dignity dated 02/2021 read in part . Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Residents are treated with dignity and respect at all times. Review of the facility's policy titled Assistance with Meals dated 03/2022 read in part . Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example: a. not standing over residents while assisting them with meals. Resident #19 Record Review revealed Resident #19 was admitted to the facility on [DATE]. Resident #19 had diagnoses that included in part . Chronic Kidney Disease, Stage 5, Type 2 Diabetes Mellitus, Congestive Heart Failure, Unspecified Protein Calorie Malnutrition, Dependence on Renal Dialysis, Chronic Pulmonary Edema, Cerebral Infarction, and Generalized Muscle Weakness. Review of Resident #19's Quarterly MDS with an ARD of 04/10/2024 revealed Resident #19 had a BIMS of 15(cognition intact). Resident #19 required Substantial/Maximal assistance from staff for toileting, showering/bathing, dressing, and personal hygiene. Review of Resident #19's Active Orders revealed in part . Clean Stage 2 Pressure Ulcer to coccyx with normal saline or wound cleanser, apply calazinc, apply collagen, and apply foam border dressing. Order date: 07/15/2024 Observation on 07/17/2024 at 10:04 a.m. revealed S9 Treatment Nurse and S13 Treatment nurse provided wound care to Resident #19. Upon entering Resident #19's room the window blinds was observed open, with a person outside of window cutting the lawn. S9 Treatment Nurse and S13 Treatment Nurse uncovered and undressed Resident #19's bottom half with window blinds opened, and Resident #19 remained exposed. Surveyor intervened and closed window blinds for resident's privacy. S9 Treatment Nurse stated she forgot to close the blinds prior to wound care treatment. Interview on 07/17/2024 at 1:33 p.m. with Resident #19 revealed she always kept her window blinds open. Resident #19 stated she did not realize that her blinds were open while she was undressed during wound care. Resident #19 stated I hope the man on the lawn [NAME] didn't see. Resident #19 revealed she would not have wanted anyone to see her undressed. Resident #32 Observation on 07/15/2024 at 12:10 p.m. of dining service revealed S12 LPN assisted Resident #32 with meal service in resident's room. S12 LPN was observed standing over the left side of Resident #32's bed while she fed resident. There were 2 chairs observed in resident's room. Interview on 07/15/2024 at 12:11 p.m. with S12 LPN confirmed she stood to assist Resident during meal service and stated she did not know she could not stand to assist residents with meals.

Based on record review, observation, and interview, the facility failed to ensure food served to residents was palatable and at an appetizing temperature for 1 (#2) of 3 (#1, #2, and #3) residents reviewed for dietary services. Findings: Resident #2 Review of Resident #2's medical record revealed an admitted [DATE] with diagnoses that included in part .Malignant Neoplasm of Left Breast, Seizures, Major Depressive Disorder, and Generalized Anxiety Disorder. Review of Resident #2's quarterly MDS with an ARD of 06/27/2023 revealed a BIMS score of 13 which indicated intact cognition. Review of the MDS revealed Resident #2 was independent with bed mobility, toilet use, transferring, and eating with set up help only. In an observation and interview on 10/09/2023 at 11:20 a.m., Resident #2 was observed eating lunch in the dining room of her household. Resident #2's tray had Salisbury steak, mashed potatoes and gravy, greens, cornbread, and water. Resident #2 stated she couldn't eat the Salisbury steak because it was cold and too hard to eat. On 10/09/2023 at 11:28 a.m., observation of the temperature log lying on the kitchen counter in Resident #2's household revealed no temperatures were recorded for today's lunch meal. In an interview at that time, S4 Homemaker confirmed no temperatures were logged for lunch today because she forgot to take the temperatures of the food before serving today. In an interview on 10/11/2023 at 8:26 a.m., S3 Dietary Manager stated S4 Homemaker was a brand new employee and had only worked at the facility for one week. S3 Dietary Manger confirmed S4 Homemaker should have checked the food temperatures before serving the lunch meal to the residents.

Based on record review and interview, the facility failed to ensure an allegation of physical abuse was reported immediately, but not later than 2 hours after the allegation was made, to the State Survey Agency for 1 (#2) of 3 (#1, #2, & #3) residents reviewed for abuse. Findings: Review of the facility's policy titled Abuse Components Plan, Elder Justice Act and Affordable Care Act revealed in part . Reporting 1. All alleged violations involving abuse, neglect, exploitation, mistreatment, injuries of unknown source, misappropriation of property/funds or a reasonable suspicion of a crime and/or other reportable incidents will be reported by the Administrator or designee, to the following persons or agencies as required to provide notification: a. LDH online tracking system, Statewide Incident Tracking System (SIMS). b. 2. An alleged violation involving abuse, neglect, exploitation, mistreatment, injuries of unknown source, misappropriation of property/funds, and/or any other reportable incident will be reported immediately, but no later than: a. Two (2) hours if the alleged violation involves abuse or has resulted in serious bodily injury; or Review of Resident #2's medical record revealed an admitted [DATE] with diagnoses that included in part .Malignant Neoplasm of Left Breast, Seizures, Major Depressive Disorder, and Generalized Anxiety Disorder. Review of Resident #2's quarterly MDS with an ARD of 06/27/2023 revealed a BIMS score of 13 which indicated intact cognition. Review of the MDS revealed Resident #2 was independent with bed mobility, toilet use, transferring, and eating with set up help only. Review of nurses' notes for Resident #2 revealed the following entry by S5 LPN: 09/09/2023 at 2:54 p.m.: Staff heard resident screaming for help. 4 CNAs attempted to enter room, Brother blocking door by standing in front of it so no one can enter. Staff entered room and brother yelling at resident that You can listen and try on these f_______ pants, then to hell with you. I ain't coming back to see you're a__. Resident stated he punched her in her chest on her surgery site to left breast and was threatening to punch her in the face. Staff made brother aware that this is abuse. He then stated he doesn't give a s___. He can touch her if he wants. Go to hell, kiss my a__ you b______. Nurse escorted him away from residents and hall for safety, reported occurrence to S2 DON, instructed to make report with City Police. In an interview on 10/11/2023 at 7:40 a.m., S5 LPN stated on 09/09/2023 she was sitting in the nurses' station talking with her aides when they heard Resident #2 yelling Help! S5 LPN stated the aides went around to check on her and came back and asked her to come now. S5 LPN stated Resident #2's brother was behind the door trying to keep it closed. S5 LPN said when they got it cracked open he jumped from behind the door and hurried over and sat on the bed. S5 LPN stated Resident #2 was sitting in her wheelchair guarding her chest, crying hysterically, and said, He hit me. S5 LPN stated the brother said I can touch you any way I want. I was trying to get you to try on these pants. S5 LPN stated Resident #2's bother cursed at the aides and he pulled his arm back like he was going to punch one of the CNAs. S5 LPN stated she told him he had to leave and directed him to the exit sign. S5 LPN stated she called S2 DON and S1 Administrator. S5 LPN stated she examined Resident #2 and stated there was some bruising but said she didn't know if it was caused by the recent surgery or this incident. S5 LPN stated Resident #2 refused to go out to be checked at the hospital. S5 LPN stated she called the police who came a short while later and spoke with her and Resident #2. In an interview on 10/10/2023 at 11:45 a.m., S2 DON stated on 09/09/2023 she received a phone call from S5 LPN who reported what had happened with Resident #2 and her brother. S2 DON stated S5 LPN had already asked him to leave and she told her to call the police. S2 DON stated she told S5 LPN he was not allowed back in the facility until an investigation was completed. S2 DON stated after the investigation, they determined Resident #2's brother would not be allowed back in the facility. S5 LPN stated during her investigation she talked with Resident #2 who did not tell her he hit her but that he yelled and cursed at her. S2 DON stated Resident #2 told her I just can't believe he would do that to me. S2 DON stated she did not see any visible sign of injury when she examined Resident #2. S2 DON stated she tried to call Resident #2's brother but he would not answer. S2 DON stated she told Resident #2 they could talk on the phone anytime and Resident #2 told her she was fine with that decision. In an interview on 10/11/2023 at 1:40 p.m., S1 Administrator stated when the incident occurred, they reported it to the police and began an investigation. S1 Administrator confirmed she did not report the allegation of abuse to the State Survey Agency within 2 hour of the allegation, as required. S1 Administrator stated she thought they had done everything they needed to do.

Based on observation, record review, and interview, the facility failed to ensure the physician was consulted, and orders were obtained for wound care for 1 (#161) resident out of 3 (#44, #93, #161) residents reviewed for pressure ulcers. Findings: Review of Resident #161's medical record revealed an admitted [DATE], with diagnoses that included in part .Type 2 Diabetes Mellitus, Hemiplegia and Hemiparesis following Cerebral Infarction affecting the right dominant side, and Muscle Wasting and Atrophy. Review of Resident's 05/23/2023 Admission MDS revealed a BIMS assessment could not be completed as Resident #161 was rarely or never understood. The MDS revealed Resident #161 required extensive two person physical assist with bed mobility, transferring, and toilet use; and extensive assistance of one person with eating. Review of Resident #161's nurse's note dated 06/23/2023 at 10:34 a.m. revealed in part .Resident #161 was sent to the ER for shortness of breath, left arm weakness. B/p 106/78, P 55 weak and thread, R 20, and O2 sat that dropped from 94 to 76. Review of the ER Practitioner record dated 06/23/2023 revealed in part . Extremities exam - other - right lateral Malleolus with pressure sore with foul smelling exudate. A = pressure sore to right ankle, anemia; P = admit, start Zosyn (an antibiotic), IV hydration, order blood for transfusion. Review of Resident #161's hospital records revealed in part . on 06/30/2023, Resident #161 had a sharp debridement, right foot down to and including bone. Review of Resident #161's hospital discharge summary dated 07/03/2023 revealed in part . discharge to home on IV antibiotics, family refused amputation. Review of a Progress Note dated 07/04/2023 by the NP (Nurse Practitioner) revealed a chief complaint of Status Post hospitalization for Sepsis. Review of the History of Present Illness revealed Resident #161 was hospitalized from 06/23/2023 through 07/03/2023, with increased white blood cell count, and wounds to the right malleolus and toe that were noted to be infected requiring debridement on 06/30/2023. The Progress Note stated General Surgery noted that bone was brittle and dead and recommended BKA (below the knee amputation), but family refused. The Progress Note stated Resident #161 was transferred back to the facility on IV antibiotics on 07/03/2023. The NP's plan on the Progress Note revealed Resident #161 had Sepsis likely secondary to right lower extremity wounds, a mild urinary tract infection, as well as Osteomyelitis of the right ankle. The NP's plan read to continue IV Vancomycin and Levaquin (antibiotics) and wound care. Review of Resident #161's Skin and Wound Evaluation by S6 LPN/Treatment Nurse dated 07/04/2023, revealed an unstageable pressure ulcer to the right lateral malleolus which measured 2.8 cm x 3.7 cm x n/a, that was acquired in-house on 06/09/2023. The evaluation revealed the wound bed was 20% epithelial coverage and 80% slough with moderate sanguineous/bloody exudate, and no odor present. The note section of the evaluation read as follows: Unstageable pressure ulcer to right lateral malleolus improving, clean with normal saline, apply Santyl, and cover with dry dressing. The notification section revealed the Nurse Practitioner was notified. During an observation on 07/11/2023 at 9:35 a.m., Resident #161 was observed lying in bed, and noted to have a dressing covering his right foot and ankle dated 07/04/2023, and S6 LPN/Treatment Nurse's initials. In an interview on 07/11/2023 at 9:36 a.m., the surveyor requested to observe wound care of Resident #161 on today, and was informed by S6 Treatment Nurse that Resident #161 was not due for wound care today (07/11/2023), and she couldn't find any orders for wound care in Resident #161's record. Review of Resident #161's EHR with S14 LPN and S5 ADON on 07/11/2023 at 9:41 a.m. revealed they were unable to find an order for wound care after Resident #161's discharge from the hospital on 07/03/2023. S5 ADON reviewed the Treatment Administration Record and confirmed there were no orders for wound care post Resident #161's hospital discharge on 07/03/2023, and no recent wound care had been documented. During an observation on 07/11/2023 at 9:43 a.m., S5 ADON observed Resident #161's dressing with surveyor, and confirmed Resident #161's dressing was last changed by S6 Treatment Nurse on 07/04/2023. S5 ADON stated wound care orders were not put back in the record after the resident returned from the hospital. Observation on 07/11/2023 at 10:40 a.m. revealed S2 DON and S6 Treatment Nurse along with other staff, evaluated Resident #161's wounds. Interview with S2 DON at that time revealed Resident #161 returned from the hospital on 07/03/2023 without wound care orders to the right malleolus and toe. S2 DON said the right malleolus was a stage 4 ulcer and should have had some wound care orders. S2 DON stated they would call the Nurse Practitioner and get wound care orders today (07/11/2023). In an interview on 07/12/2023 at 9:18 a.m., S5 ADON confirmed she was the Unit Manager over Resident #161's hall. S5 ADON stated the floor nurse puts in the orders when a resident returns from the hospital. S5 ADON stated the treatment nurse should evaluate the resident's skin on return from the hospital. S5 ADON stated if there were no wound care orders at that time, the treatment nurse should have called the doctor to obtain wound care orders. Review of Resident #161's Skin and Wound Evaluation by S6 LPN/Treatment Nurse dated 07/11/2023, revealed the right lateral malleolus pressure ulcer was staged as a Stage 4 and measured 5.8 cm x 5.1 cm x n/a. The evaluation revealed the wound bed was 90% granulation and 10% slough with no evidence of infection and no exudate or odor. Review of the wound evaluation revealed the progress was documented as deteriorating. Observation on 07/12/2023 at 10:59 a.m., of wound care for Resident #161, and interview with S6 Treatment Nurse at that time revealed Resident #161 returned from the hospital on 07/03/2023 after she had already left for the day, so she assessed his wounds on 07/04/2023. S6 Treatment Nurse stated she was off work after the 4th until yesterday, 07/11/2023. S6 Treatment Nurse stated Resident #161's pressure wound to his right ankle was open on 07/04/2023, but not as deep as it is today. S6 stated there was another treatment nurse or the weekend RN who should have done wound care while she was off work. S6 Treatment nurse reported she didn't call the NP on 07/04/2023 as documented in Skin and wound Evaluation note dated 07/04/2023, and must have used the old wound care orders to clean with normal saline, apply Santyl, and cover with dry dressing. In an interview on 07/12/2023 at 11:25 a.m., S15 NP stated he was notified by staff on 07/11/2023 that Resident #161 had not received wound care from 07/04/2023 through 07/11/2023. S15 NP confirmed staff should have called him to get wound care orders, but did not. S15 NP acknowledged that Resident #161's pressure ulcer to the right lateral malleolus probably needed daily wound care. In an interview on 07/12/2023 at 11:55 a.m., S2 DON confirmed Resident #161 had not received wound care from 07/04/2023 to 07/11/2023, when this surveyor brought it to their attention. S2 DON stated they didn't receive any wound care orders on hospital discharge orders, but staff should have called the NP to obtain orders. Interview of S16 RN/ADON on 07/12/2023 at 12:00 p.m. revealed she documented some of the assessment of Resident #161's wound to the right ankle that was done on 07/11/2023; however, S6 Treatment Nurse documented that it had deteriorated. S16 RN/ADON stated on assessment of the wound on 07/11/2023, the wound was pink and beefy, but had increased in depth and size. S16 RN/ADON stated she didn't see the wound on 07/04/2023, and didn't have anything to compare it to.

Based on interview and record review the facility failed to ensure a resident's environment remained as free of accident hazards as is possible for 1 (#3) of 5 (#1, 2, 3, 4, and 5) sampled residents out of a total of 64 residents who were wheelchair bound and transported via the facility's wheelchair accessible conversion van. The facility failed to: 1. ensure S4 CNA van driver was not allowed to continue to transport wheelchair bound residents in the facility's conversion van after S4 CNA van driver was involved in two (2) incidents (08/07/18 and 09/11/18) in which resident #3, a wheelchair bound resident, was not properly secured in the van while the van was in motion. This failed practice resulted in an immediate jeopardy situation for resident #3 which began on 09/11/18 at 6:30 a.m. when resident #3 was placed in the conversion van on 9/11/18 at 6:45 a.m. When the van was in motion, the resident slid out of his wheelchair on his buttock, scratching his left pointing finger and hitting his head on the back of the seat after the van brakes were applied and the van came to a sudden stop. S4 CNA had not buckled resident #3's seatbelt. The resident had already fallen on 8/7/18 when the same van driven, S4CNA, placed the resident in the van and while in route to a doctor's appointment, the resident's wheelchair tilted over backwards and the resident hit his head on the floor. On 08/07/18, the S4CNA attached the safety belts to the wheels of the wheelchair and not to the frame of the wheelchair. S1 Administrator was notified of the deficient practice at the immediate jeopardy level on 09/18/18 at 2:37 p.m. The immediate jeopardy situation and was removed on 09/18/20 at 4:03 p.m. when the facility provided an acceptable plan of removal which included the following: 1. No back up transportation driver allowed to drive residents until completely in-serviced and check off completed. 2. Primary transportation driver will be in-serviced and checked off when returns from appointment. She is currently in Alexandria. 3. Maintenance will in-service and complete check off on all transportation drivers, with return demonstration. 4. Administrator will compete in-service and check off Maintenance. 5. Maintenance or Administrator will monitor transportation drivers 1 per day to ensure that residents are secured in the van appropriately - straps for wheelchair and seatbelts, for 2 weeks, then 2 per week for 2 months. 6. Transportation drivers will be observed and checked on in-service every 6 months. 7. Any new driver hired/added will be in-serviced and have check off completed before being allowed to drive the vans. 8. S4 transportation driver will no longer be allowed to drive the van. 9. Affected resident received no injury and will be transported by new driver who has been properly trained at 6:10 a.m., 19 (MONTH) (YEAR) by Maintenance Supervisor. 10. All residents that are transported via wheelchair have the potential to be affective by the deficient practice. All other drivers were in-service on 18 (MONTH) (YEAR) at 3:25 p.m. by Maintenance Supervisor on the proper method of securing the wheelchair to the van and proper method of attaching seatbelt for residents. Return demonstration was provided by all drivers and observed by Maintenance Supervisor with 100% accuracy. 11. Policy and Procedure review was conducted. New policy and procedure will be developed. The Driver that allowed the incident to happen will no longer transport residents in van. New drivers will be properly in-service by Maintenance Supervisor or Administrator on how to properly secure the wheelchair to the van and proper use of the seatbelt before allowed to transport wheelchair bound residents. Employees must be able to provide return demonstration and a written posttest with a score of 100% accuracy to determine competency. Documentation of in-service and return demonstration competency will be recorded on facility Driver Check Off List form by Maintenance Supervisor or Administrator, upon hire and every 3 months. 12. Maintenance Supervisor or Administrator will monitor each scheduled transportation driver daily, for one scheduled transport run, Monday through Saturday for 2 weeks to ensure that residents are properly secured in the van which includes both sets of straps to secure the wheelchair to the van and seatbelts applied to the resident. Monitoring will continue two times a week for two months. Quality Assurance Committee will meet weekly to evaluate the plan and process, so they can make revisions, recommendations, or resolution to the plan. 13. Completion date - 28 (MONTH) (YEAR). This deficient practice continued at a potential for more than minimal harm for 64 residents who are transported in the facility's vans. Findings: Review resident #3's EHR revealed he was admitted to the facility on [DATE] and readmitted on [DATE] with a [DIAGNOSES REDACTED]. Review of the resident's [DIAGNOSES REDACTED]. Review of the resident's 30 Day Medicare MDS revealed a BIMS of 11 (moderately impaired cognitively). The MDS further revealed the resident's Functional Status as follows: Bed Mobility - Extensive 2 + person assist, Transfer - Extensive 2+ person assist, Walk in room and corridor - Activity did not occur, Locomotion on and off unit - Extensive one person assist, Eating - Extensive one person assist, Toilet Use - Extensive 2+ person assist, Personal Hygiene - Extensive one person assist, and Bathing - Total Dependence. The resident was also coded for wheelchair use as a mobility device. Review of the resident's Plan of Care with a target date of 11/07/18, revealed a problem of I am at risk for falls r/t Gait/balance problems, Vision/Hearing problems. I have had no falls since admit to facility. Needs extensive assist with transfers. Has refused PT/OT in the past. Has a Right AKA and (DC 7/25/18) wound to left foot. I have a Left AKA. Fall 8/7/18, 9/11/18. Care plan approaches included: Fall 8/7/18. Staff in-serviced on securing wheelchair on van. Fall 9/11/18. Staff in-serviced on securing seat belts while on transportation. Review of a NCCC Transportation Drivers List revealed the following staff were listed as drivers: S2 HHC, S6 HHC, S5 HHC, S4 CNA and S3 CNA. Review of a Progress Note for resident #3 dated 8/7/18 at 9:19 a.m. read as follows: Late Entry (no date or time) - Transportation had loaded resident into facility van in an attempt to transport resident to doctor's appointment. Once the resident was loaded and all brakes on and latches secured, the resident's wheelchair tilted backwards and the resident fell over. Review of an in-service given by S7 Maintenance Staff dated 8/7/18 revealed the signatures of S2 HHC, S5 HHC, S6 HHC and S4 CNA. The in-service was to show proper way to secure wheelchairs down in vans and use of seatbelt. Review of a Progress Note for resident #3 dated 9/11/18 at 6:45 a.m. revealed the following: A CNA reported to the nurse that the resident refused his bath tonight and complained of pain in his stumps (sore) and hurting due to him falling on the transportation van this morning on his way to an appointment. The resident stated the driver had to stop suddenly due to traffic and he slid out of his wheelchair onto his buttock, scratching his left pointing finger and hitting his head on the back of the seat. Transportation CNAs then put him back in his wheelchair and proceeded to his appointment. The nurse contacted the transportation driver on the unreported fall, and the CNA stated yes, resident did fall out his chair on the van and she reported the incident to the Administrator. Interview of S1 Administrator on 9/17/18 at 10:48 a.m. revealed S4 CNA came to him early one morning (stated he was not sure of the date), and reported while enroute to an out of town appt with resident #3 in the van, S4 CNA had to suddenly apply her breaks causing the resident to slid out of his wheelchair to the floor. S1 Administrator stated that S4 CNA said the wheelchair was secured; however, the resident's seat belt was not buckled. The S1 Administrator said that he could not believe that this had happened again since an incident had occurred involving S4 CNA and resident #3, in which resident #3's wheelchair was attached by safety belts to the wheels of his wheelchair and not the frame as it should have been, and the resident fell because the wc tilted backwards. The Administrator stated he did not in-service the other drivers specific to seatbelt placement after the incident on 09/11/18 because they had already been in-serviced after the first incident involving resident #3 on 8/7/18. Review of an in-service provided to the surveyor by S1 Administrator on 9/17/18 at 11:00 a.m. revealed an in-service was done on 9/12/18 with S3 CNA and S4 CNA regarding Secure Resident Wheelchair on Van and to cover Seatbelt Usage. There were no other van driver signatures on the in-service sheet. Interview of S7 Maintenance Staff on 09/18/18 at 10:24 a.m. revealed he in-serviced van drivers once a year, when there is a new van driver, and if something occurs on the van. He stated that he demonstrated seatbelt safety and how to lock the wheelchair in the van on 8/7/18; however, he did not have the drivers do a return demonstration. He further stated that the in-service on 08/07/18 was done after an accident occurred on the van that involved S4 CNA and resident #3. Interview of S2 HHC on 09/18/18 at 10:34 a.m. revealed the following: S2 HHC stated that she has been employed at the facility for [AGE] years, and has driven the facility's vans for [AGE] years. She stated she worked from 8:00 a.m. to 4:00 p.m., and was resident #3's Household Coordinator. Resident #3 had not returned to the facility on [DATE] prior to her getting off work. S2 HHC stated that she heard about the incident of resident #3 falling while being transported in the van (09/11/18), on the night of 09/11/18 when S8 CNA called her and told her that she was trying to give the resident a bath and he refused because he said he fell on the van that day. S2 HHC stated she told S8 CNA to notify the nurse (S9 LPN). Further interview of S2 HHC revealed she was in-serviced on van safety for residents when she was hired, and recently on 8/7/18 in which S7 Maintenance Staff demonstrated how to secure a wheelchair in the van and secure the seatbelt. She stated that she then demonstrated wc and seatbelt safety while the others looked on. She stated no one else returned a demonstration. S2 HHC stated that she had not been re-inservice after the 09/11/18 incident. Interview of S5 HHC on 09/18/18 at 10:34 a.m. confirmed she was in-serviced on van safety for residents when she was hired, and recently on 8/7/18 in which S7 Maintenance Staff demonstrated how to secure a wheelchair in the van and secure the seatbelt. She stated she did not return a demonstration on 08/07/18. She also stated that she recently (couldn't remember the date) had to call S4 CNA when she was sent to pick up a resident from the wound care clinic, and was unable to secure the wc in the van. She stated S4 CNA went to the clinic and secured the wc. S5 HHC further stated that she had not been re-trained after the 09/11/18 incident. Interview of S6 HHC on 09/18/18 at 10:43 a.m. revealed that although she was in-serviced on driving the van and resident safety on the van, she has not driven the van, and was not re-inservice after the 09/11/18 incident. Telephone interview on 09/18/18 at 11:12 a.m. of the physician's nurse who saw resident #3 on 09/11/18 revealed the resident was seen by the doctor for follow-up for his Stump. She stated he complained of pain in his R Shunt area during that time. She stated there was no documentation in resident #3's chart that the resident or the van driver stated to the doctor that the resident had fallen in the van prior to his appointment. She stated there was no documentation of any injuries. Telephone interviews of S8 CNA and S9 LPN on 09/18/18 at 11:22 a.m. were unsuccessful. Telephone interview of S4 CNA on 09/18/18 at 11:26 a.m. revealed the following: S4 CNA stated resident #3 was loaded on the van around 6:30 a.m. on 09/11/18, and confirmed that on 09/11/18, she did not put the seatbelt on resident #3, and that it just slipped her mind to do so. She stated that she had to apply her breaks while enroute to a MD appt, and the resident slid out of the chair. She stated that S3 CNA was with her, and they picked him up and put him back in the wc. When she got to the doctor's office she informed the nurse about the incident. S4 CNA stated that she arrived back at the facility with the resident on 09/11/18 between 10:30 a.m. and 10:45 a.m., and immediately looked for the nurse (who she found out had left the faciity on a personal errand). She stated the Corporate Nurse was not there so she told the S1 Administrator about the incident. She stated she continued on with transportation on that day. Further interview of S4 CNA revealed she drove on 09/12/18, and drove resident #3 to an out of town appt on 09/13/18. She stated her last day to drive was 09/13/18. Interview of the S1 Administrator on 09/18/18 at 11:40 a.m. revealed S12 Ward Clerk was the van drivers' supervisor. He stated the facility had no manufacturer's brochure or guidance on using the van's safety equipment, and how to secure residents in wcs in the van. He stated that CCC used the same company for vans and S7 Maintenance Staff took a Train the Trainer training, and trained as a result of how he was trained. The S1 Administrator also stated that he did not have a policy on wc safety in the vans. Interview of S12 Ward Clerk on 09/18/18 at 11:45 a.m. revealed she handled the schedule for the van, and was the supervisor of sorts for van drivers. She stated she observed S4 CNA return to the facility on [DATE] with resident #3, and go into the Administrator's office. She stated that she learned that the resident had fallen out of the wc while on the van that day. She stated that she told S4 CNA to let S3 CNA drive on 9/12/18 because she had been trained and cleared to drive. She further stated that she did not specifically tell S4 CNA not to drive the van anymore until well into the day on 09/12/18 (could not remember the time of day). Further interview of S12 Ward Clerk and review of her calendar revealed S4 CNA drove the van on 9/12/18 for appts scheduled for 6:00 a.m., 6:30 a.m. (resident #3), and 11:30 a.m. S12 Ward Clerk stated she was not made aware until yesterday (9/17/18) that S4 CNA had driven resident #3 to an out of town appt on 9/13/18. Review of a documentation of drivers, dates and wheelchair residents driven in the van for the month of 09/2018 revealed S4 CNA transported 1 other resident in the van on 09/13/18. Interview of S3 CNA on 09/18/18 at 11:55 a.m. revealed she started driving the facility's van by herself on Friday 9/14/18. She confirmed she and S4 CNA drove resident #3 to an out of town appt in the van on 9/13/18, and that S4 CNA drove the van. She stated that on 9/11/18, the resident slid out of his wheelchair when S4 CNA had to break suddenly. S3 CNA stated that S4 CNA secured the resident in the van prior to them leaving for his appt on 9/11/18. S3 CNA stated that she had not been re-inservice since the 09/11/18 incident with resident #3.