Every finding on record at Neurorestorative

Based on observation, interview, record review and document review the facility failed to ensure a vulnerable pediatric resident was free from neglect when for 1 of 3 sampled residents (Resident 1). The deficient practice had the potential to result in access to electrical outlets, sharp objects, oxygen tanks, tubing, cords and other environmental hazards including placing objects in the mouth which could cause choking, entanglement or serious injury.Findings include:Resident 1 (R1) was admitted on [DATE], and readmitted on [DATE], with diagnoses including delayed milestone in childhood and child in welfare custody.The facility report dated 06/24/2026, documented child neglect involving R1, a one-year and five-month-old with delayed developmental milestones. The report indicated that on 06/23/2026, R1 closed the door on self, leaving R1 contained in the room, and was found face down with a baby gate lying on top of them. The facility investigation documented the Licensed Practical Nurse (LPN) placed R1 on a floor mat without providing direct supervision, and the Certified Nursing Assistant (CNA) failed to complete resident rounds before leaving the pod for a lunch break.On 08/06/2026 at 9:00 AM, R1 was observed sitting and crawling in a playpen with toys in the pod. A Registered Nurse (RN) and a Certified Nursing Assistant (CNA) assigned to R1 were observed providing care to another resident while R1 remained in the playpen. The RN indicated R1 should have been placed in the playpen for safety when direct supervision could not be maintained because R1 was able to crawl.On 08/06/2026 at 10:30 AM, a Certified Nursing Assistant (CNA1) assigned to R1 on 06/23/2026, indicated R1 required continuous visual supervision due to age and developmental status. R1 was able to crawl but could not walk and was expected to be placed in a playpen when direct supervision could not be maintained. CNA1 indicated on the day of the incident, CNA1 left the pod to take two other residents outside and later returned the residents to the pod but failed to check on R1, verify R1's location, or notice the door to room [ROOM NUMBER] was closed. CNA1 then informed the nurse of leaving for a 30-minute lunch break. After CNA1 returned from the lunch break, another CNA heard R1 crying from inside room [ROOM NUMBER] while the door was closed. Upon opening the door, R1 was found lying face down on the floor with a folded six-panel plastic baby gate on top of R1. CNA1 acknowledged R1 had remained unaccounted for and unsupervised for an extended period and confirmed R1 should have remained under visual supervision or been placed in a playpen when direct supervision could not be maintained. CNA1 indicated the facility provided education post incident.On 08/06/2026 at 11:00 AM, Certified Nursing Assistant 2 (CNA2) was not assigned to Resident 1 (R1) on 06/23/2026 but was familiar with R1's supervision needs. CNA2 indicated R1 was able to crawl, required visual supervision, and was typically placed in a playpen when direct supervision could not be maintained. CNA2 demonstrated the circumstances of the incident in the pod and room [ROOM NUMBER], including the closed door and R1's location behind the door. CNA2 indicated hearing a faint sound from behind the closed door, which was difficult to distinguish due to noise from the television and other residents. After hearing the sound again, CNA2 opened the door and found R1 lying face down behind the door with a folded six-panel baby gate covering R1's back and lower body. CNA2 immediately called the assigned nurse and left the gate in place until the nurse entered the room. CNA2 indicated the assigned nurse believed R1 was with therapy and was unaware R1 was inside room [ROOM NUMBER]. CNA2 confirmed R1 should not have been left unsupervised and indicated the incident could have been prevented by maintaining awareness of R1's location and providing appropriate supervision. CNA2 indicated the failure to account for and supervise R1 constituted neglect.On 08/06/2026 at 1:10 PM, surveillance footage dated 06/23/2026 was reviewed with the Administrator. The footage showed R1 crawled throughout the pod without staff supervision and entering another resident's room [ROOM NUMBER] at approximately 10:27 AM. room [ROOM NUMBER] door slowly closed, leaving R1 alone without staff awareness and left unsupervised. CNA1 failed to account for R1 before leaving for break and upon returning. During the CNA1's break, the assigned Licensed Practical Nurse (LPN) exited the pod multiple times without identifying R1's absence. At approximately 11:16 AM, CNA2 appeared to hear a sound from room [ROOM NUMBER] and at 11:18 AM, opened the door, followed by another CNA and the assigned LPN. The assigned LPN observed carrying R1 from room [ROOM NUMBER]. The Administrator confirmed R1 remained unaccounted for and unsupervised for approximately 50 minutes.On 08/06/2026 at 10:00 AM, the Administrator indicated Pod 2 was staffed with one licensed nurse and two Certified Nursing Assistants (CNAs). One CNA was assigned to provide one-to-one care, while the remaining licensed nurse and CNA were responsible for the care and supervision of the other residents in the pod. The Administrator indicated that when direct supervision could not be maintained, R1 should have been placed in a playpen where staff could maintain visual observation. The Administrator confirmed R1 should not have been left alone in a room with the door closed due to the potential for injury from environmental hazards, including becoming trapped under the crib, accessing furniture, or other hazards without staff awareness. The Administrator indicated a playpen had been purchased for residents 'use when direct supervision could not be maintained, and staff had received training regarding R1's supervision and playpen use. The Administrator indicated the neglect was substantiated against the LPN for failing to provide appropriate supervision and safeguards to protect R1, resulting in termination. The neglect against CNA1 was not substantiated; however, CNA1 received corrective action and re-education on resident rounds, resident location verification, playpen use, and abuse and neglect reporting. The resident's care plan continued to require placement in a playpen whenever direct supervision was unavailable.On 08/06/2026 at 3:25 PM, an Occupational Therapist (OT) indicated residents taken on therapy outings were documented on a log signed by the therapist and licensed nurse upon return to the facility. The OT confirmed that on 06/23/2026, the assigned LPN received R1 upon return from the outing. The OT indicated the incident constituted neglect because the LPN failed to provide appropriate supervision despite prior education that R1 was to be placed in a playpen when direct supervision could not be maintained.On 08/06/2026 in the afternoon, the Director of Nursing (DON) indicated the incident was not intentional but constituted neglect related to staff failure to adequately monitor and account for R1. The DON indicated R1 sustained no apparent injury and was monitored following the incident. The DON indicated the incident was investigated, and the involved LPN was immediately suspended and subsequently terminated.On 08/06/2026 at 1:30 PM, the attending physician indicated R1, based on age and developmental status, required close visual supervision The physician explained staff were expected to maintain visual accountability of R1 to ensure the resident did not crawl into unsafe areas, place objects in the mouth, pull on equipment, or otherwise encounter environmental hazards. The physician indicated no injuries were identified upon examination of R1 following the incident. The physician explained that the primary intervention was to increase staff monitoring, maintain closer supervision, improve communication among staff regarding the resident's location, and ensure accountability for knowing where the resident was at all times. The physician indicated assumptions that another staff member or therapy was supervising the resident were not acceptable and emphasized the importance of confirming the resident's location through effective communication.The physician acknowledged leaving R1 unsupervised in a closed room created the potential for injury if the resident pulled equipment or objects onto himself, became entangled in cords, crawled into unsafe areas, or encountered other environmental hazards without staff awareness. The physician further indicated staff should investigate a closed door of resident room when the resident's whereabouts were unknown and expected staff to verify the location of residents at least every 15 minutes if they were not in direct view. The physician indicated the incident could have been prevented through closer monitoring, improved communication, and consistent accountability for resident location. The physician indicated the assigned nurse's failure to maintain awareness of R1's whereabouts and provide appropriate supervision constituted neglect.A facility policy titled Abuse-Dependent Adult/Child revised 10/02/2024, indicated the facility protected residents from abuse and neglect by providing adequate supervision, identifying and monitoring residents at risk, maintaining sufficient staffing, protecting residents from health and safety hazards, and ensuring residents received the care and services necessary to prevent physical harm. The policy further indicated all allegations of abuse or neglect were immediately reported, thoroughly investigated, appropriate protective measures were implemented, and corrective actions were taken to prevent recurrence.A facility policy titled Safety and Supervision of Residents dated 07/2017, directed the facility to maintain an environment as free from accident hazards as possible and to prioritize resident safety, supervision and assistance to prevent accidents.Facility Reported Incident 3056144

Based on observation, interview, record review and document review, the facility failed to ensure a care plan for enteral feeding was reviewed and updated after a resident was hospitalized for aspiration pneumonia for 1 of 22 sampled residents (Resident 7). The deficient practice placed the residents at risk for repeat aspiration episodes and other tube feeding-related complications. Findings include: Resident 7 (R7) was admitted on [DATE] and readmitted [DATE], with diagnoses including malignant neoplasm of the brain and gastrostomy status. A respiratory flow chart summary dated 01/07/2026, documented R7 had been vomiting since 4:30 AM and was placed up in wheelchair at 6:30 AM. R7 was looked pale and Oxygen saturation did not have good reading. R7 placed back in bed, started to vomit through tracheostomy and nose, elevated to 90 degrees and suction obtained orange/yellow thin secretions. R7 was placed on ventilator.A change of condition form dated 01/07/2026, revealed a physician ordered R7 to be transferred to the hospital for nausea, vomiting and increased confusion and disorientation.A hospital Discharge summary dated [DATE], revealed R7 was treated for septic shock and aspiration pneumonia. R7 had significant mucous plugging. A computed tomography (CT) scan performed on 01/08/2026, revealed R7 was found to have moderate to large areas of consolidation identified on bilateral lower lobes with few scattered areas of nodular opacities identified at bilateral lung bases and right middle lobe and lingula segment.R7's tube feeding care plan initiated 05/11/2018, documented a goal to keep R7 free from aspiration, and complications associated with tube feeding. Interventions included: keep head of bed elevated 45 degrees during feeding and 30 minutes before and after, check for tube placement, hold feed if greater than 50% of enteral volume, listen to lung sounds, monitor for aspiration and provide care to gastrostomy site. The medical record lacked documented evidence R7's tube feeding care plan was reviewed and updated after R7 returned from the hospital on [DATE] following an aspiration pneumonia episode.A Licensed Practical Nurse (LPN) recalled being assigned to R7 on 01/07/2026 (days) but R7 was in transit to hospital when the LPN arrived for shift. The LPN indicated being informed R7 had been vomiting and the respiratory therapist (RT) had suctioned orange/yellow secretions which was most likely R7's enteral formula. The LPN confirmed R7's tube feeding care plan should have been reviewed and updated when R7 returned from the hospital on [DATE].On 04/16/2026 at 2:53 PM, two Registered Nurses (RNs) who alternated as charge nurses indicated being familiar with R7 who received nutrition by enteral means. The RNs reviewed R7's care plan and verbalized there was no evidence R7's care plan was reviewed and updated when R7 returned from the hospital after being treated for aspiration pneumonia. The RNs explained R7 had a special tube feeding schedule five times a day lasting one hour long at 6:00 AM, 11:00 AM, 4:00 PM, 8:00 PM and 1:00 AM. On 04/16/2026 at 3:31 PM, the Director of Nursing (DON) indicated care plans needed to be reviewed and updated after a change of condition. The DON indicated being informed R7 was treated for aspiration pneumonia which according to the DON was highly likely related to the resident's tube feeding given the color of the secretions suctioned by RT. The DON reviewed R7's tube feeding care plan and confirmed there was no evidence it had been reviewed and updated after the aspiration episode in January 2026.The facility Care Plan policy revised 09/27/2018, revealed care plans would be updated as issues arise or upon a change in condition.

Based on observation, interview, record review and document review, the facility failed to ensure a resident's crib environment was free from accidental hazards when cords were observed hanging into a crib for one unsampled resident (Resident 35). The deficient practice placed the resident at risk for entanglement.Findings include:Resident 35 (R35) was admitted on [DATE], with diagnoses including extreme immaturity of a newborn at 26 weeks, cortical blindness and anoxic brain injury. The annual minimum data set (MDS) dated [DATE], revealed R35 had no impairment on upper and lower extremity, was nonverbal and hard of hearing. On 04/16/2026 at 7:45 AM, R35 was asleep inside crib. On the left side of the crib hung two cords - one for the light switch and one for the call system. On the right side of the crib was a red electrical outlet which had three equipment plugged into it namely, the enteral feeding pump, Oxygen saturation device and suction equipment. On 04/16/2026 at 8:18 AM, a life safety code inspector indicated R35's crib was cluttered with too many cords which was a safety concern. The inspector demonstrated how the cords were long enough to become a ligature risk for R35.On 04/16/2026 at 8:29 AM, R35 was awake and was moving inside the crib. R35 would sit up and lie back down and at one-point R35's left hand grabbed on to the electrical cord attached to the Oxygen saturation device which was clamped to the resident's crib.On 04/16/2026 at 10:00 AM, the Administrator entered R35's room and held the cords which dangled form the light switch and call system. The Administrator confirmed R35 did have the cognitive ability to use the cord to call for staff or turn on lights and were mainly for staff use. Two life safety inspectors were present when the Administrator demonstrated how the cords were long enough to loop around R35's neck causing entanglement and the position of the crib was a safety concern.R35's care plan included an intervention to ensure and provide the resident with a safe environment.The facility Safety and Security Management Plan revised 06/22/2010, revealed the safety and security plan was designed to provide a safe and secure environment for residents and intervene whenever conditions or situations of safety existed which posed as a threat or danger to life.

Based on interview, record review and document review, the facility failed to act upon a pharmacist's recommendation to monitor seizures for 1 of 22 sampled residents (Resident 28). The deficient practice placed the resident at risk for ineffective seizure management.Findings include:Based on interview, record review and document review, the facility failed to act upon a pharmacist recommendation to monitor seizures for 1 of 22 sampled residents (Resident 28). The deficient practice placed the resident at risk for ineffective seizure management.Findings include:Resident 28 (R28) was admitted [DATE], with diagnosis including chronic respiratory failure with hypoxia, tracheostomy status, and dependence on respirator ventilator status.A Psychotropic Medication Informed Consent dated 11/01/2025, documented R28's specific condition/diagnosis was seizures. Medication intervention recommended was Diazepam 1 mg every 8 hours for seizures. The beneficial effect expected was a decrease in seizure activity.A Physician order dated 11/01/2025 documented Diazepam oral tablet 2 milligrams (mg). Give 1 mg via gastrostomy tube (G-Tube) every 8 hours for seizures.A Pharmacist Consultation Report dated 01/16/2026 documented R28 received Diazepam but did not have seizure monitoring documented in the medical record. The Pharmacist recommended adding seizure monitoring. The Pharmacist's Consultation report indicated psychotropic medication without adequate indications, in excessive dose, for an excessive duration, or without adequate monitoring may increase the broad range of adverse consequences to the resident.The medical record lacked documented evidence seizure monitoring was implemented following the consultant pharmacist's recommendation.On 04/17/2026 at 7:50 AM, the Director of Nursing (DON), confirmed the pharmacist's recommendation for seizure monitoring for R28 was not implemented and R28 was not monitored for seizures. The DON acknowledged the recommendation should have been implemented. The DON reported the lack of seizure monitoring prevented the facility from determining if the medication was effective, identifying breakthrough seizures, and determining if medication adjustments were needed. A facility policy titled Medication Regimen Review revised 06/01/2024, documented the facility should have encouraged the physician/prescriber or other responsible parties receiving the medication regimen review (MRR) and the Director of Nursing to act upon the recommendations contained in the MRR. The attending physician should have documented in the resident's medical record the identified irregularity had been reviewed and what, if any, action had been taken to address it.

Based on observation, interview, record review and document review, the facility failed to ensure behavior monitoring was accurately completed for a resident on a psychotropic medication for 1 of 22 sampled residents (Resident 34). The deficient practice placed the resident at risk for receiving unnecessary medications. Findings include:Resident 34 (R34) was admitted on [DATE], with diagnoses including unspecified lack of expected normal physiological development in childhood, gastrostomy status and insomnia.On 04/15/2026 in the morning, R34 lay awake in bed while tube feeding was infusing. R35's left hand was covered with a gray mitten while right hand was being used by the resident for iPad device. A certified nursing assistant (CNA) seated by 34's bedside explained R34 and roommate were on two residents to one staff (2:1) sitter orders due to behaviors. The CNA explained R34 was not aggressive towards staff but exhibited self-harm behaviors such as scratching self and pulling lines.A physician order dated 11/27/2025, documented to give Trazadone (anti-depressant) 150 milligrams via gastrostomy tube at bedtime for insomnia.A physician order dated 07/21/2025, instructed to document behavior monitoring for Trazadone every shift. Use codes for 1) Behavior, 2) Intervention, and 3) Outcome.The medical record lacked documented evidence codes were provided for specific 1) Behaviors, 2) Interventions and 3) Outcome such as number of episodes, behaviors of agitation, scratching self and disturbed sleep cycle and whether the intervention was effective or ineffective.The medication administration record (MAR) for April 2026, revealed R34 had zero behaviors, zero interventions and zero outcomes from 04/01/2026 to 04/15/2026 related to Trazadone use.The quarterly behavior support plan updated by R34's attending physician on 04/14/2026, revealed R34 required a two-to-one (2:1) sitter due to lack of self-awareness, and impulsiveness. Staff utilize the Observation and Monitoring tool every 30 minutes to ensure consistent completion of behavior monitoring. Behavior goals include decreasing maladaptive behaviors such as physical resistance, skin picking, medical line pulling, disruptive behaviors, aggressive and combative behaviors.The medical record lacked documented evidence the Observation/Monitoring Tool was completed for R34.On 04/16/2026 at 12:38 PM, R34 was seated in wheelchair outside room while being supervised by a CNA. R34 was using iPad device when suddenly R34 had a verbal outburst and started shaking wheelchair. On 04/16/2026 at 12:39 PM, a Registered Nurse (RN) was near R34 during the observation. The RN reviewed R34's MAR for behavior monitoring related to Trazadone use which reflected R34 exhibited zero episodes of behaviors, intervention and outcome for the month of April 2026. The RN indicated the physician order was lacking behavior codes, intervention codes and outcome codes for nurses to use and follow during behavior monitoring in the MAR. The RN indicated the MAR was inaccurate based on personal experience because the RN had been assigned to R34 multiple times and R34 constantly had more pronounced behavior during the evening shift.On 04/16/2026 at 1:02 PM, the Director of Nursing (DON) reviewed R34's physician orders for behavior monitoring related to Trazadone use and confirmed 1) physician orders for behavior monitoring were lacking codes for specific behaviors, interventions and outcomes, 2) the Behavior Monitoring and Observation Tool was not utilized or maintained for R34 and 3) the MAR entries were inaccurate.On 04/16/2026 at 1:20 PM, the DON indicated the MAR reflected mechanical documentation by nurses who failed to identify codes were lacking for behaviors/interventions and outcomes and failed to seek clarification from the physician who was in the facility daily. On 04/16/2026 at 1:30 PM, the DON explained the purpose of behavior monitoring was to guide the clinician with regards to effectiveness of medications particularly psychoactive medications. The DON indicated failing to record behaviors accurately prevented the physician from making informed decisions with regards to changing medications, adjusting dosage or discontinuing medications.On 04/16/2026 at 1:32 PM, the DON indicated lack of monitoring may render R34's Trazadone use as unnecessary medication due to the failure to track the medication's effectiveness. The facility Psychotropic Medication Use revised 03/01/2025, documented psychotropic medications were drugs which affect mood, perception or behavior, and include antipsychotics, anxiolytics, antidepressants, mood stabilizers or hypnotics. Facility staff should monitor behaviors pursuant to facility policy. The facility Psychotherapeutic Medications policy revised 03/21/2025, documented occurrences of behaviors for which psychotherapeutic medications were used would be documented every shift. Each quarter, at a minimum, the interdisciplinary team reviewed the behavior monitoring sheet with the physician to evaluate the continued need for, or reduction of psychotherapeutic medications.

Based on observation, interview, and document review, the facility failed to ensure a portable oxygen tank was secured in the room of one sampled resident (Resident 22). The deficient practice had the potential to cause injury to residents and staff. Findings include: Resident 22 (R22) R22 was admitted on [DATE] with diagnoses including severe hypoxic ischemic encephalopathy (not enough oxygen or blood being supplied to the brain), and chronic respiratory failure. On 04/16/2025 at 10:29 AM, there was a portable oxygen tank standing upright in the corner of room for R22. The tank was free-standing and not attached to the wall or secured to any type of portable carrying device or cart. There was no regulator to determine amount of oxygen still left in bottle. On 04/16/2025 at 10:35 AM, a Licensed Practical Nurse (LPN) confirmed the tank was in the room and not secured. The LPN indicated all portable oxygen tanks should be secured whether empty or full. The LPN explained empty tanks would be taken to storage and kept separated from tanks which were full. On 04/17/2025 at 3:00 PM, a Respiratory Therapist (RT) indicated portable oxygen tanks should not be left attended without being secured in stand with buckle. Oxygen tanks were always kept in cart or [NAME] and then taken to storage area and kept separate from full tanks in a secured container rack. The RT verbalized it did not matter if tank was full, half full or empty all oxygen tanks should be secure at the tanks could cause injury to residents or staff if knocked over. On 04/17/2025 at 3:16 PM, the Director of Nursing (DON) explained checking room for potential hazards was shared task among leadership and staff. Respiratory equipment such as portable oxygen tanks would be in carrier bags, or a metal oxygen holder. The DON indicated the portable oxygen tank found in room for R22 should have been in an oxygen holder. The nursing staff and respiratory staff were primarily responsible for ensuring rooms were safe from hazards while making the normal rounds throughout the day. The DON verbalized there would be an increased risk of injury for kids roaming around who may inadvertently knock over a tank if not secured. The facility policy titled Administration of Oxygen Therapy (revised 06/2015) documented safety measures to include making sure the oxygen was in an approved stand to prevent rolling or accidental fall. Empty oxygen tanks were stored in a separate location or storage cart, oxygen storage areas were identified as oxygen storage full and oxygen storage empty.

Based on observation, interview, record review, and document review, the facility failed to ensure expired medications were removed from the active supply and discarded. The deficient practice had the potential to compromise the effectiveness of the medication treatment. Findings include: On 05/24/2024 at 12:44 PM, an inspection of the facility's medication room with the Assistant Director of Nursing (ADON)(E2). The Narcotic (Narc) Box in the medication refrigerator stored expired Lorazepam 2mg/1ml oral, with an expiration date of 03/2024. On 05/24/2024 at 1:05 PM, the ADON confirmed the Lorazepam 2mg/1ml oral was expired and should have been removed from the active supply to prevent administration. The ADON indicated the expired medication should have been taken out of the refrigerator and placed in the designated area for disposal. On 05/24/2024 at 2:11 PM, the Director of Nursing (DON)(E1) explained the Pod 3 nurse holds the Refrigerator Narc Box key and therefore was responsible for checking the expiration dates daily upon shift change and discarding the expired medication appropriately. On 05/24/2024 at 2:36 PM, the Pod 3 Nurse (E3) explained the Pod 3 Nurse was responsible for checking the expiration dates and discarding expired medications appropriately at shift change. However, E3 was confused about what was the expiration date and what was the delivery date based on E3's understanding of the medication sheet. A facility policy titled 5.3 Storage and Expiration Dating of Medications, Biologicals, with the revision date of 01/01/22, revealed the facility should ensure medications and biologicals which had an expiration date on the label and had been retained longer than recommended by the manufacturer or supplier's guidelines were to be stored separate from other medications until destroyed or returned to the pharmacy or supplier.

Based on observation, interview, record review, and document review, the facility failed to ensure the nursing staff did not sign off on the medication administration record before administering the medication in PODS 1, 2, and 3. Failure to accurately document the medication administration could potentially result in medication errors, falsified medication records, altered therapeutic benefits, medication underdosing or overdosing, and adverse reactions. Findings include: Resident 11 (R11) R11 was admitted on [DATE], with diagnoses including gastrostomy status, gastroparesis (delayed stomach emptying) and gastro-esophageal reflux disease with esophagitis. On 03/09/2023 at 7:53 AM, during medication pass observation, a Registered Nurse 2 (RN2) in POD 2 prepared R11's medications. RN2 signed off the medication administration and saved the record right after preparation, which indicated the medications were successfully administered. After completing the documentation, RN2 proceeded to R11's room to administer the six medications. On 03/09/2023 at 8:13 AM, RN2 checked the gastrostomy tube (GT) placement and administered the medications one at a time. R11's GT leaked during administration. Two medications were not completely administered and RN2 called the charge Registered Nurse (CRN) for assistance. The CRN indicated the GT was clogged. On 03/09/2023 at 11:15 AM, RN2 confirmed the medication administration record (MAR) was signed off right after the medications were prepared. RN2 explained was unsure if the MAR could still be corrected. RN2 indicated it should not have been documented as given when some of the medications were not administered due to GT clogging or leaking. RN2 indicated the facility provided education related to medication administration upon hire in 2022. On 03/09/2023 in the morning, the Assistant Director of Nursing (ADON) indicated the protocol was to sign off the MAR right after the medications were administered. The ADON explained the staff could click yes upon administration but not save the record until the administration was completed. The ADON indicated there could be a way to edit the documentation, but the protocol was to document right after the medications were administered. Resident 13 (R13) R13 was admitted on [DATE], with diagnoses including gastrostomy status and gastro-esophageal reflux disease. On 03/09/2023 at 8:56 AM, during medication pass observation, a Registered Nurse 3 (RN3) in POD 1 prepared R13's medications. RN3 signed off the medication administration and saved the record right after the preparation, which indicated the medications were successfully administered. RN3 proceeded to R13's room and administered the four medications. On 03/09/2023 at 11:22 AM, RN3 confirmed the medication administration record was signed off after the medications were prepared but not after they were administered. RN3 indicated was aware the administration record should have been signed off right after the medications were administered but was distracted. Resident 2 (R2) R2 was admitted on [DATE] and readmitted on [DATE], with admitting diagnoses including gastrostomy status and gastroesophageal reflux disease. On 03/09/2023 at 9:15 AM, Registered Nurse 4 (R4) in POD 3 prepared R2's 10 medications, signed off the medication administration and saved the record, which indicated the medications were successfully administered. RN3 proceeded to R2's room and administered the medications via GT. On 03/09/2023 at 11:30 PM, RN4 acknowledged the MAR should have been signed off right after the medications were administered, not during or after the medications were prepared. On 03/09/2023 at 11:56 AM, the Director of Nursing (DON) indicated the standard of practice was to document right after the medication was administered, not before. The DON indicated there could be a circumstance where the medication was not successfully administered and required assessment and reporting. The DON indicated staff were expected to document after the task was done and completed to maintain accuracy. A facility policy titled Medication Administered through an Enteral Tube revised 12/11/2019, documented the facility staff should take all the measures required by facility policy and applicable law to document necessary medication/treatment administration information when medications were given or administered after medication administration.

Based on observation, interview, record review, and document review the facility failed to keep an accurate account of a resident's personal belongings for 1 of 12 sampled residents (Resident #5). The failed practice had the potential to lead to the loss of personal property for the resident. Findings include: Resident #5 (R5) R5 was admitted to the facility on [DATE] with medical diagnoses including seizures. On 03/07/2023 at 1:35 PM, the family member of R5 indicated R5 had missing clothes on a monthly base. A review of medical records for R5 lacked documented evidence an inventory sheet was completed. On 03/08/2023 at 4:46 PM, the Assistant Director of Nursing (ADON) indicated R5 had been in the facility since 2017 and some of their physical charts had been moved to an offsite location. The ADON explained they were unable to obtain the inventory sheets for R5 and there were no new inventory sheets created. On 03/07/2023 at 11:04 AM, Certified Nursing Assistant #1 (CNA1) indicated residents' personal items went missing a lot in the facility. CNA1 explained residents' personal items were documented on the inventory sheet upon admission and the inventory sheet was updated as new items were brought into the facility. On 03/09/2023 at 11:06 AM, the Director of Nursing (DON) explained inventory sheets for the residents were placed in their charts. The DON indicated a copy of the inventory sheet for R5 should have been available in their chart and on site. A review of the facility's policy titled Personal Effects policy revised 01/01/2011 revealed there needed to be a complete and accurate list of all residents' personal belongings and explained all items subsequently brought into the facility were added to the inventory list.

Based on observation, interview, and record review the facility failed to ensure staff followed the facility's policy and protocol related to emergency care for a resident with a potential emergent situation for 1 of 12 sampled residents (Resident #2). The failed practice had the potential to delay securing the safety of the resident. Findings include: Resident #2 (R2) R2 was admitted on [DATE] with medical diagnoses including seizures and cerebral palsy. The facility's policy titled Emergency Care last revised 02/10/2015 revealed the first staff member to discover a resident requiring emergency care was to shout for help and not leave the resident. On 03/09/2023 at 1:45 PM, R2 was observed lying in bed, eyes locked upward, increased reddish coloration of the face, and intermittent groaning sounds. Oxygen levels for R2 were being monitored through a small vitals machine which revealed oxygen levels between 75 to 84 percent. On 03/09/2023 at 1:45 PM, Certified Nursing Assistant #1 (CNA1) entered the room of R2 and indicated R2 was having a seizure. CNA1 left the room and verbalized they were going to go grab a nurse. Approximately thirty seconds later, three staff members entered the room of R2, including CNA1 and Registered Nurse #1 (RN1). On 03/09/2023 in the afternoon, RN1 indicated the resident had history of seizures. RN1 explained R2 had a seizure approximately every three months. RN1 explained a staff member should have stayed in the room with R2 when they were having the seizure. On 03/09/2023 in the afternoon, Certified Nursing Assistant #2 (CNA2) indicated in an Emergency, staff was to stay in the room with the resident and yell out for help. On 03/10/2023 at 12:01 PM, the Director of Nursing (DON) indicated a seizure was considered an emergency. The DON explained during emergency situations staff was instructed to yell out for help. The DON indicated staff was to remain in the room and not leave the resident unattended.

Based on observation, interview, record review, and document review, the facility failed to ensure: 1) the [NAME] bag (continuous gastric pressure relief infusion set) for gastrostomy tube (GT) feeding was changed for 1 of 12 sampled residents (Resident 24), 2) the GT site and surrounding skin were assessed, cleansed and dressed as ordered for 1 of 12 sampled residents (Resident 24), and 3) a physician order was obtained timely for 1 of 12 sampled residents (Resident 8). Failure to follow proper GT feeding protocols could potentially result in complications such as infection or other medical issues related to improper management of the GT site and gastric pressure relief infusion set. Findings include: 1) A facility policy titled [NAME] Bags for Gastrostomy Tube Feedings revised on 01/13/2022, documented to change the [NAME] bag every seven days. Resident 24 (R24) R24 was admitted on [DATE], with diagnoses including gastrostomy status and obstructive hydrocephalus. On 03/08/2023 at 11:45 AM, R24 was sitting in the chair and tube feeding (TF) was infusing at 45 milliliters (ml) per hour. The TF bag was connected to another bag labeled [NAME] valve system continuous gastric pressure relief, which was soiled and dated 01/31/2023. On 03/08/2023 at 11:58 AM, a Registered Nurse 2 (RN2) confirmed the [NAME] bag was dated 01/31/2023. RN2 indicated the [NAME] valve system was utilized to relieve the gastric pressure in the resident's stomach. The RN explained the [NAME] set would serve as the main line and be connected to the resident's GT. RN2 indicated the use of the [NAME] set was required by order and should have been changed weekly but was not done for more than a month. R24's medical records lacked documented evidence a physician order was obtained for the use of the [NAME] valve system. On 03/08/2023 at 12:15 PM, a Charge Registered Nurse (CRN) explained the [NAME] valve system infusion set should have been changed every week and should have an order in place. The RN indicated the [NAME] valve infusion set was the main line in which the TF and the Mic-key button (a feeding tube button that sits at the level of the skin) were connected to the GT. The RN indicated the risk if the [NAME] valve set was not changed timely, it could lead to an increased risk of infection. On 03/08/2023 at 12:50 PM, the Assistant Director of Nursing (ADON) indicated the [NAME] valve set should have been changed weekly and required an order for continuous monitoring. The ADON indicated a physician order should have been obtained and the valve set should have been changed weekly to prevent complications. 2) A facility policy titled Gastrostomy Tube Feeding Site Care and Replacement (undated), documented to provide care for the Mic-Key Button insertion site. Inspect the skin around the stoma after feedings and medication passes to ensure there is no gastric leakage. Clean the skin around the stoma with warm water and soap using a cotton-tipped applicator or soft cloth. A physician order in R24's medical record dated 03/07/2023, documented to cleanse the enteral insertion site with normal saline. Assess the enteral site for redness and irritation. Apply split gauze on site every shift. On 03/07/2023 at 10:56 AM, R24 was in bed with eyes closed. TF was running at 45 milliliters (ml) per hour via kangaroo pump. The GT or Mic-Key Button insertion site was soiled with dried brownish residue around the site and had no dressing. On 03/08/2023 at 11:58 AM, a Certified Nursing Assistant confirmed R24's GT site had dried brownish residue. The CNA indicated the nursing staff were responsible for cleaning the site. The CNA called the assigned Registered Nurse 2 (RN2). RN2 confirmed R2's GT insertion site and the surrounding skin was soiled with dried brownish residues. The RN indicated the surrounding skin should be assessed, cleansed promptly, and dressed as ordered to prevent skin irritation, but this was not done. On 03/08/2023 at 12:15 PM, a Charge Registered Nurse (CRN) explained the GT site should have been assessed and cleansed each shift and depending on the order if a dressing was needed. The RN indicated if there was no order in place, the physician would be contacted to obtain orders for GT site care and the order should have been followed. 3) Resident 8 (R8) R8 was admitted on [DATE], with diagnoses including gastrostomy status and hypoxic-ischemic encephalopathy. On 03/07/2023 in the morning, R8 was in bed with eyes closed. The GT insertion site had no dressing. R24's medical records lacked documented evidence GT site care orders were obtained timely. On 03/08/23 at 3:27 PM, a Registered Nurse indicated a resident's GT site should have been assessed and cleansed each shift, depending upon the order. The RN indicated if there was no order, the physician would be notified to obtain one because everything should be covered by the physician's instructions. The RN confirmed the order was just placed dated 03/07/2023. On 03/08/23 at 3:29 PM, the Director of Nursing (DON) confirmed R8 had no GT care site orders in place until 03/07/2022. The DON indicated the residents on GT or Mic-Key Button were required to have an order to assess and cleanse the GT insertion site. The DON explained the admission staff was responsible for obtaining and transcribing the order set for GT site care but had missed it.

Based on observation, interview, record review, and document review, the facility failed to ensure: 1) the availability of Tizanidine (a medication used as a muscle relaxant) and 2) the order was communicated and clarified for 1 of 12 sampled residents (Resident 26). Failure to administer the Tizanidine medication for muscle spasms on time could lead to ineffective management of muscle spasticity, which may result in increased risk of pain, discomfort, reduced mobility, withdrawal symptoms and adverse consequences. Findings include: Resident 26 (R26) R26 was admitted on [DATE], with diagnoses including gastrostomy status, generalized idiopathic epilepsy and epileptic syndrome. The Brief Interview of Mental Status dated 01/23/2023, documented a score of 99, which means the interview was not completed due to cognitive impairment. A physician order dated 10/21/2022, documented to give a 0.5 milligram (mg) Tizanidine Hydrochloride tablet via gastrostomy tube (GT) three times a day for spasms. On 03/09/2023 at 8:35 AM, a Registered Nurse 2 (RN2) in POD 2 prepared all of R26's medications except the Tizanidine Hydrochloride (HCL). On 03/09/2023 at 11:30 AM, RN2 confirmed Tizanidine HCL had not been administered because it had not been available since the previous day. The RN indicated the Tizanidine was already requested from the pharmacy, but there was no delivery. The pharmacy request record dated 03/08/2023, documented Tizanidine HCL was requested due to non-availability. The Prescriptions Delivery Receipt dated 02/27/2023, documented Tizanidine 1 mg/1 ml oral solution was previously delivered. On 03/09/2023 in the afternoon, the Assistant Director of Nursing (ADON) indicated the physician order was in tablet form and converted by the pharmacy into a solution, but it was not communicated to the facility to clarify the order. The ADON conveyed it was important to clarify the order because if the order was in tablet form and the medication delivered was in solution, it may cause confusion with the staff during administration. The ADON indicated per verification from the pharmacy, Tizanidine was not delivered due to the pre-authorization issue. The pharmacy was compounding the medication into a solution, and it had an expiration date of 14 days. The ADON confirmed the facility was not aware of the information until during the survey. On 03/10/2023 at 2:29 PM, the pharmacist confirmed Tizanidine HCL was not delivered due to a pre-authorization issue and the medication was converted into a solution form. The pharmacist confirmed the order was in tablet form and was delivered in solution form because the order was for 0.5 mg. The solution form had an expiration date of 14 days. The pharmacist referred to the pharmacy general manager (GM) when asked if the information was communicated to the facility. On 03/10/23 at 2:51 PM, the pharmacy GM indicated the order was converted to a solution for the resident's safety. The pharmacy GM indicated the minimum dosage of the Tizanidine was 2 mg and could not be cut into quarters and the score of the pill could only be equally split into a half dosage (1 mg) and had to be compounded as a liquid formula. The viscosity of the medication could account for not having enough for a 14-day supply of the medication. The GM assumed the information was communicated to the facility. R26 ' s medical records lacked documented evidence the clarification or conversion of the Tizanidine medication was communicated. A Quality Improvement: Consultant Pharmacist Summary for the month of October 2022, documented isolated issues with new orders were inaccurately transcribed. On 03/10/2023 at 3:30 AM, the Director of Nursing (DON) confirmed there was no communication by the pharmacy regarding the conversion and the pre-authorization issue until 03/09/2023. The DON indicated the expectation was the medication would be available for timely administration. A facility policy titled Physician/Prescriber Authorization and Communication Orders to Pharmacy revised 01/01/2022, documented the facility staff should monitor pharmacy communications to address or correct all orders requiring clarification before the next scheduled medication delivery. Orders as entered by the nursing staff into an electronic record may require alterations or changes prior to pharmacy dispensing. The pharmacy will notify the facility when alterations require a physician's or prescriber's order. A facility policy titled Delivery and Receipt of Routine Deliveries revised 01/01/2022, documented if any item ordered by the facility was not received in the delivery, facility staff should check a pharmacy communication slip indicating the reason and should contact the pharmacy.

Based on observation, interview, record review, and document review, the facility failed to ensure a resident who was receiving an anticoagulant medication was monitored for bleeding or an adverse reaction and the injection site was documented per policy for 1 of 12 sampled residents (Resident 34). Failure to adequately monitor the resident on anticoagulant (blood thinner) medication could increase the risk of bleeding and potentially lead to serious harm or death. Findings include: A facility policy titled Medication Administered through Certain Routes of Administration - Subcutaneous Injections, dated 01/01/2022, indicated to document the site of injection. Resident 34 (R34) R34 was admitted on [DATE], with diagnoses including long-term use of anticoagulants, left mastoiditis (bacterial infection of the mastoid bone located behind the ears), and mastoidectomy (a surgical removal of diseased mastoid air cells). The Brief Interview of Mental Status dated 02/17/2023, documented a score of 99, which means the interview was not completed due to impairment. The History and Physical dated 02/16/2023, documented had some communication with hematology as there was a concern of cerebral clot previously and recommended started on Lovenox which was initiated on 02/11/2023. On 03/07/2023 at 1:04 PM, R34 was verbally responsive and ambulatory. R34 had injection marks noted on the lateral arms and thighs. A Physician order dated 02/14/2023, documented Lovenox injections of 19 milligrams (mg) to inject subcutaneously every twelve hours for sinus venous thrombosis for five weeks. A Care Plan dated 02/15/2023, documented R34 was on anticoagulant therapy with Lovenox injections related to post-surgical. The interventions included monitoring for side effects and effectiveness every shift. R34's medical records lacked documented evidence the injection site was documented, and the adverse side effects of anticoagulant use were monitored. On 03/09/2023 at 4:00 PM, a Registered Nurse 2 (RN2) indicated R34 was on Lovenox anticoagulant therapy and should have been monitored for bruising, bleeding, and any possible side effects. RN2 explained there should have been an order to monitor, but one was not obtained. RN2 indicated a physician order should have been obtained because it would serve as a reminder R34 was at risk for bleeding. On 03/09/2023 at 4:10 PM, the Assistant Director of Nursing (ADON) explained the monitoring for bleeding and side effects was vital for anticoagulant use and a physician's order should have been obtained. On 03/09/2023 in the afternoon, the Director of Nursing (DON) confirmed R34 was on anticoagulant therapy and had been administered for three weeks since admission, but there was no monitoring in place for adverse reactions. The DON indicated there should have been a monitoring order in the Medication Administration Record, but one was not obtained. The DON indicated the Licensed Nurse was responsible for ensuring the appropriate orders were obtained and transcribed upon R34's admission. A facility policy titled Anticoagulation Management Guidelines dated 06/14/2011, documented the use of validated instruments to assess effectiveness, adherence, and outcomes. Resident and family education included the importance of follow-up monitoring, compliance issues, and the potential for adverse drug reactions and interactions. The facility evaluated anticoagulation safety practices.

Based on observation, interview, record review, and document review, the facility failed to ensure their medication error rate was not five percent or greater when two errors were identified with 25 opportunities observed, resulting in an error rate of 8%. Failure to reduce the medication error rate to less than 5% could lead to an adverse drug reaction from overdose or underdose, which can cause harm or injury to the resident. Findings include: A facility policy titled Medication-Related Errors revised 05/01/2010 documented: Delivery error: drug product not received by the facility at the required or expected time. Omission error: The facility failed to administer an ordered dose to the resident unless it was refused by the resident or not administered because of a recognized contraindication. Resident 26 (R26) R26 was admitted on [DATE], with diagnoses including gastrostomy status, generalized idiopathic epilepsy and epileptic syndrome. The Brief Interview of Mental Status dated 01/23/2023, documented a score of 99, which means the interview was not completed due to cognitive impairment. A physician order dated 10/21/2022, documented to give a 0.5 milligram (mg) Tizanidine Hydrochloride (Muscle relaxant) tablet via gastrostomy tube (GT) three times a day for spasms. On 03/09/2023 at 8:35 AM, during medication pass observation, Registered Nurse 2 (RN2) in POD 2 prepared all of R26's medications except the Tizanidine Hydrochloride (HCL). On 03/09/2023 at 11:30 AM, RN2 confirmed Tizanidine HCL had not been administered because it had not been available since the previous day. The RN indicated the Tizanidine was already requested from the pharmacy, but there was no delivery. The Prescriptions Delivery Receipt dated 02/27/2023, documented Tizanidine 1 mg/1 ml oral solution had previously been delivered. On 03/09/2023 in the afternoon, the Assistant Director of Nursing (ADON) confirmed Tizanidine HCL was not administered due to unavailability. The ADON explained Tizanidine HCL was requested on 03/08/2023 but was not delivered. The ADON indicated per verification from the pharmacy, Tizanidine was not delivered due to a pre-authorization, but the facility was unaware until a follow-up was done. The ADON indicated if an ordered dose was not administered, it was considered a medication error. On 03/10/2023 at 2:29 PM, the pharmacist confirmed the Tizanidine HCL was not delivered on time due to a pre-authorization issue and the medication was in need of conversion into a solution form. Resident 2 (R2) R2 was admitted on [DATE] with diagnoses including seizures, gastrostomy status and tracheostomy status. A Physician order dated 03/09/2023, documented Vitamin D3 tablet 1000 unit to give 1 tablet via Gastrostomy Tube (GT) daily for supplement. On 03/09/2023 at 9:15 AM, Registered Nurse 4 (RN4) prepared nine medications for R2, except a Vitamin D3 tablet. RN4 indicated Vitamin D3 tablets were not available in the medication cart but the liquid was. RN4 almost gave the VIT D3 liquid but was hesitant to convert the dosage from tablet form to liquid. On 03/09/2023 at 11:30 AM, during observation in the medication room, the charge Registered Nurse indicated the Vitamin D3 tablet was available. The CRN explained the Vitamin D3 tablet was difficult to administer via GT. The CRN indicated the order should have been clarified to change it to a liquid form. On 03/10/2023 at 3:30 AM, the Director of Nursing (DON) indicated the expectation was the medication would be available for timely administration.

Based on observation, interview, and document review, the facility failed to ensure formula cans, electrolyte solution bottles, and creams were dated when they were opened. Failure to date the items upon opening could lead to decreased potency, effectiveness, or even toxicity, putting the patient at risk of harm. Findings include: On 03/09/2023 at 9:52 AM, the medication cart in POD 2 contained unlabeled formula can, electrolyte solution bottle and creams as follows: -Pedialyte 1L electrolyte solution: 160 ml left in the bottle -Alfamino pediatric formula, [NAME] 400 g; approximately 8 scoops left. -Desitin daily defense cream 4 oz, opened and unlabeled -Zinc oxide ointment skin protectant -Thera Calazinc body shield -Eucerin cream 4 0z. On 03/09/2023 at 10:14 AM, a Registered Nurse (RN) confirmed the 400-gram formula can with approximately 8-10 scoops left in the can. The Pedialyte 1 liter electrolyte solution with 160 milliliters left in the bottle was opened but undated. The RN was unsure how long the formula can, and the electrolyte solution had been opened since it was not dated. The RN indicated each resident had a dedicated cream. The RN indicated the medication and supply should be labeled to monitor when it was opened and discarded to preserve its potency. THE RN confirmed the creams were actively used but not labeled with dates when it was opened. On 03/09/2023 at 12:18 PM, a charge RN indicated all the formula cans, Pedialyte water, and creams should have been dated per facility protocol. On 03/10/2023 at 11:14 AM, the Director of Nursing (DON) indicated the medications, formula, creams, and supplies should have been dated or labeled upon opening. The DON indicated when the container was opened, it was important to determine the expiration date. Pedialyte should be discarded within certain hours, the canned formula within 30 days, and treatment creams within six months. The Manufacturer's Instructions dated 2023, revealed after opening the Pedialyte oral rehydration solution, indicated after opening the bottle, replace the cap, refrigerate, and use within 96 hours or discard. The Manufacturer's Instructions dated 2015, revealed to tightly cover an open can and use within one month. A facility policy titled General Dose Preparation and Medication Administration revised 01/01/2022, documented to follow manufacturer medication administration guidelines.

Based on observation, interview, and record review the facility failed to measure the accurate portion size when preparing a resident's lunch meal for one unsampled resident (Resident #27). The failed practice had the potential to not meet the resident's nutritional needs. Findings include: Resident #27 (R27) R27 was admitted on [DATE] with medical diagnoses including respiratory failure and gastrostomy. A Physician order dated 02/27/2023 revealed R27 was on a puree diet. On 03/09/2023 at 11:07 AM, the Cook indicated the lunch menu included chicken Caesar salad. On 03/09/2023 at approximately 11:30 AM, the Cook was observed preparing lunch for R27 in which they added three pieces of chicken and approximately a palm size of the prewashed salad to the food processor. The Cook took the food processor bowl and added the puree mix directly to the plate for R27. The Cook was asked how they measure the food to ensure appropriate meal portion. The Cook indicated they eyeball the meal portion. The Cook explained the portion for R27 was 1 ounce per years of life and R27 was two years old, so the serving portion for R27 was two ounces. On 03/10/2023 at 8:30 AM, the Director of Food Services explained eyeballing was not an appropriate measurement and there were different measuring tools available in the kitchen to measure portion sizes. The Director of Food Services indicated Speech Therapy explained to them R27 was to receive one tablespoon per years of life for their meal portion. The Director of Food Services verbalized not measuring meal portions could mean residents were receiving food portions which were either too much or too little. On 3/10/2023 at 9:32 AM, a Speech Therapist indicated R27 was on an intensive feeding program and the current recommendation was for R27 to consume breakfast and lunch. The Speech Therapist indicated they were working closely with the Registered Dietician and rule of thumb regarding portion sizes for R27 was one tablespoon per years of life. The Speech Therapist explained the resident was one year old and was to receive one tablespoon of each food item being served. The Speech Therapist verbalized this was communicated to the kitchen staff. The Speech Therapist indicated not measuring the meal portion could lead to weight gain and impact the hunger satiety cycle for R27. On 03/10/2023 in the morning, a Registered Dietician (RD) confirmed the meal portion for R27 was one tablespoon per years of life. The RD explained if the resident was receiving a Caesar salad, R27 should have received one tablespoon of the chicken and one tablespoon of the salad.

Based on observation, interview, and document review, the facility failed to ensure 1) expired food items from the dry storage and refrigerator were discarded and 2) dishwasher was in good repair. The failed practices had the potential to impact the well-being of the residents through potential consumption of expired food items and breaches in infection control due to ineffective disinfection of dishes. 1) On [DATE] at approximately 8:15 AM, the following expired food items were identified in the dry storage: - Flour with an expiration date of [DATE] - Brown sugar with an expiration date of [DATE] - Powdered sugar with an expiration date of ,d+[DATE] On [DATE] in the morning, the Director of Food Services confirmed the expiration date of the flour, brown sugar, and powdered sugar. On [DATE] at approximately 8:15 AM, the following expired food items were identified in the refrigerator: -Chobani peach yogurt with an expiration date of ,d+[DATE] -One bag of cinnamon sticks with an expiration date of [DATE] On [DATE] in the morning, the Director of Food Services confirmed the expiration date of the Chobani peach yogurt and bag of cinnamon sticks. On [DATE] at 8:30 AM, the Director of Food Services indicated they were responsible for clearing out expired food items from the dry storage and refrigerator. The Director of Food Services explained the residents could get sick if they were to consume expired food items. The facility's policy titled Dry Goods Storage and policy titled Refrigerated Storage; both were last revised on [DATE] revealed new food stock was stored behind old stock, so the older items were used first. 2) On [DATE] in the morning, during the kitchen tour, the facility dishwasher was identified as a chlorine sanitizer, low temperature machine. The following attempts were made to test the chlorine level after completion of the rinse cycle: -Attempt one: Chlorine strip did not have a color change -Attempt two and three: Chlorine strip turned a light gray indicating a value of 10 with normal range being ,d+[DATE] On [DATE] in the morning, the Director of Food Services indicated they performed the chlorine strip test that morning and the range was within normal. On [DATE] at approximately 11:07 AM, the Director of Food Services indicated the dishwasher was still under repair as there was tubing which was deteriorating and needed to be replaced. On [DATE] at 8:30 AM, the Director of Food Services indicated the staff member washing the dishes was responsible for ensuring the chlorine test was done before breakfast, lunch, and dinner. The Director of Food Services explained the potential outcome of the dishwasher not being within good repair meant dishes were not being disinfected properly, which meant bacteria could still be present on the dishes.

Based on interview and document review, the facility failed to ensure an allegation of physical abuse by a staff member towards a resident was reported to the State Agency in a timely manner for 1 of 1 resident. The failure to report incidents timely may place the facility residents at risk for abuse. Findings include: The facility policy Abuse-Dependent Adult/Child, revised on 07/02/2014, when an alleged or suspected case of mistreatment, neglect, injury of unknown source or abuse was reported the Administrator/Director of Nursing would notify the State Agency within 24 hours of when the abuse was reported. On 01/05/2023 the facility Administrator acknowledged the facility did not report the allegation of abuse to the State Agency within the required time frame. The facility submitted an initial and final report to the State Agency on 10/10/2022, 48 hours after they were aware of the alleged incident on 10/08/2022.

Based on observation, interview, record review, and document review, the facility failed to ensure a facility reported neglect incident regarding tube feeding (TF) deprivation was followed through, and the affected residents were assessed and monitored for potential adverse outcome for 2 of 7 sampled residents (Residents #1 and #2). Failure to thoroughly follow-up on the investigation, assess and monitor the adverse outcome of the affected residents, could place the residents at a higher risk of further recurrence and physical harm. Findings include: On 09/01/2022 at 6:45 AM, the TF formulas were prepared by the night shift licensed nurses and TF bags were labeled with the resident's name, current date, and volume to be administered. TF was infused as ordered through a gastrostomy tube. The facility reported incident dated 03/19/2022, documented a complaint/allegation received from a night Registered Nurse 1 (NOC RN1) via email that the dayshift Licensed Practical Nurse 1 (LPN1) had not been appropriately using the tube feeding which were prepared for the residents by NOC RN1 and allegedly LPN1 had not been feeding the pediatric patients. Resident #1 (R1) R1 was admitted on [DATE] and readmitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN1 had worked on the following shifts: 03/05/2022, 03/11/2022, 03/12/2022, 03/17/2022, 03/18/2022, and 03/19/2022. R1's weight Summary: 02/25/2022 19.2 pounds 03/04/2022 19.0 pounds 03/15/2022 18.3 pounds 03/22/2022 18.7 pounds 03/25/2022 18.8 pounds 04/26/2022 18.7 pounds 04/29/2022 18.9 pounds Resident #2 (R2) R2 was admitted on [DATE] and readmitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN1 had worked on the following shifts: 03/05/2022, 03/11/2022, 03/12/2022, 03/17/2022, 03/18/2022, and 03/19/2022. On 09/01/2022 at 7:21 AM, the NOC RN1 reported suspected neglect on 03/19/2022, for not giving the ordered TF formula to the residents during LPN1's shift. The NOC RN1 explained for several days, the TF for the residents were prepared at 6:00 AM and endorsed prior to the change of shift. The NOC RN1 explained the TF bag was labeled and readily available for the morning shift but noted it was not used or administered, upon NOC RN1's return for the evening shift. The NOC RN1 indicated the bag was labeled with own penmanship, the same date when previously prepared, and the tubing was not primed. The NOC RN1 noticed the same for successive shifts, so LPN1 was observed closely for two weeks during shift until NOC RN1 confronted LPN1 on 03/19/2022. The NOC RN1 indicated LPN1's alibi was another TF bag was ready and did not use the feeding NOC RN1 had prepared. The NOC RN1 indicated there was an occurrence when R1 had a low glucose of 39 milligrams per deciliter (mg/dl) (normal blood glucose level range within 70 to 99 mg/dL) and believed LPN1 did not give the TF as scheduled. The NOC RN1 indicated on 03/19/2022, there was no Administrator or DON in the building and decided to email the DON regarding the suspected neglect. The NOC RN1 indicated on the same day, LPN1 was escorted out of the facility and was suspended pending investigation. On 09/01/2022 at 7:30 AM, the night shift LPN 2 (NOC LPN2) and night RN 2 (NOC RN2) confirmed they had the same experience when the TF was not administered to the residents by LPN1. NOC LPN2 and NOC RN2 were not interviewed by the administration when the incident was exposed. Both indicated there was no abuse training provided post-incident. R1's and R2's medical records lacked documented evidence a focused assessment was completed and were monitored for potential adverse outcome post incident of the ordered TF not administered. On 09/01/2022 at 9:28 AM, the Director of Nursing (DON) indicated an email was received on 03/19/2022, from NOC RN1 and allegedly TF was not administered by LPN1. The DON indicated on the same day, the Administrator in the North was informed and LPN1 was sent home pending investigation. The DON indicated the allegation of neglect was substantiated when the video footage or recording in the POD revealed no indication LPN1 prepared and administered the TF for the residents. The DON indicated after a thorough investigation, the allegations were substantiated, and the LPN was terminated on 03/24/2022. The DON indicated the incident was reported to the Board of Nursing and the Metropolitan Police Department was involved. The DON confirmed the affected residents were vulnerable because they were unable to communicate, were not assessed and monitored for the potential adverse outcome of the deprivation of ordered TF. The DON indicated an interim DON from the past had helped with the investigation. On 09/01/2022 in the morning, during a telephone interview, the former interim DON confirmed the affected residents were not assessed or monitored for potential adverse effects of tube feeding deprivation at the time of the incident. The former interim DON indicated the other staff members or other witnesses were not interviewed and lacked documented evidence interventions were implemented to prevent recurrence. On 09/01/2022 at 9:40 AM, the current DON confirmed there was no summary of investigation, no focused assessment of the affected residents, no monitoring for the potential adverse outcome, and no abuse prevention training was provided to staff members post neglect incident. On 09/01/2022 at 3:56 PM, the Registered Dietitian (RD) indicated was not informed regarding the TF not having been administered to R1 and R2. The RD indicated the staff were expected to inform the RD when the resident's nutrition was altered to monitor possible weight changes. The RD indicated a weighing should have been requested and the feeding adjusted to increase calories to keep up or maintain the resident's nutrition. On 09/01/2022 at 4:10 PM, the current administrator acknowledged the reported neglect on 03/19/2022, should warrant a follow up interview with other staff members or any possible witness, determine how many residents were affected, and monitor the potential adverse outcome of ordered TF not being administered. The current administrator confirmed corrective actions and monitoring were not implemented to prevent further occurrences and physical harm. The current administrator indicated the physician should have been notified to obtain orders post-neglect incident. A facility policy titled Abuse Dependent Adult/Child revised dated 07/02/2014, documented all staff members were responsible for ensuring all residents were free from deprivation of goods and services that were necessary to avoid physical harm or mental suffering. The physician would order measures required to address the consequences of an abuse situation. The staff would monitor residents who have been abused at least until their medical condition, mood and function have stabilized, and periodically thereafter. Staff would ensure the basic, medical, functional, and psychosocial needs were being met and the potentially preventable or treatable conditions affecting function and quality of life were addressed appropriately. The investigation would include, at a minimum, review of the completed Incident Report Form; review of the resident's medical record to determine events leading up to the incident; interview the person(s) reporting the incident; interview any witness to the incident; interviewing staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; interview the resident's roommate, family members, and visitors; and review all events leading up to the alleged incident. The Administrator / DON should make a reasonable attempt to reach a conclusion as to the cause of the incident and take corrective actions during the duration of the investigation and to provide residents with a safe environment. Facility Reported Incident #NV 963

Based on interview and document review, the facility failed to ensure 1) a staff member reported the abuse incident timely to the Abuse Coordinator and the alleged perpetrator was removed from the schedule after receiving a report of an allegation of abuse for 1 of 5 sampled residents (Resident #1); and 2) the staff members were not familiar with their abuse policy for reporting. Findings include: 1.) Abuse reporting and resident protection The facility's Abuse-Dependent Adult/Child Policy revised on 07/02/2014, documented the staff members would immediately (including after hours) report all incidents or suspected incidents of resident abuse, mistreatment, neglect, or injury of unknown source to the Administrator or Director of Nursing (DON) and correct reporting agency. The facility would protect residents during an abuse investigation. If the suspected perpetrator was a staff member, the supervisor would remove the individual from the care of the resident and suspend the staff member during the investigation. Resident #1 (R1) was admitted on [DATE], with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/03/2021, a facility reported incident was received by the State agency for an allegation of abuse that occurred on 10/29/2021. The incident was witnessed by a Certified Nursing Assistant (CNA). On 12/22/2021 at 8:16 AM, the CNA verbalized was bottle feeding R1 in Pod 2 on 10/29/2021, the time of incident. Another CNA grabbed a package of string cheese from the charting table, opened the package and threw a piece of string cheese towards R1, which landed on the resident's forehead. The CNA indicated R1 was sleeping and was startled by the incident. The CNA asked the other CNA why they threw a piece of string cheese towards R1 and was told it was a social media trend. The CNA thought it was inappropriate and reported the incident to the Registered Nurse (RN). The CNA conveyed there was no redness on R1's forehead after the incident. On 10/29/2021, the CNA reported the incident to an RN. The alleged perpetrator worked the rest of the shift and had access to R1. On 12/22/2021 at 8:23 AM, the RN confirmed on 10/29/2021, an allegation of abuse involving R1 was reported by a CNA. The RN indicated the incident happened around 6:00 P.M. and was reported to the Director of Nursing (DON #1) on 10/30/2021, between 9:00 to 10:00 AM. The RN explained the reason they did not report the incident immediately was because R1 was not harmed. On 10/31/2021, DON #1 reported the incident to the previous Abuse Coordinator. On 11/03/2021, the previous Abuse Coordinator conducted an investigation and reported the allegation of abuse to the State agency. The alleged perpetrator worked half the shift and was suspended due to the allegation of abuse. On 12/22/2021 at 10:45 AM, the Administrator and DON #2 (from the sister facility) confirmed on 10/29/2021, an incident involving R1 had occurred. The Administrator conveyed the allegation of abuse was not reported immediately by the RN. The Administrator indicated after the allegation of abuse was reported to the RN, the RN should have contacted the previous Abuse Coordinator immediately and not the following day. The Administrator explained if the allegation was reported immediately, the perpetrator would have been suspended on Friday, 10/29/2021, and an investigation would have been initiated immediately. The Administrator verbalized the allegation of abuse was reported to DON #1 on Saturday, 10/30/2021, but DON #1 did not report the incident to the previous Abuse Coordinator timely to initiate an investigation, suspend the perpetrator and report the allegation of abuse to the State Agency. The Administrator confirmed the previous Abuse Coordinator did not suspend the perpetrator after they were notified of the abuse allegation on Sunday, 10/31/2021. The perpetrator was suspended on Wednesday, 11/03/2021, after working half the shift. The facility's Day Shift Assignment dated 10/29/2021 and 11/03/2021, documented the perpetrator had worked on these dates and had access to R1. 2.) Abuse Policy On 12/22/2021 at 10:23 AM, DON #1 conveyed the previous Administrator conducted abuse training with the staff members. DON #1 indicated the staff members were provided with abuse training after the incident on 10/29/2021. The current Administrator explained the facility had conducted annual training, including abuse training with the staff members. On 12/22/2021 at 8:16 AM, a CNA conveyed suspected or confirmed abuse would have been reported to the DON within two hours for physical abuse and three days for all other types of abuse. On 12/22/2021 at 8:23 AM, a RN indicated would report a suspected or confirmed abuse to the DON within 24-hours. On 12/22/2021 at 9:31 AM, the Director of Rehabilitation indicated an allegation of abuse should have been reported immediately, but staff members were given 24-hours to report the incident to the Abuse Coordinator. The Administrator and DON #2 indicated when reporting abuse to the State agency, it needed to be reported within 24 hours and if staff initially identify abuse in the facility the incident needed to be reported immediately.

Based on observation, interview, and record review, the facility failed to prevent a fall with injury for one of 12 residents selected for review, (Resident (R85), when the facility failed to develop a policy and procedure and staff training system related to the implementation of safety measures associated with enclosure beds. As a result of this deficient practice, R85 fell to the floor through an unsecured access panel in the netting that surrounded his enclosure bed, hit his head on the floor sustaining a laceration, and required transfer to the emergency room for evaluation. Findings include: Review of R85's Person Summary Sheet, dated 06/13/18, indicated the facility admitted the resident on 06/13/18 with [DIAGNOSES REDACTED]. Review of R85's physician's orders [REDACTED]. Review of R85's significant change in status Minimum Data Set assessment (MDS), an assessment tool completed by the facility staff used to identify resident care problems and assist with care planning, with an Assessment Reference Date (ARD), the end-point of the evaluation period, of 08/02/18, indicated under Section G: Functional Status, that R85 required extensive assistance of two persons for transfers, but was mobile in his bed with supervision. Section J: Health Conditions, indicated R85 had no falls since his last MDS assessment. Review of a facility Accident/Incident Form, dated 07/30/18 at 6:05 PM, indicated [REDACTED]. Further review of the Accident/Incident Form and related documentation, indicated under Antecedent Events the staff documented, He (R85) was inside of (the) enclosure bed. Under Incident Narrative Registered Nurse (RN) 1 documented, I was attending (resident room number) client for desats (decreased oxygen saturation) and was called out by loud voices by (the) social worker and my CNA (later identified as Certified Nursing Assistant 1) to (the) POD (common area), to find R85 lying on (the) POD couch, covered by blood on (his) face, (the initials of CNA1) states (sic) R85 was crying in (his) highchair, his roommate's pulse oximetry alarm went off at the same time, then stopped and his heart rate returned to normal. (Initials of CNA1) positioned R85 in bed, changed his diaper and left him in bed, then went to attend (R85's roommate). She heard R85 crying again, she ran to him, only (to) find him lying on the floor. (He) fell from (the) head flap which (was) not zipped, (the head flap was) hanging on there (the netting), without notice. (Name of R85) sustained a cut on (his) right forehead, about 2 cm (centimeters) in length, blood stopped spontaneously, vital signs within normal limits. Client awake and alert. Ate snack and watched TV. Physician and family notified. Physician ordered to send him out to the emergency room . Review of a witness statement by CNA1, dated 07/30/18 at 6:05 PM, provided the following information, I was the CNA in Pod 1 on 7/30/18 day shift. Approximately 5 -7 minutes before the incident, multiple pulse oximetry alarms went off in the Pod. My nurse at the time, (name of nurse), went to attend to the patient in room [ROOM NUMBER] and I went to room [ROOM NUMBER]. (R85's roommate), who was in his high-chair watching TV while dancing and jumping (sic) had a high heart rate, explained by him jumping up and down. I walked over to (R85), who was in his high-chair watching TV and crying. I assumed he might be wet and laid him down to check using the main opening of the enclosure bed. (R85) was wet; I changed his brief and went on to change him from day clothes to night clothes. (Name of R85's roommate) pulse oximetry began to alarm again. I zipped and closed the main flap from the entrance (that) I used to change (R85) and quickly ran to check on his roommate. (R85's roommate) was crying, so I assumed he may be wet as well. At this point, (R85) had stopped crying. I changed (the roommate's) brief and clothing, buckled/secured the patient into his high-chair, as I was securing his table top (R85) began crying again. I turned the corner to where (R85) was in sight, until I see (R85) on the floor under the (wall mounted) TV between the dresser and night stand. I dropped whatever clothing and briefs in my hand and pick (sic) him up. I took R85 out into the general Pod area shouting for my Pod nurse, who was still tending to (resident name) in room (number). We tended to (R85). Nurses cleaned (R85) up, applied pressure, and applied a butterfly bandage and ice. Bleeding quickly stopped. Vital signs were taken, nurse confirmed. (R85) was given hydration via apple juice in sippy cup, along with crackers. Staff provided reassurance, (R85) was calm and giggling. At this point (R85) stopped crying. We sat him in his high-chair in the general Pod area. When (the) patient's (R85's) room was examined, the patient's far end of the bed flap was unzipped; it was assumed the patient fell through. It is unknown how or why this was not zipped/buckled/secured correctly. Patient was sent out. Review of R85's care plans indicated the staff had not developed a care plan related to the resident's potential for falls or related to enclosure bed safety. Observation on 07/31/18 at 8:30 AM, revealed R85 sat in a high chair watching television in the communal area of the Pod 1. A small butterfly bandage partially covered a laceration on right side of the resident's forehead. During an attempted interview with R85 at this same time, the resident was unable to answer questions about his fall due to limited communication skills. Observation of R85's semi-private room on 07/31/18 at 8:40 AM revealed the room contained two enclosure beds each fully enclosed with netting. The netting that surrounded R85's bed included zippered access panels on each of the four sides. The distance from the top of R85's mattress to the floor measured 3 feet, 6 inches. The cement floor in the room was covered with industrial grade carpeting without an underlying pad. During an interview on 07/31/18 at 10:20 AM, R85's grandfather (Family (F) 1) reported he visits R85 almost every day on his way to work. F1 stated R85's father visits the resident on the days he is unable to visit. F1 stated he was notified R85's father of the resident's fall from his bed on 07/30/18. F1 stated he talked with nursing staff and the facility physician the next morning about the fall and received additional information. F1 stated the fall reportedly occurred because someone left one of the access panels unzipped. He stated it was believed that R85 leaned on the unsecured access panel from inside the enclosed bed and fell to the floor, landing on his forehead. F1 stated he expressed concern that an access panel was left unsecured on the bed and that the bed was raised so high from the floor. F1 added that his comfort level with the facility's capacity to provide for R85's safety was shaken by the fall. During a telephone interview on 08/01/18 at 9:10 AM, CNA1 stated she worked on Pod 1 on 07/30/18 at 6:00 PM. The nurse on duty was in the room with a newly admitted resident whose gastric tube alarm kept sounding. The CNA stated she went to R85's room because his roommate's pulse oximetry alarm kept sounding. She first checked the roommate's alarm and then checked R85 who was crying, sitting in his high chair watching television. CNA1 stated she identified that R85's diaper needed to be changed, and then unzipped the flap on the right side of his enclosed bed, placed the resident on the mattress, changed the diaper, and changed him into his pajamas. As she was finishing with R85, his roommate's pulse oximetry alarm sounded again. CNA1 stated that she zipped the right flap of R85's enclosure bed back into place and secured the buckle. She then moved to the roommate's enclosed bed and changed the resident's diaper. As she finished, R85 began crying. She turned to visualize R85 and discovered he was no longer in his bed. She stated she didn't hear a sound like someone falling to the floor. She didn't see him on the floor between the beds and followed the sound to the end of his bed closest to the television where she found him on the floor between the end of the bed and the wall mounted television. He was crying and had blood on his face. CNA1 stated she scooped up R85 from the floor and called out for the nurse. She hurried to the communal area of the Pod and placed R85 on the top flat surface of the couch. The nurse came quickly, assessed R85, and then took him back to his room where she continued to administer first aid. CNA1 called for back-up and other nurses arrived to assist. The CNA stated she did not open or access the end flap on R85's bed for any reason on the day of the incident and did not know if anyone else accessed the end flap on R85's bed on that day. CNA1 stated she did not check the zippered flaps on the enclosure beds prior to the incident. The CNA stated she was aware that R85 could fall and had an unsteady gait. She was aware of R85's care plans and what interventions to use when she provided care for F85. CNA1 stated she was a new CNA and had worked at the facility for about three months. She stated as part of her initial facility orientation, she received training from a nurse on using the enclosure beds. CNA1 stated the training focused on how to put a child in, and how to take a child out, of the bed and moving the zipper along the track and securing it when it was fully engaged with the buckle but did not include instructions on checking the flaps on an ongoing basis. During an interview on 08/02/18 at 8:45 AM, RN1, who was on duty in Pod 1 at the time of R85's fall, stated on 07/30/18 at 6:05 PM, she was in another room attending to another resident when she heard CNA1 yelling her name for help. She ran into the common room and saw R85 laying on the flat surface on top of the center couch with blood on his face with CNA1 next to him. RN1 stated R85 had a laceration on his right forehead that had bled onto his face. She put out a call for help, cleaned the blood from his wound, and applied pressure. The wound stopped bleeding quickly. She checked his vital signs and conducted an assessment. She determined he was safe to move and took him back to his room and continued to administer first aid. Other nurses arrived and began assisting with next steps. RN1 stated she did not access the end panel of R85's bed on that day and did not know if anyone had done so that day RN1 stated she did not check the zippered flaps on any of the enclosure beds prior to the incident as there was no expectation that was necessary. RN1 stated the facility provided her with training on the use of enclosure beds, but the training did not include instructions on assuring each access flap was fully closed. During an interview on 08/01/18 at 11:25 AM, the Director of Nursing (DON) stated the facility had no documentation to show that CNA1 received training on the use of enclosure beds. She explained the facility had not previously required staff to complete competency-based demonstrations of accessing enclosure beds. The DON stated she expected all staff who provide direct support to the residents receive training on the use of enclosure beds during orientation. Review of the facility's policies and procedures indicated the facility had no policy and procedure that addressed the use, safety precautions, and warnings for enclosure beds.

Based on observation, interview, record review, document review, and policy review, the facility failed to: 1) ensure medication administration and oxygen treatment were provided in accordance with physician's orders [REDACTED].#11, #1); 2) ensure respiratory treatment was provided in accordance with physician's orders [REDACTED].#11); and 3) ensure a nurse did not leave a resident with severe risk of respiratory decline unmonitored by the pulse oximeter machine and unattended for 1 of 14 sampled residents (Resident #11). Findings include: 1. Inadequate respiratory monitoring for Resident #11 Resident #11 Resident #11 was a 7 month old male with a [DIAGNOSES REDACTED].#1 and admitted to the facility on [DATE]. -The Discharge Summary dated [DATE] from Acute Care Facility #1 to the facility indicated the discharge respiratory orders for the setting for "Tracheal 02 (oxygen) Fri at 0.3 AL (liters)". -The history and physical examination [REDACTED]." -The history and physical examination [REDACTED]. The patient has had [MEDICAL CONDITION] and is on oxygen...The patient has [MEDICAL CONDITION] at 30% half hour O 2 (oxygen)...Impression: A 27-week old infant with multiple dystrophies, [DIAGNOSES REDACTED], hypertension, [MEDICAL CONDITION] post blood [MEDICAL CONDITION], and grade 1 hydrocephalous...Problem List: Possible Jeune's syndrome (asphyxiating [MEDICATION NAME] dystrophy); 2) History of ventilator dependence - resolved; 3) [MEDICAL CONDITION] dependent; 4) [DEVICE] dependent; 5) Mild hypoxemia, stable on supplemental oxygen...Plan: 2: 02 prn." -The Admission Nursing Assessment (undated) did not include orders for oxygen. -The Admission Nursing Assessment and the history and physical examination [REDACTED]. -There was no documented evidence the facility contacted the physician to obtain initial orders for oxygen. -The physician's orders [REDACTED]." -The Medication Administration Record [REDACTED]. -The Nursing Care Plan (undated) for the risk for aspiration and ineffective breathing patterns (problem onset: [DATE]) indicated: "Risk for aspiration r/t (related to) being NPO (nothing by mouth) [MEDICAL CONDITION] place. MBS (modified [MEDICATION NAME] swallow) on [DATE] performed in hospital with aspiration occurring on all consistencies." Approaches included: "Suction as needed/ordered and continuous pulse oximeter as ordered." "Ineffective breathing patterns related [MEDICAL CONDITION] place, episodes of increase secretions and dx (diagnosis) of Jeune's syndrome (asphyxiating [MEDICATION NAME] dystrophy, hx (history) of ventilator dependence (resolved) and mild hypoxemia, stable on supplemental oxygen." Approaches included: Monitor respiratory rate, depth and effort. Monitor lung sounds, pallor, cough and character of sputum. Notify MD (Medical Doctor) as indicated; Suction as needed. -The [MEDICAL CONDITION] Care Plan (Date Initiated: [DATE]; signed by Respiratory Therapist #1) indicated the first problem identified: "Potential/actual medical instability related to alteration in [MEDICAL CONDITION] status as evidenced by ineffective airway clearance secondary to [MEDICAL CONDITION]." The interventions included to administer oxygen as ordered, check saturation levels continuously, and suction prn increase of secretions or inability to effectively clear airway by coughing. The second problem identified was dysphasia, and interventions included "suction as needed". -Review of nurse's notes revealed fluctuations in the amount of oxygen administered (ranging from 3 liters to 5 liters) to Resident #11 from [DATE] through [DATE]. There was no documented evidence of physician's change orders or assessment/justification of the amount of oxygen administered to Resident #11. -The Weekly Nursing Summary dated [DATE] for the day shift indicated, the suction frequency (average day) was ,[DATE] times/shift, with 5 liters of oxygen. -Review of nurse's notes (undated) revealed: "06:45 (6:45 AM): Pt's (patient's) 02 saturation (down) to 46% sat (saturation level) was bagged & suctioned. Pt's 02 Sats returned to 92%. 06:55 (6:55 AM): Pt's 02 sats (down) 70%. Suctioned (with) + (positive) results. 02 sats returned to normal levels 92%. Will continue to monitor." (It was unable to be determined in the clinical record exactly when this event occurred.) There was no documented evidence the facility notified the physician and the family member of this incident. -The nurse's notes (written by Employee #19) dated [DATE], indicated the following: "07:30 (7:30 AM): 02 5 L [MEDICAL CONDITION]. 08:30 (8:30 AM): "...Suctioned [MEDICAL CONDITION] sm (small) amt (amount) tan mucus. 10:30 (10:30 AM) Feeding completed & tol (tolerated) well. Suction x1 for sm amt tan mucus. 11:00 (11:00 AM): "Entered rm (room) to find 02 tubing had come ___ (illegible). Pt cyanotic, no spontaneous respirations noted. CPO (Continuous Pulse Oximeter) off. Called for Charge Nurse. Pulse detected. Began rescue breathing using ambu-bag. 911 called by CNA (certified nursing assistant). Charge nurse to observe pt & is now taking slow shallow breaths on his own. Cont (continue) rescue breathing (with) ambu bag. 11:15 (11:15 AM): Paramedics arrived & took over care of pt. 11:30 (11:30 AM): Transferred to (Acute Care Facility #2)" Resident #11 was transferred to Acute Care Facility #2 on [DATE]. -The Transferring Facility Report (the facility) indicated report was given to a licensed nurse in the NICU (neonatal intensive care unit). The report indicated primary dx (diagnosis) was "Trach collar 35% 1.5 L (to) 3 L". -The Ambulance Report indicated, "Physical Findings: Neck:[MEDICAL CONDITION] place, thick yellow sputum present...Narrative: Called for [MEDICAL CONDITION]. U/A (sic) per staff. Pt with occlusion [MEDICAL CONDITION] in resp/[MEDICAL CONDITION]. Staff states CPR (cardiopulmonary resuscitation) performed for approx (approximately) 1 min with BVM (bag valve mask) -[MEDICAL CONDITION]. Staff states return of pulses/resp effort s/p (status/post)[MEDICAL CONDITION]. Staff with conflicting version of med hx (history). Staff without further pertinent info (information). Staff repeatedly stating, 'I don't know. I don't have his chart with me.' No family available on scene." -The Acute Care Facility #2 Emergency Physician's Record dated [DATE] reported Resident #11 became cyanotic at the facility, was bagged and suctioned, and transferred to the Emergency Department. -Resident #11 was transferred from Acute Care Facility #2 and readmitted to the facility on [DATE]. -The Acute Care Facility's Discharge/Transfer Summary, dated [DATE] indicated, "(Physician #2) is okay to discharge the patient on oxygen support at 3 liters per minute...Special Instruction:...Advised to frequent nasal suctioning..." -The Physician's admission orders [REDACTED]. The admission orders [REDACTED]. -The Respiratory Notes dated [DATE] (written by Respiratory Therapist #2) indicated, "Pt has #[MEDICAL CONDITION] 4L via T-collar, 02 sats 95%..." -On [DATE], [DATE], [DATE], and [DATE], Resident #11's oxygen was observed to be set at ranges between 3 and 4 liters. -On [DATE] in the late afternoon, Respiratory Therapist (RT) #2 indicated he had assessed Resident #11 on [DATE]. The RT further indicated the 02 was set at parameters (between 3 to 5 liters per minute) which differed from the physician's orders [REDACTED]. The RT verified he had read the physician's orders [REDACTED]. The RT stated, "I should have called the doctor to clarify the orders." The RT verbalized he did not know Resident #11's medical history and was not aware the baby had been admitted to an acute care facility due to the respiratory distress incident on [DATE]. The RT further indicated he was not knowledgeable of the physician's orders [REDACTED]. He verified the physician's orders [REDACTED]. -Two employee interviews which were documented by the DON regarding the incident on [DATE] were as follows: (Note: The documented interviews were not signed or dated by the employees.) The interview with Employee #19 by the DON dated [DATE] indicated the employee acknowledged that she had left the room after turning off Resident #11's pulse oximeter alarm, and further indicated the following: "I went to check on (Resident #11). I was getting (another resident's) feeding together and something just told me that I needed to check on him. When I got to his room I noticed that his color was off. As I put down what I had in my hands I looked at the oximeter. I noticed the oximeter was off and that the 02 tubing has pulled loose from the nebulizer barrel attached to [MEDICAL CONDITION]. When I looked at him closer I noticed he was not breathing. I checked his pulse and found out he had one. I put the 02 on the ambu-bag, started bagging him and called for help. (Employee #4) came in and suctioned him while I put the oximeter on (Resident #11)." In response to the DON's question why the pulse oximeter had been turned off, Employee #19 indicated, "I don't know. I had been working with the oximeter earlier. I was doing his cares between 10:40 and 10:45. I noted that the oximeter was reading a lot of artifact so I figured the probe was loose. I turned off the oximeter to readjust the probe so the alarm would not go off. Then I found a spot that worked. I don't remember turning the machine back on but there was so much going on all morning it is hard to put things in the order that they happened. Alarms were going off because the kids need frequent suctioning. I was passing meds (medications) and hanging feedings, family members were asking for help, the carpet cleaning guy was here so it was very noisy and I had to pay attention to where the hose was so I could jump over it." The DON then asked the employee (Employee #19) whether it was her normal practice to turn off the machine while adjusting the probe. Employee #19 indicated, "Yes". Employee #19 further indicated, "I found a spot with good readings then realized that the adhesive on the probe was wearing off and I would need tape to secure it...I shut the machine off and stepped out to get tape from my cart. There was so much going on. I got distracted, pulled away by something. I can't remember exactly what but it must have been urgent, an alarm going off or something...I forgot. I forgot to go back..." The documented interview with Employee #4 by the DON dated [DATE] indicated, "...I ran back to room [ROOM NUMBER] and saw (Employee #19) bagging the baby. He was pale. I told (Employee #20), CNA to call 911. I turned on the suction machine and began to suction the baby while (Employee #19 put the oximeter probe on the baby and turned it on. The machine showed that he was in the 40's. After about 30 seconds his color started getting better and the pulse ox (oximeter) showed him at 92%. He was breathing on his own but (Employee #19) was giving support breaths. We stayed with him until the ambulance came..." -On [DATE], the DON indicated her internal investigation revealed that Employee #19 had disarmed the pulse oximeter and left the room. The Administrator and the DON indicated Employee #19 was terminated from employment because she left the baby alone with the pulse oximeter turned off. -The facility's Internal Investigation results following the incident included the determinable causes as the resident having copious secretions, incorrect technique, failure to follow policies and procedures, inadequate training, communication failure, inadequate plan of care, and breach of code of conduct. The Internal Investigation results further included a summary that Resident #11 had a history of [REDACTED]. The action to be taken included an updated plan of care. This action was documented as completed [DATE] on the internal investigation. -On [DATE], the DON indicated the nursing schedules were completed by the Charge Nurse. The DON indicated she did not review or audit the nurse staffing schedules to oversee the ratio of nurses to residents to ensure that there were enough nurses to provide care for residents with a high level of acuity. -On [DATE], the nursing staff schedules were reviewed with the Administrator. It was pointed out to the Administrator that the staffing schedules and the census sheet on [DATE] indicated there was one nurse (LPN) in the Pediatric Unit assigned to 10 residents, including 4 out of the 5 pediatric residents with tracheostomies (which included Resident #11). The Administrator indicated she was not aware one nurse was assigned to a total of 4 pediatric residents with tracheostomies (which included Resident #11), while the other LPN in the Pediatric Unit was assigned only 1 residents with tracheostomies. -On [DATE], the Administrator verified the care plan was not updated as indicated in the internal investigation. The Administrator also verified the facility did not document an assessment of the acuity of care needed by Resident #11. The Administrator indicated the facility did not increase the nursing staff. On [DATE] in the afternoon, the Director of Education indicated the reason she did not update the care plan was due to no changes needed by Resident #11, and stated, "The care plan was the same one as before, so I just added the date (Resident #11) was readmitted ." -On [DATE] in the afternoon, the DON verified she did not report the incident to the Bureau of Health Care Quality and Compliance (the Bureau) and did not report Employee #19 to the Board of Nursing because the action was not intentional, and stated, "It was just a mistake on the nurse's part. It wasn't neglect." On [DATE] in the afternoon, the DON indicated a neglectful action which should be reported to the Bureau and to the Board of Nursing would be an act which was "careless", and verbalized she should have completed the reporting. -On [DATE], the Administrator indicated she did not consider the nurse's actions of turning off the pulse oximeter and leaving the resident's room as abuse or neglect "because it wasn't willful. She didn't intentionally mean to harm someone". 2. Qualifications of staff permitted to perform suctioning care: The Policy, "[MEDICAL CONDITION] Care", dated [DATE], indicated licensed nurses and respiratory therapists have the scope of practice to suction a [MEDICAL CONDITION]. The policy did not include speech therapists. The Job Description for a Speech Therapist did not include duties to perform suctioning care. On [DATE], the Director of Rehabilitation (Rehab) verified the speech therapists in the facility perform suctioning care. The Director of Rehab indicated the speech therapists did not have special training or competencies in suctioning, and she considered the speech therapists qualified because they had Master's degrees. On [DATE], a resident's family member was interviewed. The family member indicated she was concerned about the abilities and qualifications of the speech therapist to provide suctioning care. Throughout the survey, licensed nurses indicated that speech therapists do perform suctioning care as needed for residents on all units who have tracheostomies, including the pediatric residents. On [DATE] in the morning, an interview was conducted with one of the Medical Directors (who is a [MEDICAL CONDITION] Specialist). The Medical Director stated, "I don't know anything about speech therapists doing suctioning. Therapists are ancillary. In my mind a speech therapist should never do the suctioning." On [DATE] and [DATE], 1 licensed nursed in the Pediatric Unit indicated that speech therapists do the suctioning care for Resident #11 in the morning after speech therapy treatment. On [DATE], a telephone interview was conducted with a representative of the Board of Speech Pathologists (Therapists), who indicated it was not considered within the scope of practice for a speech therapist to perform suctioning procedures unless the speech therapist had training, education, and experience. On [DATE], Respiratory Therapist #2 indicated he had been employed by the contracted agency for approximately 1 week at the facility, and works part time. He indicated he was aware the speech therapists were performing suctioning. He further indicated he was not aware if they had had training or competencies in suctioning performed. On [DATE] in the afternoon, the DON and the Administrator verified there was no documented evidence the speech therapists have had training and education and were competent to perform suctioning. Resident #1 Resident #1 was admitted on [DATE], with [DIAGNOSES REDACTED]. 1) Review of Resident #1's record documented a physician order [REDACTED]. Review of Resident #1's Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. Review of Resident #1's MAR indicated [REDACTED]. On [DATE], during the medication administration observation, the medication cart assigned to the area where Resident #1 resided was inspected with Employee #12. Vitamin D 5000 units for Resident #1 was not located in the cart. Employee #12 affirmed if a medication was ordered once a month, pharmacy delivered the medication once a month. On [DATE] at 11:10 AM, the pharmacist was interviewed via telephone about the vitamin D order for Resident #1. She stated the initial physician order [REDACTED]. According with the pharmacist, vitamin D 5000 units was a lower dose for monthly administration. She confirmed monthly dose for vitamin D should be 50,000 units instead 5000 units and a clarification of the order was requested via fax to the facility on [DATE]. The pharmacist recalled a verbal clarification order was made by a nurse via telephone the same day. She confirmed after the verbal clarification, the vitamin D 50,000 units was delivered on [DATE] and [DATE]. During the interview, the inspector requested an evidence of the written clarification order for Vitamin D. The Pharmacist confirmed a written clarification order was never received because it was a verbal clarification. She stated the order should have been processed only after receiving a written order via fax. The pharmacist confirmed vitamin D 5000 units was never delivered to the facility. Review of pharmacy medication delivery receipt revealed vitamin D2 1.25 mg 50,000 Units one tablet was delivered to the facility on [DATE]. On [DATE] at 3:30 PM, Employee #2 explained after a new physician order [REDACTED]. She stated if pharmacy requested an order clarification, nurses communicated with the physician to obtain the clarification. Employee #2 confirmed once the clarification was obtained, the order was faxed to pharmacy for processing. Resident #1's record was reviewed with Employee #2. The record lacked documented evidence a clarification order for Vitamin D was obtained. There was no evidences the two Vitamin D 50,000 units delivered by the pharmacy were administered, returned to pharmacy, or discarded. The facility policy titled Ordering and Receiving Medications dated 2007, read: "... a. Original medication orders are transmitted to the pharmacy..." 2) On [DATE] at 8:30 AM during medpass, Employee #12 was observed preparing and administering medications for Resident #1. The medications included: - [MEDICATION NAME] 800 milligrams (mg) 2 tablets - [MEDICATION NAME] 20 mg 1 tablet - [MEDICATION NAME] sulfate 325 mg 1 tablet - Multi vitamin 1 tablet - Zinc Sulfate 220 mg 1 tablet - [MEDICATION NAME] 5 mg 1 capsule - [MEDICATION NAME] 40 mg 1 tablet - Vitamin C 500 mg 1 tablet - [MEDICATION NAME] 2 micrograms 1 capsule - Insulin NPH 65 units Review of Resident #1's record documented a physician order [REDACTED]. Review of Resident #1's MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The medication was administered twice within 3 hours. On [DATE] during an interview, Employee #12 stated she administered the medication that appeared in the medication cart computer screen scheduled to be administered at 09:00 AM. The employee could not explain why [MEDICATION NAME] 5 mg appeared on the screen since the medication was not scheduled for 09:00 AM medication administration. Resident #3 Resident #3 was admitted on [DATE], with [DIAGNOSES REDACTED]. On [DATE] at 8:30 AM during medpass, Employee #14 was observed preparing and administering medications for Resident #3. The medications included: - Cetrizine 10 mg 1 tablet - Vitamin C 250 mg 2 tablets - [MEDICATION NAME] 10 mg/ milliliter (ml) 10 ml - Levetiracetam 100 mg/ml 12 ml - Calcium 500 mg with vitamin D 200 units 1 tablet - [MEDICATION NAME] 125 mcg 1 tablet - [MEDICATION NAME] ,[DATE] mg 1 tablet Review of Resident #3's record documented a physician order [REDACTED].

Based on observation and interview, the facility failed to ensure physician orders [REDACTED].#1) were followed as prescribed. Findings include: Resident #4 Resident #4 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #4's May 2013 recapitulation orders indicated the following orders: - Oxygen 1-3 liters per minute via nasal cannula and as needed respiratory distress. - RT (Respiratory Therapist)/RN (Registered Nurse)/LPN (Licensed Practical Nurse) may titrate (oxygen) O2 to maintain SATO (saturation level of oxygen in hemoglobin) at or above 92% (percent) - Notify MD (Medical Doctor) if titration is above most recent O2 order dated 4/17/13. On 5/2/13 at 4:15 PM, Resident #4 was observed in bed with a nasal cannula on and the resident's oxygen saturations at the time read 89 - 90 percent. The nasal cannula was observed to be connected a flow meter attached to the wall outlet with a humidification bottle of water attached. The flow meter was observed to be at the zero (0) position and the water in the humidification bottle was observed without bubbling movement. On 5/2/13 at approximately 4:18 PM, the Registered Nurse (RN) (Employee #2) explained the resident should be on 1-3 liters of oxygen. The RN looked at the flow meter and stated, "It's off." At this time, the RN turned the oxygen on to 3 liters. The RN could not explain who turned Resident #4's oxygen off. The RN indicated, I will ask the CNA (Certified Nurses Assistant). On 5/2/13 at 4:25 PM, the CNA (Employee #3) explained Resident #4 was transferred from the common area in the Pediatric Unit to bed with the assist of the resident's nurse. The CNA indicated the resident was transferred before her lunch which was a little before 2:00 PM. The CNA identified the nurse caring for the resident as the nurse who assisted with the transfer. On 5/2/13 at 4:27 PM, the RN indicated Resident #4's oxygen should have been checked every 2 hours. The facility failed to ensure Resident #4's oxygen was provided to maintain oxygen saturations at or above 92% per physician orders. Resident #1 Resident #1 was admitted on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #1's record revealed a physician order [REDACTED]. "...1) Insurance Company Name to arrange Lexiscan stress test for cardiac clearance... ... 2) EKG (electrocardiogram) r/t (related to) chest pn (pain) 3) Add CBC (complete blood count)... ... TORB (telephone order read back) Dr. (physician name)..." The record lacked documented evidence the order was processed. There was no written evidence the EKG was performed. On 5/2/13 at 12 PM, Resident #1 indicated that on 4/29/13, she complained of abdominal, back, and right shoulder pain. The resident affirmed she did not have an EKG performed that day. On 5/2/13 at 12:40 PM, Employee #1 indicated she got a report from another nurse that Resident #1 had complained of chest pain. The employee affirmed she assessed Resident #1 and found the resident had abdominal pain and right shoulder pain. Employee #1 indicated she called the physician to report the resident's conditions. According with the employee, the physician gave her telephone orders including an EKG. The employee explained when an order for [REDACTED]. After inspector request, the facility could not provide evidence the EKG order was faxed to the external diagnostic services provider. On 5/2/13 at 2:38 PM, Resident #1's attending physician indicated he ordered an EKG for cardiac clearance and not for chest pain. The physician explained Resident #1 was complaining of abdominal pain for several days and needed cardiac clearance to perform a [MEDICATION NAME] acid scan (HIDA scan, a procedure used to diagnose problems in the liver, gallbladder and bile ducts). On 5/2/13 during the afternoon, Resident #1's attending physician wrote a clarification order to hold the EKG until HIDA study was completed.

Based on observation, interview and record review, the facility failed to justify the need for an indwelling Foley catheter when a resident was admitted to the facility and failed to provide appropriate urology services in a timely manner for 3 of 14 sampled residents (Resident #6, #2, #9). Findings include: Resident #6 Resident #6 was admitted [DATE], with [DIAGNOSES REDACTED]. Resident #6 was admitted to the facility with an indwelling Foley catheter (F/C) on 11/30/12. Throughout the survey, the inspector requested for the policy regarding justification for the use for an indwelling F/C. The policy was never given to the inspector. On 3/6/13 in the morning, the Administrator confirmed the facility did not have a written policy regarding justification for the use for an indwelling F/C. On 3/5/13 in the morning, the Director of Nursing (DON) indicated there was no written policy regarding the justification for the use of an indwelling F/C but she would expect the nursing staff to fill out the bladder assessment form justification section. The DON also indicated the physician should write the justification for the use of an indwelling F/C when orders were written to place an indwelling F/C or continue an indwelling F/C on a resident who was admitted to the facility. The DON indicated if there was no documented justification for the use of an indwelling F/C the physician would be informed and a possible post void residual would be ordered to determine if the F/C was justified. Resident #6's undated initial Bladder Evaluation form indicated the resident had an indwelling F/C. The section for justification for the use of the catheter was left blank. Resident #6's Physician's admission orders [REDACTED]. There was no documented evidence on the physician order [REDACTED]. On 3/5/13, in the morning, the DON indicated there was no justification for the use of a F/C on Resident #6 when the resident was initially admitted on [DATE]. Resident #6's urinalysis results collected on 12/2/12, documented: " ...Leukocyte Esterase 2+ (reference range negative) ... Appearance cloudy (reference range clear to slightly cloudy) ... White Blood Cell >(greater than) 50 (reference range 0-5) Bacteria Many (reference range none seen) ... " Resident #6's urine culture results collected 12/2/12, documented >100,000 of [MEDICATION NAME] aerogenes. Resident #6's Physician's Telephone Orders dated 12/4/12, indicated to start [MEDICATION NAME] 500 mg (milligrams) IV (intravenously) daily for 7 days. There was no documented evidence on the order form the reason the antibiotic was ordered. Resident #6's Physician's Telephone Orders form dated 12/7/12, indicated to: - Start Meropenem 1 gm (gram) IV every 8 hours for 3 days. - To start [MEDICATION NAME] 1 gm IV every 8 hours for 3 days. There was no documented evidence on the order form the reason antibiotics were ordered. Resident #6's Physician's Telephone Order form dated 12/8/12, indicated to: - Discontinue the [MEDICATION NAME] and the Meropenem IV antibiotics. - Continue the Meropenem IV antibiotic until further orders. - Start [MEDICATION NAME] 100 mg IV for one dose then administer [MEDICATION NAME] 50 mg every 12 hours. There was no documented evidence on the order form the reason antibiotics were ordered. Resident #6's urine culture results dated 12/8/12, no longer reported [MEDICATION NAME] aerogenes organisms. The report documented: -"[MEDICATION NAME] Resistant 10,000 colonies/ML Yeast Organism #1 50,000 colonies/ML [MEDICATION NAME] spp ... " Resident #6's Telephone Orders form dated 12/10/12, indicated to: - Discontinue the IV antibiotic [MEDICATION NAME] - Start [MEDICATION NAME] 6 mg/kilograms every 24 hours for 7 days. - Continue the IV antibiotic Meropenem for 7 more days. There was no documented evidence on the order form the reason antibiotics were ordered. The ordered IV antibiotics were administered and the last antibiotic was completed on 12/17/12. The F/C remained intact and was not discontinued after the antibiotic administration. There was no documented evidence for the justification for continuing the indwelling F/C for Resident #6 after the antibiotics were completed. On 3/1/13 in the afternoon, the Director of Nursing (DON) and the Staff Developer indicated the physician should have written on the order form the indication antibiotics ([MEDICATION NAME], Meropenem, [MEDICATION NAME], and [MEDICATION NAME]) were being ordered for Resident #6. The DON indicated the nursing staff should have clarified the order and placed the indication for use on the order form next to the antibiotic medication order. The Staff Developer indicated the antibiotics were probably used for Resident #6's UTI (urinary tract infection). The DON confirmed an order to discontinue the F/C should have been obtained and there was no justification to continue the F/C for Resident #6 after the antibiotics were completed. Resident #6's urinalysis results collected on 12/29/12, documented: "...Leukocyte Esterase 3+ (Reference range negative) ... Appearance Turbid (reference range clear to slightly cloudy) ... White Blood Cell >50 (reference range 0-5) ... Bacteria Few (reference range none seen) ... " Resident #6's urine culture results collected 12/29/12, no longer reported [MEDICATION NAME] aerogenes, [MEDICATION NAME] and yeast. The report documented: -"....100,000 colonies/ML Organism #1 [DIAGNOSES REDACTED] pneumonia ... " Resident #6's urinalysis results collected on 1/7/13, documented: "[MEDICATION NAME] Positive (reference range negative) ... Leukocyte Esterase 3+ (Reference range negative) ... Appearance cloudy (reference range clear to slightly cloudy) ... White Blood Cell >50 reference range 0-5) ... Bacteria Few (reference range none seen) ... " Resident #6's urine culture results collected 1/7/13, documented: -"....>100,000 colonies/ML Organism #1 [DIAGNOSES REDACTED] pneumonia ... " Resident #6's Physician's Progress Notes dated 1/10, documented: -"...UTI 2 (secondary to) + (positive) UC (urine culture) 1) Start PO (orally)[MEDICATION NAME]([MEDICATION NAME]) 500 mg BID (twice a day) X 5 days ... " Resident #6's Physician's Telephone Orders dated 1/10/13, indicated to start [MEDICATION NAME] 500 mg twice a day for 5 days. There was no documented evidence on the order form the reason the antibiotic was ordered. [MEDICATION NAME] was started on 1/11/13 and completed on 1/15/13. Resident #6's urinalysis results collected on 1/15/13, documented: "[MEDICATION NAME] Positive (reference range negative) ... Leukocyte Esterase 3+ (Reference range negative) ... Appearance Turbid (reference range clear to slightly cloudy) ... White Blood Cell >50 reference range 0-5) ... Bacteria Few (reference range none seen) ... " Resident #6's urine culture results collected 1/15/13, no longer reported [MEDICATION NAME] aerogenes, [MEDICATION NAME], Yeast and [DIAGNOSES REDACTED] pneumonia. The report documented: -"...>100,000 colonies/ML Multiple Resistant Drug Organism (MRDO) Organism #1 Pseudomonas Aeruginosa ... " On 2/28/13 in the morning, Resident #6's family member indicated she was aware of the numerous urinary tract infections Resident #6 had. Resident #6's family member was concerned that the F/C was causing the urinary tract infections and she informed the charge nurse regarding her concerns. On 3/1/13 at 9:00 AM, Employee #6 remembered the concerns Resident #6's family member had regarding why the F/C was still being used for Resident #6 and concerns the family member had regarding the possibility the F/C was causing the UTI's. Employee #6 indicated the concerns were brought up to the primary physician and orders were obtained to discontinue the F/C. Resident #6's Physician's Telephone Orders form dated 1/25/13, documented: -"...1/25/13 1520 (3:20 PM) Bladder Training X48H (hours) then DC (discontinue) Foley ... " On 3/1/13 in the afternoon, the DON indicated bladder training was done to train the bladder before the F/C was discontinued. The urine tube was crimped off as long as possible with a minimum of 30 minutes and then released so the urine can expand the bladder. The DON indicated bladder training would be done for a couple of days and then the catheter would be discontinued. The DON indicated if the F/C was discontinued and there was no urine output for more than 6 to 8 hours then the physician would be informed and an order to do a straight catheterization would be obtained. The DON indicated there would be a possibility of re-inserting the F/C if it was determined the resident was retaining urine. The DON indicated a post void residual of 100cc's or more would be considered retaining urine. Resident #6's Daily Nurses Notes form dated 1/25/13, documented: -"...1830 (6:30 PM) Pt (patient) started on bladder training ... " -"2000 (8:00 PM) F/C patent/intact noted with 150 cc (cubic centimeters) c/y (clear/yellow urine, draining to gravity, no s/s (signs and symptoms) of infection noted at this time, remains on bladder training ... " -"...2300 (11:00 PM) F/C 16 Fr (French) c\ (with)10 cc H2O (water) balloon removed intact, noted c\ 300 cc C/Y urine, F/C 16 Fr c\ 10cc Balloon H2O inserted c\ one attempt, intact noted 50 cc c/y urine, UA (urinalysis) obtained ... " There was no documented evidence bladder training was conducted for 48 hours. Documented evidence from the nursing notes indicated there was no [MEDICAL CONDITION] noted with only 50cc urine return noted. There was no documented evidence a reason was given to discontinue bladder training on 1/27/13 for Resident #6. On 3/1/13 in the morning, Employee #6 indicated the primary physician ordered on [DATE] to start bladder training for 48 hours and then discontinue the F/C. Employee #6 indicated the infection control physician came in later in the day, possibly not knowing the primary physician ordered the F/C to be discontinued, and wrote an order for [REDACTED].#6 continued to use the F/C and why bladder training was discontinued. On 3/1/13 in the afternoon, the DON indicated there was no justification why Resident #6's F/C was still being used even after orders were obtained for bladder training on 1/25/13 and to discontinue the F/C after the training. Resident #6's urinalysis results collected on 1/26/13, documented: "...Leukocyte Esterase 3+ (Reference range negative) ... Appearance Turbid (reference range clear to slightly cloudy) ... White Blood Cell >50 reference range 0-5) ... Bacteria Few (reference range none seen) ... " Resident #6's urine culture results collected 1/26/13, no longer reported [MEDICATION NAME] aerogenes, [MEDICATION NAME], Yeast, [DIAGNOSES REDACTED] pneumonia and Pseudomonas Aeruginosa. The report documented: -"...100,000 colonies/ML Organism #1 Morganella morganii ... " Resident #6's urinalysis results collected on 2/5/13, documented: "...Leukocyte Esterase 3+ (Reference range negative) ... Appearance Turbid (reference range clear to slightly cloudy) ... White Blood Cell >50 reference range 0-5) ... Bacteria moderate (reference range none seen) ... " Resident #6's urine culture results collected 2/5/13, no longer reported [MEDICATION NAME] aerogenes, [MEDICATION NAME], Yeast, [DIAGNOSES REDACTED] pneumonia and Pseudomonas Aeruginosa. The report documented: -"...>100,000 colonies/ML Organism #1 [DIAGNOSES REDACTED] pneumonia ... Organism #2 Morganella morganii ... " Resident #6's Physician's Telephone Orders dated 2/10/13, indicated to start [MEDICATION NAME] 1 gram IV every 24 hours for 3 days. There was no documented evidence on the order form the reason the antibiotic was ordered but Resident #6's February 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Resident #6's Daily Nurses Notes dated 2/12/13, documented: -"...2/12/13 0600 (6:00 AM) ...Foley cath (catheter) removed at 0500 (5:00 AM) due to patient having discomfort and cath clogged. Pt voided a large amount after cath was removed ... " -"...1900 (7:00 PM) ...smiled a lot today Incontinent x1 very large amount clear urine lt (light) amber in color ... " -"...2000 (8:00 PM) ...Incont (incontinent) of B/B (bowel and bladder) ... " Resident #6's Physician's Telephone Orders form dated 2/12/13, documented: -"...2/12/13 2000 (8:00 PM) Discontinue Foley Catheter. Replace if no void in 8 hrs (hours) ... " There was no documented evidence Resident #6 had any [MEDICAL CONDITION] when the F/C was discontinued on 2/12/13. On 3/1/13 in the afternoon, the DON confirmed Resident #6 had no [MEDICAL CONDITION] when the F/C was discontinued on 2/12/13 and attempts to discontinue the F/C should have been initiated when the resident was admitted on [DATE]. In Summary: -There was no process implemented to justify the use of the F/C for Resident #6 when she was admitted on [DATE]. -The F/C was in place from 11/30/12 to 2/12/13 with no justification for use. -Urine culture results collected from 12/2/12 to 2/5/13, identified several different organisms ([MEDICATION NAME] aerogenes, [MEDICATION NAME], Yeast, [DIAGNOSES REDACTED] pneumonia, Pseudomonas Aeruginosa, Morganella morganii) through-out the months when the F/C was being used. -Multiple antibiotic medications ([MEDICATION NAME], Meropenem, [MEDICATION NAME] and [MEDICATION NAME]) were ordered to treat urinary tract infections through-out the months when the F/C was being used by Resident #6. After each antibiotic therapy was completed there was no attempt to discontinue the the F/C. -On 1/25/13, an attempt to start bladder training for Resident #6 and to discontinue the F/C was ordered but there was no documented evidence why bladder training was discontinued and there was no justification why the F/C was continued. Resident #2 Resident #2 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #2's initial Bladder Evaluation form dated 2/8/13, indicated the resident had an indwelling Foley catheter (F/C). The section for justification for the use of the catheter was left blank. Resident #2's Physician's admission orders [REDACTED]. The amount of water to inflate the catheter balloon was left blank. The section on when to change the F/C was left blank. There was no documented evidence on the physician order [REDACTED]. There was no documented history the reason a F/C was needed for Resident #2. There was no documented evidence attempts to justify the F/C for Resident #2 was initiated. On 3/5/13 in the afternoon, the Administrator indicated Resident #2 had no documented history for [MEDICAL CONDITION] or justification for using a F/C. Resident #9 Resident #9 was originally admitted on [DATE] and re-admitted on [DATE], with [DIAGNOSES REDACTED]. Resident #9's Physician's Telephone Orders form dated 2/14/12, documented: -"...Urology consult for supra pubic catheter eval (evaluation) ... " On 3/5/13 in the afternoon, the Director of Nursing (DON) indicated Resident #9 has had an indwelling Foley catheter (F/C) since his admission to the facility. The DON indicated the F/C was causing irritation to the meatus and a urology consult was ordered last year on 2/14/12. The DON indicated making the appointment for the resident was difficult because the family lived out of the State and the family needed to be present at the time of the appointment to sign papers at the clinic. Communication was documented with the family member to attempt to set up the urology appointment for Resident #9. Communication was documented on the following months: -2/17/12 -2/28/12 -3/6/12 -3/14/12 -3/22/12 -5/20/12 Email documentation sent by Resident #9's family member to the facility clerical case manager assistant (Employee #15) on 5/21/12, documented: -"...I also called the Urologist office but the receptionist said that she would check if the doctor would see (Resident #9) because (Resident #9 is in a coma.(?) She said she would get back to me as soon as she finds out. I will let you know when she calls me back ... " There was no documented evidence the facility attempted to assist Resident #9's family member regarding the urology clinic not seeing the resident due to him being in a coma. Email documentation sent by Employee #15 to Resident #9's family member to the on 7/3/12, documented: -"...I wanted to know if you made the urologist appointment. Did they call you back concerning the appointment... " Resident #9's family member replied on 7/3/12: -"...no, I didn't hear back from them. Is there any way I can call a different urologist. I really don't feel comfortable with (Resident #9) going to this place if they are giving us such a hard time about his conditions. " -"Please let me know what my other options are. If there are any ... " There was no documented evidence the facility attempted to assist Resident #9's family member regarding other options. Email documentation sent by Resident #9's family member to Employee #15 on 8/24/12, documented: -"...I'm back to work now, so I've been extremely busy these past weeks, so I haven't called to see if you've contacted a Urologist that can see (Resident #9)." "Please let me know as soon as you find out something. I'll probably be in LV (Las Vegas) in mid Sept (September) so if you can schedule it for a fri. (Friday) that would be ideal for me ... " There was no documented evidence the facility attempted to assist Resident #9's family member regarding setting up an appointment in September 2012. Email documentation sent by the insurance case manager to Employee #15 on 1/9/13, documented: -"...The adjuster just emailed me saying that she just spoke with the (family member) asking why the referrals were not made. What number do you have for her ... " Employee #15's reply documented: "...I'm sorry, I'm trying to get in touch with the (family member). I left her plenty of messages, haven't heard from her. I wanted to hear from her before I spoke to you ... " There was no documented evidence communication was made between August 24, 2012 to January 9, 2013 to assist the family member make the urology appointment for Resident #9. A reply was sent to Employee #15 by the insurance case manager 72 minutes later and documented: -"...I got a hold of (family member), and here are her availabilities. She wants (Resident #9) to see a urologist and a neurologist ... " On 1/17/13 an appointment was made to see the urologist on 3/11/13 which was 13 months after the physician ordered for the urology consult on 2/14/12. On 3/6/13 in the morning, the Administrator was not aware there was lack of communication for several months with Resident #9's family member with making the urology appointment.

Based on record review, policy review and interview, the facility failed to provide the necessary care and services for residents to maintain their highest practicable physical well-being for 3 of 15 residents (Resident #1, #7, and #12) for a Physical Therapist not conducting a comprehensive assessment and informing a charge nurse and the physician a resident (Resident #1) was grimacing for three days while braces were applied, for failing to follow a physician's orders [REDACTED].#7), and for failing to follow a physician's orders [REDACTED]. Findings include: Resident #1 Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #1 was transported to the acute care hospital on [DATE], after it was found on x-ray the resident had sustained a [MEDICAL CONDITION] leg. The form Physical Therapy Daily Progress Report for Resident #1 documented: "...2/27/12, Pain grimacing with bracing; 2/28/12, Pain grimacing with bracing, 2/29/12 Pain grimacing with bracing..." The form was signed by Employee #66 (the physical therapist with the previous contracted group). On 7/17/12 at 11:30 AM, the Administrator (Employee #67) of the contracted therapy group with the facility was shown a therapy form for Resident #1. The form, "Physical Therapy Daily Progress Report" indicated on 2/27/12, 2/28/12 and 2/29/12, Resident #1 was noted to be grimacing with bracing documented by Employee #66. There was no documentation before or after those dates indicating Resident #1 was grimacing with bracing. Employee #67 indicated the company Employee #66 worked with was no longer contracted with the facility. Employee #67 indicated if a child was grimacing with bracing she would notify the physician. Employee #67 indicated an assessment would need to be done to advise the physician on what to do next, possibly an x-ray. Employee #67 indicated it, It looked like the therapist (Employee #66) put the brace back on even though the child was grimacing, which would indicate the child was having some kind of pain. On 7/17/12 at 11:00 AM, A Physical Therapist (Employee #68) agreed with what Employee #67 stated. Employee #68 indicated she would have tried to assess Resident #1 to find out why the resident was grimacing. Employee #68 indicated she would immediately tell the charge nurse. Employee #68 indicated she would want to find out why the child was grimacing when the bracing was applied. There was no documentation by Employee #66 that an assessment on Resident #1's leg or that the charge nurse or physician were informed on 2/27/12, 2/28/12 or 2/29/12 Resident #1 was having grimacing during bracing. Complaint #NV 594 Resident #7 On 2/15/11, Resident #7 was admitted with [DIAGNOSES REDACTED]. On 4/12/12 at 3:00 PM, a nurse reinserted a 16 French Foley catheter in the gastrostomy tube site of Resident #7 per standing order. On 4/12/12 at 6:00 PM, a physician ordered a radiology test to check gastrostomy tube placement. On 4/12/12 at 7:30 PM, a nurse documented the administration of tube feeding. On 4/13/12 at 5:00 AM, a nurse documented the tube feeding was off and the feeding was tolerated. On 4/13/12 at 10:25 AM, a radiology company performed a test for abdominal pain and verifying gastrostomy tube placement. On 4/13/12 at 1:00 PM, the radiology result showed [MEDICAL CONDITION] air distention and "...no feeding tube seen..." On 4/13/12 at 3:00 PM, the facility sent Resident #7 to a hospital. According to the facility's policy, Gastrostomy Tube dated 1/1/11, "...5.c. NEVER proceed with a tube feeding until the tube is determined to be correctly placed. Resident #12 On 1/14/12, Resident #12 was admitted with [DIAGNOSES REDACTED]. On 6/15/12 at 8:30 AM, a physician order [REDACTED]." On 6/19/12 and 6/20/12, the facility's splint/brace action log showed documentation the bilateral lower extremity braces were applied with plantar pressure and ankle redness observed. On 6/27/12 at 12:15 PM, a physician ordered "Do not use LE splints as they are 2* (secondary to) skin trauma." On 7/17/12, the Administrator indicated the braces were designed to prevent foot drop but were causing skin redness. The manufacturer was contacted to modify the braces and did so, but the braces still caused redness and were discontinued. On 7/17/12 in the morning, Resident #12 was observed wearing the braces on the feet. The Administrator was brought to the room, and the braces were removed. Complaint #NV 272